Risk of methicillin-resistant staphylococcus aureus prosthetic joint infection in elective total hip and knee arthroplasty following eradication therapy

BACKGROUND Prosthetic joint infection(PJI)is a devastating complication requiring prolonged treatment and multiple operations,leading to significant morbidity for the patient.Patients are routinely tested for methicillin-resistant staphylococcus aureus(MRSA)colonisation.MRSA positive patients are given eradication therapy.We hypothesise that patients who are MRSA positive pre-operatively,have increased risk of developing PJI.AIM To identify deep wound infection(PJI)rates in patients who are colonised MRSA positive compared with those who are not colonised;and long term clinical and radiological outcomes.METHODS All patients who underwent total hip and knee replacements(THR/TKR)between December 2009 and December 2019 were identified.Patients who were also identified as being MRSA positive at pre-operative assessment were then selected.Confirmation of prescribing eradication treatment was recorded.Patient records,including consultation letters,operation notes and microbiology results were reviewed retrospectively.Comparison of outcomes for each MRSA positive patient was made with 2 MRSA negative patients undergoing the same operation of a similar age by the same consultant.RESULTS Screening identified 42 knee and 32 hip arthroplasty patients as MRSA positive,84 MRSA negative knee and 64 hip patients were reviewed.Patients were matched with medical co-morbidities in each group.Mean follow up was 5 years.PJI was identified in 4/32(12.5%)of THR MRSA positive and 3/42(7%)of TKR patients.All patients had PJI within one year of surgery.CONCLUSION MRSA positive patients are given eradication therapy routinely.However,no confirmation of eradication is sought.Patients who have MRSA colonisation preoperatively,in our study had a significantly increased risk of PJI,when compared to negative patients.We would recommend establishing true eradication after treatment prior to arthroplasty.

Technetium-99m-labeled annexin V imaging for detecting prosthetic joint infection in a rabbit model

Accurate and timely diagnosis of prosthetic joint infection is essential to initiate early treatment and achieve a favorable outcome. In this study, we used a rabbit model to assess the feasibility of technetium-99m-labeled annexin V for detecting prosthetic joint infection. Right knee arthroplasty was performed on 24 New Zealand rabbits. After surgery, methicillin-susceptible Staphylococcus aureus was intra-articularly injected to create a model of prosthetic joint infection （the infected group, n = 12）. Rabbits in the control group were injected with sterile saline （n= 12）. Seven and 21 days after surgery, technetium-99m-labeled annexin V imaging was per- formed in 6 rabbits of each group. Images were acquired 1 and 4 hours after injection of technetium-99m- labeled annexin V （150 MBq）. The operated-to-normal-knee activity ratios were calculated for quantitative ana- lysis. Seven days after surgery, increased technetium-99m-labeled annexin V uptake was observed in all cases. However, at 21 days a notable decrease was found in the control group, but not in the infected group. The operated-to-normal-knee activity ratios of the infected group were 1.84 ±0.29 in the early phase and 2.19 ±0.34 in the delay phase, both of which were significantly higher than those of the control group （P=0.03 and P=0.02）. The receiver operator characteristic curve analysis showed that the operated-to-normal-knee activity ratios of the delay phase at 21 days was the best indicator, with an accuracy of 80%. In conclusion, technetium- 99m-labeled annexin V imaging could effectively distinguish an infected prosthetic joint from an uninfected prosthetic joint in a rabbit model.

Prosthetic joint infection of the hip and knee due to Mycobacterium species:A systematic review

BACKGROUND Mycobacterium species(Mycobacterium sp)is an emerging cause of hip and knee prosthetic joint infection(PJI),and different species of this organism may be responsible for the same.AIM To evaluate the profile of hip and knee Mycobacterium PJI cases as published in the past 30 years.METHODS A literature search was performed in PubMed using the MeSH terms“Prosthesis joint infection”AND“Mycobacterium”for studies with publication dates from January 1,1990,to May 30,2021.To avoid missing any study,another search was performed with the terms“Arthroplasty infection”AND“Mycobacterium”in the same period as the previous search.The Preferred Reporting Items for Systematic Reviews and Meta-Analyses chart was used to evaluate the included studies for further review.In total,51 studies were included for further evaluation of thecases,type of pathogen,and treatment of PJI caused by Mycobacterium sp.RESULTS Seventeen identified Mycobacterium sp were reportedly responsible for hip/knee PJI in 115 hip/knee PJI cases,whereas in two cases there was no mention of any specific Mycobacterium sp.Mycobacterium tuberculosis(M.tuberculosis)was detected in 50/115(43.3%)of the cases.Nontuberculous mycobacteria(NTM)included M.fortuitum(26/115,22.6%),M.abscessus(10/115,8.6%),M.chelonae(8/115,6.9%),and M.bovis(8/115,6.9%).Majority of the cases(82/114,71.9%)had an onset of infection>3 mo after the index surgery,while in 24.6%(28/114)the disease had an onset in≤3 mo.Incidental intraoperative PJI diagnosis was made in 4 cases(3.5%).Overall,prosthesis removal was needed in 77.8%(84/108)of the cases to treat the infection.Overall infection rate was controlled in 88/102(86.3%)patients with Mycobacterium PJI.Persistent infection occurred in 10/108(9.8%)patients,while 4/108(3.9%)patients died due to the infection.CONCLUSION At least 17 Mycobacterium sp can be responsible for hip/knee PJI.Although M.tuberculosis is the most common causal pathogen,NTM should be considered as an emerging cause of hip/knee PJI.

Periprosthetic joint infections in femoral neck fracture patients treated with hemiarthroplasty–should we use antibiotic-loaded bone cement?

BACKGROUND Hemiarthroplasty is the most common treatment in elderly patients with displaced intra-capsular femoral neck fracture(FNF).Prosthetic joint infection(PJI)is one of the most feared and frequent complications post-surgery because of the frail health status of these patients and the need for fast track surgery.Therefore,priorities should lie in effective preventive strategies to mitigate this burden.AIM To determine how much the implementation of the routine use of antibioticloaded bone cement(ALBC)as a relatively easy-to-apply amendment to the surgical practice reduces the infection rate in our hemiarthroplasty cohort.METHODS We retrospectively assessed all demographic,health status and treatment-related data of our FNF patients undergoing cemented hemiarthroplasty in the period from 2011 to 2017;241 patients were further analyzed after exclusion of patients with cancer-related sequelae and those who died before the end of the 1-year observation period.The PJI rate as diagnosed on basis of the Musculoskeletal Infection Society(MSIS)criteria 2011 was determined for each included patient and compared in function of the bone cement used for hip stem fixation.Patients were split into a group receiving a plain bone cement in the period from January 2011 to June 2013(non-ALBC group)and into a group receiving an ALBC in the period July 2013 to December 2017(ALBC group).Data analysis was performed with statistical software.We further calculated the cost-efficacy of the implementation of routine use of ALBC in the second group balancing the inhospital infection related treatment costs with the extra costs of use of ALBC.RESULTS In total 241 FNF patients who received cemented hemiarthroplasty in the period from January 2011 to January 2017 were eligible for inclusion in this retrospective study.There were 8 PJI cases identified in the ALBC group among n=94 patients,whereas 28 PJI cases were observed in the non-ALBC group among n=147 patients.The statistical analysis showed an infection risk reduction of 55.3%(in particular due to the avoidance of chronic delayed infections)in the ALBC group(95%CI:6.2%-78.7%;P=0.0025).The cost-evaluation analysis demonstrated a considerable cost saving of 3.500€per patient,related to the implementation of routine use of ALBC in this group.CONCLUSION Use of ALBC is a potent infection preventive factor in FNF patients receiving cemented hemiarthroplasties.It was further found to be highly cost-effective.

Systematic review of single stage revision for prosthetic joint infection

While advanced technology,increased medical knowledge and improved surgical technique has improved patient outcomes in total joint arthroplasty,prosthetic joint infection still remains one of the leading causes of increased healthcare costs,medical resources and societal burdens in orthopaedic care.Two stage arthroplasty revision remains the gold standard for treatment of prosthetic joint infection.Proponents of single stage revision arthroplasty for infection argue that it results in lower healthcare costs while improving patient reported functional outcomes and with equivalent success rates.Here we review the history of single stage revision arthroplasty,discuss the key principles,highlight the indications and contraindications,and review the reported outcomes with a focus on future developments of single stage revision arthroplasty for hip and knee periprosthetic joint infections.

Risk of methicillin-resistant Staphylococcus aureus prosthetic joint infection in elective total hip and knee arthroplasty following eradication therapy

Re-screening following methicillin-resistant Staphylococcus aureus(MRSA) decolonization will be helpful to minimize the development of prosthetic joint infection among MRSA colonizers.

Dual antibiotic loaded bone cement in patients at high infection risks in arthroplasty: Rationale of use for prophylaxis and scientific evidence

In view of the demographic changes and projected increase of arthroplasty procedures worldwide,the number of prosthetic joint infection cases will naturally grow.Therefore,in order to counteract this trend more rigid rules and a stricter implementation of effective preventive strategies is of highest importance.In the absence of a"miracle weapon"priorities should lie in evidence-based measures including preoperative optimization of patients at higher infection risks,the fulfilment of strict hygiene rules in the operating theatre and an effective antibiotic prophylaxis regimen.Instead of a"one size fits all"philosophy,it has been proposed to adjust the antibiotic prophylaxis protocol to major infection risks taking into account important patient-and procedure-related risk factors.A stronger focus on the local application mode via use of high dose dual antibioticloaded bone cement in such risk situations may have its advantages and is easy to apply in the theatre.The more potent antimicrobial growth inhibition in vitro and the strong reduction of the prosthetic joint infection rate in risk for infection patients with aid of dual antibiotic-loaded bone cement in clinical studies align with this hypothesis.