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Special Issue "Complications in Total Joint Arthroplasties"

A special issue of Journal of Clinical Medicine (ISSN 2077-0383). This special issue belongs to the section "Orthopedics".

Deadline for manuscript submissions: closed (15 May 2019)

Special Issue Editors

Guest Editor
Prof. Dr. Enrique Gómez-Barrena

Department of Orthopaedic Surgery and Traumatology, Autonomous University of Madrid, Knee Unit at Hospital Universitario La Paz, Madrid, Spain
Website | E-Mail
Interests: fracture, arthroplasty, hip/knee surgery, orthopedic biomechanics, orthopedic surgery
Guest Editor
Dr. Eduardo García-Rey

Department of Orthopaedic Surgery and Traumatology, Autonomous University of Madrid, Hip Unit at Hospital Universitario La Paz, Madrid, Spain
Website | E-Mail
Interests: arthroplasty, hip surgery

Special Issue Information

Dear colleagues,

Total joint arthroplasties are among the surgical interventions that have provided a higher quality of life for human kind. The benefit of these interventions extend for many years, thus confirming the high efficiency of the procedure. Well-established registries provide follow-up data that have confirmed this favourable outcome in many cases, and millions of interventions are performed world-wide yearly. These facts are well known to the general population and general practitioners, fostering the referral of patients with serious articular damage that eventually may benefit from the operations.

However, the number and severity of related complications remind us of the complexity and seriousness of these surgical procedures. While many patients perform remarkably well without any complications, and although these are well-described to the patient, they are often not well-understood by the patient at the time of informed consent. Thus, the prognosis of the complicated procedure jeopardizes the expectations of those patients affected by a complication.

In this context, today more information from clinical studies is available to analyze the diagnosis and treatment of joint arthroplasty complications. Several approaches have been developed, including epidemiological, observational, or experimental studies. Early and late complications have generated new classification series in the currently used coding. The overall diagnosis and treatment of infectious complications, material failures, prosthetic loosening, joint instability, or others have been the subject of intensive research to understand, prevent and treat well-known or new circumstances related to the failure of this otherwise highly successful technique.

The current Special Issue aims to deepen this research, offering the reader an overview of the present debates that intend to clarify and further improve the outcome of these unhappy patients who, looking for an improved quality of life, face a difficult situation that may require complex surgical and medical treatments, hospital stays and occasionally limited recovery.

Prof. Dr. Enrique Gómez-Barrena
Dr. Eduardo García-Rey
Guest Editors

Manuscript Submission Information

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Please visit the Instructions for Authors page before submitting a manuscript. The Article Processing Charge (APC) for publication in this open access journal is 1800 CHF (Swiss Francs). Submitted papers should be well formatted and use good English. Authors may use MDPI's English editing service prior to publication or during author revisions.

Keywords

  • Epidemiology of joint arthroplasty complications
  • Recent complications after joint arthroplasty
  • Long-term complications after joint arthroplasty
  • Septic joint arthroplasty
  • Implant loosening
  • Joint instability after total joint arthroplasty
  • Hip revision surgery due to failed arthroplasty
  • Knee revision surgery due to failed arthroplasty

Published Papers (11 papers)

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Research

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Open AccessArticle
Does Prophylactic Administration of Edoxaban Increase D-Dimer Levels after Total Hip Arthroplasty?
J. Clin. Med. 2019, 8(5), 678; https://doi.org/10.3390/jcm8050678
Received: 29 March 2019 / Revised: 10 May 2019 / Accepted: 13 May 2019 / Published: 14 May 2019
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Abstract
This study aimed to examine the effect of thromboprophylactic edoxaban on D-dimer levels and anemia after total hip arthroplasty (THA). We retrospectively analyzed data from 349 patients undergoing primary THA. Univariate regression and multivariate regression analyses were performed with D-dimer levels on the [...] Read more.
This study aimed to examine the effect of thromboprophylactic edoxaban on D-dimer levels and anemia after total hip arthroplasty (THA). We retrospectively analyzed data from 349 patients undergoing primary THA. Univariate regression and multivariate regression analyses were performed with D-dimer levels on the 7th, 14th, and 21st days postoperatively as the dependent variable Edoxaban use, age, sex, body mass index (BMI), renal function, drop in hemoglobin (Hb) drop, intraoperative blood loss and duration of surgery as were independent variables. Multivariate regression analysis was also performed with Hb drop as the dependent variable. Edoxaban administration of 15 mg/day and 30 mg/day after THA was correlated with higher D-dimer levels at 21, but not at 7 or 14, days postoperatively. Other significant independent predictors for high D-dimer levels were the duration of surgery (at 7 and 14 days), BMI (at 7 days), sex (at 14 days), and age (at 14 and 21 days). Edoxaban use was significantly, weakly correlated with a larger Hb drop at 7 and 14 days, but this was less than a clinically important difference. D-dimer levels after THA can be elevated by thromboprophylactic edoxaban after three weeks postoperatively. Full article
(This article belongs to the Special Issue Complications in Total Joint Arthroplasties)
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Open AccessArticle
The Different Microbial Etiology of Prosthetic Joint Infections according to Route of Acquisition and Time after Prosthesis Implantation, Including the Role of Multidrug-Resistant Organisms
J. Clin. Med. 2019, 8(5), 673; https://doi.org/10.3390/jcm8050673
Received: 17 April 2019 / Revised: 6 May 2019 / Accepted: 9 May 2019 / Published: 13 May 2019
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Abstract
The aim of our study was to characterize the etiology of prosthetic joint infections (PJIs)—including multidrug-resistant organisms (MDRO)—by category of infection. A multicenter study of 2544 patients with PJIs was performed. We analyzed the causative microorganisms according to the Tsukayama’s scheme (early postoperative, [...] Read more.
The aim of our study was to characterize the etiology of prosthetic joint infections (PJIs)—including multidrug-resistant organisms (MDRO)—by category of infection. A multicenter study of 2544 patients with PJIs was performed. We analyzed the causative microorganisms according to the Tsukayama’s scheme (early postoperative, late chronic, and acute hematogenous infections (EPI, LCI, AHI) and “positive intraoperative cultures” (PIC)). Non-hematogenous PJIs were also evaluated according to time since surgery: <1 month, 2–3 months, 4–12 months, >12 months. AHIs were mostly caused by Staphylococcus aureus (39.2%) and streptococci (30.2%). EPIs were characterized by a preponderance of virulent microorganisms (S. aureus, Gram-negative bacilli (GNB), enterococci), MDROs (24%) and polymicrobial infections (27.4%). Conversely, coagulase-negative staphylococci (CoNS) and Cutibacterium species were predominant in LCIs (54.5% and 6.1%, respectively) and PICs (57.1% and 15.1%). The percentage of MDROs isolated in EPIs was more than three times the percentage isolated in LCIs (7.8%) and more than twice the proportion found in AHI (10.9%). There was a significant decreasing linear trend over the four time intervals post-surgery for virulent microorganisms, MDROs, and polymicrobial infections, and a rising trend for CoNS, streptococci and Cutibacterium spp. The observed differences have important implications for the empirical antimicrobial treatment of PJIs. Full article
(This article belongs to the Special Issue Complications in Total Joint Arthroplasties)
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Open AccessArticle
Influence of Hospital Volume of Procedures by Year on the Risk of Revision of Total Hip and Knee Arthroplasties: A Propensity Score-Matched Cohort Study
J. Clin. Med. 2019, 8(5), 670; https://doi.org/10.3390/jcm8050670
Received: 2 April 2019 / Revised: 7 May 2019 / Accepted: 10 May 2019 / Published: 13 May 2019
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Abstract
The volume of total hip (THA) and knee arthroplasties (TKA) performed in a hospital per year could be an influential factor on the revision of these procedures. The aims of this study were: To obtain comparable cohorts in higher- and lower-volume hospitals; and [...] Read more.
The volume of total hip (THA) and knee arthroplasties (TKA) performed in a hospital per year could be an influential factor on the revision of these procedures. The aims of this study were: To obtain comparable cohorts in higher- and lower-volume hospitals; and to assess the association between the hospital volume and the incidence of revision. Data from patients undergoing THA and TKA caused by osteoarthritis and recorded in the Catalan Arthroplasty Register (RACat) between January 2005 and December 2016 were used. The main explanatory variable was hospital volume by year (higher/lower). The cut-off point was fixed, based on previous research, at 50 THA and 125 TKA procedures/year. To obtain comparable populations, a propensity-score matching method (1:1) was used. Patient characteristics prior to and after matching were compared. To assess differences by volume, subhazard ratios (SHRs) from competing risks models were obtained. After matching, 13,772 THA and 36,316 TKA patients remained in the study. Prior to matching, in both joints, significant differences in all confounders were observed between volume groups. After matching, none of them remained significant. Both in THA and TKA, a higher risk of revision in higher-volume hospitals was observed (THA SHR: 1.25, 95%CI: 1.02–1.53; and TKA SHR: 1.29, 95%CI: 1.16–1.44). Unlike other contexts, currently in Catalonia, higher-volume hospitals have a greater risk of revision than lower-volume hospitals. Further research could be valuable to define context-dependent measures to reduce the incidence of revision. Full article
(This article belongs to the Special Issue Complications in Total Joint Arthroplasties)
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Open AccessArticle
Similar Risk of Re-Revision in Patients after One- or Two-Stage Surgical Revision of Infected Total Hip Arthroplasty: An Analysis of Revisions in the Swedish Hip Arthroplasty Register 1979–2015
J. Clin. Med. 2019, 8(4), 485; https://doi.org/10.3390/jcm8040485
Received: 1 March 2019 / Revised: 29 March 2019 / Accepted: 4 April 2019 / Published: 10 April 2019
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Abstract
Late chronic infection is a devastating complication after total hip arthroplasty (THA) and is often treated with surgery. The one-stage surgical procedure is believed to be the more advantageous from a patient and cost perspective, but there is no consensus on whether the [...] Read more.
Late chronic infection is a devastating complication after total hip arthroplasty (THA) and is often treated with surgery. The one-stage surgical procedure is believed to be the more advantageous from a patient and cost perspective, but there is no consensus on whether the one- or two-stage procedure is the better option. We analysed the risk for re-revision in infected primary THAs repaired with either the one- or two-stage method. Data was obtained from the Swedish Hip Arthroplasty Register and the study groups were patients who had undergone a one-stage (n = 404) or two-stage (n = 1250) revision due to infection. Risk of re-revision was analysed using Kaplan–Meier analysis with log-rank test and Cox regression analysis. The cumulative survival rate was similar in the two groups at 15 years after surgery (p = 0.1). Adjusting for covariates, the risk for re-revision due to all causes did not differ between patients who were operated on with the one- or two-stage procedure (Hazard Ratio (HR) = 0.9, 95% Confidence Interval (C.I.) = 0.7–1.2, p = 0.5). The risk for re-revision due to infection (HR = 0.7m, 95% C.I. = 0.4–1.1, p = 0.2) and aseptic loosening (HR = 1.2, 95% C.I. = 0.8–1.8, p = 0.5) was similar. This study could not determine whether the one-stage method was inferior in cases when the performing surgeons chose to use the one-stage method. Full article
(This article belongs to the Special Issue Complications in Total Joint Arthroplasties)
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Open AccessArticle
Smoking Dependent Alterations in Bone Formation and Inflammation Represent Major Risk Factors for Complications Following Total Joint Arthroplasty
J. Clin. Med. 2019, 8(3), 406; https://doi.org/10.3390/jcm8030406
Received: 26 February 2019 / Revised: 15 March 2019 / Accepted: 19 March 2019 / Published: 24 March 2019
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Abstract
Numerous studies have described a correlation between smoking and reduced bone mass. This not only increases fracture risk but also impedes reconstruction/fixation of bone. An increased frequency of complications following surgery is common. Here, we investigate the effect of smoking on the clinical [...] Read more.
Numerous studies have described a correlation between smoking and reduced bone mass. This not only increases fracture risk but also impedes reconstruction/fixation of bone. An increased frequency of complications following surgery is common. Here, we investigate the effect of smoking on the clinical outcome following total joint arthroplasty (TJA). 817 patients receiving primary or revision (including clinical transfers) TJA at our level-one trauma center have been randomly interviewed twice (pre- and six months post-surgery). We found that 159 patients developed complications (infections, disturbed healing, revisions, thrombosis, and/or death). Considering nutritional status, alcohol and cigarette consumption as possible risk factors, OR was highest for smoking. Notably, mean age was significantly lower in smokers (59.2 ± 1.0a) than non-smokers (64.6 ± 0.8; p < 0.001). However, the number of comorbidities was comparable between both groups. Compared to non-smokers (17.8 ± 1.9%), the complication rate increases with increasing cigarette consumption (1–20 pack-years (PY): 19.2 ± 2.4% and >20 PY: 30.4 ± 3.6%; p = 0.002). Consequently, mean hospital stay was longer in heavy smokers (18.4 ± 1.0 day) than non-smokers (15.3 ± 0.5 day; p = 0.009) or moderate smokers (15.9 ± 0.6 day). In line with delayed healing, bone formation markers (BAP and CICP) were significantly lower in smokers than non-smokers 2 days following TJA. Although, smoking increased serum levels of MCP-1, OPG, sRANKL, and Osteopontin as well as bone resorption markers (TRAP5b and CTX-I) were unaffected. In line with an increased infection rate, smoking reduced 25OH vitamin D3 (immune-modulatory), IL-1β, IL-6, TNF-α, and IFN-γ serum levels. Our data clearly show that smoking not only affects bone formation after TJA but also suppresses the inflammatory response in these patients. Thus, it is feasible that therapies favoring bone formation and immune responses help improve the clinical outcome in smokers following TJA. Full article
(This article belongs to the Special Issue Complications in Total Joint Arthroplasties)
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Open AccessArticle
Suitability of Metal Block Augmentation for Large Uncontained Bone Defect in Revision Total Knee Arthroplasty (TKA)
J. Clin. Med. 2019, 8(3), 384; https://doi.org/10.3390/jcm8030384
Received: 31 January 2019 / Revised: 14 March 2019 / Accepted: 18 March 2019 / Published: 19 March 2019
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Abstract
This study was performed to determine whether metal block augmentation is suitable for large uncontained bone defect via evaluations of differences in biomechanical characteristics among the configurations of metal block augmentations for medium or large uncontained bone defects in revision total knee arthroplasty [...] Read more.
This study was performed to determine whether metal block augmentation is suitable for large uncontained bone defect via evaluations of differences in biomechanical characteristics among the configurations of metal block augmentations for medium or large uncontained bone defects in revision total knee arthroplasty (TKA). Three-dimensional finite element (FE) models of the proximal tibia with revision TKA were developed and analyzed considering the configurations of the metal block augmentations for medium and large uncontained bone defects. To identify differences in biomechanical characteristics according to the configurations of metal block augmentations, the stress transfer, strain distribution, and peak von Mises stresses (PVMSs) were assessed. Large and medium uncontained bone defects had similar ranges of strain below the critical bone-damage strain for the metal block augmentations, but the strain distribution characteristics differed in response to the metal block-augmentation configurations. PVMSs exceeding the yield strength of the bone cement for the single metal block-augmentation configurations were, on average, 1.4 times higher than those for double metal block-augmentation configurations for both medium and large uncontained bone defects. These findings suggest that metal block augmentation may be suitable for large uncontained bone defects (≤20 mm), compared with the results obtained for metal block augmentation used in medium uncontained bone defects (≤10 mm). If possible, double metal block augmentation is recommended for both medium and large uncontained bone defects rather than single metal block augmentation. It is also recommended that the metal block augmentation should be customized to meet the contact characteristics with the cortical bone, thereby ensuring better stress transfer and reducing the risk of the bone resorption due to stress shielding and bone-cement failure. Full article
(This article belongs to the Special Issue Complications in Total Joint Arthroplasties)
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Open AccessArticle
The Benefice of Mobile Parts’ Exchange in the Management of Infected Total Joint Arthroplasties with Prosthesis Retention (DAIR Procedure)
J. Clin. Med. 2019, 8(2), 226; https://doi.org/10.3390/jcm8020226
Received: 27 December 2018 / Revised: 28 January 2019 / Accepted: 5 February 2019 / Published: 9 February 2019
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Abstract
Background: The management of prosthetic joint infections (PJI) with debridement and retention of the implant (DAIR) has its rules. Some authors claim that lacking the exchange of mobile prosthetic parts is doomed to failure, while others regard it as optional. Methods: Single-center retrospective [...] Read more.
Background: The management of prosthetic joint infections (PJI) with debridement and retention of the implant (DAIR) has its rules. Some authors claim that lacking the exchange of mobile prosthetic parts is doomed to failure, while others regard it as optional. Methods: Single-center retrospective cohort in PJIs treated with DAIR. Results: We included 112 PJIs (69 total hip arthroplasties, 9 medullary hip prostheses, 41 total knee arthroplasties, and 1 total shoulder arthroplasty) in 112 patients (median age 75 years, 52 females (46%), 31 (28%) immune-suppressed) and performed a DAIR procedure in all cases—48 (43%) with exchange of mobile parts and 64 without. After a median follow-up of 3.3 years, 94 patients (84%) remained in remission. In multivariate Cox regression analysis, remission was unrelated to PJI localization, pathogens, number of surgical lavages, duration of total antibiotic treatment or intravenous therapy, choice of antibiotic agents, immune-suppression, or age. In contrast, the exchange of mobile parts was protective (hazard ratio 1.9; 95% confidence interval 1.2–2.9). Conclusions: In our retrospective single-center cohort, changing mobile parts of PJI during the DAIR approach almost doubled the probability for long-term remission. Full article
(This article belongs to the Special Issue Complications in Total Joint Arthroplasties)
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Open AccessArticle
Orthopedic Implant-Associated Infection by Multidrug Resistant Enterobacteriaceae
J. Clin. Med. 2019, 8(2), 220; https://doi.org/10.3390/jcm8020220
Received: 20 December 2018 / Revised: 25 January 2019 / Accepted: 4 February 2019 / Published: 8 February 2019
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Abstract
Introduction: Orthopedic implant-associated infections caused by multidrug-resistant Enterobacteriaceae are a growing challenge for healthcare providers due to their increasing incidence and the difficulties of medical and surgical treatment. Material and Methods: A retrospective observational study of all cases of multidrug resistant Enterobacteriaceae orthopedic [...] Read more.
Introduction: Orthopedic implant-associated infections caused by multidrug-resistant Enterobacteriaceae are a growing challenge for healthcare providers due to their increasing incidence and the difficulties of medical and surgical treatment. Material and Methods: A retrospective observational study of all cases of multidrug resistant Enterobacteriaceae orthopedic implant-associated infection diagnosed in a tertiary European hospital from December 2011 to November 2017 was carried out. Clinical records were reviewed using a previously designed protocol. Data analysis was performed with IBM® SPSS®, version 22. Results: 25 patients met inclusion criteria. The infected implants included 10 prosthetic joints, seven osteosyntheses, six combinations of prosthetic joint and osteosynthesis material, and two spacers. Of the multidrug resistant Enterobacteriaceae obtained on culture, 12 were extended-spectrum beta-lactamase-producing Escherichia coli, three OXA-48-producing Klebsiella pneumoniae, nine extended-spectrum beta-lactamase-producing Klebsiella pneumoniae, and one extended-spectrum beta-lactamase-producing Proteus mirabilis. Combination antimicrobial therapy was employed in all cases but two. Overall, 16 (64%) patients underwent implant removal. The rate of infection control in the overall implant removal group was 100% compared to 33% in the implant retention group. A strong relationship between implant removal and infection control was observed (p = 0.001). Discussion: Implant removal is strongly associated with infection control. However, in some cases, patient age and comorbidity contraindicate hardware extraction. Potential objectives for future studies should be geared towards targeting the population in which debridement, antibiotic therapy, and implant retention can be used as a first-line therapeutic strategy with a reasonable probability of achieving infection control. Full article
(This article belongs to the Special Issue Complications in Total Joint Arthroplasties)
Open AccessArticle
Patient- and Surgery-Related Factors that Affect Patient-Reported Outcomes after Total Hip Arthroplasty
J. Clin. Med. 2018, 7(10), 358; https://doi.org/10.3390/jcm7100358
Received: 28 September 2018 / Revised: 9 October 2018 / Accepted: 11 October 2018 / Published: 15 October 2018
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Abstract
Patient-reported outcome measures (PROMs) are used to assess satisfaction after total hip arthroplasty (THA); however, the factors that determine these PROMs remain unclear. This study aimed to identify the patient- and surgery-related factors that affect patient satisfaction after THA as indicated by the [...] Read more.
Patient-reported outcome measures (PROMs) are used to assess satisfaction after total hip arthroplasty (THA); however, the factors that determine these PROMs remain unclear. This study aimed to identify the patient- and surgery-related factors that affect patient satisfaction after THA as indicated by the Oxford Hip Score (OHS). One-hundred-and-twenty patients who underwent primary THA were included. Various patient-related factors, including clinical scores, and surgery-related factors were examined for potential correlations with the OHS at 3, 6, and 12 months post-THA. Univariate regression analysis showed that higher preoperative University of California Los Angeles (UCLA) activity score (p = 0.027) and better preoperative OHS (p = 0.0037) were correlated with better OHS at 3 months post-THA. At 6 months post-THA, the factors associated with better OHS were higher preoperative UCLA activity score (p = 0.039), better preoperative OHS (p = 0.0006), and use of a cemented stem (p = 0.0071). At 12 months post-THA, the factors associated with better OHS were higher preoperative UCLA activity score (p = 0.0075) and better preoperative OHS (p < 0.0001). Multivariate regression analysis showed that the factors significantly correlated with better OHS were female sex (p = 0.011 at 3 months post-THA), osteoarthritis (p = 0.043 at 6 months), higher preoperative OHS (p < 0.001 at 3 and 12 months, p = 0.018 at 6 months), higher preoperative Harris Hip Score (p = 0.001 at 3 months), higher preoperative UCLA activity score (p = 0.0075 at 3 months), and the use of a cemented femoral component (p = 0.012 at 6 months). Patient- and surgery-related factors affecting post-THA PROMs were identified, although the effect of these factors decreased over time. Full article
(This article belongs to the Special Issue Complications in Total Joint Arthroplasties)
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Review

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Open AccessFeature PaperReview
Single-Stage Revision Surgery in Infected Total Knee Arthroplasty: A PRISMA Systematic Review
J. Clin. Med. 2019, 8(2), 174; https://doi.org/10.3390/jcm8020174
Received: 24 December 2018 / Revised: 23 January 2019 / Accepted: 29 January 2019 / Published: 2 February 2019
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Abstract
Periprosthetic joint infection in total knee arthroplasty is a significant complication that is a common reason for revision surgery. The current standard of care is two-stage revision surgery. There is however increasing evidence to support the use of single-stage revision surgery. We conducted [...] Read more.
Periprosthetic joint infection in total knee arthroplasty is a significant complication that is a common reason for revision surgery. The current standard of care is two-stage revision surgery. There is however increasing evidence to support the use of single-stage revision surgery. We conducted a PRISMA systematic review of the current evidence on the use of single-stage revision for infected total knee arthroplasty. Four databases (PubMed, Embase, Science Direct, and Cochrane Library) were systematically screened for eligible studies. The risk bias of each study was identified using ROBINS-I tool, and the quality of evidence was assessed using the GRADE criteria. Sixteen articles were retained after applying the inclusion and exclusion criteria that evaluated 3645 knee single-stage revision surgeries. Our review reveals satisfactory outcomes for single-stage revision in the management of infected total knee arthroplasty. The reinfection rates in the studies included in our review varied however the majority reported low reinfection rates and good functional outcomes. Although strict patient selection criteria have yielded successful results, good results were also reported when these criteria were not applied. The greater use of risk factors in identifying patients likely to have a successful outcome needs to be balanced with the practical benefits of performing a single stage procedure in higher risk patients. Future large clinical randomized control trials are required to confirm our results. Full article
(This article belongs to the Special Issue Complications in Total Joint Arthroplasties)
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Other

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Open AccessConcept Paper
The W.A.I.O.T. Definition of High-Grade and Low-Grade Peri-Prosthetic Joint Infection
J. Clin. Med. 2019, 8(5), 650; https://doi.org/10.3390/jcm8050650
Received: 25 March 2019 / Revised: 6 May 2019 / Accepted: 9 May 2019 / Published: 10 May 2019
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Abstract
The definition of peri-prosthetic joint infection (PJI) has a strong impact on the diagnostic pathway and on treatment decisions. In the last decade, at least five different definitions of peri-prosthetic joint infection (PJI) have been proposed, each one with intrinsic limitations. In order [...] Read more.
The definition of peri-prosthetic joint infection (PJI) has a strong impact on the diagnostic pathway and on treatment decisions. In the last decade, at least five different definitions of peri-prosthetic joint infection (PJI) have been proposed, each one with intrinsic limitations. In order to move a step forward, the World Association against Infection in Orthopedics and Trauma (W.A.I.O.T.) has studied a possible alternative solution, based on three parameters: 1. the relative ability of each diagnostic test or procedure to Rule OUT and/or to Rule IN a PJI; 2. the clinical presentation; 3. the distinction between pre/intra-operative findings and post-operative confirmation. According to the WAIOT definition, any positive Rule IN test (a test with a specificity > 90%) scores +1, while a negative Rule OUT test (a test with a sensitivity > 90%) scores −1. When a minimum of two Rule IN and two Rule OUT tests are performed in a given patient, the balance between positive and negative tests, interpreted in the light of the clinical presentation and of the post-operative findings, allows to identify five different conditions: High-Grade PJI (score ≥ 1), Low-Grade PJI (≥0), Biofilm-related implant malfunction, Contamination and No infection (all scoring < 0). The proposed definition leaves the physician free to choose among different tests with similar sensitivity or specificity, on the basis of medical, logistical and economic considerations, while novel tests or diagnostic procedures can be implemented in the definition at any time, provided that they meet the required sensitivity and/or specificity thresholds. Key procedures to confirm or to exclude the diagnosis of PJI remain post-operative histological and microbiological analysis; in this regard, given the biofilm-related nature of PJI, microbiological investigations should be conducted with proper sampling, closed transport systems, antibiofilm processing of tissue samples and explanted biomaterials, and prolonged cultures. The proposed WAIOT definition is the result of an international, multidisciplinary effort. Next step will be a large scale, multicenter clinical validation trial. Full article
(This article belongs to the Special Issue Complications in Total Joint Arthroplasties)
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