Search Results (187)

Introduction: Sarcopenia is a systemic condition linked to increased morbidity and mortality in older adults. Point-of-Care Ultrasound (POCUS) offers a rapid, bedside method to assess muscle mass. This study evaluates the diagnostic accuracy of POCUS compared to Dual-energy X-ray Absorptiometry (DXA), the gold standard method, and explores its prognostic value in old patients undergoing surgery for hip fractures. Patients and Methods: In this prospective, single-center study, 126 patients aged ≥ 70 years and hospitalized with hip fractures were included. Sarcopenia was defined according to the revised 2018 EWGSOP2 criteria. Muscle mass was assessed by the Appendicular Skeletal Muscle Mass Index (ASMI) using DXA and by the thickness of the rectus femoris (RF) muscle using POCUS. Results: Of the 126 included patients, 52 had both DXA and POCUS assessments, and 43% of them met the diagnostic criteria for sarcopenia or severe sarcopenia. RF muscle thickness measured by POCUS was significantly associated with ASMI (R² = 0.30; p < 0.001). POCUS showed a fair diagnostic accuracy in women (AUC 0.652) and an excellent accuracy in men (AUC 0.905). Optimal diagnostic thresholds according to Youden’s index were 5.7 mm for women and 9.3 mm for men. Neither RF thickness, ASMI, nor sarcopenia status predicted mortality or major postoperative complications. Conclusions: POCUS is a promising, accessible tool for diagnosing sarcopenia in old adults with hip fractures. Nonetheless, its prognostic utility remains uncertain and should be further evaluated in long-term studies. Full article

Background: Periprosthetic joint infections (PJIs) are considered as one of the most serious complications after total joint arthroplasty. Aim of this study was to evaluate the prevalence of PJI caused by difficult-to-treat (DTT) pathogens as well as PJIs with a superinfection with a DTT pathogen in the course of the infection and assess the risk factors leading to this emergence. Methods: Data of 169 consecutive patients with a PJI was analyzed in this retrospective observational single-center study, and cases were categorized into PJIs with initial DTT pathogens, PJIs with DTT pathogen superinfection, non-DTT PJIs, and PJIs with superinfection. Recorded parameters comprised age, gender, side, body mass index (BMI), preoperative anticoagulation, and serum level of C-reactive protein (CRP) at admission, as well as preoperative patient status using the ASA (American Society of Anesthesiologists) score and the age-adjusted form of the Charlson comorbidity index (CCI). Furthermore, the infecting microorganism and the type of infection as well as the chosen operative treatment regime, duration of the antibiotics interval, and the outcome were recorded. Results: In total, 46.2% of cases were DTT PJIs, and 30.8% of them were superinfections. Elevated serum CRP levels at admission (≥92.1 mg/L) were linked to a nearly 7-fold increased likelihood of a DTT PJI (OR 6.981, CI [1.367–35.63], p = 0.001), compared to patients with a non-DTT PJI. Hip joint involvement was also associated with a 3.5-fold higher risk compared to knee joints (OR 3.478, CI [0.361–33.538], p = 0.0225). Furthermore, patients undergoing ≥3 revision surgeries demonstrated a significantly 1.3-fold increased risk of developing a DTT superinfection (OR 1.288, CI [1.100–1.508], p < 0.0001). Chronic PJIs were similarly associated with a markedly 3.5-fold higher likelihood of superinfection by DTT pathogens (OR 3.449, CI [1.159–10.262], p = 0.0387). Remaining parameters did not significantly affect the rate of a DTT PJI or a PJI with DTT superinfection. Conclusions: These findings underscore the importance of early identification of high-risk patients and highlight the need for tailored preventive and therapeutic strategies in managing DTT PJIs. Full article

Background: Preparing patients for surgery considers assessing the patient’s somatic health, for example by the American Society of Anesthesiology (ASA) scale or the Revised Cardiac Risk Index (RCRI), known as the Lee index. This process usually ignores mental functioning (personality and anxiety), which is known to influence health. The purpose of this study is to analyze the existence of a relationship between personality traits (the Big Five model and trait-anxiety) and anesthesia scales (ASA scale, Lee index) used for the preoperative evaluation of patients. Methods: The study group comprised 102 patients (59 women, 43 men) scheduled for hip replacement surgery. Patients completed two psychological questionnaires: the NEO-FFI (NEO Five Factors Inventory) and the X-2 STAI (State-Trait Anxiety Inventory) sheet. Next, the presence and possible strength of the relationship between personality traits and demographic and medical variables were analyzed using Spearman’s rho rank correlation coefficient. Results: Patients with a high severity of trait anxiety are classified higher on the ASA scale (rs = 0.359; p < 0.001). Neuroticism, defined according to the Big Five model, significantly correlates with scales of preoperative patient assessment: the ASA classification (rs = 0.264; p < 0.001) and the Lee index (rs = 0.202; p = 0.044). A hierarchical regression model was created to test the possibility of predicting ASA scores based on personality. It explained more than 34% of the variance and was a good fit to the data (p < 0.05). The controlled variables of age and gender accounted for more than 23% of the variance. Personality indicators (trait anxiety, neuroticism) additionally accounted for slightly more than 11% of the variance. Trait anxiety (Beta = 0.293) proved to be a better predictor than neuroticism (Beta = 0.054). Conclusions: These results indicate that inclusion of personality screening in the preoperative patient evaluation might help to introduce a more individualized approach to patients, which could result in better surgical outcomes. Full article

Background and Objectives: To characterize the epidemiological profile of patients undergoing revision total hip arthroplasty (THA) using bone allografts from a tissue bank, and to identify clinical and surgical factors associated with the selection of graft type in cases of severe periprosthetic bone loss. Materials and Methods: This observational, cross-sectional study involved a retrospective review of medical records from a specialized referral center, including revision THA procedures performed between 2013 and 2019. Data were collected on 36 variables covering demographic details (age, sex), surgical history of both hips, comorbidities, medication use, perioperative complications, hospitalization, surgical technique, and characteristics of the bone grafts used. Patients were grouped based on the type of allograft received—structured or morselized (impacted)—and comparative analyses were performed. Results: A total of 67 revision THA cases were evaluated, with a mean patient age of 63.2 years. Nearly half (47.8%) had no prior hip revision. The average number of previous procedures per patient was 1.73, and the mean interval from primary THA to revision was 178.4 months. Morselized bone allografts were used in 66.7% of cases, and structured allografts in 33.3%. Patients receiving structured grafts had undergone a significantly higher number of prior surgeries (p = 0.01) and had a longer duration since the initial THA (p = 0.04). Conclusions: These findings suggest that younger patients undergoing primary total hip arthroplasty may be at increased risk for complex revision procedures involving structured grafts later in life, underscoring the need for long-term monitoring and tailored surgical planning in this population. Full article

Total hip arthroplasty is one of the most common and rapidly growing surgical procedures, with over one million cases performed annually in the United States. Despite high success rates, revision surgeries remain a significant concern due to complications such as aseptic loosening, often resulting from inadequate primary implant stability. This study presents an automated computational framework that integrates three-dimensional preoperative planning and finite element modeling to predict the primary stability of hip implants. Data obtained from the virtual surgery phase are used to generate subject-specific finite element models, which are executed on high-performance computing systems. The simulation evaluates implant stability by analyzing the contact interaction between the bone and the implant. The pipeline is demonstrated using data from the open-source HFValid collection and a commercial implant. Automation substantially reduced the time required to set up simulations, improving the efficiency on high-performance infrastructure. This integrated computational approach bridges the gap between biomechanical modeling and clinical decision-making and can serve as a preclinical tool for identifying personalized implant strategies and for conducting large-scale virtual cohort studies. Full article

Objective: In recent years, a significant increase in the incidence of both total hip arthroplasty and acetabular revision surgery has been observed. A substantial proportion of patients requiring these revision procedures present with major bone deficits and extensive osteolysis. In light of these challenges, this study aims to provide a comprehensive comparison between two commonly utilized methods: trabecular titanium shell implants and Burch–Schneider acetabular reinforcement cages. Methods: Participants of both sexes were included through a retrospective review of medical records. The sole inclusion criterion was that the patient had undergone revision hip arthroplasty using either Burch–Schneider acetabular reinforcement cages or Regenerex trabecular titanium shell within the past 18 years. No exclusion criteria were applied concerning patient age, laterality, ethnicity, or post-operative status. Each patient was evaluated based on nine predictive factors, including the Paprosky classification, duration of surgery, perioperative blood loss, number of bone grafts and screws used, as well as pre- and post-operative Harris Hip Score (HHS) and Visual Analogue Scale (VAS). Results: A total of 220 patients were included in the analysis, with 75% (n = 165) comprising the group treated with trabecular titanium implants and 25% (n = 55) treated with Burch–Schneider cages. The use of Regenerex trabecular titanium was associated with a 32.40% (n = 23.13 mL) reduction in bone graft tissue required and a 13.7% (n = 0.59) increase in the number of screws needed. Additionally, the trabecular titanium group experienced a 15.93% (n = 179.64 mL) reduction in perioperative blood loss compared to the Burch–Schneider cage group. The other parameters analyzed in the study did not demonstrate statistical significance. Conclusions: The use of a trabecular titanium acetabular shell may be an effective option, particularly in patients with severe acetabular deficits, as it provides favorable clinical and radiological outcomes. Additionally, it reduces the number of bone grafts required and allows for faster and more immediate partial weight-bearing on the operated limb. Full article

Background: The effectiveness of hip hemiarthroplasty in managing femoral neck fractures in individuals with cerebral palsy has seldom been reported. Objectives: Given the complex neuromuscular issues associated with cerebral palsy (CP), this retrospective study aims to document the outcomes and characterize the complications of hip hemiarthroplasty for fractures of the femoral neck in a series of patients with CP, emphasizing the role of precision medicine in management. Methods: Six cases of hip hemiarthroplasty in six male patients with cerebral palsy and displaced femoral neck fractures have been reviewed in this study. The patients’ mean age at the time of surgery was 55.6 ± 14.1 years (range, 33–71). All the patients were independent indoor ambulators before their femoral neck fracture and had various medical comorbidities. Five patients had intellectual disabilities. Results: The mean clinical and radiographic follow-ups for the patients included in this series were 91.5 and 71.3 months, respectively. All the patients developed significant heterotopic ossification (HO) around the operated hip, which was observed as early as the second week postoperatively on radiographs. HO progressed throughout the follow-up for all the patients. One patient had an early postoperative dislocation with femoral stem loosening, which was managed by implant revision. Another patient had an acetabular protrusion, leading to the loss of their weight-bearing ability and mobility due to pain. Four patients were deceased at a mean of 86.5 months after the index surgery. Conclusions: After considering the preliminary evidence provided with this small case series, this study suggests the overall guarded outcomes of hip hemiarthroplasty in patients with CP. Given the 100% rate of heterotopic ossification, a precision medicine framework with consideration for HO prophylaxis may be recommended after hip hemiarthroplasty in patients with CP. It may also be reasonable to scrutinize a personalized risk assessment approach in this patient subset regarding decision making, surgical approach, and rehabilitation program. The clinical outcomes and the risks of complications following hemiarthroplasty should be sensibly presented to patients with cerebral palsy and their caregivers to achieve reasonable postoperative expectations. Full article

This study examines temporal patterns in pathogens isolated from prosthetic joint infection (PJI) cases and antimicrobial resistance patterns at a Romanian orthopedic center. We have conducted a retrospective cohort study that included 674 patients undergoing hip or knee replacement revision surgery between January 2016 and December 2023. From these, 102 confirmed PJI cases requiring surgical intervention were selected for analysis. We isolated 27 microorganisms from acute PJI cultures and 82 from chronic PJIs. Staphylococcus epidermidis (33 cases, 30.3%; 95% CI 22.0–40.3) was the predominant pathogen, with coagulase-negative Staphylococci (22 cases, 20.18%; 95% CI 0.9–41.3) and Enterobacteriaceae (13 cases, 11.9%; 95% CI 6.4–18.3) also prevalent. Methicillin resistance was identified in 43.6% of coagulase-negative staphylococci and 45.5% of Staphylococcus aureus isolates. All Gram-positive isolates remained susceptible to vancomycin, linezolid, and tigecycline. Among Gram-negative bacilli, Klebsiella oxytoca and Proteus mirabilis showed resistance to third-generation cephalosporins, with phenotypic profiles suggestive of extended-spectrum β-lactamase (ESBL) production. All Escherichia coli, Enterobacter spp., and Citrobacter freundii strains were fully susceptible to tested agents, while Pseudomonas aeruginosa exhibited reduced susceptibility to ciprofloxacin, aztreonam, and imipenem. Among the isolated strains, 47 were multidrug-resistant (MDR), with Staphylococcus aureus accounting for the highest MDR count, including methicillin resistance. The distribution of microorganism types and MDR strains remained consistent throughout the study period, with no significant association between infection type and MDR strain presence or between infection site and microorganism presence except for a strong association between MDR strains and the type of microorganism (p < 0.05). The microbial profile and resistance patterns in PJIs have remained stable over eight years. Our observations do not suggest that MDR PJIs are more commonly acute cases, contrary to what has been highlighted in previous reports. The ongoing prevalence of MDR strains underscores the importance of targeted antimicrobial treatments based on local susceptibility profiles. Full article

Background: Periprosthetic joint infections (PJIs) remain a major challenge in arthroplasty. This study tries to evaluate the PJI-TNM classification as predictor for the revision-free implant survival in patients with PJI of the hip or knee joint. Methods: To this end, we perform a retrospective study of all consecutive patients with PJI of an inlying hip or knee arthroplasty between January 2015 and December 2019. Results: A total of 443 cases (hip: n = 247; knee n = 196) were identified. In total, 439 patients underwent surgery (DAIR: n = 138 cases (31%), explantation: n = 272 (61%), irrigation with debridement without exchange of implant components: n = 29 (6.5%)). Four patients refused surgical treatment and 39.5% were lost to follow-up. In total, 78 patients died during follow-up and 27 deaths were directly related to PJI/complications during treatment. Patients with inlying “standard”-implants (p < 0.001) and without previous history of PJI (p = 0.002) displayed a significantly higher postoperative revision-free implant survival. In terms of the PJI-TNM subclassification, patients with loosened implants but without soft-tissue defects (T1) displayed the highest revision-free implant survival. In contrast, patients classified as M3 (no surgical treatment possible) displayed an inferior outcome compared to M0, M1, or M2. Patients with different N-subclassifications (“non-human cells”/causative pathogen) did not display differences in revision-free implant survival. Conclusions: The PJI-TNM classification is well suited to classify PJIs. Its complexity allows for more than 500 different combinations of classifications. Further validation data are needed, but to us, the PJI-TNM classification seems to offer the possibility of comparing patients with PJIs. It may, therefore, be a very valuable tool in order to compare cohorts with PJIs and provide individual data for patient specific outcomes. Full article

Introduction: Intertrochanteric femoral fractures (IFFs) are the most common traumatic injuries in elderly people and significantly impact the patient’s health status. The current evidence indicates that short intramedullary nails may be a better choice than dynamic hip screws in IFF management, being less invasive and biomechanically superior, providing a buttress to limit fracture collapse. On the other hand, an unstable fracture may collapse even after adequate reduction and fixation. This paper aims to describe the surgical complexity of the nail-to-total hip arthroplasty (THA) conversion, focusing on the restoration of normal hip geometry. Material and Methods: Patients referred to our level I trauma center with failed cephalomedullary nailing following IFFs and managed with the nail-to-THA conversion were retrospectively recruited. The anteroposterior postoperative pelvis radiographs were analyzed to establish whether the normal biomechanics of the involved hip were restored. The following radiographic parameters were recorded and compared to the contralateral unaffected side: hip offset, cervical–diaphyseal angle, and limb length discrepancy. Clinical assessment was performed using the following scores: the Harris hip score (HHS) and the visual analog scale for pain (VAS). The independent samples t-test and the Pearson correlation test were performed. The tests were two-tailed; a p < 0.05 was considered significant. Results: A total of 31 patients met the inclusion and exclusion criteria (10 males and 21 females; mean age: 76.2 years; range: 66–90 years) and were included in this study. The modes of trochanteric nail failure included the following: cut-out in 22 cases (70.97%), non-union in 4 cases (12.9%), peri-implant fracture in 1 case (3.23%), cut-through in 2 cases (6.45%), and femoral head avascular necrosis (HAN) in 2 cases (6.45%). Long stems were used in 21 patients out of 31 (67.74%), while dual-mobility cups were implanted in 24 patients out of 31 (77.41%). A significant mean neck shaft angle (NSA) increase (p < 0.001) and a significant mean femoral offset reduction (FO, p 0.001) compared to the contralateral hip were recorded; a mean limb length discrepancy (LLD) of 8.35 mm was observed. A significant correlation between HHS and ∆NSA (p = 0.01) and ∆FO (p = 0.003) was recorded. Conclusions: Conversion from a cephalomedullary nail to THA is a complex procedure that should be considered a revision surgery, rather than a primary surgery. Surgeons must be aware that normal hip geometry may not be obtained during this surgical procedure; thus, a patient undergoing the nail-to-THA conversion for intertrochanteric fixation failure may have an increased risk of implant-related complications. Full article

Introduction: The present study investigates the five-year outcomes of hip arthroscopy for cam or pincer-type femoroacetabular impingement (FAI) and associated labral tears in a defined patient population. Methods: Patients who underwent hip arthroscopy for cam or pincer-type arthroscopy femoroacetabular impingement (FAI) and labral tears at our hospital in the past five years were included. All patients who underwent revision—like a total hip arthroplasty (THA), a subsequent hip arthroscopy at another hospital, or had primary osseous diseases—were excluded. Patients were contacted via mail and asked to answer a clinical questionnaire called the “Hip Osteoarthritis Outcome Score” (HOOS) and to indicate whether there was a second surgery like a subsequent arthroscopy or THA. Results: There were 77 hip arthroscopies in 75 patients the last 5 years. A total of 29 patients responded. Those who did not respond were contacted via phone. All in all, we obtained the results of 49 patients (50 hips—29 right, 19 left, and 1 bilateral) who underwent hip arthroscopy over the past five years. The mean age at the time of operation was 41 years. Our results were as follows: 24 hips had an isolated labral tear, 49 hips a combined FAI pathology with cam and/or pincer-type impingement and labral tears, 3 patients had a posttraumatic FAI, and 1 patient suffered from hip chondromatosis, who was subsequently excluded; further, 22 patients (23 procedures) were lost to follow-up. HOOS contains various subscales; only the postoperative result of subscale 1 (symptoms) did not show a statistically significant improvement compared with the preoperative value. All other subscales showed a statistically significant improvement in comparison with the preoperative condition. Five patients (10.2%) still experienced symptoms, so we performed a total hip arthroplasty (THA) as a second surgical procedure. One patient was revised due to chondromatosis. One patient was revised at another center, and another was excluded because of chondromatosis. Conclusions: The five-year follow-up results of hip arthroscopy proved successful outcomes. Hip arthroscopy is an effective treatment for FAI in order to delay primary THA, regaining mobility and range of motion and reducing pain. Longer-term studies with a larger cohort are necessary. Full article

Introduction: Periprosthetic joint infections (PJIs) remain a major challenge in orthopedic and trauma surgeries. The microbial resistance profiles and the optimal choice of empirical antibiotic therapy in shoulder arthroplasty revision are less well characterized compared to those in knee or hip arthroplasty revision. Materials and Methods: This retrospective study constitutes a novel comparative analysis, providing valuable insights into the presence of joint-specific pathogen resistance and the empirical treatment accuracy of shoulder and knee arthroplasties. A review of all the revision cases following primary shoulder and knee arthroplasties conducted between January 2012 and December 2023 was performed. Cases that required revision because of PJIs were identified, and microbial cultures were analyzed to determine the presence of pathogens and their resistance profiles. Results: The most administered postoperative empirical antibiotics were cefuroxime and amoxicillin–sulbactam. A statistically significant difference in the prevalence of anerobic pathogens was observed between total shoulder arthroplasty and knee arthroplasty. Furthermore, a statistically significant difference was observed in the sensitivities of pathogens to metronidazole (p < 0.001) and erythromycin (p = 0.014). Conclusions: This study demonstrates microbiological and antimicrobial resistance differences between PJI TSA and TKA cases. Full article

Background: Microbial analysis of tissue samples represents an important diagnostic tool in the course of revision total joint arthroplasty. Currently, unexpected positive intraoperative cultures are commonly observed during presumed aseptic revision surgery and evoke a degree of uncertainty among physicians. To date, it is unclear if there are deviations in pathogen detection between certified laboratories. Methods: Tissue samples of sixty consecutive patients undergoing presumably aseptic total hip and knee revision surgery were sent to two different internationally certified accredited laboratories and tested for any microbial growth as well as pathogen differentiation. Results: Each laboratory analyzed 300 samples. Laboratory 1 observed an unexpected positive culture rate of 16.7%; laboratory 2 indicated that 18.3% of all processed specimens showed pathogen growth. In comparison, a consistent microbial evaluation was only present in one patient. The kappa correlation coefficient showed a poor correlation between the two laboratories in all evaluated categories. Coagulase-negative staphylococci represented the most common pathogens of laboratory 1, while laboratory 2 predominantly observed cutibacterium acnes species. Within a mean follow-up period of 17.6 ± 18.6 months (range: 0–63 months), there was no revision due to periprosthetic joint infection. Conclusions: Unexpected positive culture results during presumed aseptic revision surgery remain a significant clinical challenge. This study is the first of its kind to evaluate the convergence of laboratory findings in the context of aseptic revision surgery. Our results suggest that even established and certified laboratories show substantial discrepancies. Thus, a careful interpretation of unexpected bacterial cultures after revision surgery is mandatory. Given the uncertainty inherent in laboratory findings, a precise clinical and histopathological evaluation of this patient cohort should be ensured. Full article

Background and Objectives: Intertrochanteric fractures of the femur are common in the elderly due to the increase in longer life expectancy. However, unstable intertrochanteric fractures in the elderly population were still a significant concern for the postsurgical period after total hip arthroplasty (THA). This study aimed to compare the demographics, operative time, dislocation rate, and length of stay of the novel interfragmentary technique (IFT) and the conventional posterolateral approach (CPA) for unstable intertrochanteric femoral fractures treated with THA in the elderly. Materials and Methods: This retrospective study investigated community-dwelling elderly patients with type III, IV, and V unstable femoral intertrochanteric fractures according to the Evans–Jensen classification, treated with THA by a well-experienced single surgeon. The patients were separated into IFT (n = 74) and CPA (n = 67) groups. Patient demographics (age, gender, and body mass index), total surgical duration, dislocation rates, length of stay and follow-up, and complication rates were recorded. Results: The mean age was 80.37 years in the IFT and 80.14 in the CPA groups (p = 0.838). Body mass index, gender, complication, and revision rates did not differ between groups (p > 0.05). The mean follow-up of the IFT group was 4.15 years, and 10.25 years in the CPA group (p = 0.001). Total surgical duration was comparable, with 69.98 min in the IFT group and 69.55 min in the CPA group (p = 0.697). The dislocation rate was 2.7% (n = 2) in the IFT group and 9% (n = 6) in the CPA group (p = 0.109). The mean length of stay was 66.97 h in the IFT group and 67.83 h in the CPA group (p = 0.729). Conclusions: The interfragmentary surgical technique, a novel technique for unstable intertrochanteric fracture surgery, shows promising clinical outcomes. Preserving the short rotator muscles and posterior capsule utilizing the novel IFT can be advantageous for the risk of dislocation without increasing surgical duration. It can be concluded that performing THA using IFT emerges as a practical and viable procedure for treating unstable intertrochanteric fractures in elderly patients. Full article

Periprosthetic joint infection (PJI) is a devastating complication after total hip arthroplasty. Synovial fluid aspiration and preoperative tissue biopsy cultures can be helpful diagnostic tools for PJI. The aim of this study is to evaluate the diagnostic value of synovial fluid aspirations in general, and preoperative biopsies after inconclusive or dry tap aspiration in patients undergoing revision hip arthroplasty in particular. Patients who underwent diagnostic aspiration and subsequent preoperative biopsy and/or revision surgery between January 2015 and January 2024 were included in the study. Synovial fluid aspirations and tissue samples obtained from biopsy and revision surgery were interpreted using the European Bone and Joint Infection Society criteria for PJI. In total, 207 patients were included with 231 synovial fluid aspirations. The sensitivity and specificity of synovial fluid aspiration cultures were 76% and 98%. In 62 cases, tissue biopsies were performed, of which 23 were after dry tap aspiration. Tissue biopsies after dry tap aspiration had a sensitivity of 44% and a specificity of 93%. Tissue biopsies after dry tap aspiration led to the confirmation of PJI in 7/23 cases. Synovial fluid aspiration yields reliable results when evaluating a patient for suspicion of PJI. Diagnosing PJI can, however, be troublesome if the synovial fluid aspiration provides a dry tap or inconclusive result. Tissue biopsy cultures after dry tap aspiration are a feasible way to confirm PJI. Full article