Search Results (457)

Background/Objectives: Thrombocytopenia increases bleeding tendency and may complicate perioperative management in total knee arthroplasty (TKA), yet data on both in-hospital burden and post-discharge adverse events are limited. This study evaluated the association between preoperative platelet count and outcomes after primary TKA. Methods: In total, 3474 primary TKAs performed for osteoarthritis at a single institution (2008–2023) were retrospectively reviewed. Patients were classified as Normal, Mild, Moderate, or Severe by preoperative platelet count; the Severe group (N = 6) was excluded from comparative analyses and reported descriptively. Inverse probability of treatment weighting (IPTW) balanced baseline covariates. In-hospital outcomes were red blood cell (RBC) transfusion, intensive care unit (ICU) admission, and length of stay; follow-up outcomes were 30-day readmission, 1-year periprosthetic joint infection (PJI), and 1-year mortality. Results: After IPTW, the RBC transfusion rate rose with lower platelet count (Normal, 14.0%; Mild, 27.0%; Moderate, 32.5%; p < 0.001), and transfusion volume peaked in the Moderate group. ICU admission was more frequent (Moderate, 6.0%; Normal, 0.7%; Mild, 0.4%; p = 0.002), and length of stay increased with severity (p = 0.008). Readmission, 1-year PJI, and mortality were comparable across groups. In multivariable analysis, moderate thrombocytopenia was independently associated with RBC transfusion (adjusted odds ratio [aOR], 3.26; 95% confidence interval [CI], 1.51–6.59; p < 0.001) and ICU admission (aOR, 5.46; 95% CI, 1.37–17.41; p = 0.008), but not PJI or mortality. Conclusions: Preoperative thrombocytopenia—particularly in the mild-to-moderate range evaluated in this study—increased perioperative burden after TKA, with higher RBC transfusion and ICU utilization, but was not associated with a significant increase in major postoperative adverse events during 1-year follow-up. Even if not causally responsible, a low preoperative platelet count is a routinely available marker that may flag patients requiring closer perioperative attention. As the associated burden appears largely limited to the hospitalization period, such attentive in-hospital management may allow these patients to achieve favorable outcomes. Full article

Background/Objectives: Chronic lymphocytic leukemia (CLL), the most common leukemia in adults, predominantly affects the aging population. With improved survival from modern targeted therapies, a growing number of CLL patients are living long enough to become candidates for quality-of-life-improving procedures such as elective total knee arthroplasty (TKA). However, the impact of CLL on postoperative outcomes remains poorly understood. Methods: A retrospective cohort analysis was performed using the TriNetX Research Network. Adult patients who underwent primary TKA were identified and divided into two cohorts. CLL and non-CLL control, and 1:1 propensity score matching was performed on demographics and comorbidities. Medical complications were assessed at 30 and 90 days, and implant-related complications at 1 and 3 years postoperatively. Relative risks (RRs) with 95% confidence intervals (CIs) were calculated. Within the CLL cohort, a Cox proportional hazards model was used to identify preoperative laboratory values, medications, and comorbid diagnoses associated with complication development. Results: After matching, 2054 patients, 1027 per cohort, were analyzed. Patients with CLL demonstrated significantly higher risks of postoperative pain at both 30 days (p < 0.001) and 90 days (p < 0.001), as well as transfusion (p = 0.035) and acute kidney injury (p = 0.036) at 90 days. At 1 year, the CLL cohort had elevated risks of periprosthetic joint infection (PJI; p = 0.015) and arthrofibrosis (p = 0.036), and these differences persisted at 3 years (PJI p = 0.033; arthrofibrosis p = 0.006). In the hazards model, preoperative hemoglobin < 8 g/dL (HR: 1.75, 95% CI: 1.27–2.41, p < 0.001), long-term anticoagulant or antiplatelet use (HR: 1.43, 95% CI: 1.13–1.80, p = 0.003), chronic kidney disease (CKD; HR: 1.28, 95% CI: 1.04–1.58, p = 0.021), and overweight/obesity (HR: 1.23, 95% CI: 1.00–1.50, p = 0.047) were independently associated with short-term complications. Chronic opioid use was found to be associated with an increased risk of long-term complications (HR: 2.80, 95% CI: 1.49–5.24, p = 0.001). Conclusions: Patients with CLL undergoing TKA had higher observed risks of both early medical and late implant-related complications. These findings may reflect the combined effects of CLL-related immune dysfunction, cytopenias, and chronic systemic inflammation, which may impair wound healing, reduce physiologic reserve, and blunt infection clearance. Identification of associated, modifiable preoperative risk factors—anemia, anticoagulant exposure, CKD, obesity, and chronic opioid use—may provide actionable targets for optimization and risk stratification. Full article

Perioperative management of antirheumatic medications in adults with rheumatoid arthritis (RA) undergoing orthopedic surgery requires balancing postoperative infection and impaired wound healing against disease flare, pain, and delayed rehabilitation. This systematic review aimed to evaluate how perioperative continuation, withholding, interruption timing, restart timing, dose modification, or exposure to antirheumatic medications relates to postoperative outcomes in adults with RA undergoing arthroplasty and non-arthroplasty orthopedic procedures. PubMed, Scopus, and the Cochrane Central Register of Controlled Trials were searched from database inception to 18 April 2026 for English-language full-text clinical studies. The primary outcomes were surgical site infection/periprosthetic joint infection, delayed wound healing, and postoperative RA flare. Secondary outcomes included reoperation, revision, readmission, mortality, venous thromboembolism, dislocation, and other procedure-specific complications. Original studies were classified as direct perioperative strategy evidence, medication-exposure evidence, or supportive clinical-context evidence. Forty-three original clinical studies were included, together with six non-original contextual sources. The evidence was predominantly observational, clinically heterogeneous, and of very low certainty. Methotrexate continuation was not associated with an evident increase in early postoperative complications, whereas direct evidence for other conventional synthetic agents was limited. Longer interruption of biologic or targeted synthetic therapy did not consistently reduce infection or wound-healing complications, while several studies associated treatment interruption with postoperative flare. Chronic baseline glucocorticoid exposure was associated with adverse outcomes but was clinically distinct from short-term perioperative administration; stress-dose supplementation was not directly evaluated. Medication decisions should therefore be individualized according to drug class, disease control, glucocorticoid burden, surgical procedure, and patient risk profile. Full article

Background: Bacterial biofilms play a key role in causing periprosthetic joint infection (PJI). Current PJI management strategies commonly combine systemic antibiotic therapy with localized delivery such as antibiotic-loaded cement or beads to achieve effective tissue penetration and high antimicrobial concentrations at the implant site. We hypothesized that antibiotic-loaded calcium sulfate beads would effectively eradicate early Staphylococcus aureus biofilms but exhibit reduced efficacy against mature biofilms formed in synovial fluid (SF). This study evaluated the efficacy of vancomycin combined with gentamicin (V+G) or tobramycin (V+T) against GFP-expressing S. aureus biofilms grown in the presence of SF. Methods: Biofilms were established on clinically relevant orthopedic implant materials such as titanium (Ti), stainless steel (316L), and polyethylene (PE). Early (1-day) and mature (3-day) biofilms were treated with calcium sulfate beads loaded with V+G or V+T. Antimicrobial efficacy was quantified by colony-forming unit (CFU) enumeration. Minimum inhibitory concentration (MIC) testing was performed on surviving populations to assess potential development of antibiotic resistance. Results: Both antibiotic combinations resulted in no detectable viable bacteria in the 1-day biofilm across all tested materials following treatment, demonstrating strong reduction in early biofilm burden below the detection limit. Treatment of mature biofilms resulted in a 4–5 log reduction. MIC analysis of representative bacteria surviving post-treatment indicated no substantial increase in resistance. Conclusions: These findings show that while locally delivered antibiotic combinations eliminate early biofilms, mature biofilms demonstrate significant tolerance. MIC analysis showed little or no change in vancomycin, gentamicin, and tobramycin susceptibility after treatment, indicating no evident increase in planktonic antibiotic resistance among the surviving isolates. Together, these results highlight the importance of early intervention and the need for strategies that disrupt biofilm structure or improve antibiotic penetration to enhance PJI treatment outcomes. Full article

Orthopedic procedures trigger a complex inflammatory response that plays a central role in tissue repair and postoperative recovery. However, excessive or dysregulated inflammation may contribute to complications such as periprosthetic joint infection, thromboembolic events, delayed healing, or systemic organ dysfunction. Therefore, accurate perioperative monitoring of inflammatory activity has become increasingly important in orthopedic surgery. Evidence discussed in this review was identified through a literature search of PubMed, Scopus, and Web of Science databases covering publications from 2000 to 2026. This narrative review summarizes the current evidence regarding both traditional inflammatory biomarkers, including C-reactive protein (CRP), interleukin-6 (IL-6), tumor necrosis factor-α (TNF-α), procalcitonin (PCT), and D-dimers, as well as emerging biomarkers derived from complete blood count (CBC), such as the neutrophil-to-lymphocyte ratio (NLR), monocyte-to-lymphocyte ratio (MLR), platelet-to-lymphocyte ratio (PLR), systemic immune-inflammation index (SII), systemic inflammatory response index (SIRI), and aggregate index of systemic inflammation (AISI). Particular attention is devoted to the clinical utility of these biomarkers in orthopedic trauma, fracture healing, total joint arthroplasty, and the early detection of postoperative complications. Increasing evidence suggests that composite CBC-derived indices may provide a practical and cost-effective approach for perioperative risk stratification and prognosis assessment. Nevertheless, their interpretation remains challenging due to the lack of standardized cutoff values and the influence of multiple patient-related factors. Current evidence indicates that assessing biomarker kinetics and interpreting multiple inflammatory indices together may be more clinically valuable than isolated measurements. Future research should focus on standardization, validation in prospective studies, and integration of inflammatory biomarkers into personalized perioperative care pathways in orthopedic surgery. Full article

The prevention and optimal treatment of periprosthetic joint infections (PJI), including antibiotic prophylaxis and DAIR (debridement, antibiotics, and implant retention), is a controversial topic. This study evaluated treatment trends over the past 10 years in the Netherlands. In November 2024, all Dutch institutions performing total hip or knee arthroplasties were contacted to complete a 21-question survey on the availability of a protocol, antibiotic prophylaxis, and treatment of PJIs. Results were compared with previously performed surveys (2013, 2016 and 2019) to describe trends in the past decade of PJI prevention and treatment. The survey response rate was 100%. The use of single-dose antibiotic prophylaxis increased from 10% in 2016 to 49% in 2024. An acute PJI protocol was present in 72% of the institutions in 2016 and 95% in 2024. During DAIR procedures, mobile components were exchanged in 94% of the institutions, whereas in 2013 this reportedly happened in only 41%. In 77% of the institutions, a periodic multidisciplinary infection meeting is implemented, representing a 22% increase since 2013. These findings demonstrate a clear tendency towards standardization and optimization of the treatment of periprosthetic infections in the Netherlands over the past decade. Full article

Background/Objectives: Bacterial contamination of the surgical field during shoulder arthroplasty may contribute to periprosthetic joint infection (PJI), yet data on intraoperative bacterial load and its clinical correlates remain limited. This study aimed to evaluate culture positivity and bacterial load in specimens collected at the end of reverse total shoulder arthroplasty (RTSA) and to explore their association with patient-related factors. Methods: Fifty-five patients undergoing elective RTSA were consecutively enrolled. At the end of surgery, three specimens per patient (two prosthetic swabs and one periprosthetic tissue sample) were collected for qualitative and quantitative microbiological analysis. Associations between bacterial load and clinical variables were assessed using mixed-effects linear regression models, while time to culture positivity was analysed using mixed-effects Cox regression models. Results: Among 165 specimens, Cutibacterium acnes was isolated in 42.4% and coagulase-negative staphylococci in 29.1%. C. acnes showed significantly higher bacterial loads (1.38 × 10³ CFU/mL) compared with aerobic bacteria (6.54 × 10¹ CFU/mL). Higher C. acnes load was associated with male sex, older age, higher body mass index, smoking, and cuff tear arthropathy, whereas massive rotator cuff tear and longer time to positivity were inversely associated. Aerobic bacterial load was primarily associated with longer surgical duration. Time to positivity was shorter for aerobes than for C. acnes. Conclusions: Intraoperative bacterial contamination during RTSA is frequent and characterized by marked differences in bacterial load and growth kinetics. Quantitative assessment of bacterial burden may improve the interpretation of unexpected positive cultures. Full article

Periprosthetic joint infection (PJI) remains a major clinical challenge after total joint arthroplasty because of its association with prolonged antimicrobial therapy, repeated surgery, implant failure, functional disability, and substantial socioeconomic burden. Current strategies, including systemic antibiotics, debridement with implant retention, staged revision, and antibiotic-loaded cement spacers, remain indispensable but are limited by mature biofilm tolerance, protected microbial reservoirs, insufficient local drug penetration, persistent inflammation, and compromised periprosthetic bone repair. Increasing evidence indicates that PJI is not merely bacterial colonization of an implant surface, but a dynamic prosthetic interface disorder involving biofilm persistence, immune dysregulation, inflammatory osteolysis, and failed osseointegration. This review summarizes recent advances in anti-infective prosthetic interface design, emphasizing the transition from passive antibacterial coatings toward multifunctional immuno-antibacterial osseointegrative systems. The pathogenic basis of PJI is first discussed, including conditioning film formation, bacterial adhesion, biofilm maturation, protected reservoirs, immune evasion, and osteolysis. Current clinical management limitations are then evaluated, followed by emerging biomaterial strategies, including anti-adhesive and contact-killing surfaces, active antimicrobial coatings, mature biofilm disruption, biological antibiofilm therapies, smart infection-responsive delivery systems, and osteoimmunomodulatory interfaces. Particular attention is given to balancing early antibacterial activity with cytocompatibility, immune resolution, angiogenesis, mechanical durability, and long-term osseointegration. Finally, key translational barriers are highlighted, including load-bearing and tribological constraints, insufficiently standardized mature biofilm and animal models, limited clinical evidence for advanced smart materials, manufacturing reproducibility, sterilization compatibility, regulatory complexity, and application-specific clinical readiness. Future anti-PJI interfaces should evolve beyond unidirectional bacterial killing toward stage-specific systems integrating biofilm control, immune restoration, vascularized bone regeneration, and durable mechanical performance. Full article

Staphylococcus epidermidis is a major cause of periprosthetic and other implant-associated orthopedic infections because of its ability to adhere to biomaterial surfaces and form biofilm. Tranexamic acid (TXA) is routinely used in arthroplasty to reduce perioperative blood loss; however, emerging evidence suggests that it may also modulate bacterial behavior and antibiotic activity. This study investigated the in vitro effects of TXA in combination with teicoplanin on planktonic growth and biofilm biomass formation in clinical Staphylococcal isolates. Clinical Staphylococcal isolates were evaluated using disk diffusion assays, microtiter plate-based planktonic growth assays, and crystal violet biofilm biomass assays. Microplate-based growth and biofilm assays were performed using five clinical isolates, whereas disk diffusion assays were performed using a separate set of seven clinical staphylococcal isolates. Teicoplanin was tested at literature-based low concentrations of 0.1 and 0.4 µg/mL, either alone or in combination with TXA at 10 and 50 mg/mL. In disk diffusion assays, inhibition zone diameters were quantified using ImageJ. Planktonic growth was assessed by optical density at 600 nm, and biofilm biomass accumulation was quantified by crystal violet staining at 570 nm. Disk diffusion data were analyzed using paired t-tests, while microplate-based growth and biofilm data were analyzed using two-way analysis of variance (ANOVA) followed by Tukey’s multiple-comparisons test. In disk diffusion assays, TXA co-application was associated with larger teicoplanin inhibition zones on both blood agar and Mueller–Hinton agar, suggesting an increased apparent inhibitory zone under agar-based conditions. In microplate-based planktonic growth assays, responses were isolate-dependent. However, co-exposure to TXA, particularly at 50 mg/mL, was associated with reduced OD600-based bacterial growth in several isolates compared with teicoplanin alone. A similar isolate-dependent pattern was observed for crystal violet-based biofilm biomass accumulation. In most tested isolates, teicoplanin combined with 50 mg/mL TXA was associated with lower biofilm biomass than teicoplanin alone, whereas one isolate showed minimal responsiveness. Under the tested in vitro conditions, TXA–teicoplanin co-exposure was associated with reduced planktonic growth and crystal violet-based biofilm biomass accumulation in several clinical staphylococcal isolates. However, because TXA-only controls were not available across the full experimental framework and formal synergy assays were not included, these findings do not establish synergistic activity or distinguish combination-specific effects from TXA-associated effects alone. Further studies are needed to clarify the biological and translational relevance of these observations. Full article

Periprosthetic joint infection (PJI) remains one of the most severe and complex complications following joint arthroplasty. With the global increase in primary hip and knee replacements, the clinical and economic burden associated with PJI continues to grow. Although relatively uncommon, PJI is linked to substantial morbidity, elevated mortality, and significantly higher healthcare costs compared to aseptic revision procedures. The challenge is compounded by the intricate pathogenesis of biofilm-forming microorganisms, heterogeneous clinical presentations, and the lack of universally standardised diagnostic criteria. This review provides an integrated overview of current evidence concerning the pathophysiology, risk factors, and microbiological patterns associated with PJI. Contemporary diagnostic pathways based on the Musculoskeletal Infection Society/International Consensus Meeting (MSIS/ICM) criteria are summarised, including the utility and limitations of established serological markers, emerging synovial biomarkers such as alpha-defensin, and the complementary roles of culture techniques, histopathology, and molecular assays. Medical and surgical treatment strategies are outlined, including debridement with implant retention, one-stage and two-stage revision approaches, and organism-directed antimicrobial therapy. Preventive strategies spanning preoperative optimisation, intraoperative protocols, and postoperative risk reduction are also highlighted. Despite significant advances, important gaps persist, particularly in antimicrobial resistance, the management of polymicrobial or culture-negative infections, and the treatment of high-risk or immunocompromised patients. Continued interdisciplinary collaboration and high-quality clinical research are essential to refine diagnostic algorithms, improve therapeutic outcomes, and reduce the incidence of this increasingly consequential complication. Full article

Background: Periprosthetic joint infection (PJI) following total knee arthroplasty (TKA) is a serious complication associated with substantial morbidity and healthcare costs. Although two-stage revision arthroplasty is widely accepted as a standard treatment, debridement, antibiotics, and implant retention (DAIR) is frequently attempted as a less invasive initial strategy. However, the impact of failed DAIR on the outcomes of subsequent two-stage revision remains controversial. Methods: This retrospective cohort study included patients who underwent two-stage revision arthroplasty for PJI following TKA at a single institution between 2005 and 2019, involving 84 knees at an average follow-up of 5.1 ± 3.3 years. Outcomes were compared between patients with a history of failed DAIR (F-DAIR group, n = 23) and those who underwent direct two-stage revision without prior procedures (DTSR group, n = 61). Treatment failure rates and associated risk factors were analyzed. Results: There was no significant difference in treatment failure rates between the F-DAIR and DTSR groups (4.3% vs. 9.8%, respectively; p = 0.668). Cox regression suggested that PJI type (acute vs. chronic) and diabetes mellitus were associated with treatment failure. Conclusions: In this retrospective cohort, prior failed DAIR was not associated with a statistically significant reduction in the success of subsequent two-stage revision arthroplasty. These findings may support consideration of DAIR as an initial treatment option in carefully selected patients; however, cautious interpretation is warranted because of the retrospective design, limited sample size, baseline imbalance, and small number of failure events. Therefore, the findings should be considered hypothesis-generating rather than definitive comparative evidence. Full article

Objectives: Periprosthetic joint infections represent a serious complication following joint arthroplasty, often leading to significant morbidity, with an economic and social impact on the health system. Timely diagnosis of periprosthetic joint infections remains a major challenge. Our study aimed to investigate the diagnostic value and accuracy of several markers, including the neutrophil-to-lymphocyte ratio, monocyte-to-lymphocyte ratio, and C-reactive protein-to-serum-hemoglobin ratio in revision surgery for periprosthetic joint infections. Methods: A total of 251 revision arthroplasty cases, including 137 cases of periprosthetic joint infections and 114 cases of aseptic revision arthroplasty, were included from the time span January 2016 to May 2025. The diagnostic value and accuracy of the C-reactive protein-to-hemoglobin ratio, neutrophil-to-lymphocyte ratio, and monocyte-to-lymphocyte ratio were evaluated using sensitivity, specificity, and receiver operating characteristic (ROC) analysis with area under the curve analysis. Results: The highest diagnostic performance was obtained by the C-reactive protein-to-hemoglobin ratio, yielding an AUC of 0.859 (SE = 0.0263, 95% CI: 0.809–0.899). This ratio also demonstrated a strong discriminative capacity, with a threshold of >0.0667, sensitivity of 80.45%, and specificity of 85.96%. For the neutrophil-to-lymphocyte count ratio and monocyte-to-lymphocyte count ratio, we obtained an AUC of 0.615 (95% CI: 0.551–0.676) and 0.620 (95% CI: 0.556–0.680), respectively, demonstrating lower sensitivity and specificity than the C-reactive protein-to-hemoglobin ratio. Conclusions: The C-reactive protein-to-hemoglobin ratio demonstrated better diagnostic strength in detecting periprosthetic joint infections, with superior sensitivity and specificity compared to the neutrophil-to-lymphocyte count ratio and monocyte-to-lymphocyte count ratio. Our findings offer new insights into the accurate and early diagnosis of periprosthetic joint infections in cases requiring revision surgery and suggest incorporating these new biomarkers and ratios into the diagnostic algorithm. Future large-scale studies are further needed to validate these results and facilitate their clinical use. Full article

Background: Periprosthetic joint infection is a severe complication after hip and knee arthroplasty, and using perioperative antibiotic prophylaxis (PABP) per guidelines and recommendations is one step in its prevention. The current study aimed to evaluate the attitude of Egyptian joint replacement surgeons toward PABP, their adherence to guidelines, and their insight into developing national guidelines. Methods: We conducted an online cross-sectional questionnaire study comprising three sections to collect information on various aspects of PABP and to gather insights into the development of national guidelines among members of the Egyptian Pelvis, Hip, and Knee Society (EPHAKS). The questionnaire targeted active practicing hip or knee replacement surgeons and was first sent by email to all members two weeks before the eighth EPHAKS annual conference. A reminder was announced during the conference, and subsequent email reminders were sent one week apart after the conference. The study was registered in clinicaltrials.gov (NCT06451224). Results: Out of 469 EPHAKS members, and among the 434 successfully delivered email invitations, 105 responded, giving a response rate of 24.2%. All were males, with a mean age of 42.98 ± 10.12 years; a total of 70.5% were consultants, and 13.3% performed more than 100 procedures annually. Most participants reported not following national or international guidelines, with response percentages of 80.9% and 62.9%, respectively. Consultants and surgeons performing more than 50 procedures annually showed significantly higher adherence to guidelines than others, with p-values of 0.046 and 0.004, respectively. Adherence to national or international guidelines for prescribing first- or second-generation cephalosporins was reported by 65.7% (preoperatively) and 59% (postoperatively). Only 9.5% reported prescribing antibiotics for the first 24 h postoperatively. Overall, 80% agreed that Egyptian patients are different and that PABP international guidelines do not suit them, and 98.1% agreed that developing national Egyptian PJI prevention guidelines is necessary owing to deficiencies and the broad applicability of the current national guidelines. Conclusions: Egyptian joint replacement surgeons rarely adhere to national or international guidelines for PABP, with higher adherence noticed among more experienced surgeons. The majority agreed that our patients are different and that international guidelines might not suit them, and nearly all participants expressed a strong desire to develop national guidelines. Full article

Background/Objectives: Despite its beneficial effect on the healing of bone fractures and in the treatment of osteoporosis, there is still a lack of evidence on the impact of clinical outcomes after a total joint arthroplasty (TJA). This review aims to establish the role of vitamin D in clinical outcomes after a total knee arthroplasty (TKA). Methods: In this review, PubMed, Scopus and Web of Science databases were cross-checked by two reviewers independently. The inclusion criteria were original human studies published in English from 2014 to 2024. For identification-relevant studies, the search terms used were as follows: “Vitamin D” and “total knee arthroplasty” or “total knee replacement” or “total joint arthroplasty” or “total joint replacement”. Case reports, letters and expert consensuses were excluded from the analysis. Finally, 19 studies were included in this review. Results: A literature review shows that vitamin D may have an impact on patients treated for osteoarthritis (OA) of the knee with a significant prevalence of hypovitaminosis in orthopedic patients. The influence was observed for periprosthetic joint infections: PJI patients have significantly lower vitamin D levels than primary ones. Also, a greater incidence of revision knee surgery due to PJIs in the deficient group compared to the non-deficient group at a one-year follow-up was found, of up to a 2-fold increase. This affects the clinical outcome with a lower Knee Society Score (KSS) functional score in the vitamin D-deficient group. Conclusions: The current data suggest that the vitamin D metabolism pathway and its implications in orthopedic patients, especially those treated with TKA surgery, may be a significant factor that improves clinical and functional outcomes. A possible relation between a low preoperative concentration of vitamin D and its impact on the outcomes, such as the length of the hospital stay, implant survival, and risk of complications, is needed to support these findings in multicenter, prospective studies and randomized controlled trials. Full article

Background: The success rates of treating chronic periprosthetic joint infection (PJI) have plateaued in the last two decades utilizing exchange protocols combined with extended parenteral antimicrobials. At the same time, extended systemic antimicrobials carry well-recognized adverse effects, including organ toxicity, metabolic derangements, and disruption of host–microbiome balance, which may themselves impair host inflammatory responses and tissue healing. The defined challenge is to intensify local site eradication while minimizing systemic antimicrobial exposure and its associated host harms. This study introduces a tactical treatment shift focusing on local microbial biocidal treatment, that we aptly name “antimicrobial brachytherapy” protocol (ABP). Methods: A consecutive case series of 25 patients with chronic PJI in total knee arthroplasty (TKA) were treated with the ABP from 2019 to 2023. In brief, the protocol includes: (1) local multimodal antimicrobial therapy applied during debridement to reach and extinguish microbial reserves, (2) eliminating parenteral antimicrobials and limiting oral antimicrobials to 3 weeks, and (3) employing variable explantation times (longer when needed) via a 1.5 exchange technique allowing individualized host and limb rejuvenation. Patients were graded according to McPherson host scoring. Musculoskeletal Infection Society (MSIS) tier levels were used to rate success. All patients had a minimum two-year follow-up. Results: Eighty percent of the patients were significantly compromised, consisting of B and C hosts having 2 and 3 limb scores. Outcomes using the MSIS tier rating show 16/25 (64%) tier 1 success (infection-free without antimicrobial suppression). In these 16 patients, three were still using their 1.5 implant at a mean 4.2 years (2–5.5 years). There were two (8%) tier 3C outcomes (aseptic revision at <1 year), and six (25%) tier 3E failures (amputation, resection arthroplasty or arthrodesis) with four amputations for continued infection, and two who underwent a repeat 1.5 exchange for recurrent infection. Of the four patients amputated, three had fungal microbes identified in post-resection aspirations. Lastly, there was one (4.15%) tier 4a outcome (mortality at <1 year). Conclusions: The ABP concept is a tactical shift focusing antimicrobial therapy within the zone of infection, avoiding long course systemic antimicrobials, and allowing variable explantation time for host and limb rejuvenation. Success was comparable to published MSIS tier 1 outcomes using traditional two-stage exchange protocols with extended parenteral antimicrobials. Given the small sample size and absence of a comparator, the results should be regarded as hypothesis-generating, and require validation in larger, randomized, controlled studies. Full article