Periprosthetic joint infection (PJI) is the most difficult complication following total joint arthroplasty. Most of the etiological strains, accounting for over 98% of PJI, are bacterial species, with Staphylococcusaureus and Coagulase-negative staphylococci present in between 50% and 60% of all PJIs. Fungi, though rare, can also cause PJI in 1%-2% of cases and can be challenging to manage. The management of this uncommon but complex condition is challenging due to the absence of a consistent algorithm. Diagnosis of fungal PJI is difficult as isolation of the organisms by traditional culture may take a long time, and some of the culture-negative PJI can be caused by fungal organisms. In recent years, the introduction of next-generation sequencing has provided opportunity for isolation of the infective organisms in culture-negative PJI cases. The suggested treatment is based on consensus and includes operative and non-operative measures. Two-stage revision surgery is the most reliable surgical option for chronic PJI caused by fungi. Pharmacological therapy with antifungal agents is required for a long period of time with antibiotics and included to cover superinfections with bacterial species. The aim of this review article is to report the most up-to-date information on the diagnosis and treatment of fungal PJI with the intention of providing clear guidance to clinicians, researchers and surgeons.
Arthritis, Infectious/etiology* ; Arthroplasty, Replacement, Knee/adverse effects* ; Fungi ; Humans ; Prosthesis-Related Infections/therapy* ; Retrospective Studies

PURPOSE: Antibiotic-loaded bone cement (ALBC) was usually used to prevent periprosthetic joint infection (PJI) in primary total knee arthroplasty (PTKA), but whether to use ALBC or plain bone cement in PTKA remains unclear. We aimed to compare the occurrence rate of PJI using two different cements, and to investigate the efficacy of different antibiotic types and doses administered in preventing surgical site infection (SSI) with ALBC. METHODS: The availability of ALBC for preventing PJI was evaluated by using a systematic review and meta-analysis referring to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Existing articles until December 2021 involving PTKA patients with both ALBC and plain bone cement cohorts were scanned by searching "total knee arthroplasty", "antibiotic-loaded cement", "antibiotic prophylaxis", "antibiotic-impregnated cement" and "antibiotic-laden cement" in the database of PubMed/MEDLINE, Embase, Web of Science and the Cochrane Library. Subgroup analysis included the effectiveness of different antibiotic types and doses in preventing SSI with ALBC. The modified Jadad scale was employed to score the qualities of included articles. RESULTS: Eleven quantitative studies were enrolled, including 34,159 knees undergoing PTKA. The meta-analysis results demonstrated that the use of prophylactic ALBC could significantly reduce the prevalence of deep incisional SSI after PTKA, whereas there was no significant reduction in the rate of superficial incisional SSI. Moreover, gentamicin-loaded cement was effective in preventing deep incisional SSI, and the use of high-dose ALBC significantly reduced the rate of deep incisional SSI after PTKA. Besides, no significant adverse reactions and complications were stated during the use of ALBC in PTKA. CONCLUSION The preventive application of ALBC during PTKA could reduce the rates of deep PJI. Furthermore, bone cement containing gentamicin and high-dose ALBC could even better prevent deep infection after PTKA. However, the existing related articles are mostly single-center and retrospective studies, and further high-quality ones are needed for confirmation.
Humans ; Bone Cements ; Arthroplasty, Replacement, Knee/methods* ; Anti-Bacterial Agents/therapeutic use* ; Prosthesis-Related Infections/etiology* ; Retrospective Studies ; Arthritis, Infectious/etiology* ; Gentamicins ; Surgical Wound Infection/drug therapy*

Humans ; Arthroplasty, Replacement, Knee/adverse effects* ; Surgical Wound Infection/etiology* ; Retrospective Studies ; Risk Factors ; Arthroplasty, Replacement, Hip/adverse effects* ; Prosthesis-Related Infections/etiology*

OBJECTIVETo summarize the experience in management of prosthetic graft infection (PGI) after lower limb arterial bypasses and investigate optimal measures for prevention and treatment.

METHODSRecords of 15 cases of PGI between January 2004 and December 2009 were retrospectively analyzed, including 14 male and 1 female with the average age of 64.8 years (ranged from 40 to 84 years). PGI occurred from 5 d to 59 months (average 6.4 months) after the last reconstructive procedures with symptoms as follow: nonhealing wound with vascular graft exposure in 8 cases, persistent sinus related to vascular graft with purulent secretion in 5 cases and without secretion in 1 case, and ill-incorporated graft with peri-graft fluid in 1 case. Broad-spectrum antibiotics were administrated in all PGI cases. Surgical treatments included local debridement and drainage in 4 cases (one death from postoperative acute myocardial infarction), local debridement and skin flap rotation in one case, complete removal of the occluded infected grafts in 8 cases including major amputation in 3 cases, removal of patent infected graft and extra-anatomic bypass with silver-bonded Dacron vascular graft in 1 case, and partial removal of patent infected graft without reconstruction in 1 case with a re-canalized stent-graft.

RESULTSLimb salvage was achieved in 9 cases, and 4 cases received major amputation. One case was failed to follow-up and one died of postoperative acute myocardial infarction. Initially 13 patients were followed and 2 died during follow-up (because of colon carcinoma and intracranial hemorrhage respectively). Eleven patients were followed for 1 to 70 months (average 22.3 months) including 8 cases with limb salvage and 3 with major amputation. Accumulative mortality rate, amputation rate, and graft occlusion rate were 20% (3/15), 26.7% (4/15), and 53.3% (8/15) respectively.

CONCLUSIONSPGI after lower limb arterial bypasses is a devastating complication with high risk of graft occlusion and amputation. Removal of the infected grafts may be mandatory for most cases, but local management for patent infected grafts may be recommendable for selected cases.

Adult ; Aged ; Aged, 80 and over ; Blood Vessel Prosthesis Implantation ; adverse effects ; Female ; Follow-Up Studies ; Humans ; Lower Extremity ; blood supply ; Male ; Middle Aged ; Prosthesis-Related Infections ; diagnosis ; etiology ; therapy ; Retrospective Studies

OBJECTIVE: To explore the difference in level of pain experienced by patients with total hip arthroplasty between aseptic loosening and periprosthetic infection, and to examine the correlation between C-reactive protein (CRP) and pain. METHODS: Fifty-one patients (recruited from our hospital between March 2010 and November 2011) suffering aseptic loosening or periprosthetic infection after total hip arthroplasty were included in this study: 24 males and 27 females, with mean age 68.13 years. The patients were divided into an aseptic loosening group (n=31) and a periprosthetic infection group (n=20). Both the visual analog scale (VAS) and Harris pain score were used to estimate the level of pain experienced by the patients. CRP levels in serum were measured. The difference in assessment of pain by VAS and Harris pain score was compared between the two groups, and the correlation between pain and CRP was analyzed. RESULTS: The mean VAS in the aseptic loosening group was 5.39 (2.10-8.13) compared with 5.48 (2.09-8.30) in the periprosthetic infection group; however, the difference was not statistically significant (P=0.85). The mean rank of Harris pain score was 26.23 in the aseptic loosening group and 25.65 in the periprosthetic infection group, but again there was no significant difference (P=0.88). The CRP level in the periprosthetic infection group (36.20-101.40 mg/L, mean 72.86 mg/L) was obvious higher than that in the aseptic loosening group (1.37-13.70 mg/L, mean 6.53 mg/L), and the difference was statistically significant (P<0.01). The VAS was related with the CRP level in the periprosthetic infection group (r=0.87, P<0.01), and the correlation between Harris pain score and CRP level was conspicuous (r=0.92, P<0.01) in this group. However, those correlations were not evident in the aseptic loosening group (r=0.25, P=0.17; r=0.19, P=0.65). CONCLUSION There is no difference in perception of pain in patients after total hip arthroplasty between those with aseptic loosening and those with periprosthetic infection. It is therefore unreliable to make a initial diagnosis only according to the level of pain. However, the level of CRP is a sensitive and effective way of differentiating the two conditions. The positive correlation between CRP and pian exists in patients with periprosthetic infection but not with aseptic loosening.
Adult ; Aged ; Aged, 80 and over ; Arthroplasty, Replacement, Hip ; adverse effects ; C-Reactive Protein ; analysis ; Female ; Humans ; Male ; Middle Aged ; Pain Measurement ; Prosthesis Failure ; etiology ; Prosthesis-Related Infections ; blood ; physiopathology

OBJECTIVETo investigate the effect of two-stage revision for infected total hip arthroplasty (THA) using antibiotic-loaded cement prosthesis.

METHODSFrom June 1999 to October 2004, 14 patients who admitted for infected primary total hip arthroplasty surgeries were performed revision surgery with antibiotic-loaded cement prosthesis in two-stage. The mean Harris score of pre-operation was 23. In the first stage operation, the following steps were performed, complete debridement, removal of infected prosthesis, implantation of cement spacer with antibiotics, treatment involved concomitant administration of 3 weeks of intravenous (IV) and 1 month of oral. After 6 months, antibiotic-loaded prosthesis was implanted in the second stage.

RESULTSThe mean follow-up was 18 months (7 - 26 months), no recurrent infection occurred in all 14 patients. The mean post-operation Harris score was 70.

CONCLUSIONSThe success of the protocol to control the delayed infection after THA are complete debridement, enough interval and using antibiotic-loaded cement prosthesis in two stage revision.

Adult ; Aged ; Anti-Bacterial Agents ; therapeutic use ; Arthroplasty, Replacement, Hip ; adverse effects ; Bone Cements ; Female ; Follow-Up Studies ; Hip Prosthesis ; Humans ; Male ; Middle Aged ; Prosthesis-Related Infections ; diagnosis ; etiology ; surgery ; Reoperation

PURPOSE: We present a case of orbital abscess following porous orbital implant infection in a 73-year-old woman with rheumatoid arthritis. METHODS: Just one month after a seemingly uncomplicated enucleation and porous polyethylene (Medpor(R)) orbital implant surgery, implant exposure developed with profuse pus discharge. The patient was unresponsive to implant removal and MRI confirmed the presence of an orbital pus pocket. Despite extirpation of the four rectus muscles, inflammatory granulation debridement and abscess drainage, another new pus pocket developed. RESULTS: After partial orbital exenteration, the wound finally healed well without any additional abscess formation. CONCLUSIONS: A patient who has risk factors for delayed wound healing must be examined thoroughly and extreme care such as exenteration must be taken if there is persistent infection.
Prosthesis-Related Infections/diagnosis/*etiology/surgery ; Porosity ; Orbital Implants/*adverse effects ; Orbital Diseases/diagnosis/*etiology/surgery ; Magnetic Resonance Imaging ; Humans ; Follow-Up Studies ; Female ; Eye Enucleation ; Device Removal ; Aged ; Abscess/diagnosis/*etiology/surgery

We retrospectively reviewed the complete medical records of 30 patients with a diagnosis of liver cirrhosis who had undergone hip arthroplasty at three academic institutions between October 1994 and May 2001. There were 26 males and 4 females with a mean age of 60 yr at index operation. Surgical procedures included 17 primary total hip arthroplasties (THA), 8 bipolar hemiarthroplasties, and 5 revision THAs. According to the Child-Pugh scoring system, 19 cirrhotic patients were categorized as class A, 9 as class B, and 2 as class C. Eight (26.7%) of the 30 patients had one or more perioperative complications. Of these, wound infection was the most common, with a rate of 10% (3 of 30 hips). Other perioperative complications included surgical site bleeding, coagulopathy, encephalopathy, gastrointestinal bleeding, pneumonia, and arrhythmia. Death occurred in 2 (6.7%) of the 30 patients; both were Child-Pugh's C cirrhotics. A higher Child-Pugh score (p=0.0001) and a high level of creatinine (p=0.0499) were associated with significantly increased perioperative complications or death. Our findings suggest that surgeons should be vigilant about perioperative complications in patients with advanced cirrhotic liver disease who undergo hip arthroplasty, albeit the mortality rates are relatively low in less severe cirrhotics.
Surgical Wound Infection/diagnosis/*etiology ; Risk Factors ; Risk Assessment/*methods ; Prosthesis-Related Infections/diagnosis/*etiology ; Middle Aged ; Male ; Liver Cirrhosis/*complications ; Humans ; Gastrointestinal Hemorrhage/diagnosis/*etiology ; Female ; Arthroplasty, Replacement, Hip/*adverse effects ; Adult ; Adolescent

BACKGROUND: The aims of our study were to evaluate the success rate of irrigation and debridement with component retention (IDCR) for acutely infected total knee arthroplasty (TKA) (< 4 weeks of symptom duration) and to analyze the factors affecting prognosis of IDCR. METHODS: We retrospectively reviewed 28 knees treated by IDCR for acutely infected TKA from 2003 to 2012. We evaluated the success rate of IDCR. All variables were compared between the success and failure groups. Multivariable logistic regression analysis was also used to examine the relative contribution of these parameters to the success of IDCR. RESULTS: Seventeen knees (60.7%) were successfully treated. Between the success and failure groups, there were significant differences in the time from primary TKA to IDCR (p = 0.021), the preoperative erythrocyte sedimentation rate (ESR; p = 0.021), microorganism (p = 0.006), and polyethylene liner exchange (p = 0.017). Multivariable logistic regression analysis of parameters affecting the success of IDCR demonstrated that preoperative ESR (odds ratio [OR], 1.02; p = 0.041), microorganism (OR, 12.4; p = 0.006), and polyethylene liner exchange (OR, 0.07; p = 0.021) were significant parameters. CONCLUSIONS: The results show that 60.7% of the cases were successfully treated by IDCR for acutely infected TKA. The preoperative ESR, microorganism, and polyethylene liner exchange were factors that affected the success of IDCR in acutely infected TKA.
Adult ; Aged ; Aged, 80 and over ; Anti-Bacterial Agents/therapeutic use ; Arthroplasty, Replacement, Knee/*adverse effects ; Arthroscopy ; Debridement ; Female ; Humans ; Joint Diseases/microbiology/surgery/therapy ; Knee Joint/microbiology/*surgery ; Knee Prosthesis/microbiology ; Male ; Middle Aged ; Prosthesis-Related Infections/etiology/microbiology/*therapy ; Retrospective Studies ; Therapeutic Irrigation ; Treatment Outcome