Aims: Single-stage revision is not widely pursued due to restrictive inclusion criteria. In this study, we evaluated the results of single-stage revision of chronically infected total hip arthroplasty (THA) using broad inclusion criteria and cementless implants.Patients and Methods: Between 2010 and 2016, 126 patients underwent routine single-stage revision with cementless reconstruction with powdered vancomycin or imipenem poured into the medullary cavity and re-implantation of cementless components. For patients with a culture-negative hip, fungal infections, and multidrug-resistant organisms, a direct intra-articular infusion of pathogen-sensitive antibiotics was performed postoperatively. Recurrence of infection and clinical outcomes were evaluated. Three patients died and 12 patients (none with known recurrent infection) were lost to follow-up. There were 111 remaining patients (60 male, 51 female) with a mean age of 58.7 (sd 12.7; 20 to 79).Results: Of these 111 patients, 99 (89.2%) were free of infection at a mean follow-up time of 58 months (24 to 107). A recurrent infection was observed in four of the 23 patients (17.4%) with culture-negative infected hip. The success rate in patients with multidrug-resistant organisms was 84.2% (16/19). The mean postoperative Harris hip score was 79.6 points (63 to 92) at the most recent assessment.Conclusion: Routine single-stage revision with cementless reconstruction can be a viable option for the treatment of chronically infected THA. The results of this study will add to the growing body of evidence supporting routine use of single-stage revision for the treatment of chronically infected THA. Cite this article: Bone Joint J 2019;101-B:396–402.

Background: Although periprosthetic joint infection (PJI) is a severe complication of total joint arthroplasty (TJA), the diagnosis of PJI remains challenging. Albumin (ALB), globulin (GLB), the albumin-to-globulin ratio (AGR), and fibrinogen could be indicators of the body’s inflammatory state. This study aimed to compare the diagnostic accuracy of these biomarkers with that of other inflammatory biomarkers in PJI patients. Methods: We conducted a retrospective cohort study that included a consecutive series of patients undergoing debridement antibiotic irrigation and implant retention (DAIR), one-stage or the first stage of a two-stage revision total knee arthroplasty (TKA) or total hip arthroplasty (THA) for acute (n = 31) or chronic (n = 51) PJI, or revision TKA or THA for aseptic failures (n = 139) between January 2017 and December 2019 in our hospital. The 2013 criteria of the Musculoskeletal Infection Society (2013 MSIS) were used as the reference standard for the diagnosis of PJI. The preoperative ALB, GLB, AGR, fibrinogen, D-dimer, platelet count, fibrin degradation product (FDP), platelet-to-lymphocyte (PLR), platelet count to mean platelet volume ratio (PVR), neutrophil-to-lymphocyte ratio (NLR), erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) levels were assessed. The receiver operating characteristic curve (ROC), sensitivity, and specificity were utilized to compare different biomarkers. Results: Compared with the aseptic patients, the GLB, D-dimer, fibrinogen, FDP, platelet count, PVR, PLR, NLR, ESR, and CRP levels of PJI patients were significantly higher (P < 0.01); however, the ALB and AGR levels were significantly lower (P < 0.01). The area under the curve (AUC), sensitivity and specificity were 0.774, 67.50, 77.54% for ALB; 0.820, 57.50, 89.86% for GLB; 0.845, 66.25, 93.48% for AGR; 0.832, 78.48, 78.95% for fibrinogen; 0.877, 81.48, 85.07% for ESR; 0.909, 83.95, 88.89% for CRP; 0.683, 55.22, 75.83% for D-dimer; 0.664, 38.81, 88.33% for FDP; 0.678, 52.44, 79.86% for platelet count; 0.707, 48.78, 86.33% for PVR; 0.700, 51.22, 80.58% for PLR; and 0.678, 52.44, 81.30% for NLR, respectively. In the clinic, GLB, AGR and fibrinogen could be used for diagnosis of patients suspected of having PJI. Conclusion: Our study demonstrated that GLB, AGR, and fibrinogen were promising biomarkers in the diagnosis of PJI.

Background: Identifying risk factors and early intervention are critical for improving the satisfaction rate of total knee arthroplasty (TKA). Our study aimed to identify patient-specific variables and establish a nomogram model to predict dissatisfaction at 1 year after TKA.Methods: This prospective cohort study involved 208 consecutive primary TKA patients with end-stage arthritis who completed self-reported measures preoperatively and at 1 year postoperatively. All participants were randomized into a training cohort (n = 154) and validation cohort (n = 54). Multiple regression models with preoperative and postoperative factors were used to establish the nomogram model for dissatisfaction at 1 year postoperatively. The least absolute shrinkage and selection operator method was used to screen the suitable and effective risk factors (demographic variables, preoperative variables, surgical variable, and postoperative variables) collected. These variables were compared between the satisfied and dissatisfied groups in the training cohort. The receiver operating characteristic (ROC) curve, calibration plot, and decision curve analysis were used to validate the discrimination, calibration, and clinical usefulness of the model. Results were evaluated by internal validation of the validation cohort.Results: The overall satisfaction rate 1 year after TKA was 77.8%. The nomogram prediction model included the following risk factors: gender; primary diagnosis; postoperative residual pain; poor postoperative range of motion; wound healing; and the rate of change in the degree of coronal lower limb alignment (hip–knee–ankle angle, HKA).The ROC curves of the training and validation cohorts were 0.9206 (95% confidence interval [CI], 0.8785–0.9627) and 0.9662 (0.9231, 1.0000) (95% CI, 0.9231, 1.0000), respectively. The Hosmer–Lemeshow test showed good calibration of the nomogram (training cohort,p = 0.218; validation cohort,p = 0.103).Conclusion: This study developed a prediction nomogram model based on partially modifiable risk factors for predicting dissatisfaction 1 year after TKA. This model demonstrated good discriminative capacity for identifying those at greatest risk for dissatisfaction and may help surgeons and patients identify and evaluate the risk factors for dissatisfaction and optimize TKA outcomes.

Aims: Periprosthetic joint infections (PJIs) with prior multiple failed surgery for reinfection represent a huge challenge for surgeons because of poor vascular supply and biofilm formation. This study aims to determine the results of single-stage revision using intra-articular antibiotic infusion in treating this condition. Methods: A retrospective analysis included 78 PJI patients (29 hips; 49 knees) who had undergone multiple prior surgical interventions. Our cohort was treated with single-stage revision using a supplementary intra-articular antibiotic infusion. Of these 78 patients, 59 had undergone more than two prior failed debridement and implant retentions, 12 patients had a failed arthroplasty resection, three hips had previously undergone failed two-stage revision, and four had a failed one-stage revision before their single-stage revision. Previous failure was defined as infection recurrence requiring surgical intervention. Besides intravenous pathogen-sensitive agents, an intra-articular infusion of vancomycin, imipenem, or voriconazole was performed postoperatively. The antibiotic solution was soaked into the joint for 24 hours for a mean of 16 days (12 to 21), then extracted before next injection. Recurrence of infection and clinical outcomes were evaluated. Results: A total of 68 patients (87.1%) were free of infection at a mean follow-up time of 85 months (24 to 133). The seven-year infection-free survival was 87.6% (95% confidence interval (CI) 79.4 to 95.8). No significant difference in infection-free survival was observed between hip and knee PJIs (91.5% (95% CI 79.9 to 100) vs 84.7% (95% CI 73.1 to 96.3); p = 0.648). The mean postoperative Harris Hip Score was 76.1 points (63.2 to 92.4) and Hospital for Special Surgery score was 78. 2 (63.2 to 92.4) at the most recent assessment. Polymicrobial and fungal infections accounted for 14.1% (11/78) and 9.0% (7/78) of all cases, respectively. Conclusion: Single-stage revision with intra-articular antibiotic infusion can provide high antibiotic concentration in synovial fluid, thereby overcoming reduced vascular supply and biofilm formation. This supplementary route of administration may be a viable option in treating PJI after multiple failed prior surgeries for reinfection. Cite this article: Bone Joint J 2022;104-B(7):867–874.

Aims: Gram-negative periprosthetic joint infection (PJI) has been poorly studied despite its rapidly increasing incidence. Treatment with one-stage revision using intra-articular (IA) infusion of antibiotics may offer a reasonable alternative with a distinct advantage of providing a means of delivering the drug in high concentrations. Carbapenems are regarded as the last line of defense against severe Gram-negative or polymicrobial infection. This study presents the results of one-stage revision using intra-articular carbapenem infusion for treating Gram-negative PJI, and analyzes the characteristics of bacteria distribution and drug sensitivity.Methods: We retrospectively reviewed 32 patients (22 hips and 11 knees) who underwent single-stage revision combined with IA carbapenem infusion between November 2013 and March 2020. The IA and intravenous (IV) carbapenem infusions were administered for a single Gram-negative infection, and IV vancomycin combined with IA carbapenems and vancomycin was applied for polymicrobial infection including Gram-negative bacteria. The bacterial community distribution, drug sensitivity, infection control rate, functional recovery, and complications were evaluated. Reinfection or death caused by PJI was regarded as a treatment failure.Results: Gram-negative PJI was mainly caused by Escherichia coli (8/34), Enterobacter cloacae (7/34), and Klebsiella pneumoniae (5/34). Seven cases (7/32) involved polymicrobial PJIs. The resistance rates of penicillin, cephalosporin, quinolones, and sulfonamides were > 10%, and all penicillin and partial cephalosporins (first and second generation) were > 30%. Of 32 cases, treatment failed to eradicate infection in only three cases (9.4%), at a mean follow-up of 55.1 months (SD 25 to 90). The mean postoperative Harris Hip Score and Hospital for Special Surgery knee score at the most recent follow-up were 81 (62 to 91) and 79 (56 to 89), respectively. One patient developed a fistula, and another presented with a local rash on an infected joint.Conclusion: The use of IA carbapenem delivered alongside one-stage revision effectively controlled Gram-negative infection and obtained acceptable clinical outcomes with few complications. Notably, first- and second-generation cephalosporins and penicillin should be administrated with caution, due to a high incidence of resistance.Cite this article: Bone Joint J 2023;105-B(3):284–293.

Osteoarthritis (OA) is a degenerative joint disease with multiple etiologies that affects individuals worldwide. No effective interventions are currently available to reverse the pathological process of OA. Sodium butyrate (NaB), a component of short-chain fatty acids (SCFAs), has multiple biological activities, including the attenuation of inflammation and anti-tumor activities in various diseases. However, whether the protective effects of NaB in OA are associated with the promotion of autophagy had not been investigated. Here, we explored the chondroprotective properties of NaB in an interleukin (IL)-1β-induced inflammatory chondrocyte model and an anterior cruciate ligament transection (ACLT) mouse model. Hematoxylin and eosin (HE), Safranin O, and immunohistochemical staining were performed to evaluate the effects of NaB treatment on articular cartilage. An optimal NaB dose for chondrocyte treatment was determined via cell counting kit-8 assays. Immunofluorescence and transmission electron microscopy were used to detect autophagy in chondrocytes. Flow cytometry was utilized to detect reactive oxygen species (ROS), cell cycle activity, and apoptosis in chondrocytes. Western blot and immunostaining were performed to evaluate the protein expression levels of relevant indicators. We found that the administration of NaB by oral gavage could attenuate cartilage degradation. In parallel, NaB treatment could enhance the activation of autophagy, increase autophagic flux, decrease extracellular matrix degradation, and reduce apoptosis by restraining inflammation, ROS production, and cell cycle arrest in IL-1β-treated chondrocytes. The protective effects of NaB could be partially abolished by the autophagy inhibitor 3-methyladenine (3-MA), which indicated that the protective effects of NaB against OA were partially governed by the enhancement of autophagy to restrain the formation of inflammatory mediators and ROS and regulate cell cycle progression and apoptosis in chondrocytes. In conclusion, NaB could attenuate OA progression by restoring impaired autophagy and autophagic flux via the phosphoinositide 3-kinase (PI3K)/protein kinase B (Akt)/mammalian target of rapamycin (mTOR) pathway, both in vitro and in vivo, implying that NaB could represent a novel therapeutic approach for OA.