Background: Current guidelines recommend serum erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) as the first-line testing for evaluation of suspected periprosthetic joint infection, in addition to synovial white blood-cell (WBC) count and polymorphonuclear percentage. However, the sensitivity and other diagnostic measures of these tests using a standardized definition of periprosthetic joint infection and the influence of organisms on these inflammatory markers remain inadequately investigated. Methods: A retrospective review of an institutional database of 549 periprosthetic joint infection cases and 653 aseptic total joint arthroplasty revisions was performed. Periprosthetic joint infection was defined using major criteria from the International Consensus Meeting (ICM) on Periprosthetic Joint Infection. The mean inflammatory marker levels were compared among organisms with Student t tests and the proportions of elevated laboratory levels were compared among organisms with chi-square analyses. Receiver operating characteristic curve analyses were performed to calculate new cutoffs, sensitivities, and specificities for each organism and overall for serum CRP and ESR and synovial WBC and polymorphonuclear percentage. Results: The sensitivity of these markers for diagnosing chronic periprosthetic joint infection was 0.85 for ESR, 0.88 for CRP, 0.83 for WBC count, and 0.78 for polymorphonuclear percentage. For ESR, antibiotic-resistant organisms had higher mean values (84.3 mm/hr) than culture-negative cases (57.4 mm/hr), coagulase-negative Staphylococcus (68.3 mm/hr), and Streptococcus species (66.1 mm/hr); Staphylococcus aureus (81.0 mm/hr) was higher than culture-negative cases (57.4 mm/hr). For CRP, culture-negative cases had lower mean values (41.0 mg/L) than gram-negative organisms (87.4 mg/L), antibiotic-resistant organisms (86.0 mg/L), S. aureus (112.2 mg/L), and Streptococcus species (114.6 mg/L); S. aureus (112.2 mg/L) was higher than coagulase-negative Staphylococcus (66.0 mg/L). For WBC count, culture-negative cases had lower mean values (27,984.5 cells/mL) than S. aureus (116,250.0 cells/mL) and Streptococcus species (77,933.7 cells/mL). For polymorphonuclear percentage, there were no significant differences in mean values among all organisms. Conclusions: It appears that serological markers, namely ESR and CRP, have a higher false-negative rate than previously reported. Synovial markers similarly exhibit high false-negative rates. Furthermore, the sensitivity of these tests appears to be related to organism type. Surgeons should be aware of the high rate of false-negatives associated with low-virulence organisms and culture-negative cases. Level of Evidence: Diagnostic Level I. See Instructions for Authors for a complete description of levels of evidence.

Background: Recent surgical site infection prevention guidelines recommend that no additional prophylactic antibiotics be administered after the surgical incision is closed in clean-contaminated procedures. Although there is ample evidence to support this recommendation in non-arthroplasty surgery, there is concern about extending these guidelines to surgical procedures with an implant such as total joint arthroplasty (TJA). The aim of this study was to compare the efficacy of a single dose of prophylactic antibiotics with that of multiple doses of antibiotics for prevention of periprosthetic joint infection (PJI) in patients undergoing TJA. Methods: A retrospective study of 20,682 primary TJAs carried out from 2006 to 2017 was performed. Patients who received a single dose of prophylactic antibiotics (n = 4,523) were compared with patients who received multiple doses of antibiotics (n = 16,159). A previously validated PJI risk score was assigned to each patient. Patients who developed PJI within 1 year were identified, and a multivariate logistic regression analysis was performed to control for potential confounders. Analyses using propensity score matching and regression adjustment were also performed. Results: The overall PJI rate was 0.60% (27 of 4,523) for patients who received a single dose of antibiotics compared with 0.88% (142 of 16,159) for those who received multiple doses. There was no difference in the PJI rate between patients who received a single dose of antibiotics and those who received multiple doses in the univariate (adjusted odds ratio [OR] = 0.674, p = 0.064), multivariate (OR = 0.755, p = 0.205), or propensity score matched analysis (OR = 0.746, p = 0.277). Furthermore, multiple doses did not demonstrate any additional benefit for patients with a high preoperative risk of PJI (p = 0.136). Conclusions: This study supports the notion that the administration of additional antibiotics following skin closure may not be required for primary TJA, regardless of the patient’s preoperative risk of PJI. The findings of this large retrospective study highlight the need for a randomized, prospective study on which to base guidelines. Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Greater trochanteric pain syndrome (GTPS) is a common complaint. Recently, it has become well recognized that tendinopathy and tears of the gluteus medius (GM) are a cause of recalcitrant GTPS. Nevertheless, the clinical syndrome associated with GM tears is not fully characterized. We characterize the clinical history, findings on physical examination, imaging and intraoperative findings associated with symptomatic GM tears. Forty-five patients (47 hips) who underwent GM repair for the diagnosis of tear were evaluated. Pain was estimated on the visual analog scale (VAS) and hip-specific scores were administered to assess functional status. The imaging modalities were reviewed and intra operative findings were recorded. The average patient age was 54 years (17–76), 93% were females. Symptom onset was commonly insidious (75%) and the average time to diagnosis was 28 months (2–240). The most common pain location was the lateral hip (75%). The average pre-surgery VAS and modified Harris Hip Score were 6.65 (0–10) and 55.5 (12–90), respectively. All patients had pathological findings on magnetic resonance angiogram (MRA) ranging from tendinosis to complete tears of the GM tendon. There was a discrepancy between MRA interpretation by a radiologist and findings during surgery. Hip abductor tears are an under-recognized cause of hip pain and hip symptomatology. In this study, we further characterize the clinical presentation of this entity. The data we present here may facilitate early diagnosis, early orthopedic care and avoid unnecessary prolonged patient sufferings.

Update: This article was updated on March 24, 2020, because of a previous error. On page 505, in the first paragraph of the “Materials and Methods” section, the sentence that had read “Patients who underwent revision TJA or simultaneous bilateral TJA and those with missing data related to VTE prophylaxis were excluded” now reads “Patients who underwent revision TJA and those with missing data related to VTE prophylaxis were excluded. A subsequent subanalysis with the exclusion of 154 patients (308 knees) who underwent bilateral procedures demonstrated no differences in the reported outcomes.” An erratum has been published: J Bone Joint Surg Am. 2020 May 6;102(9):e42. Background: The use of aspirin as prophylaxis against venous thromboembolism (VTE) following total joint arthroplasty (TJA) has increased in popularity; however, the potential cardioprotective effects of aspirin when administered as VTE prophylaxis remain unknown. The present study investigated the influence of VTE prophylaxis, including aspirin, on mortality following TJA. Methods: We retrospectively reviewed 31,133 patients who underwent primary TJA from 2000 to 2017. Patient demographics, body mass index, and comorbidities were obtained from an electronic chart query. Patients were allocated into 2 cohorts on the basis of the VTE prophylaxis administered: aspirin (25.9%, 8,061 patients) and non-aspirin (74.1%, 23,072 patients). Mortality was assessed with use of an institutional mortality database that is updated biannually. Univariate and multivariate regression analyses were performed. Results: The overall mortality rate was 0.2% and 0.6% at 30 days and 1 year after TJA, respectively. The use of aspirin was independently associated with lower risk of death at both 30 days (odds ratio [OR], 0.39; p = 0.020) and 1 year (OR, 0.51; p = 0.004). Patients in the non-aspirin cohort showed 3 times the risk of death at 30 days compared with the aspirin cohort (0.3% compared with 0.1%; p = 0.004), and twice the risk of death at 1 year (0.7% compared with 0.3%; p < 0.001). At 1 year, the primary cause of death in the non-aspirin group was cardiac-related (46 of 23,072, 0.20%). In the aspirin group, the rate of cardiac-related death was almost 5 times lower (3 of 8,061, 0.04%; p = 0.005). Risk factors for mortality at 1 year included higher age (p < 0.001), male sex (p = 0.020), history of congestive heart failure (p = 0.003), cerebrovascular disease (p < 0.001), malignancy (p < 0.001), and history of prior myocardial infarction (p < 0.001). Conclusions: The present study demonstrates that the use of aspirin as prophylaxis against VTE following TJA may reduce the risk of mortality. Given the numerous options available and permitted by the current guidelines, orthopaedic surgeons should be aware of the potential added benefits of aspirin when selecting a VTE-prophylactic agent. Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.