A review of postoperative infected anterior cruciate ligament reconstructions was done on 3500 consecutive arthroscopic procedures. The purpose was to assess incidence, diagnosis, treatment, and outcome factors. Six postoperative intraarticular infections were detected. Average followup was 3 years (range, 2–8 years). The rate of infection was 0.14%. Five men and one woman with a median age of 32.5 years (range, 20–51 years) comprised the study group. The average interval from the onset of symptoms to the initial arthroscopic intervention was 7.5 days (range, 2–20 days). Staphylococcus aureus was present in three knees, Staphylococcus epidermidis in two, and Streptococcus nonhemolytic in one. All patients had initial arthroscopic debridement and lavage followed by 6 weeks of intravenous antibiotics. Two grafts were removed: one patient had delayed ligament reconstruction and the other had total knee arthroplasty. The remaining patients had full range of motion. In the group with the best result, two patients had Staphylococcus epidermidis and one had Staphylococcus aureus, which was treated 2 days after clinical symptoms began. The other two patients infected with Staphylococcus aureus had unsatisfactory results. Anterior cruciate ligament infection is rare, but diagnosable. When treated early with appropriate antibiotic therapy and arthroscopic debridement, four of six grafts were retained. If the infection does not respond rapidly to early therapy, then graft removal is an option.

Historically, general anesthesia has been the “gold standard” for surgeons and patients when major hip surgery is being done. The recent introductions of improved techniques and catheters for continuous peripheral nerve blocks have made regional anesthesia more attractive to patients and surgeons. We focus on current trends and future directions in perioperative pain management for major orthopaedic procedures done on the hip. The use of epidural or spinal anesthesia during major hip surgery has been linked to a reduced risk of perioperative complications like deep venous thrombosis, less deterioration of cerebral and pulmonary functions in patients who are at high risk for complications, and overall reduced blood loss. In addition, continuous peripheral nerve blocks showed effective and safe postoperative pain control, allowing for lower opioids consumption, improved and earlier rehabilitation, and high patient satisfaction. Accurate patient selection and patient education are fundamental for the success of any regional anesthesia technique. Modern regional anesthesia for major hip surgery includes the use of a single shot and continuous epidural injections, single-shot and continuous spinal injection, continuous lumbar plexus blockade, and continuous peripheral blockade of the femoral and sciatic nerves. Continuous peripheral nerve blocks represent an adjunctive, effective, and safe technique for postoperative pain control after total hip arthroplasty. Future directions in postoperative pain control include the creation of a comprehensive system that supervises the use of continuous peripheral nerve blocks outside the acute inpatient setting for few days following the surgical procedure. Level of Evidence: Therapeutic study, Level V (expert opinion). See the Guidelines for Authors for a complete description of levels of evidence.

This study defines a single-cell proteomic atlas of human OA cartilage to reveal rare subpopulations that stratify patients.

Periprosthetic joint infections (PJI) represent one of the most catastrophic complications following total joint arthroplasty (TJA). The lack of standardized diagnostic tests and protocols for PJI is a challenge for arthroplasty surgeons. Next generation sequencing (NGS) is an innovative diagnostic tool that can sequence microbial deoxyribonucleic acids (DNA) from a synovial fluid sample: all DNA present in a specimen is sequenced in parallel, generating millions of reads. It has been shown to be extremely useful in a culture-negative PJI setting. Metagenomic NGS (mNGS) allows for universal pathogen detection, regardless of microbe type, in a 24–48-hour timeframe: in its nanopore-base variation, mNGS also allows for antimicrobial resistance characterization. Cell-free DNA (cfDNA) NGS, characterized by lack of the cell lysis step, has a fast run-time (hours) and, together with a high sensitivity and specificity in microorganism isolation, may provide information on the presence of antimicrobial resistance genes. Metagenomics and cfDNA testing have reduced the time needed to detect infecting bacteria and represent very promising technologies for fast PJI diagnosis. NGS technologies are revolutionary methods that could disrupt the diagnostic paradigm of PJI, but a comprehensive collection of clinical evidence is still needed before they become widely used diagnostic tools. Cite this article: EFORT Open Rev 2021;6:236-244. DOI: 10.1302/2058-5241.6.200099

Background: Periprosthetic joint infection (PJI) represents 25% of failed total knee arthroplasties (TKA). The European Knee Associates (EKA) formed a transatlantic panel of experts to perform a literature review examining patient-related risk factors with the objective of producing perioperative recommendations in PJI high-risk patients. Methods: Multiple databases (Pubmed/MEDLINE, EMBASE, Scopus, Cochrane Library) and recommendations on TKA PJI prevention measures from the International Consensus Meetings on PJI from the AAOS and AAHKS were reviewed. This represents a Level IV study. Results: Strong evidence was found on poor glycemic control, obesity, malnutrition, and smoking being all associated with increased rates of PJI. In the preoperative period, patient optimization is key: BMI < 35, diet optimization, Hemoglobin A1c < 7.5, Fructosamine < 292 mmol/L, smoking cessation, and MRSA nasal screening all showed strong evidence on reducing PJI risk. Intraoperatively, a weight-based antibiotic prophylaxis, accurate fluid resuscitation, betadine and chlorhexidine dual skin preparation, diluted povidone iodine solution irrigation, tranexamic acid administration, and monofilament barbed triclosan-coated sutures for soft tissues closure all represented effective prevention measures. In the postoperative period, failure to reach normalization of ESR, CRP, D-dimer, and IL-6 six weeks postoperatively suggested early PJI. Conclusion: The current recommendations from this group of experts, based on published evidence, support risk stratification to identify high-risk patients requiring implementation of perioperative measures to reduce postoperative PJI.

Background: Traditional total knee implants designs, usually, are not able to reproduce the physiological kinematics of the knee, leaving almost 20% of the patients, those who underwent a total knee arthroplasty (TKA), not fully satisfied. Modern inserts are nowadays designed with a fully congruent medial compartment to reproduce the normal medial pivoting biomechanics of the knee. The aim of this article was to evaluate preliminary clinical improvement using the Medial Congruent (MC) insert as specific level of constraint. Materials and methods: A total of 10 consecutive patients have been enrolled in this study and treated using an MC tibial polyethylene insert. The Oxford Knee Score (OKS) and the Knee Society Score (KSS) have been assessed preoperatively and at 3-month, 6-month, and 1-year follow-up (FU) and used as validated measurements to evaluate early clinical improvements. Postoperative radiological examination was reviewed looking for radiolucent lines or loosening of the components. Results: Average improvement in OKS was from 19.5 to 41.2, whereas KSS improved with an average score from 64.7 preoperatively to 167.5 at the final FU showing good to excellent results in 95% of the treated knees. Evaluating the range of motion, the average maximum active movement was 124° and none of the patients needing for a revision surgery or manipulation under anesthesia. No complications were observed at the final FU as septic or aseptic loosening or vascular or neurologic injury. Discussion and conclusions: Medial Congruent insert showed good to excellent clinical results at 1-year FU. Range of motion and subjective outcomes were satisfying and comparable with results obtained in literature using traditional TKA design.