The Second International Consensus Meeting (ICM) on Musculoskeletal Infection was held in July 2018 in Philadelphia, Pennsylvania. This meeting involved contributions from an international multidisciplinary consortium of experts from orthopaedic surgery, infectious disease, pharmacology, rheumatology, microbiology, and others. Through strict delegate engagement in a comprehensive 13-step consensus process based on the Delphi technique, evidence-based consensus guidelines on musculoskeletal infection were developed. The 2018 ICM produced updates to recommendations from the inaugural ICM that was held in 2013, which primarily focused on periprosthetic infection of the hip and the knee, and added new guidelines with the expansion to encompass all subspecialties of orthopaedic surgery. The following proceedings from the pediatrics section are an overview of the ICM consensus recommendations on the prevention, diagnosis, and treatment of pediatric musculoskeletal infection.

Pain after total knee arthroplasty (TKA) is not infrequent and may be indicative of a broad spectrum of prosthesis-related, intra-articular, or extra-articular pathologies. To diagnose and treat the underlying cause of a painful TKA, systematic evaluation of the patient is critical to ensure that they are managed appropriately and expeditiously. This evidence-based review presents current concepts regarding the pathophysiology, etiology, and diagnosis of painful TKA and our recommended approach for management. [ Orthopedics . 2021;44(6):341–352.]

The publisher regrets the country information stated for affiliations b and c in the original article was incorrect. The online article has now been updated and the correct information is also shown above. The publisher would like to apologise for any inconvenience caused. Increased Postoperative Glucose Variability Is Associated With Adverse Outcome Following Two-Stage Exchange Arthroplasty for Periprosthetic Joint InfectionThe Journal of ArthroplastyVol. 35Issue 5PreviewGlucose variability in the postoperative period has been associated with increased rates of periprosthetic joint infection (PJI) following primary arthroplasty. It is unknown how postoperative glucose control affects outcome of surgical treatment of PJI patients. We hypothesized that postoperative glucose variability adversely affects the outcome of 2-stage exchange arthroplasty. Full-Text PDF

The undesirable burden periprosthetic joint infection (PJI) inflicts on patients and the healthcare system is increasingly acknowledged. The strenuous course of treatment required to manage PJI negatively affects patients' quality of life and results in an increased demand for physical, psychological, and socioeconomic support. With total joint arthroplasty set to become one of the most frequently performed elective surgical procedures in North America, further advancement on the prevention, diagnosis, and treatment of PJI is essential.1 This chapter presents recent findings from the scientific literature and updated perspectives on the management of PJI.

Background: Glucose variability in the postoperative period has been associated with increased rates of periprosthetic joint infection (PJI) following primary arthroplasty. It is unknown how postoperative glucose control affects outcome of surgical treatment of PJI patients. We hypothesized that postoperative glucose variability adversely affects the outcome of 2-stage exchange arthroplasty. Methods: We retrospectively reviewed records of 665 patients with PJI of the knee and hip who underwent 2-stage exchange arthroplasty from 2000 to 2017. Of them, 341 PJIs with a minimum follow-up of 1 year, and either a minimum of 2 glucose values per day or greater than 3 overall during the reimplantation were included. Glucose variability was assessed by calculating the coefficient of variation. Adverse outcomes included treatment failure according to the Delphi consensuses criteria, reinfection, reoperation, and mortality. A subgroup analysis was performed based on patients with or without diabetes. Results: Glucose variability following reimplantation was associated with higher treatment failure, reinfection, and reoperation. Adjusted analysis indicated that for every standard deviation (15%) increase in the coefficient of variation, the risks of treatment failure, reinfection, and reoperation increased by 27%, 31%, and 26%. Although stratifying patients with (n = 81) or without diabetes (n = 260), these associations remained robust in nondiabetic patients, but not in diabetic patients. Conclusion: Higher glucose variability is associated with increased risks of treatment failure, reinfection, and reoperation after 2-stage exchange arthroplasty in PJI patients. Compared to diabetic patients, nondiabetic patients have a higher association between glucose variability and poor outcomes. Reducing adverse outcomes may be achieved with close monitoring and strict postoperative glucose control. (C) 2019 Elsevier Inc. All rights reserved.

Background: End-stage hemophilic arthropathy is the result of recurrent joint hemarthrosis. Although total hip arthroplasty (THA) and total knee arthroplasty (TKA) can reduce severe joint pain and improve functional activity, controversy remains regarding outcomes after THA and TKA among patients with hemophilia. This study evaluated the risk of adverse outcomes of hemophilia patients who underwent THA and TKA. Methods: This retrospective cohort study was conducted using data from the National Health Insurance Research Database. Patients who had hemophilia and underwent THA and TKA between 2000 and 2015 were identified. A total of 121 patients with hemophilia and 194,026 patients without hemophilia were included. Through propensity score matching, patients with hemophilia were matched at a 1: 4 ratio to patients without hemophilia. Multivariable regression analysis was used to control for confounding variables and compare the risk of postoperative complications and mortality, differences in length of stay, and cost of care for the hospital. Results: After propensity score matching and multivariate regression analysis, the adjusted hazard ratio of postoperative transfusion for hemophilia patients was 5.262 (95% confidence interval [CI] = 3.044-26.565, P < .001) in THA group and 6.279 (95% CI = 3.246-28.903, P < .001) in TKA group, when compared with the control group. Patients with hemophilia had longer length of hospital stay (THA group: 95% CI, 1.541-2.669, P < .001; TKA group: 95% CI, 1.568-2.786; P < .001) and higher total hospital charges (THA group: 95% CI, 3.518-8.293, P < .001; TKA group: 95% CI, 3.584-8.842; P <.001) compared to patients without hemophilia. Hemophiliacs had a higher yet nonsignificant 1-year infection rate (8.11% vs 3.38%, P = .206) in the THA group. There were no differences between the rates of 30-day and 90-day complications, 1-year infection, reoperation and mortality between the hemophilia and nonhemophilia groups. Conclusion: Hemophilia patients have higher rates of postoperative transfusion, hospital costs, and increased length of stay. There is an appreciable clinical difference in 1-year infection rates following THA but our analysis was limited by the small sample size. Other postoperative complications and mortality rates were comparable. Patients with hemophilia should be counseled that infection rate maybe as high as 8% following THA. Further investigation is needed to develop prophylactic and effective methods to decrease the rates of transfusions and associated adverse outcomes in hemophilia patients undergoing THA and TKA. (C) 2019 Elsevier Inc. All rights reserved.

Abstract: The Second International Consensus Meeting (ICM) on Musculoskeletal Infection was held in July 2018 in Philadelphia, Pennsylvania. This meeting involved contributions from an international multidisciplinary consortium of experts from orthopaedic surgery, infectious disease, pharmacology, rheumatology, microbiology, and others. Through strict delegate engagement in a comprehensive 13-step consensus process based on the Delphi technique, evidence-based consensus guidelines on musculoskeletal infection were developed. The 2018 ICM produced updates to recommendations from the inaugural ICM that was held in 2013, which primarily focused on periprosthetic infection of the hip and the knee, and added new guidelines with the expansion to encompass all subspecialties of orthopaedic surgery. The following proceedings from the pediatrics section are an overview of the ICM consensus recommendations on the prevention, diagnosis, and treatment of pediatric musculoskeletal infection.

Research studies with evidence impacting clinical practice have used disparate definitions of shoulder periprosthetic joint infection, likely leading to variable and inconsistent conclusions about its diagnosis and management. In an effort to establish uniform guidelines for clinical decision making and research reporting, a clear definition of periprosthetic shoulder infection was established at the 2018 International Consensus Meeting on Orthopedic Infections.

As noted by the Centers for Disease Control and Prevention, preoperative skin cleansing with an antiseptic agent can substantially decrease skin microbial counts [1,2]. Studies examining this practice and its role in the reduction of SSI and PJI rates have produced conflicting findings. To determine the utility of preoperative skin cleansing in preventing SSIs/PJIs, the effectiveness and logistics of the practice must be taken into account. Preoperative skin cleansing can be executed using a variety of agents. Garibaldi et al. performed a prospective trial on over 700 patients and found rates of positive intraoperative wound cultures to be 4% for patients who showered and scrubbed with CHG, 9% for those who used povidone-iodine, and 14% for those who used medicated soap and water [3]. Several other published studies supported a connection between preoperative skin shower and CHG with decreasing overall culture rates [4–8]. Chlorhexidine bathing at home prior to surgery involves the use of either a 4% solution or a 2% cloth for a varying number of days based on the literature. Low-level evidence recommends the use of CHG cloths over bathing in its soap form [9]. Regardless of application methodology, CHG can either be bacteriostatic or bactericidal based on the concentration used for cleansing and its efficacy has been known to improve with frequency and duration of use [5,10,11]. The applicability of the aforementioned findings to SSI/PJI prevention in patients undergoing orthopaedic surgery remains unclear due to contradictory findings in the literature. Kapadia et al. studied 3,717 patients who underwent primary or revision total knee arthroplasties. The group found that the use of a pre-admission chlorhexidine protocol was associated with a reduced relative risks of PJIs after total knee arthroplasty (TKA), when compared to patients who did not receive a CHG protocol (0.3% vs. 1.9%; rate ratio (RR): 6.3, 95% confidence interval (CI) 1.9 to 20.1, p = 0.002) [12]. Similar results were seen even when the two patient cohorts were risk-stratified. A review of modern papers from 2009 to 2015 also showed a reduction in infection rates with preoperative chlorhexidine preparation [13]. A systematic review by Webster et al. of over 10,000 patients in the Cochrane Database also concluded chlorhexidine washes were better than not bathing at all. However, the use of chlorhexidine washes did not seem to change infection rates [11]. Nevertheless, the review reported a lower relative risk for SSIs in patients who used CHG compared to those who used placebo (RR: 0.91, 95% CI 0.8 to 1.40). Farber et al. reported on over 3,700 total joint cases with 1,891 using 2% cloth wipes at the surgical site one hour prior to their procedure [12]. They also found no differences in infection rates at the one-year follow-up for either group. As described above, the literature cannot affirm emphatically that skin cleansing at home prior to orthopaedic surgery has a role in reduction of subsequent SSIs or PJIs. There has yet to be any reports on the negative effects of preoperative skin cleansing at home prior to arthroplasty surgery and concerns for skin hypersensitivity associated with use of CHG are minor [4]. With really no downside and some potential upside (Table 1), it seems reasonable to consider some form of preoperative skin cleansing at home. Moreover, well-controlled trials are required to truly assess the efficacy of the preoperative skin baths. Initial cost data seems promising but may be institutionally-related with a potential net savings of $0.78 to $3.1 billion [14]. A true cost-assessment is necessary to understand if this low-risk means of infection prevention is cost-effective and whether it should be the standard of care prior to any orthopaedic/arthroplasty surgical procedure. In conclusion, Table 1 summarizes studies that have been completed regarding chlorhexidine preoperative bathing and its effects on SSIs/PJIs. The heterogeneity of skin cleansing regimens and varying compliance rates make it difficult to isolate preoperative preparation as the main determinant for infection prevention in patients undergoing orthopaedic surgery. Despite the data listed, it is important to understand that compliance is always a concern with this protocol as one study found 78% noncompliance despite focused pre-surgery education efforts [15].

BACKGROUND:Existing evidence on whether marathon running contributes to hip and knee arthritis is inconclusive. Our aim was to describe hip and knee health in active marathon runners, including the prevalence of pain, arthritis, and arthroplasty, and associated risk factors. METHODS:A hip and knee health survey was distributed internationally to marathon runners. Active marathoners who completed ≥5 marathons and were currently running a minimum of 10 miles per week were included (n = 675). Questions assessed pain, personal and family history of arthritis, surgical history, running volume, personal record time, and current running status. Multivariable analyses identified risk factors for pain and arthritis. Arthritis prevalence in U.S. marathoners was compared with National Center for Health Statistics prevalence estimates for a matched group of the U.S. POPULATION: RESULTS:Marathoners (n = 675) with a mean age of 48 years (range, 18 to 79 years) ran a mean distance of 36 miles weekly (range, 10 to 150 miles weekly) over a mean time of 19 years (range, 3 to 60 years) and completed a mean of 76 marathons (range, 5 to 1,016 marathons). Hip or knee pain was reported by 47%, and arthritis was reported by 8.9% of marathoners. Arthritis prevalence was 8.8% for the subgroup of U.S. marathoners, significantly lower (p < 0.001) than the prevalence in the matched U.S. population (17.9%) and in subgroups stratified by age, sex, body mass index (BMI), and physical activity level (p < 0.001). Seven marathoners continued to run following hip or knee arthroplasty. Age and family and surgical history were independent risk factors for arthritis. There was no significant risk associated with running duration, intensity, mileage, or the number of marathons completed (p > 0.05). CONCLUSIONS:Age, family history, and surgical history independently predicted an increased risk for hip and knee arthritis in active marathoners, although there was no correlation with running history. In our cohort, the arthritis rate of active marathoners was below that of the general U.S. POPULATION:Longitudinal follow-up is needed to determine the effects of marathon running on developing future hip and knee arthritis. LEVEL OF EVIDENCE:Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.