Periprosthetic joint infection (PJI) remains one of the most serious complications of total joint arthroplasty. While two-stage revision arthroplasty remains the most commonly utilized treatment strategy for chronic PJI in North America, recurrent infection following revision represents an increasingly encountered and particularly challenging clinical problem. These patients often have substantial host comorbidity, prior surgical burden, compromised soft tissues, and limited reconstructive options, contributing to high rates of treatment failure and morbidity. This narrative review summarizes current evidence regarding the mechanisms, evaluation, risk factors, and management of recurrent PJI. Recurrence may result from persistence of the original pathogen or reinfection with a new organism. Host-related factors, microbiologic characteristics, and surgical variables all contribute to recurrence risk. Diagnostic evaluation requires integration of clinical assessment, serum inflammatory markers, synovial fluid analysis, microbiologic testing, and emerging molecular diagnostic technologies. Treatment options include repeat two-stage revision, debridement with implant retention in selected cases, chronic suppressive antibiotic therapy, arthrodesis, resection arthroplasty, and/or amputation. Outcomes following recurrent PJI remain inferior to those reported after index revision, highlighting the importance of optimizing initial infection management and carefully individualizing treatment strategies. Continued advances in diagnostics, risk stratification, and infection management will be essential to improve outcomes in this complex patient population.

Mentor: Christopher Deans Program: Orthopaedic Surgery Type: Original Research Background: As the third leading prescriber of opioid medications, orthopedic surgeons serve a critical role in addressing the opioid epidemic. The goal of this study is to analyze current opioid prescribing practices for post-operative primary total knee arthroplasty (pTKA) and primary total hip arthroplasty (pTHA) patients at a single academic institution. This information will be used to develop a novel multi-disciplinary opioid tapering program for use in pTKA and pTHA populations. Methods: A retrospective review of opioid prescribing trends post-operatively during hospitalization and upon discharge for patients undergoing pTKA (n = 167) and pTHA (n = 121) was conducted at a single academic institution. Descriptive statistics were used to summarize the demographic and clinical characteristics of the patients. Results: Patients undergoing pTKA require an increased number of refills, total morphine milligram equivalents (MME) refilled, and total MME used when compared to pTHA. For those undergoing pTKA, females required increased total MME and chronic opioid users required increased in-hospital MME/day. For those undergoing pTHA, an increase in total MME used was identified in those <70 years old, mental health diagnosis, and chronic opiate users. For pTKA and pTHA, the total MME used was separated into quartiles to identify utilization patterns for protocol development ( Table 1). Table 1 MME distribution for ordering and use. MME Distribution for Ordering and Use: Post-Op and Discharge, pTKA MME amount Timing of Order/Use N Mean Minimum 25th Petl Median 75th Pctl Maximum Post-op Ordered 167 108.28 0.00 45.00 102.50 170.00 330.00 Post-op Used 167 43.51 0.00 15.00 35.00 65.00 172.00 Total Discharge ordered 167 484.24 0.00 525.00 525.00 525.00 787.50 Total Discharge used 167 1331.73 106.40 565.00 1065.00 1637.50 12195.50 MME Distribution for Ordering and Use: Post-Op and Discharge, pTKA MME amount Timing of Order/Use N Mean Minimum 25th Petl Median 75th Pctl Maximum Post-op Ordered 121 113.62 3.80 85,00 120,00 170,00 290.00 Post-op Used 121 37.47 0.00 15.00 30.00 52.50 142.50 Total Discharge ordered 121 464.88 0.00 450.00 525.00 525.00 975.00 Total Discharge used 115 978.48 7.50 533.50 583.80 1102.50 11025.00 Conclusion: This study describes patterns in opioid use for pTKA and pTHA at a single high-volume academic institution. Future goals of this study include working with pharmacy and Information Technology to set discharge opioid prescription counts with a described standard refill protocol for opioid tapering based on predicted opioid utilization determined by pre-operative factors.

BackgroundAs the number of total hip and knee arthroplasties (TJA) performed increases, there is heightened interest in perioperative optimization to improve outcomes. Sleep is perhaps one of the least understood perioperative factors that affects TJA outcomes. The purpose of this article is to review the current body of knowledge regarding sleep and TJA and the tools available to optimize sleep perioperatively.MethodsA manual search was performed using PubMed for articles with information about sleep in the perioperative period. Articles were selected that examined: sleep and pain in the perioperative period; the effect of surgery on sleep postoperatively; the relationship between sleep and TJA outcomes; risk factors for perioperative sleep disturbance; the effect of anesthesia on sleep; and the efficacy of interventions to optimize sleep perioperatively.ResultsSleep and pain are intimately associated; poor sleep is associated with increased pain sensitivity. Enhanced sleep is associated with improved surgical outcomes, although transient sleep disturbances are normal postoperatively. Risk factors for perioperative sleep disturbance include increasing age, pre-existing sleep disorders, medical comorbidities, and type of anesthesia used. Interventions to improve sleep include optimizing medical comorbidities preoperatively, increasing sleep time perioperatively, appropriating sleep hygiene, using cognitive behavioral therapy, utilizing meditation and mindfulness interventions, and using pharmacologic sleep aids.ConclusionsSleep is one of many factors that affect TJA. As we better understand the interplay between sleep, risk factors for suboptimal sleep, and interventions that can be used to optimize sleep, we will be able to provide better care and improved outcomes for patients.

There is concern for cementless total knee arthroplasty (TKA) in patients with decreased bone mineral density (BMD) due to the potential increase in complications, namely failed in-growth or future aseptic loosening. Some data suggest that advances in cementless prostheses mitigate these risks; however this is not yet born out in long-term registry data. It is crucial to expand our understanding of the prevalence and etiology of osteoporosis in TKA patients, survivorship of cementless implants in decreased BMD, role of bone-modifying agents, indications and technical considerations for cementless TKA in patients with decreased BMD. The purpose of this study is to review current literature and expert opinion on such topics.

Cementless TKA indications have been expanding rapidly, including utilization in patients with poor BMD secondary to glucocorticoid use, osteoporosis, smoking, or other causes. There are mixed results reported in early-, mid-, and long-term outcome studies. Surgeons should entertain a healthy skepticism for cementless TKA utilization in populations with decreased BMD, particularly in the elderly given such strong outcomes of long-term cemented TKA. In younger and more active patients, contemporary cementless TKA may provide more durable and long-lasting biologic fixation, even in decreased BMD. Open communication with patients regarding the risk and benefit profile is of utmost importance. Longer term outcomes studies and direct comparisons in patients with decreased BMD are needed.

Background: Larger head-to-neck ratio of dual mobility (DM) hip arthroplasties provide greater range of motion/less risk of dislocation, but raise concerns for high wear and friction. We measured in vitro, the wear rates of contemporary DM hips with highly cross-linked ultra high molecular weight polyethylene (UHWMPE), where it came from, and their frictional torques. Methods: Hip simulators were used to compare the wear of DM to fixed-bearing (FB) designs of 2 different implants. Each of 8 different configurations underwent millions of simulated walking cycle tests, some as full DM, some as FB controls, some DM with the outer-articulation deliberately immobilized, and some the inner. Wear and 3-dimensional-frictional torques were measured and friction independent of size was deduced. Results: The DM hips produced lower wear and friction-torque than the FB hips. The DM wear during walking gait comes mostly from the smaller inner articular surface. If the outer surface was immobilized, the wear and torque of the inner alone would be small, but the full DM (inner and outer free-to-move) wear and torque were smallest of all. Friction measurements expectedly showed larger hips having higher frictional torques, but the DM showed the lowest, again because its motion was mostly the smaller inner articulation; smaller than even a modern fixed-bearing hip. Conclusion: The DM hips appear to combine the benefits of greater range of motion and less impingement of larger hips, with the lower wear and friction of smaller FB hips, with some benefits compromised if the outer or inner articulations are immobilized. (c) 2023 Elsevier Inc. All rights reserved.

CASE:We present a 51-year-old woman with Aitken A proximal femoral focal deficiency (PFFD) managed with total hip arthroplasty (THA). This patient presented with a history of disabling hip arthritis and multiple operations to improve her proximal femoral deformity and maintain a reduced hip. The hip was dysplastic with persistent femoral deformity, erosive acetabular changes, and abductor weakness. The surgical treatment was a THA. CONCLUSION:In the setting of hip arthritis, despite abductor weakness and deformity of the proximal femur, hip arthroplasty is a viable option for management of the patient with Aitken A PFFD.

INTRODUCTION To evaluate the effects of a trauma performance improvement project involving standardized protocols for the administration of antibiotics in open fractures at a level one trauma center. This study specifically evaluated the protocol's efficacy for improving the timing of delivery and appropriate therapy administration and sought to identify factors that lead to the delay in antibiotic delivery. METHODS Retrospective comparative cohort study comparing patients with open fractures treated at our hospital between January 2013 and September 2015 (group 1) and between April 2016 and June 2017 (group 2). Group 1 was treated before implementation of the performance improvement project and group 2 was treated after implementation. RESULTS Group 1 consisted of 79 patients and group 2 consisted of 80 patients with open fractures. Each group was statistically similar in patient and injury factors. Group 1 received antibiotics at an average of 97 minutes after arrival to our hospital while group 2 patients received them at an average of 46 minutes (P < 0.0001). Average time from admission to initial evaluation improved from 10 to 3 minutes (P < 0.0001). Average time from evaluation to antibiotic order placement improved from 77 to 26 minutes (P < 0.0001). Average time from order entry to antibiotic administration showed no significant difference (12 versus 15 minutes, P = 0.25). Thirty-four percent (27/79) of group 1 patients and 84% (67/80) of group 2 patients received antibiotics within 1 hour of admission (P < 0.0001), while 91% and 99% received antibiotics within 3 hours, respectively (P = 0.03). DISCUSSION The described multifaceted performance improvement protocol was highly effective for producing a more coordinated, efficient, and timely process for administration of antibiotics to patients with open fractures at our hospital. This protocol may be adopted and implemented at other facilities. LEVEL OF EVIDENCE Therapeutic level III.

Prehabilitation prior to major surgery has increased in popularity over recent years and aims to improve pre-operative conditioning of patients to improve post-operative outcomes. The beneficial effect of such protocols is not well established with conflicting results reported. This review aimed to assess the effect of prehabilitation on post-operative outcome after major abdominal surgery.

To review the relevant literature surrounding acromioclavicular (AC) joint injuries particularly pertaining to overhead athletes.The AC joint is a unique anatomic and biomechanical portion of the shoulder that can be problematic for athletes, particularly throwers, when injured. Treatment of these injuries remains a topic in evolution. Low-grade injuries (Rockwood types I & II) are typically treated non-operatively while high-grade injuries (types IV, V, and VI) are considered unstable and often require operative intervention. Type III AC separations remain the most controversial and challenging as no clear treatment algorithm has been established. A wide variety of surgical techniques exist. Unfortunately, relatively little literature exists with regard to overhead athletes specifically. Treatment of AC joint injuries remains challenging, at times, particularly for overhead athletes. Operative indications and techniques are still evolving, and more research is needed specifically surrounding overhead athletes.

Effective analgesia following open oesophagogastric (OG) resection is considered a key determinant of recovery. This review aimed to compare epidural to alternative analgesic techniques in patients undergoing major open resection for OG cancer.

Introduction: Cancer cachexia is a multifactorial syndrome characterized by skeletal muscle loss. Cross-sectional analysis of CT scans is a recognized research method for assessing skeletal muscle volume. However, little is known about the relationship between CT-derived estimates of muscle radio-density (SMD) and muscle protein content. We assessed the relationship between CT-derived body composition variables and the protein content of muscle biopsies from cancer patients. Methods: Rectus abdominis biopsies from cancer patients (n = 32) were analysed for protein content and correlated with phenotypic data gathered using CT body composition software. Results: Skeletal muscle protein content varied widely between patients (median mu g/mg wet weight = 89.3, range 70-141). There was a weak positive correlation between muscle protein content and SMD (r = 0.406, p = 0.021), and a weak positive correlation between protein content and percentage weight change (r = 0.416, p = 0.018). Conclusion: The protein content of skeletal muscle varies widely in cancer patients and cannot be accurately predicted by CT-derived muscle radio-density. (C) 2017 Elsevier Ltd and European Society for Clinical Nutrition and Metabolism. All rights reserved.

BackgroundCachexia affects the majority with advanced cancer. Based on current demographic and clinical factors, it is not possible to predict who will develop cachexia or not. Such variation may, in part, be due to genotype. It has recently been proposed to extend the diagnostic criteria for cachexia to include a direct measure of low skeletal muscle index (LSMI) in addition to weight loss (WL). We aimed to explore our panel of candidate single nucleotide polymorphism (SNPs) for association with WL +/− computerized tomography‐defined LSMI. We also explored whether the transcription in muscle of identified genes was altered according to such cachexia phenotypeMethodsA retrospective cohort study design was used. Analysis explored associations of candidate SNPs with WL (n = 1276) and WL + LSMI (n = 943). Human muscle transcriptome (n = 134) was analysed using an Agilent platform.ResultsSingle nucleotide polymorphisms in the following genes showed association with WL alone: GCKR, LEPR, SELP, ACVR2B, TLR4, FOXO3, IGF1, CPN1, APOE, FOXO1, and GHRL. SNPs in LEPR, ACVR2B, TNF, and ACE were associated with concurrent WL + LSMI. There was concordance between muscle‐specific expression for ACVR2B, FOXO1 and 3, LEPR, GCKR, and TLR4 genes and LSMI and/or WL (P < 0.05).ConclusionsThe rs1799964 in the TNF gene and rs4291 in the ACE gene are new associations when the definition of cachexia is based on a combination of WL and LSMI. These findings focus attention on pro‐inflammatory cytokines and the renin–angiotensin system as biomarkers/mediators of muscle wasting in cachexia.

The variable predisposition to cachexia may, in part, be due to the interaction of host genotype. We analyzed 129 single nucleotide polymorphisms (SNPs) in 80 genes for association with cachexia based on degree of weight loss (>5, >10, >15%) as well as weight loss in the presence of systemic inflammation (C-reactive protein, >10?mg/l). 775 cancer patients were studied with a validation association study performed on an independently recruited cohort (n?=?101) of cancer patients. The C allele (minor allele frequency 10.7%) of the rs6136 (SELP) SNP was found to be associated with weight loss >10% both in the discovery study (odds ratio (OR) 0.52; 95% confidence intervals (CI), 0.290.93; p?=?0.026) and the validation study (OR 0.09, 95% CI 0.010.98, p?=?0.035). In separate studies, induction of muscle atrophy gene expression was investigated using qPCR following either tumour-induced cachexia in rats or intra-peritoneal injection of lipopolysaccharide in mice. P-selectin was found to be significantly upregulated in muscle in both models. Identification of P-selectin as relevant in both animal models and in cachectic cancer patients supports this as a risk factor/potential mediator in cachexia. See accompanying article