A desirability of outcome ranking (DOOR) for periprosthetic joint infection - a Delphi analysis.

Background: Treatment outcomes in studies on prosthetic joint infection are generally assessed using a dichotomous outcome relating to treatment success or failure. These outcome measures neither include patient-centred outcome measures including joint function and quality of life, nor do they account for adverse effects of treatment. A desirability of outcome ranking (DOOR) measure can include these factors and has previously been proposed and validated for other serious infections. We aimed to develop a novel DOOR for prosthetic joint infections (PJIs). Methods: The Delphi method was used to develop a DOOR for PJI research. An international working group of 18 clinicians (orthopaedic surgeons and infectious disease specialists) completed the Delphi process. The final DOOR comprised the dimensions established to be most important by consensus with > 75  % of participant agreement. Results: The consensus DOOR comprised four main dimensions. The primary dimension was patient-reported joint function. The secondary dimensions were infection cure and mortality. The final dimension of quality of life was selected as a tie-breaker. Discussion: A desirability of outcome ranking for periprosthetic joint infection has been proposed. It focuses on patient-centric outcome measures of joint function, cure and quality of life. This DOOR provides a multidimensional assessment to comprehensively rank outcomes when comparing treatments for prosthetic joint infection.

The horizontal shear fracture of the pelvis.

PURPOSE: Various classification systems describe fractures of the acetabulum and pelvis separately. Horizontal shear fractures involve the pelvic ring and both acetabula and have not been previously described. The aim of this study is to describe the horizontal shear fracture of the pelvis. METHODS: At a level 1 trauma centre over 10 years from December 2008 to December 2018, 1242 patients had pelvic and acetabular fractures. Six patients had horizontal shear fractures, comprising 0.5% of all pelvic and acetabular fractures. Demographic, clinical and radiological data was collected. Clinical outcomes were pain and mobility level, sciatic nerve symptoms, further acetabular or pelvic surgery, or total hip arthroplasty. Radiological outcomes included fracture displacement, implant migration, femoral head osteonecrosis, and post-traumatic arthritis. Outcomes were assessed at a minimum 12 month follow-up. RESULTS: The median patient age was 35 years. Five of six shear fractures were due to motorcycle crashes. No mortalities occurred. At follow-up, three patients reported pain, two patients had difficulty mobilising associated with traumatic sciatic nerve injury, and one patient underwent total hip arthroplasty for femoral head osteonecrosis. No fracture displacement or implant migration occurred. The Matta arthritis grade was excellent or good in all except one hip. Median follow-up time was 1.8 (range 1.1-7.8) years. CONCLUSION: The horizontal shear fracture of the pelvis is a high-energy injury characterised by separation of the anterior and posterior pelvic ring through the acetabula. Good outcomes can be achieved with open reduction and internal fixation of displaced fractures.

Open Debridement is Superior to Arthroscopic Debridement for the Infected Total Knee Arthroplasty.

BACKGROUND: Acutely infected total knee arthroplasty (TKA) is commonly treated with debridement, antibiotics, and implant retention (DAIR). There are no direct comparative studies to determine whether debridement should be performed open or arthroscopically for infected TKA. The aim of this study is to compare the outcomes of open vs arthroscopic debridement of infected TKAs. METHODS: All patients at a university teaching hospital with an infected TKA treated with DAIR between 2002 and 2017 were analyzed. The primary outcome was successful treatment defined using international consensus criteria. Secondary outcomes included antibiotic suppression, prosthesis retention, mortality, postoperative range of motion, and length of stay. Clinical, laboratory, surgical, and antibiotic treatment data were collected. Propensity score matching was performed to control for selection bias. RESULTS: DAIR was used in 141 patients. The initial DAIR procedure was open for 96 patients and arthroscopic for 45 patients. The success rate was 29% greater for open DAIR (45% open vs 16% arthroscopic; P < .001). After propensity score matching, this benefit was estimated to be 36% (95% confidence interval, 22%-50%; P < .0001). When those on antibiotic suppression were also considered successfully treated, open DAIR was still superior by 34% (95% confidence interval, 18%-51%; P < .0001). CONCLUSION: For infected TKA, open DAIR is a more successful index procedure compared with arthroscopic DAIR. Open DAIR remained more successful even when antibiotic suppression is considered successful treatment.

Outcomes of paediatric septic arthritis of the hip and knee at 1-20 years in an Australian urban centre.

BACKGROUND: Septic arthritis in children is a joint threatening condition with potentially severe consequences; however, long-term outcome data is lacking. This study aims to determine 1-20-year outcomes following septic arthritis of hip and knee joints in children in an Australian population. METHODS: All paediatric patients with septic arthritis of the hip or knee from 1995 to 2015 treated at our Australian institution were retrospectively assessed. Clinical features, treatment and investigation results were recorded. Long-term functional and radiological outcomes, infection recurrence and reoperation rate at final follow-up (mean 8.5 years, range 1.0-20.3; hip versus mean 7.7 years, range 1.1-20.3; knee) were recorded. RESULTS: Sixty-four patients (37 hip, 27 knee) met inclusion criteria. Fifty-two patients (81.3%) attended follow-up. No mortalities or late infection recurrence occurred. Three patients (1; hip versus 2; knee) had a later operation. Median Oxford scores were excellent (48; hip versus 48; knee); however, a significant proportion had a degree of impaired function (31.3%; hip versus 42.1%; knee). Radiological outcomes were excellent in knees more commonly than hips (81.3%; hip versus 100%; knee). CONCLUSIONS: Outcomes at 1-20 years for the majority of patients following septic arthritis of the hip and knee are excellent with early joint irrigation and intravenous antibiotics. Our results demonstrate a significant proportion of patients following septic hip arthritis have mild to moderately poor functional and radiological outcomes. Those with septic knee arthritis demonstrated universally excellent radiological outcomes and mild functional impairment in approximately one-third of cases.

Open Compared with Arthroscopic Treatment of Acute Septic Arthritis of the Native Knee.

BACKGROUND: Acute native knee septic arthritis is a joint-threatening emergency. Operative treatments by open or arthroscopic methods are available to surgeons. To our knowledge, the literature to date has primarily consisted of case series and no large study has yet compared these methods. The aim of this study was to compare open and arthroscopic treatment for acute native knee septic arthritis. METHODS: All adult patients with acute native knee septic arthritis treated at our institution with either open or arthroscopic irrigation from 2000 to 2015 were retrospectively evaluated. The clinical findings, laboratory evidence, arthrocentesis and microbiology results, knee radiographs, and outcomes were compared. RESULTS: There were 161 patients (166 knees) with acute native knee septic arthritis treated between 2000 and 2015. Initially, 123 knees were treated by arthroscopic irrigation and 43 knees were treated by open irrigation; however, 71% in the open treatment group required repeat irrigation compared with 50% in the arthroscopic treatment group. The superiority of an arthroscopic procedure persisted after adjustment for potential confounders by multivariable analysis, with an odds ratio of 2.56 (95% confidence interval, 1.1 to 5.9; p = 0.027). After 3 irrigation procedures, the cumulative success rate was 97% in the arthroscopic treatment group and 83% in the open treatment group (p = 0.011). The total number of irrigation procedures required was fewer in the arthroscopic treatment group (p = 0.010). In the arthroscopic treatment group, the mean postoperative range of motion was greater (p = 0.016) and there was a trend toward a shorter median length of stay (p = 0.088). CONCLUSIONS: Arthroscopic treatment for acute native knee septic arthritis was a more successful index procedure and required fewer total irrigation procedures compared with open treatment. Long-term postoperative range of motion was significantly greater following arthroscopic treatment. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.