Periprosthetic Joint Infection After Total Knee Arthroplasty With or Without Antibiotic Bone Cement.

Importance: Despite increased use of antibiotic-loaded bone cement (ALBC) in joint arthroplasty over recent decades, current evidence for prophylactic use of ALBC to reduce risk of periprosthetic joint infection (PJI) is insufficient. Objective: To compare the rate of revision attributed to PJI following primary total knee arthroplasty (TKA) using ALBC vs plain bone cement. Design, Setting, and Participants: This international cohort study used data from 14 national or regional joint arthroplasty registries in Australia, Denmark, Finland, Germany, Italy, New Zealand, Norway, Romania, Sweden, Switzerland, the Netherlands, the UK, and the US. The study included primary TKAs for osteoarthritis registered from January 1, 2010, to December 31, 2020, and followed-up until December 31, 2021. Data analysis was performed from April to September 2023. Exposure: Primary TKA with ALBC vs plain bone cement. Main Outcomes and Measures: The primary outcome was risk of 1-year revision for PJI. Using a distributed data network analysis method, data were harmonized, and a cumulative revision rate was calculated (1 - Kaplan-Meier), and Cox regression analyses were performed within the 10 registries using both cement types. A meta-analysis was then performed to combine all aggregated data and evaluate the risk of 1-year revision for PJI and all causes. Results: Among 2 168 924 TKAs included, 93% were performed with ALBC. Most TKAs were performed in female patients (59.5%) and patients aged 65 to 74 years (39.9%), fully cemented (92.2%), and in the 2015 to 2020 period (62.5%). All participating registries reported a cumulative 1-year revision rate for PJI of less than 1% following primary TKA with ALBC (range, 0.21%-0.80%) and with plain bone cement (range, 0.23%-0.70%). The meta-analyses based on adjusted Cox regression for 1 917 190 TKAs showed no statistically significant difference at 1 year in risk of revision for PJI (hazard rate ratio, 1.16; 95% CI, 0.89-1.52) or for all causes (hazard rate ratio, 1.12; 95% CI, 0.89-1.40) among TKAs performed with ALBC vs plain bone cement. Conclusions and Relevance: In this study, the risk of revision for PJI was similar between ALBC and plain bone cement following primary TKA. Any additional costs of ALBC and its relative value in reducing revision risk should be considered in the context of the overall health care delivery system.

The use of antibiotic-loaded bone cement and systemic antibiotic prophylactic use in 2,971,357 primary total knee arthroplasties from 2010 to 2020: an international register-based observational study among countries in Africa, Europe, North America, and Oceania.

BACKGROUND AND PURPOSE: Antibiotic-loaded bone cement (ALBC) and systemic antibiotic prophylaxis (SAP) have been used to reduce periprosthetic joint infection (PJI) rates. We investigated the use of ALBC and SAP in primary total knee arthroplasty (TKA). PATIENTS AND METHODS: This observational study is based on 2,971,357 primary TKAs reported in 2010-2020 to national/regional joint arthroplasty registries in Australia, Denmark, Finland, Germany, Italy, the Netherlands, New Zealand, Norway, Romania, South Africa, Sweden, Switzerland, the UK, and the USA. Aggregate-level data on trends and types of bone cement, antibiotic agents, and doses and duration of SAP used was extracted from participating registries. RESULTS: ALBC was used in 77% of the TKAs with variation ranging from 100% in Norway to 31% in the USA. Palacos R+G was the most common (62%) ALBC type used. The primary antibiotic used in ALBC was gentamicin (94%). Use of ALBC in combination with SAP was common practice (77%). Cefazolin was the most common (32%) SAP agent. The doses and duration of SAP used varied from one single preoperative dosage as standard practice in Bolzano, Italy (98%) to 1-day 4 doses in Norway (83% of the 40,709 TKAs reported to the Norwegian arthroplasty register). CONCLUSION: The proportion of ALBC usage in primary TKA varies internationally, with gentamicin being the most common antibiotic. ALBC in combination with SAP was common practice, with cefazolin the most common SAP agent. The type of ALBC and type, dose, and duration of SAP varied among participating countries.

Antibiotic-Loaded Bone Cement in Prevention of Periprosthetic Joint Infections in Primary Total Knee Arthroplasty: A Register-based Multicentre Randomised Controlled Non-inferiority Trial (ALBA trial).

INTRODUCTION: The current evidence on the efficacy of antibiotic-loaded bone cement (ALBC) in reducing the risk of periprosthetic joint infections (PJI) after primary joint reconstruction is insufficient. In several European countries, the use of ALBC is routine practice unlike in the USA where ALBC use is not approved in low-risk patients. Therefore, we designed a double-blinded pragmatic multicentre register-based randomised controlled non-inferiority trial to investigate the effects of ALBC compared with plain bone cement in primary total knee arthroplasty (TKA). METHODS AND ANALYSIS: A minimum of 9,172 patients undergoing full-cemented primary TKA will be recruited and equally randomised into the ALBC group and the plain bone cement group. This trial will be conducted in Norwegian hospitals that routinely perform cemented primary TKA. The primary outcome will be risk of revision surgery due to PJI at 1-year of follow-up. Secondary outcomes will be: risk of revision due to any reason including aseptic loosening at 1, 6, 10 and 20 years of follow-up; patient-related outcome measures like function, pain, satisfaction and health-related quality of life at 1, 6 and 10 years of follow-up; risk of changes in the microbial pattern and resistance profiles of organisms cultured in subsequent revisions at 1, 6, 10 and 20 years of follow-up; cost-effectiveness of routine ALBC versus plain bone cement use in primary TKA. We will use 1:1 randomisation with random permuted blocks and stratify by participating hospitals to randomise patients to receive ALBC or plain bone cement. Inclusion, randomisation and follow-up will be through the Norwegian Arthroplasty Register. ETHICS AND DISSEMINATION: The trial was approved by the Western Norway Regional Committees on Medical and Health Research Ethics (reference number: 2019/751/REK vest) on 21 June 2019. The findings of this trial will be disseminated through peer-reviewed publications and conference presentations. TRIAL REGISTRATION NUMBER: NCT04135170.

Outcome of Revision Surgery for Infection After Total Knee Arthroplasty: Results of 3 Surgical Strategies.

BACKGROUND: Periprosthetic joint infection (PJI) after knee arthroplasty surgery remains a serious complication, yet there is no international consensus regarding the surgical treatment of PJI. This study aimed to assess prosthesis survival rates, risk of revision, and mortality rate following different surgical strategies (1-stage versus 2-stage implant revision and irrigation and debridement with implant retention) that are used to treat PJI. METHODS: The study was based on 644 total knee arthroplasties (TKAs) that were revised because of a deep infection (i.e., surgically treated PJI) and reported to the Norwegian Arthroplasty Register (NAR) from 1994 to 2016. Kaplan-Meier and multiple Cox regression analyses were performed to assess implant survival rate and risk of revision. We also studied mortality rates at 90 days and 1 year after revision for PJI. RESULTS: During the follow-up period, 19% of the irrigation and debridement cases, 14% of the 1-stage revision cases, and 12% of the 2-stage revision cases underwent a subsequent revision because of a PJI. The 5-year Kaplan-Meier survival rate with revision for infection as the end point was 79% after irrigation and debridement, 87% after 1-stage revision, and 87% after 2-stage revision. There were no significant differences between 1-stage and 2-stage revisions with subsequent revision for any reason as the end point (relative risk [RR], 1.7; 95% confidence interval [CI], 0.9 to 3.5) and no difference with revision because of infection as the end point (RR, 1.6; 95% CI, 0.7 to 3.7). In an age-stratified analysis, however, the risk of revision for any reason was 4 times greater after 1-stage revision than after 2-stage revision in patients over the age of 70 years (RR, 4.3; 95% CI, 1.3 to 14.8). Age had no significant effect on the risk of subsequent revision for knees that had been revised with the irrigation and debridement procedure. The 90-day and 1-year mortality rates after revision for PJI were 1.2% and 2.5%, respectively. CONCLUSIONS: Irrigation and debridement yielded good results compared with previous published studies. Although the 1-stage revisions resulted in a fourfold increase in risk of subsequent revision compared with the 2-stage revisions in older patients, the overall outcomes after 1-stage and 2-stage revisions were similar. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Outcomes of Unicompartmental Knee Arthroplasty After Aseptic Revision to Total Knee Arthroplasty: A Comparative Study of 768 TKAs and 578 UKAs Revised to TKAs from the Norwegian Arthroplasty Register (1994 to 2011).

BACKGROUND: The general recommendation for a failed primary unicompartmental knee arthroplasty (UKA) is revision to a total knee arthroplasty (TKA). The purpose of the present study was to compare the outcomes, intraoperative data, and mode of failure of primary UKAs and primary TKAs revised to TKAs. METHODS: The study was based on 768 failed primary TKAs revised to TKAs (TKA→TKA) and 578 failed primary UKAs revised to TKAs (UKA→TKA) reported to the Norwegian Arthroplasty Register between 1994 and 2011. Patient-reported outcome measures (PROMs) including the EuroQol EQ-5D, the Knee Injury and Osteoarthritis Outcome Score (KOOS), and visual analog scales assessing satisfaction and pain were used. We performed Kaplan-Meier and Cox regression analyses adjusting for propensity score to assess the survival rate and the risk of re-revision and multiple linear regression analyses to estimate the differences between the two groups in mean PROM scores. RESULTS: Overall, 12% in the UKA→TKA group and 13% in the TKA→TKA group underwent re-revision between 1994 and 2011. The ten-year survival percentage of UKA→TKA versus TKA→TKA was 82% versus 81%, respectively (p = 0.63). There was no difference in the overall risk of re-revision for UKA→TKA versus TKA→TKA (relative risk [RR] = 1.2; p = 0.19), or in the PROM scores. However, the risk of re-revision was two times higher for TKA→TKA patients who were greater than seventy years of age at the time of revision (RR = 2.1; p = 0.05). A loose tibial component (28% versus 17%), pain alone (22% versus 12%), instability (19% versus 19%), and deep infection (16% versus 31%) were major causes of re-revision for UKA→TKA versus TKA→TKA, respectively, but the observed differences were not significant, with the exception of deep infection, which was significantly greater in the TKA→TKA group (RR = 2.2; p = 0.03). The surgical procedure of TKA→TKA took a longer time (mean of 150 versus 114 minutes) and more of the procedures required stems (58% versus 19%) and stabilization (27% versus 9%) compared with UKA→TKA. CONCLUSIONS: Despite TKA→TKA seeming to be a technically more difficult surgical procedure, with a higher percentage of re-revisions due to deep infection compared with UKA→TKA, the overall outcomes of UKA→TKA and TKA→TKA were similar.

Secondary patella resurfacing in painful non-resurfaced total knee arthroplasties : A study of survival and clinical outcome from the Norwegian Arthroplasty Register (1994-2011).

PURPOSE: In Norway, 19 % of revisions of non-resurfaced total knee arthroplasties done for knee pain between 1994 and 2011 were Secondary Patella Resurfacing (SPR). It is, however, unclear whether SPR actually resolves the pain. The aim was to investigate prostheses survival and clinical outcomes following SPR. METHOD: A total of 308 knees (301 patients) with SPR were used to assess implant survival, and a sub-cohort (n = 114 out of 301 patients) with Patient Reported Outcome Measures (PROMs) data were used to assess the clinical outcomes. The EuroQol (EQ-5D), the Knee Injury and Osteoarthritis Outcome Score, and Visual Analogue Scales on satisfaction and pain were used to collect PROM data. Outcomes were analysed by Kaplan-Meier, Cox regression, and multiple linear regression. RESULTS: The five- and ten-year Kaplan-Meier survival percentages were 91 % and 87 %, respectively. Overall, 35 knees were re-revised at a median follow-up of eight years and pain alone (10 knees) was the main cause of re-revision. Younger patients (<60 years) had nearly nine times higher risk of re-revision compared to older patients (>70 years) (RR = 8.6; p < 0.001). Mean EQ-5D index score had improved from 0.41 (SD 0.21) preoperative to 0.56 (SD 0.25) postoperative following SPR. A total of 63 % of patients with PROM data were satisfied with the outcomes of SPR. CONCLUSION: The long-term prostheses survival following SPR was satisfactory, although not as good as for primary knee replacement. Patients' health related quality of life improved significantly following SPR. Still, more than a third of patients with PROMs data were dissatisfied with the outcomes of the SPR procedure.

Failure of aseptic revision total knee arthroplasties.

BACKGROUND AND PURPOSE: In Norway, the proportion of revision knee arthroplasties increased from 6.9% in 1994 to 8.5% in 2011. However, there is limited information on the epidemiology and causes of subsequent failure of revision knee arthroplasty. We therefore studied survival rate and determined the modes of failure of aseptic revision total knee arthroplasties. METHOD: This study was based on 1,016 aseptic revision total knee arthroplasties reported to the Norwegian Arthroplasty Register between 1994 and 2011. Revisions done for infections were not included. Kaplan-Meier and Cox regression analyses were used to assess the survival rate and the relative risk of re-revision with all causes of re-revision as endpoint. RESULTS: 145 knees failed after revision total knee arthroplasty. Deep infection was the most frequent cause of re-revision (28%), followed by instability (26%), loose tibial component (17%), and pain (10%). The cumulative survival rate for revision total knee arthroplasties was 85% at 5 years, 78% at 10 years, and 71% at 15 years. Revision total knee arthroplasties with exchange of the femoral or tibial component exclusively had a higher risk of re-revision (RR = 1.7) than those with exchange of the whole prosthesis. The risk of re-revision was higher for men (RR = 2.0) and for patients aged less than 60 years (RR = 1.6). INTERPRETATION: In terms of implant survival, revision of the whole implant was better than revision of 1 component only. Young age and male sex were risk factors for re-revision. Deep infection was the most frequent cause of failure of revision of aseptic total knee arthroplasties.

Factors affecting voluntary HIV counselling and testing among men in Ethiopia: a cross-sectional survey.

BACKGROUND: Voluntary HIV counselling and testing (VCT) is one of the key strategies in the HIV/AIDS prevention and control programmes in Ethiopia. However, utilization of this service among adults is very low. The aim of the present study was to investigate factors associated with VCT utilization among adult men since men are less likely than women to be offered and accept routine HIV testing. METHODS: The study utilized data from the Ethiopian Demographic Health Survey (EDHS) 2005, which is a cross-sectional survey conducted on a nationally representative sample. Using cluster sampling, 6,778 men aged 15-59 years were selected from all the eleven administrative regions in Ethiopia. Logistic regression was used to analyze potential factors associated with VCT utilization. RESULTS: Overall, 21.9% of urban men and 2.6% of rural men had ever tested for HIV through VCT and most of them had learned their HIV test result. Having no stigmatizing attitudes toward people living with HIV/AIDS was found to be strongly and positively associated with VCT utilization in both urban and rural strata. In rural areas HIV test rates were higher among younger men (aged ≤44 years) and those of higher socio-economic position (SEP). Among urban men, risky sexual behaviour was positively associated with VCT utilization whereas being Muslim was found to be inversely associated with utilization of VCT. Area of residence as well as SEP strongly affected men's level of stigmatizing attitudes toward people living with HIV/AIDS. CONCLUSIONS: VCT utilization among men in Ethiopia was low and affected by HIV/AIDS-related stigma and residence. In order to increase VCT acceptability, HIV/AIDS prevention and control programs in the country should focus on reducing HIV/AIDS-related stigma. Targeting rural men with low SEP should be given first priority when designing, expanding, and implementing VCT services in the country.