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What’s New in Musculoskeletal Infection

Fehring, Thomas K. MD1; Fehring, Keith A. MD1; Hewlett, Angela MD, MS2; Higuera, Carlos A. MD3; Otero, Jesse E. MD, PhD1; Tande, Aaron MD4

doi: 10.2106/JBJS.19.00403
Editorial
Free
Disclosures

1OrthoCarolina Hip & Knee Center, Charlotte, North Carolina

2University of Nebraska Medical Center, Omaha, Nebraska

3Cleveland Clinic Florida, Weston, Florida

4Mayo Clinic, Rochester, Minnesota

E-mail address for T.K. Fehring: Thomas.Fehring@orthocarolina.com

Investigation performed at the OrthoCarolina Hip & Knee Center, Charlotte, North Carolina; University of Nebraska Medical Center, Omaha, Nebraska; Cleveland Clinic Florida, Weston, Florida; and the Mayo Clinic, Rochester, Minnesota

Disclosure: The authors indicated that no external funding was received for any aspect of this work. On the Disclosure of Potential Conflicts of Interest forms, which are provided with the online version of the article, one or more of the authors checked “yes” to indicate that the author had a relevant financial relationship in the biomedical arena outside the submitted work (http://links.lww.com/JBJS/F368).

This update on musculoskeletal infection presents a review of infection-related articles from January 2018 through the present from English-language journals, located using the National Center for Biotechnology Information web site, with a special emphasis on periprosthetic infection. The additional sections will cover recent salient articles in the areas of spine, trauma, hand, and pediatrics.

In a recent analysis of the Medicare Inpatient Data Set from 2005 to 2015, the risk of periprosthetic joint infection was 1.09% for hips and 1.38% for knees at 5 years. This risk did not change significantly during this 10-year period. Therefore, because the demand for total joint arthroplasty is projected to increase substantially in the coming years, the incidence of periprosthetic joint infection is anticipated to scale up proportionally1.

Conversely, the risk of mortality after periprosthetic joint infection decreased significantly during the time frame studied. However, the 5-year survival for Medicare patients was only 67% for periprosthetic infection after total hip arthroplasty and 72% for periprosthetic infection after total knee arthroplasty1. This high mortality rate following periprosthetic infection was echoed in 2 other studies in which the 5-year mortality for patients with periprosthetic joint infection after undergoing total joint arthroplasty was 21.12% for those who underwent total hip arthroplasty2 and 21.64% for those who underwent total knee arthroplasty3. The reported 1-year mortality in these studies had an odds ratio of 3.58 for periprosthetic joint infection after total hip arthroplasty2 and 3.05 for periprosthetic joint infection after total knee arthroplasty3 compared with the national age-adjusted risk of mortality.

Included in the cost of health care and, in particular, periprosthetic infection is the cost of litigation. In a retrospective review of medical malpractice lawsuits in a 5-county area in the Northeast United States including 113 total joint surgeons, 27% (31 of 113) were named in at least 1 lawsuit. Infection was the top reason for such litigation, representing 26.5% of all lawsuits4.

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Prevention

Prevention of periprosthetic joint infection has been a topic of considerable interest4-6 with a focus on preoperative, intraoperative, and perioperative considerations. Optimization of patients’ comorbidities is important in the prevention of periprosthetic joint infection. In a meta-analysis study designed to determine the influence of a bariatric surgical procedure prior to arthroplasty, Li et al. found that a bariatric surgical procedure reduced short-term medical complications, length of stay, operative time, and short-term periprosthetic infection in the knees but not the hips. A bariatric surgical procedure did not reduce the long-term risk of infection or complications7. In a retrospective cohort, Castano-Betancourt et al. determined that patients with rheumatoid arthritis or ≥2 other defined comorbidities, such as diabetes and anemia, are at elevated risk for periprosthetic joint infection8. Previous work has demonstrated the importance of long-term glycemic control in the prevention of periprosthetic joint infection9. Recently, there has been interest in glucose control more proximate to a surgical procedure10. Concern has been raised with regard to dexamethasone administration in total joint arthroplasty in patients with diabetes. O’Connell et al. observed an association between dexamethasone administration and a significant increase in early postoperative blood glucose levels in patients with diabetes following total joint arthroplasty and advised that dexamethasone be used with caution in this population11. The association between preoperative dexamethasone and elevated postoperative blood glucose in patients with diabetes was confirmed in a separate study by Godshaw et al.; however, the study did not demonstrate a connection between dexamethasone and postoperative periprosthetic joint infection12.

The routine use of adjuvant antibiotic-laden cement in primary total joint arthroplasty has been called into question. In a meta-analysis, King et al. found that the use of antibiotic-laden cement did not reduce the risk of postoperative periprosthetic joint infection compared with regular cement but was associated with a significant increase in cost13.

Substantial attention has been dedicated to local irrigation solutions for the prevention of periprosthetic joint infection in primary total joint arthroplasty. In an in vitro study investigating commonly used solutions, Campbell et al. showed that the Dakin solution forms potentially toxic precipitates when mixed with hydrogen peroxide and chlorhexidine gluconate; the authors recommended that surgeons avoid mixing irrigation solutions in the wound during a surgical procedure14. Ernest et al. performed an in-depth, in vitro analysis to assess the efficacy of povidone-iodine, chlorhexidine, hydrogen peroxide, the Dakin solution, and chlorine dioxide in reducing adherent Staphylococcus aureus colonies on common orthopaedic materials. The authors showed that the most effective solutions were hydrogen peroxide, with a 97% reduction in colony-forming units (CFU)/cm2, and povidone-iodine, with a 98% reduction in CFU/cm2. However, these solutions did not eliminate bacteria completely, and the authors recommended continued pursuit of adjuvants to eliminate adherent bacteria during irrigation and debridement for periprosthetic joint infection15.

Efficiency and cleanliness in the surgical environment are critical for economic and clinical success in arthroplasty. Two studies demonstrated that prolonged surgical time is associated with the development of infection after total joint arthroplasty16,17. In another study addressing the effect of the operating room environment on periprosthetic joint infection, Vijaysegaran et al. showed that space suits are associated with increased particle and microbiological emission rates in a simulated operating room compared with standard operating room attire, calling into question the safety of routine space suit use during total joint arthroplasty18.

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Antimicrobial Treatment

Oral Antibiotics in Arthroplasty

A randomized controlled trial did not show that preoperative doxycycline reduced the prevalence of Cutibacterium acnes (formerly Propionibacterium acnes) on the skin and in the deep tissues at the time of periprosthetic joint implantation19. Debridement, antibiotics, and implant retention followed by chronic oral antibiotic suppression for acute total knee arthroplasty periprosthetic joint infection produced a 5-year infection-free survival of 66% in 1 small single-center study that lacked a control group20. A retrospective cohort study found that oral antibiotic prophylaxis for 7 days after a primary total knee arthroplasty or total hip arthroplasty in patients deemed at high risk for periprosthetic joint infection lowered the risk of periprosthetic joint infection21. However, the authors did not have a control group of high-risk patients and thus recommended the need for further study before widespread adoption of this protocol.

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Topical Vancomycin

Two meta-analyses evaluating the effect of intrawound vancomycin in spinal surgery found that the groups treated with vancomycin had a significantly lower risk of surgical site infection22,23. Two single-center studies demonstrated a lower rate of surgical site infection in patients who underwent primary arthroplasty with the use of intrawound vancomycin powder24,25. However, both studies were retrospective studies with historical controls. One of these studies24 was confounded by the concomitant use of a povidone-iodine solution, and both authors noted the need for further study. One other study demonstrated an increased rate of sterile wound complications in the vancomycin group26. These authors recommended against the use of vancomycin powder, stating that higher-powered studies were needed to demonstrate its efficacy.

Animal studies contributed to knowledge regarding the use of topical vancomycin. In a rat model of open contaminated fractures, reduced bacterial growth was observed in both antibiotic bead and vancomycin powder groups when compared with a control group who underwent debridement alone. There were no significant differences between the antibiotic bead and vancomycin powder groups27. In a rabbit model with fixation implants seeded with methicillin-resistant S. aureus (MRSA), the application of intraoperative vancomycin powder at the time of fixation decreased the risk of bone infection and biofilm formation28.

Given the retrospective, uncontrolled study designs and conflicting results, the issue of whether topical vancomycin is beneficial in preventing surgical site infection remains unresolved.

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Antibiotic Complications

There were several reports of complications of antibiotic use in orthopaedic patients, including red man syndrome and drug-induced linear immunoglobulin A (IgA) bullous dermatosis after the routine use of vancomycin-loaded bone cement29,30. Acute kidney injury requiring dialysis to lower toxic tobramycin levels after receipt of a vancomycin and tobramycin-impregnated cement spacers has also been reported31. A database review of 83,806 patients who underwent revision total knee arthroplasty due to periprosthetic joint infection found a 1.0% incidence of a Clostridioides difficile (formerly Clostridium difficile) infection after a revision total knee arthroplasty. A diagnosis of C. difficile infection was associated with longer length of stay, higher costs, and greater in-hospital mortality32.

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Intra-Articular Antibiotics

One study assessed local, plasma, and urine concentrations of a gentamicin or vancomycin-loaded mineral composite antibiotic carrier and found a low plasma concentration and high local concentration of both antibiotics. The results also indicated that a deep surgical drain may decrease the amount of antibiotic available for systemic absorption33. A small prospective study evaluated the concentrations of gentamicin and vancomycin from antibiotic-impregnated spacers in 2-stage revision arthroplasty, as well as in vitro. The antibiotic concentration in spacer cement decreased rapidly in vitro within the first 24 hours, but in vivo, antibiotics were present much longer in tissues34. Work on an improved antibiotic delivery system using a layer-by-layer technique to load gentamicin on nanoparticles blended into the powder of bone cement demonstrated longer antimicrobial activity when compared with control cement specimens35.

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Antibiotic Prophylaxis for Dental Procedures

In a survey of antibiotic-prescribing practices of dentists, 39% of respondents identified the presence of a prosthetic joint as a high-risk condition that required antibiotic prophylaxis. The dentists included in the survey reported greater antibiotic use than currently recommended by existing guidelines36.

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Diagnosis of Periprosthetic Joint Infection

Synovial Biomarkers

Renz et al.37 reported on a point-of-contact lateral flow test for synovial alpha-defensin that showed a sensitivity of 54% to 84% depending on the criteria defined by 3 different infection organizations. They concluded that, given the limited sensitivity and high specificity, this test should be used as a confirmatory test rather than as a screening test. Gehrke et al. also compared the accuracy of the laboratory-based quantitative enzyme-linked immunosorbent assay (ELISA) alpha-defensin test with the point-of-contact lateral flow test and found no significant difference in the diagnostic accuracy38. They also reported improved results using a similar methodology (n = 223), with a sensitivity of 92.1% and a specificity of 100%. In a systematic review and meta-analysis, Marson et al.39 noted that the point-of-contact lateral flow test had a lower pooled sensitivity (85%) than the laboratory-based alpha-defensin test pooled sensitivity (95%). The authors believed that these lower pooled results for the lateral flow test were only comparable with the leukocyte esterase test and that further study was necessary prior to widespread adaption.

The alpha-defensin biomarker has some limitations in certain cases. Stone et al.40 showed that alpha-defensin in combination with synovial C-reactive protein (CRP) had a high sensitivity for a periprosthetic joint infection diagnosis, but had false-positive results in the presence of metallosis or false-negative results in the presence of low-virulence organisms. Another group confirmed that alpha-defensin is prone to false-positive results in the presence of an adverse local tissue reaction41.

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Molecular Diagnosis and Sonication

Technical advances have decreased the cost of the molecular diagnosis of periprosthetic joint infection. Tarabichi et al.42,43 reported on the use of next-generation sequencing to identify pathogens in synovial fluid and tissue. They showed that cultures were positive in only 61% when compared with next-generation sequencing that identified a pathogen in 89.3% of the infected cases. However, next-generation sequencing also identified microbes in 25% of aseptic revisions with negative cultures and in 35.3% of primary total joint arthroplasties. Therefore, despite the increased yield of identifying pathogens in culture-negative cases, the identification of pathogens in what are currently identified as aseptic cases is a source of concern and needs further research. Similarly, Moshirabadi et al.44 reported on the use of polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) techniques to diagnose periprosthetic joint infection. They compared PCR-RFLP with cultures and found a sensitivity of 97.4% and a specificity of 100% for PCR-RFLP compared with a sensitivity of 31.6% and a specificity of 100% for cultures. In contrast, in another related study using PCR, Fink et al.45 reported limited operative characteristics of PCR in the diagnosis of periprosthetic joint infection, with a limited sensitivity of 55.6% and a specificity of 82%. However, the PCR techniques varied widely between studies, which can alter the number of false positives when standard PCR techniques are used. Another study showed that PCR results may vary depending on the source: synovial fluid compared with tissue or implant sonication. Sonicated fluid had the best diagnostic accuracy46.

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Reimplantation Criteria

The diagnosis of persistent periprosthetic joint infection after the placement of a cement spacer is challenging with minimal tools available to measure it. Kanwar et al.47 reported the potential use of alpha-defensin in combination with Musculoskeletal Infection Society criteria to predict the success of reimplantation. However, in 27 patients who had negative alpha-defensin results prior to reimplantation, 3 (11%) had a recurrent infection within 1 year.

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Treatment

Published research in 2018 continues to clarify the role of each of the 3 major treatment options for periprosthetic joint infection: irrigation and debridement, 2-stage exchange, and 1-stage exchange.

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Irrigation and Debridement

Irrigation and debridement with retention of components continued to show a high failure rate of 57% in a multicenter study for periprosthetic joint infection after total knee arthroplasty at 4 years48. Patients treated with irrigation and debridement with polyethylene exchange for periprosthetic joint infection within 2 weeks of the index arthroplasty had higher success rates (82%) when compared with those treated beyond 2 weeks (50%)49.

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Two-Stage Exchange

It is often assumed that 2-stage treatment is very successful. However, a recent study questioned the validity of that assumption. In a study of 80 patients who underwent a 2-stage procedure, 14 (17.5%) never underwent reimplantation, 24 (30%) had a serious complication, and of the 66 patients with a successful reimplantation, only 48 (73%) remained infection-free50. Additionally, 9 (11%) of 80 patients required a spacer exchange for persistent infection, 3 of whom underwent eventual failure. Spacer exchange due to persistent infection is not uncommon, occurring in 59 of 3,417 patients in another study, one-third of whom became reinfected within 5 years compared with one-fifth of patients without an interim spacer51. Similarly, if a 2-stage hip procedure fails requiring a repeat 2-stage hip procedure, a reinfection rate of 42% (8 of 19) was noted in a series of 19 patients52.

The optimal timing for reimplantation following placement of an antibiotic-loaded spacer remains elusive. Predicting which patients are at risk for failed treatment remains difficult. In a study of 205 patients who underwent a 2-stage procedure, 27% (56 of 205) had a recurrent periprosthetic joint infection. Failure was 1.8 to 2.5 times more likely if the preoperative synovial fluid white blood cell count was >60,000, a neutrophil percentage of >92%, or an erythrocyte sedimentation rate (ESR) of >99 mm per hour53. In a review of 81 infected knees, another group noted an 88% success rate at 4 years. They noted poor diagnostic values of ESR and CRP but found a frozen section to have a sensitivity of 90%, making it a good indicator of success or failure at the time of reimplantation50.

Articulating antibiotic spacers appear to be safe for interim treatment. In a series of 135 hips undergoing a 2-stage procedure with an articulating spacer, an 88% infection-free survivorship at 5 years was noted54. In another study, 23 patients underwent a temporary 2-stage knee revision using an articulating spacer made of a loosely cemented primary implant; of these patients, 1 patient died, 13 patients underwent re-revision, and, in 9 patients, the implant remained in situ. No infections were noted at a 3.5-year follow-up55.

The importance of treatment consolidation at a tertiary center was highlighted in a study regarding patients referred to a tertiary center after resection arthroplasty and placement of an antibiotic spacer. A high rate of retained foreign material was noted, requiring re-debridement in which persistently positive cultures were present in 41% of cases56.

Two-stage treatment with high-dose antibiotic spacers can result in nephrotoxicity. Serum antibiotic levels were collected in 21 patients with such spacers57. Systemic accumulation of antibiotics persisted for at least 8 weeks, and, thus, patients should be monitored for complications related to systemic absorption of antibiotics postoperatively.

Although the results of culture-negative periprosthetic joint infections after total hip arthroplasties were similar when compared with culture-positive infections58, polymicrobial and fungal infections are much more challenging to treat. Polymicrobial infections were associated with significantly lower treatment success compared with single-organism infections59, and the overall success for fungal infections at 5 years was 29% for irrigation and debridement and 46% for 2-stage exchange60. Acute kidney injury requiring dialysis to lower toxic tobramycin levels after spacer placement has been reported31.

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One-Stage Exchange

However, in a recent European study of 22 patients using antibacterial hydrogel-coated implants, 1-stage treatment showed results at 2.5 years that were similar to a 2-stage group without a coating61. Additionally, as noted previously, a decision-tree analysis found greater health utility while being more cost-effective when a 1-stage treatment strategy was utilized62.

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Spine

Although magnetic resonance imaging (MRI) remains the most common radiographic technique for diagnosis of infection of the native spine, a fluorodeoxyglucose positron emission tomography (PET) scan may offer similar sensitivity and specificity and allows for the evaluation of sites of metastatic infection63. There appears to be a high degree of concordance between blood and spine biopsy cultures, not only in patients with S. aureus bloodstream infection and infection of the native spine, but also in those in whom the infection involves other organisms64. Among patients who require operative intervention for spinal infection, the ideal operative strategy is uncertain. A single-stage posterior approach or a 2-stage anterior and posterior approach was associated with similar clinical outcomes in patients with bacterial infection65. A single-stage approach may also be an option for selected patients with an infection due to Mycobacterium tuberculosis66-68 and Brucella species69.

Although infection associated with spinal instrumentation infection occurs most often in the first 3 months after the surgical procedure70, the consequences of deep infection may be long-lasting. An observational cohort study found that spinal instrumentation infection was an independent risk factor for unsuccessful fusion after instrumented lumbar spine surgery, resulting in a >12-fold increase in risk of unsuccessful fusion71. The accurate identification of patients at high risk for infection after spinal instrumentation remains difficult. A previously published prediction model performed poorly in a subsequent study72, and the Revised Cardiac Risk Index demonstrated an inferior discriminative ability compared with the American Society of Anesthesiologists (ASA) score73. A large cohort study of patients with S. aureus infection after spinal instrumentation demonstrated a failure rate of 36% for revision procedures to eradicate the infection. Debridement with retention of the implants and infection with MRSA were independently associated with treatment failure, and the use of rifampin-based combination therapy had a protective effect74.

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Trauma

Although infection after fracture fixation is a feared complication, a systematic review found no standardized definition, which hampers the study of this problem75. The risk of infection after fracture fixation is higher than that of infection following elective clean orthopaedic surgery, with rates of infection after fracture fixation ranging from 2% to 8% after operative fixation of an ankle fracture76,77, a high-energy femoral fracture78, and a closed tibial plateau fracture79. Reported risk factors for infection after fracture fixation were similar to those previously reported, including obesity76,77,79, diabetes76, open fracture76,77, high ASA score76, high-energy mechanism of fracture76,77, prolonged surgical duration79, smoking79, increased age77, and lack of antimicrobial prophylaxis76. In a retrospective study that used propensity score analysis, the ultimate rate of fracture union did not differ between patients treated with primary intramedullary nailing compared with a 2-stage approach initially using external fixation for high-energy femoral fractures78.

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Hand

Any open fracture presents a risk for infection. However, a systematic review found that the infection rate for upper-extremity open fractures is lower than that commonly reported for lower-extremity open fractures80. The authors concluded that prompt administration of empiric antimicrobials and urgent debridement and treatment of open upper-extremity fractures are both important components to prevent infection. A prospective cohort study of hand infections requiring operative intervention found that patients with diabetes were more likely to have deep infections, require repeat intervention, and require eventual amputation, compared with patients without diabetes81. A 4-year, single-center, cohort study of flexor tenosynovitis observed that staphylococcal and streptococcal infection predominated, and 90% of patients required >1 surgical debridement82. Among patients with upper-extremity nontuberculous mycobacterial infections, outcomes were similar between immunocompetent patients and immunocompromised patients, and a delay of diagnosis of >4 months was associated with a more than fourfold risk of treatment failure83.

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Pediatrics

A multicenter, retrospective study of infections of the native spine in pediatric patients found that S. aureus was the most common pathogen, but that Kingella kingae continues to be important among patients who are 6 months to 4 years of age84. The risk of osteoarticular infection with K. kingae, a commensal organism in the oropharynx of young children, was significantly associated with the incidence of human rhinovirus infection, but not other community respiratory viral infections, supporting a postulated pathophysiologic mechanism85. Compared with children with methicillin-susceptible S. aureus (MSSA) infection, children with MRSA osteoarticular infection have more surgical procedures, more complications, longer hospital stays, and more frequent intensive care unit admissions86,87. Dexamethasone may have a role as an adjunctive therapy for pediatric septic arthritis, based on a meta-analysis of 3 randomized controlled trials and 1 cohort study88.

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Conclusions

The prevention, diagnosis, and treatment of musculoskeletal infection remain challenging. Preoperative patient optimization and vigilance with regard to sterile technique are essential components of infection prevention. A high index of suspicion for the possibility of infection is critical when a patient with painful musculoskeletal symptoms presents, and the appropriate use of the currently available diagnostic tools is important for the clinician to fully understand. Prompt intervention using evidence-based treatment guidelines should maximize results.

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Evidence-Based Orthopaedics

The editorial staff of The Journal reviewed a large number of recently published studies related to the musculoskeletal system that received a higher Level of Evidence grade. In addition to articles cited already in this update, 4 other articles with a higher Level of Evidence grade relevant to musculoskeletal infection are appended to this review after the standard bibliography, with a brief commentary about each article to help guide your further reading, in an evidence-based fashion, in this subspecialty area.

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Evidence-Based Orthopaedics

Löwik CAM, Jutte PC, Tornero E, Ploegmakers JJW, Knobben BAS, de Vries AJ, Zijlstra WP, Dijkstra B, Soriano A, Wouthuyzen-Bakker M; Northern Infection Network Joint Arthroplasty (NINJA). Predicting failure in early acute prosthetic joint infection treated with debridement, antibiotics, and implant retention: external validation of the KLIC score. J Arthroplasty. 2018 Aug;33(8):2582-7. Epub 2018 Mar 27.

Irrigation and debridement is a commonly used treatment for acute periprosthetic joint infection; however, results are variable. A risk score was developed to predict the success of irrigation and debridement in periprosthetic joint infection, consisting of renal failure, cirrhosis, the index surgical procedure, a cemented prosthesis, and a CRP of >115 mg/L. However, it had an area under the curve of only 0.64; in comparison, the original study describing this risk score had an area under the curve of 0.84. Unfortunately, an instrument to consistently predict outcomes in a procedure that has variable results remains lacking.

Partridge DG, Winnard C, Townsend R, Cooper R, Stockley I. Joint aspiration, including culture of reaspirated saline after a ‘dry tap’, is sensitive and specific for the diagnosis of hip and knee prosthetic joint infection. Bone Joint J. 2018 Jun 1;100-B(6):749-54.

The purpose of this study was to evaluate the practice of injecting saline solution into an aspirated joint that initially was without fluid. Using intraoperative tissue cultures as the gold standard for infection, for 313 wet aspirations, the sensitivity was 81% and the specificity was 90%; saline solution-injected dry aspirates had 81% sensitivity and 79% specificity. The sensitivity of dry taps is surprising in light of the conventional belief that injecting saline risks contamination and that joints without fluid are rarely infected.

Parvizi J, Tan TL, Goswami K, Higuera C, Della Valle C, Chen AF, Shohat N. The 2018 definition of periprosthetic hip and knee infection: an evidence-based and validated criteria. J Arthroplasty. 2018 May;33(5):1309-1314.e2. Epub 2018 Feb 26.

This study evaluated a more comprehensive definition of periprosthetic joint infection using 11 different diagnostic variables. Assigning points to each variable, they found that the new definition correlated 100% with the current major criteria from the Musculoskeletal Infection Society definition of periprosthetic joint infection. Concerns about complexity, the availability of alpha defensin, and the weighting of individual variables will limit widespread acceptance of this definition.

Zahar A, Lausmann C, Cavalheiro C, Dhamangaonkar AC, Bonanzinga T, Gehrke T, Citak M. How reliable is the cell count analysis in the diagnosis of prosthetic joint infection? J Arthroplasty. 2018 Oct;33(10):3257-62. Epub 2018 May 17.

Cell counts and polymorphonuclear cell percentages are sensitive methods for diagnosing periprosthetic joint infection. Although polymorphonuclear percentages are similar between hips and knees, the cutoff levels for cell counts may be somewhat different. The best cutoff levels for all patients with periprosthetic joint infection were 2,500 leukocytes/µL and a polymorphonuclear percentage of 66%. Elevated cell counts with a high percentage of polymorphonuclear cells have been a useful to diagnose periprosthetic joint infection. Although multiple attempts have been made to determine an exact cutoff, such efforts should be used only as a general guide without a focus on an exact number.

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References

1. Kurtz SM, Lau EC, Son MS, Chang ET, Zimmerli W, Parvizi J. Are we winning or losing the battle with periprosthetic joint infection: trends in periprosthetic joint infection and mortality risk for the Medicare population. J Arthroplasty. 2018 Oct;33(10):3238-45. Epub 2018 Jun 1.
2. Natsuhara KM, Shelton TJ, Meehan JP, Lum ZC. Mortality during total hip periprosthetic joint infection. J Arthroplasty. 2018 Dec 24:S0883-5403(18)31225-7. [Epub ahead of print].
3. Lum ZC, Natsuhara KM, Shelton TJ, Giordani M, Pereira GC, Meehan JP. Mortality during total knee periprosthetic joint infection. J Arthroplasty. 2018 Dec;33(12):3783-3. Epub 2018 Aug 25.
4. Kheir MM, Rondon AJ, Woolsey A, Hansen H, Tan TL, Parvizi J. Infection following total joint arthroplasty is the main cause of litigation: data from one metropolitan area. J Arthroplasty. 2018 May;33(5):1520-3. Epub 2017 Dec 14.
5. Alamanda VK, Springer BD. The prevention of infection: 12 modifiable risk factors. Bone Joint J. 2019 Jan;101-B(1_Supple_A):3-9.
6. Papas PV, Congiusta D, Scuderi GR, Cushner FD. A modern approach to preventing prosthetic joint infections. J Knee Surg. 2018 Aug;31(7):610-7. Epub 2018 Feb 28.
7. Li S, Luo X, Sun H, Wang K, Zhang K, Sun X. Does prior bariatric surgery improve outcomes following total joint arthroplasty in the morbidly obese? A meta-analysis. J Arthroplasty. 2019 Mar;34(3):577-85. Epub 2018 Nov 20.
8. Castano-Betancourt MC, Fruschein Annichino R, de Azevedo E Souza Munhoz M, Gomes Machado E, Lipay MV, Marchi E. Identification of high-risk groups for complication after arthroplasty: predictive value of patient’s related risk factors. J Orthop Surg Res. 2018 Dec 29;13(1):328.
9. Suleiman LI, Mesko DR, Nam D. Intraoperative considerations for treatment/prevention of prosthetic joint infection. Curr Rev Musculoskelet Med. 2018 Sep;11(3):401-8.
10. Stryker LS, Abdel MP, Morrey ME, Morrow MM, Kor DJ, Morrey BF. Elevated postoperative blood glucose and preoperative hemoglobin A1C are associated with increased wound complications following total joint arthroplasty. J Bone Joint Surg Am. 2013 May 1;95(9):808-14: S1-2.
11. O’Connell RS, Clinger BN, Donahue EE, Celi FS, Golladay GJ. Dexamethasone and postoperative hyperglycemia in diabetics undergoing elective hip or knee arthroplasty: a case control study in 238 patients. Patient Saf Surg. 2018 Nov 5;12:30.
12. Godshaw BM, Mehl AE, Shaffer JG, Meyer MS, Thomas LC, Chimento GF. The effects of peri-operative dexamethasone on patients undergoing total hip or knee arthroplasty: is it safe for diabetics? J Arthroplasty. 2019 Apr;34(4):645-9. Epub 2018 Dec 18.
13. King JD, Hamilton DH, Jacobs CA, Duncan ST. The hidden cost of commercial antibiotic-loaded bone cement: a systematic review of clinical results and cost implications following total knee arthroplasty. J Arthroplasty. 2018 Dec;33(12):3789-92. Epub 2018 Aug 13.
14. Campbell ST, Goodnough LH, Bennett CG, Giori NJ. Antiseptics commonly used in total joint arthroplasty interact and may form toxic products. J Arthroplasty. 2018 Mar;33(3):844-6. Epub 2017 Nov 11.
15. Ernest EP, Machi AS, Karolcik BA, LaSala PR, Dietz MJ. Topical adjuvants incompletely remove adherent Staphylococcus aureus from implant materials. J Orthop Res. 2018 Jun;36(6):1599-604. Epub 2017 Nov 30.
16. Teo BJX, Yeo W, Chong HC, Tan AHC. Surgical site infection after primary total knee arthroplasty is associated with a longer duration of surgery. J Orthop Surg (Hong Kong). 2018 May-Aug;26(2):2309499018785647.
17. Anis HK, Sodhi N, Klika AK, Mont MA, Barsoum WK, Higuera CA, Molloy RM. Is operative time a predictor for post-operative infection in primary total knee arthroplasty? J Arthroplasty. 2018 Nov 22:S0883-5403(18)31150-1. [Epub ahead of print].
18. Vijaysegaran P, Knibbs LD, Morawska L, Crawford RW. Surgical space suits increase particle and microbiological emission rates in a simulated surgical environment. J Arthroplasty. 2018 May;33(5):1524-9.
19. Rao AJ, Chalmers PN, Cvetanovich GL, O’Brien MC, Newgren JM, Cole BJ, Verma NN, Nicholson GP, Romeo AA. Preoperative doxycycline does not reduce propionibacterium acnes in shoulder arthroplasty. J Bone Joint Surg Am. 2018 Jun 6;100(11):958-64.
20. Weston JT, Watts CD, Mabry TM, Hanssen AD, Berry DJ, Abdel MP. Irrigation and debridement with chronic antibiotic suppression for the management of infected total knee arthroplasty: a contemporary analysis. Bone Joint J. 2018 Nov;100-B(11):1471-6.
21. Inabathula A, Dilley JE, Ziemba-Davis M, Warth LC, Azzam KA, Ireland PH, Meneghini RM. Extended oral antibiotic prophylaxis in high-risk patients substantially reduces primary total hip and knee arthroplasty 90-day infection rate. J Bone Joint Surg Am. 2018 Dec 19;100(24):2103-9.
22. Tailaiti A, Shang J, Shan S, Muheremu A. Effect of intrawound vancomycin application in spinal surgery on the incidence of surgical site infection: a meta-analysis. Ther Clin Risk Manag. 2018 Oct 31;14:2149-59.
23. Texakalidis P, Lu VM, Yolcu Y, Kerezoudis P, Alvi MA, Parney IF, Fogelson JL, Bydon M. Impact of powdered vancomycin on preventing surgical site infections in neurosurgery: a systematic review and meta-analysis. Neurosurgery. 2019 Mar 1;84(3):569-80.
24. Patel NN, Guild GN 3rd, Kumar AR. Intrawound vancomycin in primary hip and knee arthroplasty: a safe and cost-effective means to decrease early periprosthetic joint infection. Arthroplast Today. 2018 Sep18;4(4):479-83.
25. Winkler C, Dennison J, Wooldridge A, Larumbe E, Caroom C, Jenkins M, Brindley G. Do local antibiotics reduce periprosthetic joint infections? A retrospective review of 744 cases. J Clin Orthop Trauma. 2018 Mar;9(Suppl 1):S34-9. Epub 2017 Aug 24.
26. Dial BL, Lampley AJ, Green CL, Hallows R. Intrawound vancomycin powder in primary total hip arthroplasty increases rate of sterile wound complications. Hip Pelvis. 2018 Mar;30(1):37-44. Epub 2018 Mar 5.
27. Caroom C, Moore D, Mudaliar N, Winkler C, Murphree J, Ratheal I, Fry M, Jenkins M, Tullar J, Hamood A. Intrawound vancomycin powder reduces bacterial load in contaminated open fracture model. J Orthop Trauma. 2018 Oct;32(10):538-41.
28. Hovis JP, Montalvo R, Marinos D, Joshi M, Shirtliff ME, OʼToole RV, Manson TT, OʼToole RV, Manson TT. Intraoperative vancomycin powder reduces Staphylococcus aureus surgical site infections and biofilm formation on fixation implants in a rabbit model. J Orthop Trauma. 2018 May;32(5):263-8.
29. Chen CT, Ng KJ, Lin Y, Kao MC. Red man syndrome following the use of vancomycin-loaded bone cement in the primary total knee replacement: a case report. Medicine (Baltimore). 2018 Dec;97(51):e13371.
30. Riemenschneider K, Diiorio DA, Zic JA, Livingood MR, Fine JD, Powers JG, Zwerner JP, Tkaczyk E. Drug-induced linear IgA bullous dermatosis in a patient with a vancomycin-impregnated cement spacer. Cutis. 2018 Apr;101(4):293-6.
31. Salim SA, Everitt J, Schwartz A, Agarwal M, Castenada J, Fülöp T, Juncos LA. Aminoglycoside impregnated cement spacer precipitating acute kidney injury requiring hemodialysis. Semin Dial. 2018 Jan;31(1):88-93. Epub 2017 Jul 31.
32. Gwam CU, George NE, Etcheson JI, Tarazi JM, Han GR, Griffith KME, Mont MA, Delanois RE. Clostridium difficile infection in the USA: incidence and associated factors in revision total knee arthroplasty patients. Eur J Orthop Surg Traumatol. 2019 Apr;29(3):667-74. Epub 2018 Oct 22.
33. Colding-Rasmussen T, Horstmann P, Petersen MM, Hettwer W. Antibiotic elution characteristics and pharmacokinetics of gentamicin and vancomycin from a mineral antibiotic carrier: an in vivo evaluation of 32 clinical cases. J Bone Jt Infect. 2018 Oct 20;3(4):234-40.
34. Klinder A, Zaatreh S, Ellenrieder M, Redanz S, Podbielski A, Reichel T, Bösebeck H, Mittelmeier W, Bader R. Antibiotics release from cement spacers used for two-stage treatment of implant-associated infections after total joint arthroplasty. J Biomed Mater Res B Appl Biomater. 2018 Oct 12. [Epub ahead of print].
35. Al Thaher Y, Yang L, Jones SA, Perni S, Prokopovich P. LbL-assembled gentamicin delivery system for PMMA bone cements to prolong antimicrobial activity. PLoS One. 2018 Dec 13;13(12):e0207753.
36. Tomczyk S, Whitten T, Holzbauer SM, Lynfield R. Combating antibiotic resistance: a survey on the antibiotic-prescribing habits of dentists. Gen Dent. 2018 Sep-Oct;66(5):61-8.
37. Renz N, Yermak K, Perka C, Trampuz A. Alpha defensin lateral flow test for diagnosis of periprosthetic joint infection: not a screening but a confirmatory test. J Bone Joint Surg Am. 2018 May 2;100(9):742-50.
38. Gehrke T, Lausmann C, Citak M, Bonanzinga T, Frommelt L, Zahar A. The accuracy of the alpha defensin lateral flow device for diagnosis of periprosthetic joint infection: comparison with a gold standard. J Bone Joint Surg Am. 2018 Jan 3;100(1):42-8.
39. Marson BA, Deshmukh SR, Grindlay DJC, Scammell BE. Alpha-defensin and the Synovasure lateral flow device for the diagnosis of prosthetic joint infection: a systematic review and meta-analysis. Bone Joint J. 2018 Jun 1;100-B(6):703-11.
40. Stone WZ, Gray CF, Parvataneni HK, Al-Rashid M, Vlasak RG, Horodyski M, Prieto HA. Clinical evaluation of synovial alpha defensin and synovial C-reactive protein in the diagnosis of periprosthetic joint infection. J Bone Joint Surg Am. 2018 Jul 18;100(14):1184-90.
41. Okroj KT, Calkins TE, Kayupov E, Kheir MM, Bingham JS, Beauchamp CP, Parvizi J, Della Valle CJ. The alpha-defensin test for diagnosing periprosthetic joint infection in the setting of an adverse local tissue reaction secondary to a failed metal-on-metal bearing or corrosion at the head-neck junction. J Arthroplasty. 2018 Jun;33(6):1896-8. Epub 2018 Jan 16.
42. Tarabichi M, Shohat N, Goswami K, Parvizi J. Can next generation sequencing play a role in detecting pathogens in synovial fluid? Bone Joint J. 2018 Feb;100-B(2):127-33.
43. Tarabichi M, Shohat N, Goswami K, Alvand A, Silibovsky R, Belden K, Parvizi J. Diagnosis of periprosthetic joint infection: the potential of next-generation sequencing. J Bone Joint Surg Am. 2018 Jan 17;100(2):147-54.
44. Moshirabadi A, Razi M, Arasteh P, Sarzaeem MM, Ghaffari S, Aminiafshar S, Hosseinian Khosroshahy K, Sheikholeslami FM. Polymerase chain reaction assay using the restriction fragment length polymorphism technique in the detection of prosthetic joint infections: a multi-centered study. J Arthroplasty. 2019 Feb;34(2):359-64. Epub 2018 Oct 25.
45. Fink B, Steurer M, Hofäcker S, Schäfer P, Sandow D, Schuster P, Oremek D. Preoperative PCR analysis of synovial fluid has limited value for the diagnosis of periprosthetic joint infections of total knee arthroplasties. Arch Orthop Trauma Surg. 2018 Jun;138(6):871-8. Epub 2018 Apr 4.
46. Huang Z, Wu Q, Fang X, Li W, Zhang C, Zeng H, Wang Q, Lin J, Zhang W. Comparison of culture and broad-range polymerase chain reaction methods for diagnosing periprosthetic joint infection: analysis of joint fluid, periprosthetic tissue, and sonicated fluid. Int Orthop. 2018 Sep;42(9):2035-40. Epub 2018 Feb 11.
47. Kanwar S, Al-Mansoori AA, Chand MR, Villa JM, Suarez JC, Patel PD. What is the optimal criteria to use for detecting periprosthetic joint infections before total joint arthroplasty? J Arthroplasty. 2018 Jul;33(7S):S201-4. Epub 2018 Feb 26.
48. Urish KL, Bullock AG, Kreger AM, Shah NB, Jeong K, Rothenberger SD; Infected Implant Consortium. A multicenter study of irrigation and debridement in total knee arthroplasty periprosthetic joint infection: treatment failure is high. J Arthroplasty. 2018 Apr;33(4):1154-9. Epub 2017 Nov 21.
49. Narayanan R, Anoushiravani AA, Elbuluk AM, Chen KK, Adler EM, Schwarzkopf R. Irrigation and debridement for early periprosthetic knee infection: is it effective? J Arthroplasty. 2018 Jun;33(6):1872-8. Epub 2018 Jan 9.
50. Ford AN, Holzmeister AM, Rees HW, Belich PD. Characterization of outcomes of 2-stage exchange arthroplasty in the treatment of prosthetic joint infections. J Arthroplasty. 2018 Jul;33(7S):S224-7. Epub 2018 Feb 17.
51. George J, Miller EM, Curtis GL, Klika AK, Barsoum WK, Mont MA, Higuera CA. Success of two-stage reimplantation in patients requiring an interim spacer exchange. J Arthroplasty. 2018 Jul;33(7S):S228-32. Epub 2018 Mar 23.
52. Brown TS, Fehring KA, Ollivier M, Mabry TM, Hanssen AD, Abdel MP. Repeat two-stage exchange arthroplasty for prosthetic hip re-infection. Bone Joint J. 2018 Sep;100-B(9):1157-61.
53. Dwyer MK, Damsgaard C, Wadibia J, Wong G, Lazar D, Smith E, Talmo C, Bedair H. Laboratory tests for diagnosis of chronic periprosthetic joint infection can help predict outcomes of two-stage exchange. J Bone Joint Surg Am. 2018 Jun 20;100(12):1009-15.
54. Chalmers BP, Mabry TM, Abdel MP, Berry DJ, Hanssen AD, Perry KI. Two-stage revision total hip arthroplasty with a specific articulating antibiotic spacer design: reliable periprosthetic joint infection eradication and functional improvement. J Arthroplasty. 2018 Dec;33(12):3746-53. Epub 2018 Aug 27.
55. Marson BA, Walters ST, Bloch BV, Sehat K. Two-stage revision surgery for infected total knee replacements: reasonable function and high success rate with the use of primary knee replacement implants as temporary spacers. Eur J Orthop Surg Traumatol. 2018 Jan;28(1):109-15. Epub 2017 Aug 5.
56. Perry KI, Sproul RC, Sierra RJ, Abdel MP, Fehring TK, Hanssen AD. High rate of positive cultures in patients referred with antibiotic spacers as part of 2-stage exchange. J Arthroplasty. 2018 Jul;33(7):2230-3. Epub 2018 Feb 21.
57. Edelstein AI, Okroj KT, Rogers T, Della Valle CJ, Sporer SM. Systemic absorption of antibiotics from antibiotic-loaded cement spacers for the treatment of periprosthetic joint infection. J Arthroplasty. 2018 Mar;33(3):835-9. Epub 2017 Oct 5.
58. Ibrahim MS, Twaij H, Haddad FS. Two-stage revision for the culture-negative infected total hip arthroplasty: a comparative study. Bone Joint J. 2018 Jan;100-B(1)(Supple A):3-8.
59. Kavolus JJ, Cunningham DJ, Rao SR, Wellman SS, Seyler TM. Polymicrobial infections in hip arthroplasty: lower treatment success rate, increased surgery, and longer hospitalization. J Arthroplasty. 2019 Apr;34(4):710-716.e3. Epub 2018 Oct 9.
60. Kuo FC, Goswami K, Shohat N, Blevins K, Rondon AJ, Parvizi J. Two-stage exchange arthroplasty is a favorable treatment option upon diagnosis of a fungal periprosthetic joint infection. J Arthroplasty. 2018 Nov;33(11):3555-60. Epub 2018 Aug 1.
61. Capuano N, Logoluso N, Gallazzi E, Drago L, Romanò CL. One-stage exchange with antibacterial hydrogel coated implants provides similar results to two-stage revision, without the coating, for the treatment of peri-prosthetic infection. Knee Surg Sports Traumatol Arthrosc. 2018 Nov;26(11):3362-7. Epub 2018 Mar 16.
62. Brochin RL, Phan K, Poeran J, Zubizarreta N, Galatz LM, Moucha CS. Trends in periprosthetic hip infection and associated costs: a population-based study assessing the impact of hospital factors using national data. J Arthroplasty. 2018 Jul;33(7S)(Supplement):S233-8. Epub 2018 Feb 22.
63. Kouijzer IJE, Scheper H, de Rooy JWJ, Bloem JL, Janssen MJR, van den Hoven L, Hosman AJF, Visser LG, Oyen WJG, Bleeker-Rovers CP, de Geus-Oei LF. The diagnostic value of 18F-FDG-PET/CT and MRI in suspected vertebral osteomyelitis - a prospective study. Eur J Nucl Med Mol Imaging. 2018 May;45(5):798-805. Epub 2017 Dec 19.
64. Bae JY, Kim CJ, Kim UJ, Song KH, Kim ES, Kang SJ, Oh MD, Park KH, Kim NJ. Concordance of results of blood and tissue cultures from patients with pyogenic spondylitis: a retrospective cohort study. Clin Microbiol Infect. 2018 Mar;24(3):279-82. Epub 2017 Jul 8.
65. von der Hoeh NH, Voelker A, Hofmann A, Zajonz D, Spiegl UA, Jarvers JS, Heyde CE. Pyogenic spondylodiscitis of the thoracic spine: outcome of 1-stage posterior versus 2-stage posterior and anterior spinal reconstruction in adults. World Neurosurg. 2018 Dec;120:e297-303. Epub 2018 Aug 23.
66. Zhou Y, Li W, Liu J, Gong L, Luo J. Comparison of single posterior debridement, bone grafting and instrumentation with single-stage anterior debridement, bone grafting and posterior instrumentation in the treatment of thoracic and thoracolumbar spinal tuberculosis. BMC Surg. 2018 Sep 3;18(1):71.
67. Wu W, Lyu J, Liu X, Luo F, Hou T, Zhou Q, Li Z, Chen Y, Li LT, Zheng Y, Wang G, Xu J, Zhang Z. Surgical treatment of thoracic spinal tuberculosis: a multicenter retrospective study. World Neurosurg. 2018 Feb;110:e842-50. Epub 2017 Dec 6.
68. Yin XH, He BR, Liu ZK, Hao DJ. The clinical outcomes and surgical strategy for cervical spine tuberculosis: a retrospective study in 78 cases. Medicine (Baltimore). 2018 Jul;97(27):e11401.
69. Yin XH, Liu ZK, He BR, Hao DJ. One-stage surgical management for lumber Brucella spondylitis with anterior debridement, autogenous graft, and instrumentation. Medicine (Baltimore). 2018 Jul;97(30):e11704.
70. Daniels AH, Bess S, Line B, Eltorai AEM, Reid DBC, Lafage V, Akbarnia BA, Ames CP, Boachie-Adjei O, Burton DC, Deviren V, Kim HJ, Hart RA, Kebaish KM, Klineberg EO, Gupta M, Mundis GM Jr, Hostin RA Jr, O’Brien M, Schwab FJ, Shaffrey CI, Smith JS; International Spine Study Group Foundation. Peak timing for complications after adult spinal deformity surgery. World Neurosurg. 2018 Jul;115:e509-15. Epub 2018 Apr 22.
71. Andrés-Cano P, Cerván A, Rodríguez-Solera M, Antonio Ortega J, Rebollo N, Guerado E. Surgical infection after posterolateral lumbar spine arthrodesis: CT analysis of spinal fusion. Orthop Surg. 2018 May;10(2):89-97. Epub 2018 May 16.
72. Janssen DMC, van Kuijk SMJ, d’Aumerie BB, Willems PC. External validation of a prediction model for surgical site infection after thoracolumbar spine surgery in a Western European cohort. J Orthop Surg Res. 2018 May 16;13(1):114.
73. Bronheim RS, Oermann EK, Bronheim DS, Caridi JM. Revised cardiac risk index versus ASA status as a predictor for noncardiac events after posterior lumbar decompression. World Neurosurg. 2018 Dec;120:e1175-84. Epub 2018 Sep 12.
74. Cho OH, Bae IG, Moon SM, Park SY, Kwak YG, Kim BN, Yu SN, Jeon MH, Kim T, Choo EJ, Lee EJ, Kim TH, Choi SH, Chung JW, Kang KC, Lee JH, Lee YM, Lee MS, Park KH. Therapeutic outcome of spinal implant infections caused by Staphylococcus aureus: a retrospective observational study. Medicine (Baltimore). 2018 Oct;97(40):e12629.
75. Metsemakers WJ, Kortram K, Morgenstern M, Moriarty TF, Meex I, Kuehl R, Nijs S, Richards RG, Raschke M, Borens O, Kates SL, Zalavras C, Giannoudis PV, Verhofstad MHJ. Definition of infection after fracture fixation: a systematic review of randomized controlled trials to evaluate current practice. Injury. 2018 Mar;49(3):497-504. Epub 2017 Feb 20.
76. Shao J, Zhang H, Yin B, Li J, Zhu Y, Zhang Y. Risk factors for surgical site infection following operative treatment of ankle fractures: a systematic review and meta-analysis. Int J Surg. 2018 Aug;56:124-32. Epub 2018 Jun 18.
77. Sun Y, Wang H, Tang Y, Zhao H, Qin S, Xu L, Xia Z, Zhang F. Incidence and risk factors for surgical site infection after open reduction and internal fixation of ankle fracture: a retrospective multicenter study. Medicine (Baltimore). 2018 Feb;97(7):e9901.
78. Dingemans SA, Sier MAT, Peters RW, Goslings JC, Schepers T. Two-stage treatment in patients with patients with high-energy femoral fractures does not lead to an increase in deep infectious complications: a propensity score analysis. Eur J Trauma Emerg Surg. 2018 Feb;44(1):125-31. Epub 2017 Jul 28.
79. Ma Q, Aierxiding A, Wang G, Wang C, Yu L, Shen Z. Incidence and risk factors for deep surgical site infection after open reduction and internal fixation of closed tibial plateau fractures in adults. Int Wound J. 2018 Apr;15(2):237-42. Epub 2017 Nov 29.
80. Warrender WJ, Lucasti CJ, Chapman TR, Ilyas AM. Antibiotic management and operative debridement in open fractures of the hand and upper extremity: a systematic review. Hand Clin. 2018 Feb;34(1):9-16.
81. Sharma K, Pan D, Friedman J, Yu JL, Mull A, Moore AM. Quantifying the effect of diabetes on surgical hand and forearm infections. J Hand Surg Am. 2018 Feb;43(2):105-14. Epub 2017 Dec 12.
82. Mamane W, Lippmann S, Israel D, Ramdhian-Wihlm R, Temam M, Mas V, Pierrart J, Masmejean EH. Infectious flexor hand tenosynovitis: state of knowledge. A study of 120 cases. J Orthop. 2018 May 12;15(2):701-6.
83. Sotello D, Garner HW, Heckman MG, Diehl NN, Murray PM, Alvarez S. Nontuberculous mycobacterial infections of the upper extremity: 15-year experience at a tertiary care medical center. J Hand Surg Am. 2018 Apr;43(4):387.e1-8. Epub 2017 Dec 6.
84. Dayer R, Alzahrani MM, Saran N, Ouellet JA, Journeau P, Tabard-Fougère A, Martinez-Álvarez S, Ceroni D. Spinal infections in children: a multicentre retrospective study. Bone Joint J. 2018 Apr 1;100-B(4):542-8.
85. Droz N, Enouf V, Bidet P, Mohamed D, Behillil S, Simon AL, Bachy M, Caseris M, Bonacorsi S, Basmaci R. Temporal association between rhinovirus activity and Kingella kingae osteoarticular infections. J Pediatr. 2018 Jan;192:234-239.e2.
86. Davis WT, Gilbert SR. Comparison of methicillin-resistant versus susceptible Staphylococcus aureus pediatric osteomyelitis. J Pediatr Orthop. 2018 May/Jun;38(5):e285-91.
87. Bouras D, Doudoulakakis A, Tsolia M, Vaki I, Giormezis N, Petropoulou N, Lebessi E, Gennimata V, Tsakris A, Spiliopoulou I, Michos A. Staphylococcus aureus osteoarticular infections in children: an 8-year review of molecular microbiology, antibiotic resistance and clinical characteristics. J Med Microbiol. 2018 Dec;67(12):1753-60. Epub 2018 Oct 23.
88. Qin YF, Li ZJ, Li H. Corticosteroids as adjunctive therapy with antibiotics in the treatment of children with septic arthritis: a meta-analysis. Drug Des Devel Ther. 2018 Jul 23;12:2277-84.

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