Carlos A. Higuera

Aims: Periprosthetic joint infection (PJI) remains one of the most devastating complications following total joint arthroplasty associated with high mortality rate. While treatment success has traditionally been defined by infection eradication and implant survivorship, growing evidence suggests that PJI is associated with substantial psychological morbidity and diminished health-related quality of life. This review aims to systematically evaluate the current literature regarding mental health outcomes following treatment for PJI. Methods: A systematic literature review was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. PubMed, MEDLINE, Embase, and Cochrane Library databases were searched for studies reporting anxiety, depression, validated patient-reported mental health or quality-of-life outcomes following treatment for PJI. Studies reporting depression, anxiety, or mental health-related patient-reported outcome measures (PROMs), including SF-12, SF-36, EQ-5D, and PROMIS, were included. Study characteristics, outcome measures, and psychological outcomes were extracted and qualitatively synthesized. Out of 1,364 screened studies, 64 were included in this review. Results: The most used PROM form was SF-12 (n=24 studies), while the most investigated surgical procedure was two-stage exchange (n=37). Through multiple studies utilizing validated PROM instruments, patients undergoing treatment for PJI consistently demonstrated a trend towards worse mental health compared to the general population (n=5), primary arthroplasty (n=8) and aseptic revision (n=8) cohorts. Reported prevalence of depression ranged from 27 to 36%, and anxiety prevalence reaching up to 29.50%. A two-stage revision arthroplasty, particularly during spacer treatment intervals, was associated with the greatest psychological distress. Although mental health outcomes generally improved following reimplantation, several studies demonstrated persistent impairments. More invasive procedures, failed treatment and chronic PJI were associated with a higher psychosocial burden, while articulating spacers were associated with better quality of life compared to static spacers. Salvage procedures and prolonged treatment courses were associated with the most severe and sustained psychological burden. Conclusions: Available evidence demonstrates that PJI is associated with substantial and often persistent psychological and physical morbidities, even following successful infection eradication. Mental health impairment represents a critical component of the overall disease burden and is not adequately reflected in traditional definitions of treatment success. However, multiple studies suffer from limited sample size and lack of separation from successful and failed treatment procedures. Standardized assessment of psychological outcomes and multidisciplinary treatment approaches are warranted as part of patient-centered care and measurement of long-term patient recovery following PJI treatment.

Aims: Septic hip revision (rTHA) for prosthetic joint infection is associated with increased venous thromboembolic (VTE) complications compared to aseptic rTHA. Furthermore, previous studies reported Aspirin to be safe and effective in rTHA, however, VTE prophylaxis after septic single-stage rTHA hasn't been described. In this study, we aim to compare the safety and effectiveness of Aspirin with other anticoagulants following septic single-stage rTHA. Methods: We queried the TriNetX database (cases from 2006 till 2025) for patients undergoing their first septic single-stage rTHA. Patients who were prescribed Aspirin monotherapy for prophylaxis (defined as prescription within 2 weeks after surgery) were compared to patients prescribed monotherapy of Enoxaparin, Apixaban or Rivaroxaban (non-Aspirin) and to patients prescribed a combination of Aspirin and non-Aspirin (dual therapy). 1:1 propensity score matching was performed using the Aspirin cohort as reference to control for relevant variables, including age at time of surgery, sex, history of VTE, stroke, cancer, coagulopathy, tranexamic acid use, body mass index, glycemic control and smoking. Outcomes of interest were the 90-day incidence of deep vein thrombosis (DVT), pulmonary embolism (PE), VTE, re-revision, death, transfusion, wound disruption and surgical site infection (SSI). Significance was set at p<0.05. Results: The matched Aspirin-non-Aspirin cohorts included 978 patients each. The non-Aspirin cohort had a significantly increased incidence of DVT (3.68% vs 2.15%, p=0.044) and VTE (5.11% vs 3.07%, p=0.022) compared to the Aspirin cohort. The rates of PE (1.84% vs 1.13%, p=0.190), re-revision (11.25% vs 12.37%, p=0.441), death (2.66% vs 2.35%, p=0.664), transfusion (9.61% vs 8.79%, p=0.532), bleeding (4.19% vs 4.50%, p=0.739), wound disruption (6.34% vs 5.52%, p=0.444), and SSI (2.05% vs 2.66%, p=0.371) were similar between both cohorts. In contrast, the matched dual therapy-Aspirin cohorts each comprised 749 patients with no difference in the rates of DVT (2.94% vs 1.87%, p=0.177), VTE (4.27% vs 3.07%, p=0.216), re-revision (13.62% vs 12.28%, p=0.442), death (1.60% vs 2.00%, p=0.560), transfusion (9.75% vs 8.41%, p=0.369), bleeding (4.14% vs 4.27%, p=0.898), wound disruption (6.01% vs 6.14%, p=0.914) and SSI (3.20% vs 2.67%, p=0.541). Conclusion: This is the first study to compare VTE prophylaxis agents in the setting of septic single-stage rTHA. Aspirin was associated with lower DVT and VTE compared to non-Aspirin monotherapy and similar outcomes compared to dual therapy. Our data suggests that Aspirin is safe and non-inferior compared to other anticoagulant regimens following septic single-stage rTHA. Further prospective studies are needed to confirm these findings.

Background: Psychiatric comorbidities are increasingly recognized as modifiers of arthroplasty outcomes. However, the effect of generalized anxiety disorder (GAD) on outcomes following total hip arthroplasty (THA) remains underexplored. Methods: A retrospective cohort study was conducted using the PearlDiver national database to identify patients who underwent primary, unilateral THA for osteoarthritis between 2010 and 2022. Patients with P P =0.006). No differences were observed in readmissions, PJI, or revision rates at any time point. GAD prevalence among THA patients rose from 0.54% in 2010 to 10.14% in 2022—a 19-fold increase ( R ² =0.99, P <0.001). Conclusion: Preoperative GAD is associated with higher risk of 90-day ED visits and reoperations following THA. The rising prevalence of GAD suggests that preoperative mental health status may be relevant to perioperative risk stratification and supports further study of targeted optimization strategies in patients undergoing THA.

Background: Culture-negative periprosthetic joint infections (CN-PJIs) remain a major problem in the field of orthopedic infections. The clinical features of CN-PJI and its risk factors remain poorly defined. The purpose of this study was to elucidate the characteristics of CN-PJI. Methods: This was a retrospective multi-center cohort study as part of the Orthopaedic Device Infection Network (ODIN). Using real-world data from five institutions across Australia, the Netherlands and the USA, 563 cases of PJI (470 culture positive, 93 culture negative) were queried between 1995 and 2021. Patients with CN-PJI had negative cultures on pre-operative aspiration, blood or intra-operative cultures. Demographics, history of surgery on the infected joint, presenting symptoms, operative details, laboratory values and intra-operative findings were recorded. Multivariable regression was used to determine the association between these variables and culture negativity. Results: The prevalence of CN-PJI was 16.5 %. Bivariate analysis revealed that patients with CN-PJI were more likely to be female, have a revision arthroplasty or prior PJI, have a longer duration of symptoms and were less likely to present with fever, wound dehiscence or wound necrosis; they also had lower hemoglobin and serum CRP (p < 0.05 for all). Using multivariable regression, the only factor significantly associated with CN-PJI was a duration of symptoms of > 12 weeks (OR 2.24, 95 % CI 1.008–4.964, p = 0.048). Conclusions: Patients with prolonged symptoms were twice as likely to have negative cultures, supporting the traditional belief that CN-PJI presents more insidiously. These clinical data should be used to guide the selection of advanced investigations.

Introduction: Perioperative nutritional, functional status, and bone health optimization has been supported in the literature before arthroplasty procedures; however, surgeon's perception and implementation of such efforts have yet to be investigated. This study aims to identify the current perception and implementation efforts of arthroplasty surgeons in the nation regarding nutritional, functional status, and bone health optimization. Methods: A 28-question survey was anonymously distributed to orthopaedic arthroplasty surgeons through the American Association of Hip and Knee Surgeon contact database. Survey responses were compiled and analyzed with chi square. Results: Sixty-four total arthroplasty surgeons completed the questionnaire with the following geographic distribution: 33% Midwest, 27% Northeast, 23% Southeast, and 16% West. Forty-six percentage of survey participants reported a formal departmental nutrition optimization protocol despite 14% of surgeons doubting the benefits of nutritional optimization. The perceived goals of nutrition intervention were predominantly decreasing complications rates and weight loss. Seventy-five percentage of surveyed respondents report an absence of functional status optimization protocol in place with 38% of surgeons' initial functional assessment begins with patient ambulation dependency. In addition, 13% of surgeon routinely assess bone health with a dual energy x-ray absorptiometry scan for suspicion of osteoporosis, and 87% of surgeons would not delay surgery for bone health optimization. Conclusion: Despite data suggesting the benefits of perioperative nutritional, functional status, and bone health optimization, many barriers to implementation exist. Predominant barriers include compliance rate and logistical challenges of implementation. Comprehension of current perceptions and common practice can provide information to direct future optimization protocol development.