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Veerman K, Raessens J, Telgt D, Smulders K, Goosen JHM. Debridement, antibiotics, and implant retention after revision arthroplasty : antibiotic mismatch, timing, and repeated DAIR associated with poor outcome. Bone Joint J 2022; 104-B:464-471. [PMID: 35360944 DOI: 10.1302/0301-620x.104b4.bjj-2021-1264.r1] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
AIMS Debridement, antibiotics, and implant retention (DAIR) is a widely accepted form of surgical treatment for patients with an early periprosthetic joint infection (PJI) after primary arthroplasty. The outcome of DAIR after revision arthroplasty, however, has not been reported. The aim of this study was to report the success rate of DAIR after revision arthroplasty with a follow-up of two years. METHODS This retrospective study, conducted at the Sint Maartenskliniek, Nijmegen, the Netherlands, included 88 patients who underwent DAIR within 90 days of revision total hip or total knee arthroplasty between 2012 and 2019. Details of the surgical procedures and PJI were collected. Univariate analysis and a subgroup analysis of the culture-positive group were performed. Kaplan-Meier survivorship curves were constructed. RESULTS The overall success rate of DAIR, with respect to the retention of components and the cure of infection, was 68% after two years. DAIR performed with an interval of > 30 days after the index revision procedure (odds ratio (OR) 0.24 (95% confidence interval (CI) 0.08 to 0.72); p = 0.008), a repeated DAIR within 90 days (OR 0.37 (95% CI 0.14 to 0.97); p = 0.040), and the use of an immunosuppressive agent (OR 0.13 (95% CI 0.02 to 0.67); p = 0.012) were associated with a significantly reduced success rate. In the culture-positive group, a mismatch between the antibiotic treatment and the susceptibility of the organism was associated with a significantly lower success rate (OR 0.13 (95% CI 0.03 to 0.62); p = 0.007). CONCLUSION DAIR is an acceptable form of surgical treatment for patients with a suspected early PJI after revision arthroplasty of the hip or knee. DAIRs performed after a prolonged interval, multiple DAIRs, and antibiotic mismatches were significantly associated with an increased risk of failure. Optimization of the host immune response and the prevention of antibiotic mismatch are modifiable factors that may improve the outcome. The high rate of mismatches was an important finding, underlining the need for a review of the local microbiological data, which might improve the outcome. Cite this article: Bone Joint J 2022;104-B(4):464-471.
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Affiliation(s)
- Karin Veerman
- Department of Orthopaedic Surgery, Sint Maartenskliniek, Nijmegen, the Netherlands
| | - Joris Raessens
- Department of Orthopaedic Surgery, Sint Maartenskliniek, Nijmegen, the Netherlands
| | - Denise Telgt
- Department of Orthopaedic Surgery, Sint Maartenskliniek, Nijmegen, the Netherlands
| | - Katrijn Smulders
- Department of Orthopaedic Surgery, Sint Maartenskliniek, Nijmegen, the Netherlands
| | - Jon H M Goosen
- Department of Orthopaedic Surgery, Sint Maartenskliniek, Nijmegen, the Netherlands
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Pullen WM, Money AJ, Ray TE, Freehill MT, Sherman SL. Postoperative Infection: Prevention, Diagnosis, and Treatment Guidelines for the Sports Surgeon. Sports Med Arthrosc Rev 2022; 30:17-23. [PMID: 35113838 DOI: 10.1097/jsa.0000000000000335] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Postoperative infection remains a potentially devastating complication facing the sports medicine surgeon. Infection prevention begins with a thorough history and physical examination to identify patient specific risk factors and aid in risk stratification. Perioperative steroid injections should be used cautiously, with increased time prior to or following surgery being associated with lower infection risk. Sterile preparation with an alcohol containing solution is typically preferred, though there is limited evidence to identify which product is superior. Diagnosis can be challenging with a high index of suspicion needed to identify and appropriately manage patients. Treatment involves prompt irrigation and debridement with deep cultures. Antibiotic coverage should begin with empiric broad treatment and be tailored based on culture results. Early consultation with an infectious disease specialist is recommended to ensure appropriate antibiotic coverage and duration of treatment.
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Affiliation(s)
- W Michael Pullen
- Department of Orthopaedic Surgery, Medical University of South Carolina, Charleston, SC
| | - Adam J Money
- Department of Orthopaedic Surgery, Medical University of South Carolina, Charleston, SC
- Department of Orthopaedic Surgery, Rothman Institute, Philadelphia, PA
| | - Taylor E Ray
- Department of Orthopaedic Surgery, Stanford University, Stanford, CA
| | | | - Seth L Sherman
- Department of Orthopaedic Surgery, Stanford University, Stanford, CA
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Bernaus M, Auñón-Rubio Á, Monfort-Mira M, Arteagoitia-Colino I, Martínez-Ros J, Castellanos J, Lamo-Espinosa JM, Argüelles F, Veloso M, Gómez García L, Crespo FA, Sánchez-Fernández J, Murias-Álvarez J, Martí-Garín D, Hernández-González N, Villarejo-Fernández B, Valero-Cifuentes G, Hernández-Torres A, Molina-González J, Coifman-Lucena I, Esteban-Moreno J, Demaria P, Esteve-Palau E, Del Pozo JL, Suárez Á, Carmona-Torre F, Darás Á, Baeza J, Font-Vizcarra L. Risk Factors of DAIR Failure and Validation of the KLIC Score: A Multicenter Study of Four Hundred Fifty-Five Patients. Surg Infect (Larchmt) 2022; 23:280-287. [PMID: 35172116 DOI: 10.1089/sur.2021.320] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: Debridement, antibiotic agents, and implant retention (DAIR) is a currently accepted approach for the treatment of early prosthetic joint infections (PJI). The success of a DAIR procedure has shown variable results throughout the published literature. Scoring systems such as the Kidney, Liver, Index surgery, Cemented prosthesis, and C-reactive protein value (KLIC) score for the selection of patients that are likely to benefit from DAIR have proved to be helpful in decision making. Our study aims to further validate the KLIC score using a large external multicentric cohort and to evaluate other risk factors for failure. Patients and Methods: A retrospective analysis of patients with an early acute PJI who were treated with DAIR and recorded in a database of eight Spanish university hospitals was performed. According to pre-operative variables of the KLIC study, patients were categorized into five groups: group A, ≤2 points; group B, 2.5-3.5 points; group C, 4-5 points; group D, 5.5-6.5 points; and group E, ≥7 points. Failure rates were compared between groups at 60 days and after 60 days of DAIR. Further variables for risk of failure were also analyzed. Results: A total of 455 patients with early acute PJI were included in the analyses. At 60 days, patients presenting with pre-operative elevated C-reactive protein serum levels, Staphylococcus aureus, and polymicrobial infections were associated with failure. Failure rates recorded were 12% for group A (n = 210), 18% for group B (n = 83), 26% for group C (n = 89), 24% for group D (n = 66), and 0% for group E (n = 7). Univariable analysis between consecutive groups of the KLIC score showed no differences for failure before 60 days of the DAIR procedure. Scheduled surgery and having the procedure performed by a specialized unit were also identified as important factors for DAIR success. Conclusions: Our results suggest the KLIC score was not useful for predicting failure in our cohort. Furthermore, our results indicate a specialized unit should conduct DAIR procedures.
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Affiliation(s)
- Martí Bernaus
- Department of Orthopedics and Traumatology, Osteoarticular Infection Unit, Hospital Universitari Mutua Terrassa, Barcelona, Spain
| | - Álvaro Auñón-Rubio
- Department of Orthopedics and Traumatology, Hospital Universitario Fundación Jiménez Díaz, Madrid, Spain
| | - Montserrat Monfort-Mira
- Septic Unit, Orthopedic Department, Parc Taulí Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí I3PT, Universitat Autònoma de Barcelona, Sabadell, Spain
| | | | - Javier Martínez-Ros
- Osteoarticular Infection Unit, Department of Orthopedics and Traumatology, Hospital Clinico Universitario Virgen de la Arrixaca, Murcia, Spain
| | - Juan Castellanos
- Department of Orthopedics and Traumatology, Hospital General del Parc Sanitari Sant Joan de Déu, Sant Boi de Llobregat, Barcelona, Spain
| | | | - Francisco Argüelles
- Department of Orthopedics and Traumatology, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - Margarita Veloso
- Department of Orthopedics and Traumatology, Osteoarticular Infection Unit, Hospital Universitari Mutua Terrassa, Barcelona, Spain
| | - Lucia Gómez García
- Department of Infectious Diseases, Osteoarticular Infection Unit, Hospital Universitari Mutua Terrassa, Barcelona, Spain
| | - Francesc Anglès Crespo
- Department of Orthopedics and Traumatology, Osteoarticular Infection Unit, Hospital Universitari Mutua Terrassa, Barcelona, Spain
- Department of Surgery, Universitat de Barcelona, Barcelona, Spain
| | - Joel Sánchez-Fernández
- Septic Unit, Orthopedic Department, Parc Taulí Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí I3PT, Universitat Autònoma de Barcelona, Sabadell, Spain
| | - Juan Murias-Álvarez
- Septic Unit, Orthopedic Department, Parc Taulí Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí I3PT, Universitat Autònoma de Barcelona, Sabadell, Spain
| | - David Martí-Garín
- Septic Unit, Orthopedic Department, Parc Taulí Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí I3PT, Universitat Autònoma de Barcelona, Sabadell, Spain
| | | | | | - Gregorio Valero-Cifuentes
- Osteoarticular Infection Unit, Department of Orthopedics and Traumatology, Hospital Clinico Universitario Virgen de la Arrixaca, Murcia, Spain
| | - Alícia Hernández-Torres
- Osteoarticular Infection Unit, Department of Infectious Diseases, Hospital Clinico Universitario Virgen de la Arrixaca, Murcia, Spain
| | - José Molina-González
- Osteoarticular Infection Unit, Department of Orthopedics and Traumatology, Hospital Clinico Universitario Virgen de la Arrixaca, Murcia, Spain
| | - Ismael Coifman-Lucena
- Department of Orthopedics and Traumatology, Hospital Universitario Fundación Jiménez Díaz, Madrid, Spain
| | - Jaime Esteban-Moreno
- Department of Microbiology, Hospital Universitario Fundación Jiménez Díaz, Madrid, Spain
| | - Pablo Demaria
- Department of Orthopedics and Traumatology, Hospital General del Parc Sanitari Sant Joan de Déu, Sant Boi de Llobregat, Barcelona, Spain
| | - Erika Esteve-Palau
- Department of Infectious Diseases, Parc Sanitari Sant Joan de Deu, Sant Boi de Llobregat, Barcelona, Spain
| | - José Luis Del Pozo
- Department of Infectious Diseases, Clínica Universidad de Navarra, Pamplona, Spain
| | - Álvaro Suárez
- Department of Orthopedics and Traumatology, Clínica Universidad de Navarra, Pamplona, Spain
| | | | - Álvaro Darás
- Department of Orthopedics and Traumatology, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - José Baeza
- Department of Orthopedics and Traumatology, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - Lluís Font-Vizcarra
- Department of Orthopedics and Traumatology, Osteoarticular Infection Unit, Hospital Universitari Mutua Terrassa, Barcelona, Spain
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First Detection of Methanogens in Orthopedic Prosthesis Infection: A Four-Case Founding Series. PROSTHESIS 2022. [DOI: 10.3390/prosthesis4010005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Orthopedic prosthesis infection must be medically managed after appropriate microbiological documentation. While bacteria and fungi are acknowledged to be causative opportunistic pathogens in this situation, the potential role of methanogens in orthopedic prosthesis infections is still unknown. In a retrospective study, a total of 100 joint and bone samples collected from 25 patients were screened by specific PCR assays for the detection of methanogens. PCR-positive samples were observed by autofluorescence, electron microscopy and tentatively cultured under specific culture conditions. Methanogens were detected by quantitative PCR in 4/100 samples, in the presence of negative controls. Sequencing identified Methanobrevibacter oralis in two cases, Methanobrevibacter smithii in one case and Methanobrevibacter wolinii in one case. Microscopic methods confirmed molecular findings and bacterial culture yielded two strains of Staphylococcus aureus, one strain of Staphylococcus epidermidis and one strain of Proteus mirabilis. These unprecedented data highlight the presence of methanogens in joint and bone samples of patients also diagnosed with bacterial orthopedic prosthesis infection, questioning the role of methanogens as additional opportunistic co-pathogens in this situation.
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55
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Davis JS, Metcalf S, Clark B, Robinson JO, Huggan P, Luey C, McBride S, Aboltins C, Nelson R, Campbell D, Solomon LB, Schneider K, Loewenthal MR, Yates P, Athan E, Cooper D, Rad B, Allworth T, Reid A, Read K, Leung P, Sud A, Nagendra V, Chean R, Lemoh C, Mutalima N, Tran T, Grimwade K, Sehu M, Looke D, Torda A, Aung T, Graves S, Paterson DL, Manning L. Predictors of treatment success following peri-prosthetic joint infection: 24-month follow up from a multi-center prospective observational cohort study of 653 patients. Open Forum Infect Dis 2022; 9:ofac048. [PMID: 35233433 PMCID: PMC8882242 DOI: 10.1093/ofid/ofac048] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Accepted: 01/30/2022] [Indexed: 12/05/2022] Open
Abstract
Background Periprosthetic joint infection (PJI) is a devastating condition and there is a lack of evidence to guide its management. We hypothesized that treatment success is independently associated with modifiable variables in surgical and antibiotic management. Methods The is a prospective, observational study at 27 hospitals across Australia and New Zealand. Newly diagnosed large joint PJIs were eligible. Data were collected at baseline and at 3, 12, and 24 months. The main outcome measures at 24 months were clinical cure (defined as all of the following: alive, absence of clinical or microbiological evidence of infection, and not requiring ongoing antibiotic therapy) and treatment success (clinical cure plus index prosthesis still in place). Results Twenty-four-month outcome data were available for 653 patients. Overall, 449 patients (69%) experienced clinical cure and 350 (54%) had treatment success. The most common treatment strategy was debridement and implant retention (DAIR), with success rates highest in early postimplant infections (119 of 160, 74%) and lower in late acute (132 of 267, 49%) and chronic (63 of 142, 44%) infections. Selected comorbidities, knee joint, and Staphylococcus aureus infections were independently associated with treatment failure, but antibiotic choice and duration (including rifampicin use) and extent of debridement were not. Conclusions Treatment success in PJI is associated with (1) selecting the appropriate treatment strategy and (2) nonmodifiable patient and infection factors. Interdisciplinary decision making that matches an individual patient to an appropriate management strategy is a critical step for PJI management. Randomized controlled trials are needed to determine the role of rifampicin in patients managed with DAIR and the optimal surgical strategy for late-acute PJI.
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Affiliation(s)
- Joshua S Davis
- Menzies School of Health Research and Charles Darwin University, Darwin, NT, Australia
- Department of Infectious Diseases, John Hunter Hospital, Newcastle, NSW, Australia
- School of Medicine and Public Health, University of Newcastle, Newcastle, NSW, Australia
| | - Sarah Metcalf
- Department of Infectious Diseases, Christchurch Hospital, Christchurch, New Zealand
| | - Benjamin Clark
- Department of Infectious Diseases, Fiona Stanley Hospital, Murdoch, WA, Australia
| | - J Owen Robinson
- Department of Infectious Diseases, Royal Perth Hospital, Perth, Western Australia, Australia
- College of Science, Health, Engineering and Education, Discipline of Health, Murdoch University, Perth Australia
| | - Paul Huggan
- Department of Infectious Diseases, Waikato Hospital, Hamilton, New Zealand
| | - Chris Luey
- Counties Manukau District Health Board, Auckland, NZ
| | - Stephen McBride
- Department of Infectious Diseases, Northern Health, Epping, Melbourne, Vic, Australia
| | - Craig Aboltins
- Department of Infectious Diseases, Northern Health, Epping, Melbourne, Vic, Australia
- Northern Clinical School, University of Melbourne, Melbourne, Vic, Australia
| | - Renjy Nelson
- Department of Infectious Diseases, Royal Adelaide Hospital, Adelaide, SA, Australia
| | - David Campbell
- Department of Orthopaedic Surgery, Wakefield Orthopaedic Clinic and The University of Adelaide, Adelaide, SA, Australia
| | - L Bogdan Solomon
- Department of Orthopaedics and Trauma, Royal Adelaide Hospital and The University of Adelaide, Adelaide, SA, Australia
| | - Kellie Schneider
- Department of Orthopaedic Surgery, Fiona Stanley Hospital, Murdoch, WA, Australia
| | - Mark R Loewenthal
- Department of Infectious Diseases, John Hunter Hospital, Newcastle, NSW, Australia
- School of Medicine and Public Health, University of Newcastle, Newcastle, NSW, Australia
| | - Piers Yates
- Department of Orthopaedic Surgery, Fiona Stanley Hospital, Murdoch, WA, Australia
- Medical School, University of Western Australia, Perth, Australia
| | - Eugene Athan
- Department of Infectious Diseases, Barwon Health, Deakin University, Geelong, Vic, Australia
| | - Darcie Cooper
- Geelong Centre for Emerging Infectious Disease, Deakin University, Geelong, Vic, Australia
| | - Babak Rad
- Department of Infectious Diseases, Barwon Health, Deakin University, Geelong, Vic, Australia
| | - Tony Allworth
- Department of Infectious Diseases, St Vincent’s Private Hospital Northside, Chermside, QLD, Australia
| | - Alistair Reid
- Department of Infectious Diseases, Wollongong Hospital, Wollongong, NSW, Australia
| | - Kerry Read
- Department of Infectious Diseases, North Shore Hospital, Auckland, New Zealand
| | - Peter Leung
- Department of Microbiology and Infectious Diseases, Royal Hobart Hospital, Hobart, Tasmania, Australia
| | - Archana Sud
- Department of Infectious Diseases, Nepean Hospital, Kingswood, NSW, Australia
| | - Vana Nagendra
- Department of Infectious Diseases, Liverpool Hospital, Liverpool, NSW, Australia
| | - Roy Chean
- Department of Infectious Diseases, Latrobe Regional Hospital, Traralgon, VIC, Australia
| | - Chris Lemoh
- Department of Infectious Diseases, Dandenong Hospital, Dandenong, VIC, Australia
| | - Nora Mutalima
- Department of Orthopaedic Surgery, Dandenong Hospital, Dandenong, VIC, Australia
| | - Ton Tran
- Department of Orthopaedic Surgery, Dandenong Hospital, Dandenong, VIC, Australia
| | - Kate Grimwade
- Department of Infectious Diseases, Tauranga Hospital, Tauranga, New Zealand
| | - Marjoree Sehu
- Infection Management Services, Princess Alexandra Hospital, QLD, Australia
| | - Davis Looke
- Infection Management Services, Princess Alexandra Hospital, QLD, Australia
| | - Adrienne Torda
- Faculty of Medicine and Health, UNSW Sydney, Randwick, NSW, Australia
| | - Thi Aung
- Department of Infectious Diseases, Redcliffe, Hospital, Redcliffe, QLD, Australia
| | - Steven Graves
- Australian Orthopaedic Association National Joint Replacement Registry, Adelaide, South Australia, Australia
- School of Surgery, University of South Australia, Adelaide, South Australia, Australia
| | - David L Paterson
- UQ Centre for Clinical Research, University of Queensland, Brisbane, QLD, Australia
| | - Laurens Manning
- Department of Infectious Diseases, Fiona Stanley Hospital, Murdoch, WA, Australia
- Medical School, University of Western Australia, Perth, Australia
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Sukhonthamarn K, Tan TL, Strony J, Brown S, Nazarian D, Parvizi J. The Fate of Periprosthetic Joint Infection Following Megaprosthesis Reconstruction. JB JS Open Access 2021; 6:JBJSOA-D-21-00003. [PMID: 34841189 PMCID: PMC8613367 DOI: 10.2106/jbjs.oa.21.00003] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
A megaprosthesis may be used for reconstruction in patients with massive bone loss or a periprosthetic fracture. Periprosthetic joint infection (PJI) may occur after a megaprosthesis reconstruction and may pose a major challenge. The outcomes of managing PJI in patients with a megaprosthesis is relatively unclear. The aim of this study was to investigate the clinical course and outcomes of PJI in patients with a megaprosthesis in place.
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Affiliation(s)
- Kamolsak Sukhonthamarn
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania.,Department of Orthopaedics, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Timothy L Tan
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - John Strony
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Scot Brown
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - David Nazarian
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Javad Parvizi
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
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57
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Cooper AM, Connolly K, Penna S, Parvizi J. Evaluation and Management of a Painful Knee After Total Knee Arthroplasty. Orthopedics 2021; 44:341-352. [PMID: 34618636 DOI: 10.3928/01477447-20211001-08] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Pain after total knee arthroplasty (TKA) is not infrequent and may be indicative of a broad spectrum of prosthesis-related, intra-articular, or extra-articular pathologies. To diagnose and treat the underlying cause of a painful TKA, systematic evaluation of the patient is critical to ensure that they are managed appropriately and expeditiously. This evidence-based review presents current concepts regarding the pathophysiology, etiology, and diagnosis of painful TKA and our recommended approach for management. [Orthopedics. 2021;44(6):341-352.].
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58
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Experiences during Switching from Two-Stage to One-Stage Revision Arthroplasty for Chronic Total Knee Arthroplasty Infection. Antibiotics (Basel) 2021; 10:antibiotics10121436. [PMID: 34943648 PMCID: PMC8698198 DOI: 10.3390/antibiotics10121436] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Revised: 11/08/2021] [Accepted: 11/19/2021] [Indexed: 12/18/2022] Open
Abstract
The objective of this study was to evaluate our preliminary results after changing our surgical strategy from 2-stage revision arthroplasty to 1-stage revision arthroplasty for patients with chronic knee periprosthetic joint infection. We conducted a prospective study of knee arthroplasty patients that had been diagnosed with chronic infection and treated using a 1-stage revision regardless of the traditional criteria applied for indication thereof. We evaluated two main variables: infection control and economic costs. The definitive diagnosis of infection of the revision was determined by using the criteria proposed by the Musculoskeletal Infection Society. The costs were calculated as average costs in USD, as described by Srivastava (2019), for 1-stage or 2-stage revisions. Eighteen patients were included in the study, and infection was controlled in 17 patients. The total economic savings for our hospital from these 18 patients amounted to USD 291,152. This clinical success has led to major changes in how our hospital approaches the treatment of chronically infected knee replacements, in addition to substantial economic advantages for the hospital.
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59
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Deng W, Li R, Shao H, Yu B, Chen J, Zhou Y. Comparison of the success rate after debridement, antibiotics and implant retention (DAIR) for periprosthetic joint infection among patients with or without a sinus tract. BMC Musculoskelet Disord 2021; 22:895. [PMID: 34674675 PMCID: PMC8532350 DOI: 10.1186/s12891-021-04756-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2021] [Accepted: 09/29/2021] [Indexed: 08/30/2023] Open
Abstract
BACKGROUND The relevance between the presence of a sinus tract and the failure risk after debridement, antibiotics and implant retention (DAIR) for periprosthetic joint infection (PJI) after hip or knee arthroplasty is still unclear. This study aimed to compare the success rate of DAIR between patients with or without a sinus tract and to explore the possible risk factors for failure after DAIR in patients with a sinus tract. METHODS Consecutive DAIR cases for PJI after hip or knee arthroplasty between January 2009 and June 2019 with a minimum 1-year follow-up in two tertiary joint arthroplasty centers were included. Patients were classified into the sinus tract group and the non-sinus tract group according to the presence of a sinus tract. The success rate after DAIR were compared using Kaplan-Meier survival analysis. Potential risk factors for failure in the sinus group were also explored. RESULTS One hundred seven patients were included. At a median 4.4 years of follow-up, 19 of 52 (36.5%) cases failed in the sinus tract group, while 15 of 55 (27.3%) cases failed in the non-sinus tract group. The 1-year and 5-year cumulative success rates were 71.2% (95% confidence interval (CI): 59.8-84.6%) and 56.8% (95% CI: 42.6-75.7%) in the sinus tract group, respectively, which were similar to the counterparts in the non-sinus tract group (P = 0.214). Among patients with a sinus tract, DAIR with the exchange of modular components showed a higher success rate (75.8% versus 47.4%, P = 0.038). CONCLUSIONS The presence of a sinus tract does not affect the success rate of DAIR. Modular component exchange in DAIR was proposed for patients with a sinus tract for an improved infection control rate.
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Affiliation(s)
- Wang Deng
- Department of Orthopedic Surgery, Beijing Jishuitan Hospital, Fourth Clinical College of Peking University, No.31 Xinjiekou East Road, Xicheng District, Beijing, 100035, China
| | - Rui Li
- Department of Orthopaedics, Chinese PLA General Hospital, No. 28 Fuxing Road, Haidian District, Beijing, 100039, China
| | - Hongyi Shao
- Department of Orthopedic Surgery, Beijing Jishuitan Hospital, Fourth Clinical College of Peking University, No.31 Xinjiekou East Road, Xicheng District, Beijing, 100035, China
| | - Baozhan Yu
- Department of Orthopaedics, Chinese PLA General Hospital, No. 28 Fuxing Road, Haidian District, Beijing, 100039, China.,Department of Orthopaedics, Bao Ding Gem Flower Eastern Hospital, Bao Ding, Hebei, China
| | - Jiying Chen
- Department of Orthopaedics, Chinese PLA General Hospital, No. 28 Fuxing Road, Haidian District, Beijing, 100039, China.
| | - Yixin Zhou
- Department of Orthopedic Surgery, Beijing Jishuitan Hospital, Fourth Clinical College of Peking University, No.31 Xinjiekou East Road, Xicheng District, Beijing, 100035, China.
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60
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Antonios JK, Bozic KJ, Clarke HD, Spangehl MJ, Bingham JS, Schwartz AJ. Cost-effectiveness of Single vs Double Debridement and Implant Retention for Acute Periprosthetic Joint Infections in Total Knee Arthroplasty: A Markov Model. Arthroplast Today 2021; 11:187-195. [PMID: 34660864 PMCID: PMC8502838 DOI: 10.1016/j.artd.2021.08.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Revised: 08/13/2021] [Accepted: 08/20/2021] [Indexed: 02/07/2023] Open
Abstract
Background Periprosthetic joint infection (PJI) is a common cause of revision total knee surgery. Although debridement and implant retention (DAIR) has lower success rates in the chronic setting, it is an accepted treatment of acute PJI, whether postoperatively or with late hematogenous seeding. There are two broad DAIR strategies: single debridement and planned double debridement. The purpose of this study is to evaluate the cost-effectiveness of single vs double DAIR for acute PJI in total knee arthroplasty. Methods A decision tree using single or double DAIR as the treatment strategy for acute PJI was constructed. Quality-adjusted life years and costs associated with the two treatment arms were calculated. Treatment success rates, failure rates, and mortality rates were derived from the literature. Medical costs were derived from both the literature and Medicare data. A cost-effectiveness plane was constructed from multiple Monte Carlo trials. A sensitivity analysis identified parameters most influencing the optimal strategy decision. Results Double DAIR was the optimal treatment strategy both in terms of the health utility state (82% of trials) and medical cost (97% of trials). Strategy tables demonstrated that as long as the success rate of double debridement is 10% or greater than the success rate of a single debridement, the two-stage protocol is cost-effective. Conclusions A double DAIR protocol is more cost-effective than single DAIR from a societal perspective.
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Affiliation(s)
| | - Kevin J Bozic
- Department of Orthopaedic Surgery, Dell Medical School, The University of Texas at Austin, Austin, TX, USA
| | - Henry D Clarke
- Department of Orthopaedic Surgery, Mayo Clinic, Phoenix, AZ, USA
| | - Mark J Spangehl
- Department of Orthopaedic Surgery, Mayo Clinic, Phoenix, AZ, USA
| | - Joshua S Bingham
- Department of Orthopaedic Surgery, Mayo Clinic, Phoenix, AZ, USA
| | - Adam J Schwartz
- Department of Orthopaedic Surgery, Mayo Clinic, Phoenix, AZ, USA
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Gerritsen M, Khawar A, Scheper H, van der Wal R, Schoones J, de Boer M, Nelissen R, Pijls B. Modular component exchange and outcome of DAIR for hip and knee periprosthetic joint infection : a systematic review and meta-regression analysis. Bone Jt Open 2021; 2:806-812. [PMID: 34592839 PMCID: PMC8558449 DOI: 10.1302/2633-1462.210.bjo-2021-0090.r1] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Aims The aim of this meta-analysis is to assess the association between exchange of modular parts in debridement, antibiotics, and implant retention (DAIR) procedure and outcomes for hip and knee periprosthetic joint infection (PJI). Methods We conducted a systematic search on PubMed, Embase, Web of Science, and Cochrane library from inception until May 2021. Random effects meta-analyses and meta-regression was used to estimate, on a study level, the success rate of DAIR related to component exchange. Risk of bias was appraised using the (AQUILA) checklist. Results We included 65 studies comprising 6,630 patients. The pooled overall success after DAIR for PJI was 67% (95% confidence interval (CI) 63% to 70%). This was 70% (95% CI 65% to 75%) for DAIR for hip PJI and 63% (95% CI 58% to 69%) for knee PJI. In studies before 2004 (n = 27), our meta-regression analysis showed a 3.5% increase in success rates for each 10% increase in component exchange in DAIR for hip PJI and a 3.1% increase for each 10% increase in component exchange for knee PJI. When restricted to studies after 2004 (n = 37), this association changed: for DAIR for hip PJI a decrease in successful outcome by 0.5% for each 10% increase in component exchange and for DAIR for knee PJI this was a 0.01% increase in successful outcome for each 10% increase in component exchange. Conclusion This systematic review and meta-regression found no benefit of modular component exchange on reduction of PJI failure. This limited effect should be weighed against the risks for the patient and cost on a case-by-case basis. The association between exchange of modular components and outcome changed before and after 2004. This suggests the effect seen after 2004 may reflect a more rigorous, evidence-based, approach to the infected implant compared to the years before. Level of Evidence: Level III Cite this article: Bone Jt Open 2021;2(10):806–812.
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Affiliation(s)
- Maxime Gerritsen
- Dept. of Orthopaedic Surgery, Leiden University Medical Center, Leiden, the Netherlands.,Dept of Infectious Disease, Leiden University Medical Center, Leiden, the Netherlands
| | - Abdullah Khawar
- Dept. of Orthopaedic Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - Henk Scheper
- Dept of Infectious Disease, Leiden University Medical Center, Leiden, the Netherlands
| | - Robert van der Wal
- Dept. of Orthopaedic Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - Jan Schoones
- Directorate of Research Policy (formerly: Walaeus Library), Leiden University Medical Center, Leiden, the Netherlands
| | - Mark de Boer
- Dept of Infectious Disease, Leiden University Medical Center, Leiden, the Netherlands
| | - Rob Nelissen
- Dept. of Orthopaedic Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - Bart Pijls
- Dept. of Orthopaedic Surgery, Leiden University Medical Center, Leiden, the Netherlands
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62
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Osmanski-Zenk K, Klinder A, Rimke C, Wirtz DC, Lohmann CH, Haas H, Kladny B, Mittelmeier W. Evaluation of the standard procedure for treatment of periprosthetic joint infections of total knee and hip arthroplasty: a comparison of the 2015 and 2020 census in total joint replacement centres in Germany. BMC Musculoskelet Disord 2021; 22:791. [PMID: 34525989 PMCID: PMC8444384 DOI: 10.1186/s12891-021-04661-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Accepted: 08/26/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND There are different procedures for both, the diagnosis and the therapy of a periprosthetic joint infection (PJI), however, national or international guidelines for a standardised treatment regime are still lacking. The present paper evaluates the use of the predominant treatment protocols for PJI in certified total joint replacement centres (EPZ) in Germany based on an EndoCert questionnaire. MATERIALS AND METHODS The questionnaire was developed in cooperation with the EndoCert Certification Commission to survey the treatment protocols for septic revision arthroplasties in EPZ. Questions targeted the various treatment options including prosthesis preserving procedures (DAIR - Debridement, antibiotics, irrigation, and retention of the prosthesis), one-stage revision, two-stage revision, removal of the endoprosthesis and diagnostic sampling prior to re-implantation. All certified EPZ participated (n = 504) and the results from the current survey in 2020 were compared to data from a previous analysis in 2015. RESULTS The number of centres that performed DAIR up to a maximum of 4 weeks and more than 10 weeks after index surgery decreased since 2015, while the number of centres that provided a one-stage revision as a treatment option increased (hip: + 6.3%; knee: + 6.6%). The majority of the centres (73.2%) indicated a 4-8 week period as the preferred interval between prosthesis removal and re-implantation in two-stage revision in hip as well as knee revisions. Centres with a higher number of revision surgeries (> 200 revisions/year), opted even more often for the 4-8 week period (92.3%). In two-stage revision the use of metal-based spacers with/without reinforcement with antibiotic-containing cement as an interim placeholder was significantly reduced in 2020 compared to 2015. There was also a clear preference for cemented anchoring in two-stage revision arthroplasty in the knee in 2020, whereas the majority of hip replacements was cementless. Additionally, in 2020 the number of samples for microbiological testing during the removal of the infected endoprosthesis increased and 72% of the centres took five or more samples. Overall, the number of EPZ with a standardised protocol for the procedure expanded from 2015 to 2020. CONCLUSION While there was a trend towards standardised therapeutic algorithms for PJI with more uniform choices among the centres in 2020 compared to 2015, the treatment often remains an individual decision. However, since a consistent treatment regime is of vital importance with an expected rise of total numbers of revision arthroplasties, uniform definitions with regard to comparability and standardisation are necessary for the further development of the EndoCert system.
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Affiliation(s)
- Katrin Osmanski-Zenk
- Orthopädische Klinik und Poliklinik, Universitätsmedizin Rostock, Doberaner Straße 142, 18057, Rostock, Germany.
| | - Annett Klinder
- Orthopädische Klinik und Poliklinik, Universitätsmedizin Rostock, Doberaner Straße 142, 18057, Rostock, Germany
| | - Christina Rimke
- Orthopädische Klinik und Poliklinik, Universitätsmedizin Rostock, Doberaner Straße 142, 18057, Rostock, Germany
| | - Dieter C Wirtz
- Klinik und Poliklinik für Orthopädie und Unfallchirurgie, Universitätsklinikum Bonn, 53127, Bonn, Germany
| | - Christoph H Lohmann
- Department of Orthopaedic Surgery, Otto-von-Guericke-Universität, 39120, Magdeburg, Germany
| | - Holger Haas
- Zentrum für Orthopädie, Unfallchirurgie und Sportmedizin, Gemeinschaftskrankenhaus Bonn, 53113, Bonn, Germany
| | - Bernd Kladny
- Fachklinik Herzogenaurach, 91074, Herzogenaurach, Germany
| | - Wolfram Mittelmeier
- Orthopädische Klinik und Poliklinik, Universitätsmedizin Rostock, Doberaner Straße 142, 18057, Rostock, Germany
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63
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van der Ende B, van Oldenrijk J, Reijman M, Croughs PD, van Steenbergen LN, Verhaar JAN, Bos PK. Timing of debridement, antibiotics, and implant retention (DAIR) for early post-surgical hip and knee prosthetic joint infection (PJI) does not affect 1-year re-revision rates: data from the Dutch Arthroplasty Register. J Bone Jt Infect 2021; 6:329-336. [PMID: 34513570 PMCID: PMC8428083 DOI: 10.5194/jbji-6-329-2021] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2021] [Accepted: 08/16/2021] [Indexed: 11/11/2022] Open
Abstract
Debridement, antibiotics, and implant retention (DAIR) is a procedure to treat a periprosthetic joint infection (PJI) after total hip arthroplasty (THA) or total knee arthroplasty (TKA). The timing between the primary procedure and the DAIR is likely a determinant for its successful outcome. However, the optimal timing of a DAIR and the chance of success still remain unclear. We aimed to assess the risk of re-revision within 1 year after a DAIR procedure and to evaluate the timing of the DAIR in primary THA and TKA. We used data from the Dutch Arthroplasty Register (LROI) and selected all primary THA and TKA in the period 2007-2016 which underwent a DAIR within 12 weeks after primary procedure. A DAIR was defined as a revision for infection in which only modular parts were exchanged. A DAIR was defined as successful if not followed by a re-revision within 1 year after DAIR; 207 DAIRs were performed < 4 weeks after THA, of which 16 (8 %) received a complete revision within 1 year. DAIR procedures performed between 4 and 12 weeks ( n = 98 ) had a failure rate of 9 % ( n = 9 ). After TKA 126 DAIRs were performed in less than 4 weeks, of which 11 (9 %) received a complete revision within 1 year; 83 DAIRs were performed between 4 and 12 weeks, of which 14 (17 %) were revised. There was no significant difference in 1-year re-revision rate after a DAIR procedure by timing of the DAIR procedure for total hip and knee arthroplasty based on Dutch registry data.
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Affiliation(s)
- Barry van der Ende
- Department of Orthopaedic Surgery and Sport Medicine, Erasmus University Medical Center, Rotterdam, 3000 CA, the Netherlands
| | - Jakob van Oldenrijk
- Department of Orthopaedic Surgery and Sport Medicine, Erasmus University Medical Center, Rotterdam, 3000 CA, the Netherlands
| | - Max Reijman
- Department of Orthopaedic Surgery and Sport Medicine, Erasmus University Medical Center, Rotterdam, 3000 CA, the Netherlands
| | - Peter D Croughs
- Department of Microbiology, Erasmus University Medical Center, Rotterdam, 3000 CA, the Netherlands
| | - Liza N van Steenbergen
- Dutch Arthroplasty Register (Landelijke Registratie Orthopedische Implantaten), 's Hertogenbosch, 5232 AD, the Netherlands
| | - Jan A N Verhaar
- Department of Orthopaedic Surgery and Sport Medicine, Erasmus University Medical Center, Rotterdam, 3000 CA, the Netherlands
| | - P Koen Bos
- Department of Orthopaedic Surgery and Sport Medicine, Erasmus University Medical Center, Rotterdam, 3000 CA, the Netherlands
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64
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Fröschen FS, Walter SG, Randau TM, Gravius N, Gravius S, Hischebeth GTR. The use of negative pressure wound therapy increases failure rate in debridement and implant retention for acute prosthetic joint infection. Technol Health Care 2021; 28:721-731. [PMID: 32444587 DOI: 10.3233/thc-192095] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND To date only scanty data exist regarding the effect of failed debridement, antibiotics, irrigation and retention of the prostheses (DAIR) and negative pressure wound therapy (NPWT) on the outcome of a subsequent exchange arthroplasty. OBJECTIVE The objective of this study was to determine the success rate of a two- or multi-stage procedure after initial failed DAIR/NPWT in patients with an acute periprosthetic joint infection (PJI) and to evaluate the influence of possible risk factors for treatment failure. METHODS Nineteen consecutive patients with a persisting PJI and ongoing NPWT after treatment of an acute PJI with DAIR of the hip or knee joint from October 2010 to June 2017 were included. All patients were treated according to a structured treatment algorithm after referral to our hospital. The endpoint was a successful reimplantation with absence of signs of infection two years after replantation ("replantation group") or treatment failure ("treatment failure group") in terms of a permanent girdlestone arthroplasty, fistula, amputation or death. A risk factor analysis was performed between the two groups. RESULTS Explantation was performed in 15 cases, amputation in one case, and DAIR/establishment of a fistula in three cases. The treatment success rate after reimplantation in terms of "definitively free of infection" two years after surgery according to Laffer was 36.85% (seven out of 19 patients). Statistical analysis revealed the number of surgeries until wound consolidation (p= 0.007), number of detected bacterial strains (p= 0.041), a polymicrobial PJI (p= 0.041) and detection of a difficult-to-treat organism (p= 0.005) as factors associated with treatment failure. After failed DAIR/NPWT we could detect a significant higher number of different bacterial strains (p= 0.001). CONCLUSIONS The treatment success rate after failed DAIR and NPWT with 36% is low and associated with a high treatment failure rate (permanent girdlestone arthroplasty, fistula or amputation, death). Thus, the definition of risk factors is crucial. We found that the number of revisions until wound consolidation, a polymicrobial PJI and detection of a difficult-to-treat organisms were risk factors for treatment failure. Furthermore, after failed DAIR/NPWT we could detect a significant higher number of different bacterial strains, with a possible adverse effect on a consecutive exchange.
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Affiliation(s)
| | | | - Thomas Martin Randau
- Department of Orthopaedics and Trauma Surgery, University Hospital Bonn, Bonn, Germany
| | - Nadine Gravius
- Department of Orthopaedics and Trauma Surgery, University Hospital Bonn, Bonn, Germany
| | - Sascha Gravius
- Department of Orthopaedics and Trauma Surgery, University Hospital Bonn, Bonn, Germany.,Orthopaedic and Trauma Surgery Centre, University Hospital Mannheim, Medical Faculty Mannheim of the University of Heidelberg, Mannheim, Germany
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65
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Local Application of Vancomycin in One-Stage Revision of Prosthetic Joint Infection Caused by Methicillin-Resistant Staphylococcus aureus. Antimicrob Agents Chemother 2021; 65:e0030321. [PMID: 34181479 DOI: 10.1128/aac.00303-21] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
The rate of eradication of periprosthetic joint infection (PJI) caused by methicillin-resistant Staphylococcus aureus (MRSA) is still not satisfactory with systemic vancomycin administration after one-stage revision arthroplasty. This study aimed to explore the effectiveness and safety of intraarticular (IA) injection of vancomycin in the control of MRSA PJI after one-stage revision surgery in a rat model. Two weeks of intraperitoneal (IP) and/or IA injection of vancomycin was used to control the infection after one-stage revision surgery. The MRSA PJI rats treated with IA injection of vancomycin showed better outcomes in skin temperature, bacterial counts, biofilm on the prosthesis, serum α1-acid glycoprotein levels, residual bone volume, and inflammatory reaction in the joint tissue, compared with those treated with IP vancomycin, while the rats treated with IP and IA administration showed the best outcomes. However, only the IP and IA administration of vancomycin could eradicate MRSA. Minimal changes in renal pathology were observed in the IP and IP plus IA groups but not in the IA group, while no obvious changes were observed in the liver or in levels of serum markers, including creatinine, alanine aminotransferase, and aspartate aminotransferase. Therefore, IA use of vancomycin is effective and safe in the MRSA PJI rat model and is better than systemic administration, while IA and systemic vancomycin treatment could eradicate the infection with a 2-week treatment course.
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66
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Gramlich Y, Steinkohl D, Kremer M, Kemmerer M, Hoffmann R, Klug A. Modular knee arthrodesis secures limb, mobility, improves quality of life, and leads to high infection control in periprosthetic knee infection, when revision knee arthroplasty is not an option. Arch Orthop Trauma Surg 2021; 141:1349-1360. [PMID: 33893531 DOI: 10.1007/s00402-021-03907-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Accepted: 04/12/2021] [Indexed: 10/21/2022]
Abstract
INTRODUCTION This study compared the outcome of knee arthrodesis versus hinged total knee arthroplasty (TKA) in patients suffering from periprosthetic joint infection (PJI). METHODS 104 patients with PJI were treated using a two-stage exchange of failed TKA. In case of non reconstructable bone loss or loss of extension mechanism, a modular intramedullary arthrodesis nail was used for reimplantation [Knee Arthrodesis Module (KAM); n = 52]. The control group was retrospectively matched treated using a hinged revision TKA [Rotating Hinge Knee (RHK); n = 52]. PJI remission rates, functional outcome (WOMAC; KSS) and quality of life (SF-12), as well as comorbidities and pain were evaluated. RESULTS Mean age was 72.5 years. Charlson Comorbidity Index was higher in the KAM group (3.3 vs. 2.8). PJI remission rate was 89.4% (88.5% vs. 90.4%, respectively). In case of reinfection, implant retention was mostly possible in the RHK group (7.7%), whereas amputations were mostly performed in the KAM group (9.6%). Significant pain reduction (VAS 7.9-2.8) was achieved in both groups. Walking distance was significantly reduced in the KAM groups versus the RHK group (504 vs. 1064 m). WOMAC and KSS function scores were significantly reduced in the KAM group (25 vs. 40 and 35 vs. 64). Only moderate reduction in quality of life in the KAM group was observed (SF-12 physical: 34 vs. 40; SF-12 mental: 51 vs. 56) respectively. CONCLUSIONS Arthrodesis using a modular intramedullary nail is an alternative for limb salvage, pain reduction, and preservation of quality of life and everyday mobility, when revision TKA is not an option. This study presents the largest number of case, comparing the outcome after performing an arthrodesis versus hinged TKA after septic failed TKA.
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Affiliation(s)
- Y Gramlich
- Department of Trauma and Orthopedic Surgery, Berufsgenossenschaftliche Unfallklinik Frankfurt Am Main, Friedberger Landstr. 430, 60389, Frankfurt am Main, Germany.
| | - D Steinkohl
- Department of Trauma and Orthopedic Surgery, Berufsgenossenschaftliche Unfallklinik Frankfurt Am Main, Friedberger Landstr. 430, 60389, Frankfurt am Main, Germany
| | - M Kremer
- Department of Trauma and Orthopedic Surgery, Berufsgenossenschaftliche Unfallklinik Frankfurt Am Main, Friedberger Landstr. 430, 60389, Frankfurt am Main, Germany
| | - M Kemmerer
- Department of Trauma and Orthopedic Surgery, Berufsgenossenschaftliche Unfallklinik Frankfurt Am Main, Friedberger Landstr. 430, 60389, Frankfurt am Main, Germany
| | - R Hoffmann
- Department of Trauma and Orthopedic Surgery, Berufsgenossenschaftliche Unfallklinik Frankfurt Am Main, Friedberger Landstr. 430, 60389, Frankfurt am Main, Germany
| | - A Klug
- Department of Trauma and Orthopedic Surgery, Berufsgenossenschaftliche Unfallklinik Frankfurt Am Main, Friedberger Landstr. 430, 60389, Frankfurt am Main, Germany
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Fröschen FS, Randau TM, Gravius N, Wirtz DC, Gravius S, Walter SG. Risk factors for implant failure of custom-made acetabular implants in patients with Paprosky III acetabular bone loss and combined pelvic discontinuity. Technol Health Care 2021; 30:703-711. [PMID: 34366301 DOI: 10.3233/thc-202236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Severe acetabular bone loss in revision total hip arthroplasty (RTHA), both with or without pelvic discontinuity, remains a great challenge in orthopaedic surgery. OBJECTIVE The aim of this study was to evaluate risk factors for failure of custom-made acetabular implants in RTHA. METHODS Seventy patients with severe acetabular bone loss (Paprosky Type III) and pelvic discontinuity, who required RTHA, were included in our study. All prostheses were constructed based on a thin-layer computed-tomography (CT) scan of the pelvis. The treatment was considered unsuccessful in the event of periprosthetic joint infection (PJI) or aseptic loosening (AL) with need for explantation of the custom-made acetabular implant. RESULTS The average follow-up was 41.9 ± 34.8 months (range 1.5-120). Implant survival at last follow-up was 75.7% (53 of 70). Explantation was necessary in 17 cases (15 PJI; 2 AL). Previous PJI as reason for RTHA (p= 0.025; OR 3.56 (95% CI: 1.14; 11.21)), additional revision of femoral components (p= 0.003; OR 8.4 (95% CI: 1.75; 40.42)), rheumatoid disease (p= 0.039; OR 3.43 (95% CI: 1.01; 11.40)), elevated preoperative CRP > 15.2 mg/l (p= 0.015; AUC: 0.7) and preoperative haemoglobin < 10.05 (p= 0.022; AUC: 0.69) were statistically significant risk factors associated with treatment failure. Age and BMI were not statistically significant contributing to implant failure. CONCLUSION Risk factors for treatment failure were a previous PJI, additional revision of femoral component, rheumatoid disease, elevated preoperative CRP and low preoperative haemoglobin. Awareness of these risk factors will help to improve future treatment standards.
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Affiliation(s)
- Frank S Fröschen
- Department of Orthopaedic Surgery and Traumatology, University Hospital Bonn, Germany
| | - Thomas M Randau
- Department of Orthopaedic Surgery and Traumatology, University Hospital Bonn, Germany
| | - Nadine Gravius
- Department of Orthopaedic Surgery and Traumatology, University Hospital Mannheim, Germany
| | - Dieter C Wirtz
- Department of Orthopaedic Surgery and Traumatology, University Hospital Bonn, Germany
| | - Sascha Gravius
- Department of Orthopaedic Surgery and Traumatology, University Hospital Mannheim, Germany
| | - Sebastian G Walter
- Department of Orthopaedic Surgery and Traumatology, University Hospital Cologne, Germany
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Anagnostakos K, Grzega C, Sahan I, Geipel U, Becker SL. Occurrence of Rare Pathogens at the Site of Periprosthetic Hip and Knee Joint Infections: A Retrospective, Single-Center Study. Antibiotics (Basel) 2021; 10:antibiotics10070882. [PMID: 34356802 PMCID: PMC8300814 DOI: 10.3390/antibiotics10070882] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Revised: 07/08/2021] [Accepted: 07/16/2021] [Indexed: 12/31/2022] Open
Abstract
The frequency and clinical relevance of rare pathogens at the site of periprosthetic infections of the hip and knee joint and their antibiotic resistance profiles have not yet been assessed in-depth. We retrospectively analyzed all periprosthetic hip and knee joint infections that occurred between 2016 and 2020 in a single center in southwest Germany. Among 165 infections, 9.7% were caused by rare microorganisms such as Veilonella sp., Pasteurella sp., Pantoea sp., Citrobacter koseri, Serratia marcescens, Parvimonas micra, Clostridium difficile, Finegoldia magna, Morganella morganii, and yeasts. No resistance to piperacillin/tazobactam, carbapenemes, fluoroquinolones, or gentamicin was observed. Some bacteria displayed resistance to ampicillin, ampicillin/sulbactam, and cefuroxime. We present follow-up data of patients with infections due to rare pathogens and discuss the importance of close, interdisciplinary collaboration between orthopedic surgeons and clinical microbiologists to carefully select the most appropriate anti-infective treatment regimens for the increasing number of patients with such infections.
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Affiliation(s)
- Konstantinos Anagnostakos
- Zentrum für Orthopädie und Unfallchirurgie, Klinikum Saarbrücken, 66119 Saarbrücken, Germany; (C.G.); (I.S.)
- Correspondence:
| | - Christoph Grzega
- Zentrum für Orthopädie und Unfallchirurgie, Klinikum Saarbrücken, 66119 Saarbrücken, Germany; (C.G.); (I.S.)
| | - Ismail Sahan
- Zentrum für Orthopädie und Unfallchirurgie, Klinikum Saarbrücken, 66119 Saarbrücken, Germany; (C.G.); (I.S.)
| | - Udo Geipel
- Bioscientia MVZ Saarbrücken GmbH, 66119 Saarbrücken, Germany;
| | - Sören L. Becker
- Institut für Medizinische Mikrobiologie und Hygiene, Universitätsklinikum des Saarlandes, 66421 Homburg/Saar, Germany;
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69
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He JW, Wang J, Cao L, Zhang XG, Li GQ, Xu BY, Ji BC, Ge SY, Yang JH. Serum and Synovial Vancomycin Concentrations in Patients with Prosthetic Joint Infection after Intra-articular Infusion. Eur J Drug Metab Pharmacokinet 2021; 46:637-643. [PMID: 34275127 DOI: 10.1007/s13318-021-00705-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/29/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND AND OBJECTIVES Vancomycin is one of the most commonly used antibiotics for intra-articular (IA) infusion in the treatment of prosthetic joint infection (PJI). This study aimed to preliminarily investigate the serum and synovial vancomycin concentrations in patients with PJI after IA infusion. METHODS In total, 16 patients who developed PJI were enrolled in this study; 14 of the patients were treated with IA infusion of vancomycin postoperatively, while the other 2 patients received intravenous (IV) infusion of vancomycin alone. Chemiluminescent immunoassay assay (CLIA) and high-performance liquid chromatography (HPLC) were used to determine the serum and synovial vancomycin concentrations, respectively. RESULTS Administration of vancomycin 0.5 g once daily (qd) IA maintained a high vancomycin trough concentration in synovial fluid before the next IA dose, regardless of whether it was given in combination with IV administration. The combination vancomycin 0.5 g qd IA + vancomycin 1 g every 12 h (q12h) IV yielded relatively good trough concentrations of vancomycin in both serum and synovial fluid. The mean trough serum vancomycin concentration of patients who used vancomycin 1 g q12h IV therapy was above 10 μg/mL; however, no vancomycin was detected in their synovial fluid. CONCLUSIONS The rational use of IA vancomycin infusion may help to achieve effective therapeutic concentrations of vancomycin in the serum and synovial fluid of patients with PJI.
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Affiliation(s)
- Jia-Wei He
- Department of Pharmacy, The First Affiliated Hospital of Xinjiang Medical University, No. 137 South Liyu Mountain Road, Urumqi, 830054, Xinjiang, China
| | - Jing Wang
- Department of Pharmacy, The Eighth Affiliated Hospital of Xinjiang Medical University, Urumqi, 830054, Xinjiang, China
| | - Li Cao
- Department of Orthopaedics, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, 830054, Xinjiang, China
| | - Xiao-Gang Zhang
- Department of Orthopaedics, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, 830054, Xinjiang, China
| | - Guo-Qing Li
- Department of Orthopaedics, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, 830054, Xinjiang, China
| | - Bo-Yong Xu
- Department of Orthopaedics, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, 830054, Xinjiang, China
| | - Bao-Chao Ji
- Department of Orthopaedics, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, 830054, Xinjiang, China
| | - Si-Ya Ge
- College of Pharmacy, Xinjiang Medical University, Urumqi, 830054, Xinjiang, China
| | - Jian-Hua Yang
- Department of Pharmacy, The First Affiliated Hospital of Xinjiang Medical University, No. 137 South Liyu Mountain Road, Urumqi, 830054, Xinjiang, China.
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Christensen DD, Moschetti WE, Brown MG, Lucas AP, Jevsevar DS, Fillingham YA. Perioperative Antibiotic Prophylaxis: Single and 24-Hour Antibiotic Dosages are Equally Effective at Preventing Periprosthetic Joint Infection in Total Joint Arthroplasty. J Arthroplasty 2021; 36:S308-S313. [PMID: 33712358 DOI: 10.1016/j.arth.2021.02.037] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2020] [Revised: 02/08/2021] [Accepted: 02/11/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Perioperative antibiotic prophylaxis is used to prevent surgical site infection and periprosthetic joint infection (PJI) after total joint arthroplasty (TJA). Secondary to a national shortage of cefazolin, patients at our institution began receiving a single preoperative prophylactic antibiotic dose for primary TJA and no 24-hour postoperative antibiotic prophylaxis. The purpose of the study was to compare the efficacy of single-dose antibiotic use versus 24-hour dosing of prophylactic antibiotics in the prevention of acute PJI and short-term complications after primary TJA. METHODS A retrospective review of 3317 patients undergoing primary TJA performed from January 2015 to December 2019 identified 554 patients who received a single dose of preoperative antibiotic prophylaxis during the antibiotic shortage and 2763 patients who received post-TJA 24-hour antibiotic prophylaxis before the shortage. Patient records were evaluated for acute PJI, superficial infection, 90-day reoperation, and 90-day complications. RESULTS There were no significant differences in patient characteristics between single-dose and 24-hour antibiotic groups. Similarly, there were no significant differences in rates of acute PJI (0.7% vs 0.2%; P = .301), superficial infection (2.4% vs 1.4%; P = .221), 90-day reoperation (2.1% vs 1.1%; P = .155), and 90-day complications (9.9% vs 7.9%; P = .169) between single and 24-hour antibiotic dose. Post hoc power analysis demonstrated adequate sample size, beta = 93%. CONCLUSION Single-dose prophylactic antibiotics did not lead to an increased risk of acute PJI or short-term complications after TJA. Our study suggests that administration of a single antibiotic dose may be safely considered in patients undergoing routine primary TJA.
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Affiliation(s)
- David D Christensen
- Dartmouth Hitchcock Medical Center, Lebanon, NH; Dartmouth College Geisel School of Medicine, Hanover, NH
| | - Wayne E Moschetti
- Dartmouth Hitchcock Medical Center, Lebanon, NH; Dartmouth College Geisel School of Medicine, Hanover, NH
| | - Marcel G Brown
- Dartmouth College Geisel School of Medicine, Hanover, NH
| | | | - David S Jevsevar
- Dartmouth Hitchcock Medical Center, Lebanon, NH; Dartmouth College Geisel School of Medicine, Hanover, NH
| | - Yale A Fillingham
- Dartmouth Hitchcock Medical Center, Lebanon, NH; Dartmouth College Geisel School of Medicine, Hanover, NH
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71
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Premkumar A, Nishtala SN, Nguyen JT, Bostrom MPG, Carli AV. The AAHKS Best Podium Presentation Research Award: Comparing the Efficacy of Irrigation Solutions on Staphylococcal Biofilm Formed on Arthroplasty Surfaces. J Arthroplasty 2021; 36:S26-S32. [PMID: 33750633 DOI: 10.1016/j.arth.2021.02.033] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 01/19/2021] [Accepted: 02/09/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND A diverse array of antibacterial solutions is utilized by orthopedic surgeons in an attempt to disperse bacterial biofilm. Few studies compare these agents against biofilm grown on clinically relevant orthopedic biomaterials, such as plastic, acrylic cement, and porous titanium. METHODS MSSA biofilm was grown on plastic 48-well plates, polymethylmethacrylate cement beads and porous Ti-6Al-4V acetabular screw caps. Antibacterial solutions were tested according to manufacturer guidance and included: isotonic saline, vancomycin (1 mg/mL), polymyxin-bacitracin (500,000 U/L-50,000 U/L), povidone-iodine 0.3%, povidone-iodine 10%, a 1:1 combination of povidone-iodine 10% & 4% hydrogen peroxide, polyhexamethylene biguanide (PHMB) and betaine 0.04%, a commercial solution containing chlorhexidine gluconate (CHG) 0.05%, and a commercial solution containing benzalkonium chloride and ethanol. Twenty four and 72-hour biofilms were exposed to solutions for 3 minutes to reproduce intraoperative conditions. Solution efficacy was measured through sonication of treated surfaces followed by counting colony forming units and validated with a resazurin assay to assess cell viability. Experiments were performed in triplicate and repeated at least once. A three-fold log reduction in CFU counts versus controls was considered as a measure of solution efficacy. RESULTS Saline, vancomycin and polymyxin-bacitracin were ineffective compared to other solutions against planktonic MSSA. Povidone-iodine 10% and a 1:1 solution of povidone-iodine 10% and 4% hydrogen peroxide were the only effective solutions against biofilm across all three surfaces and time points. CONCLUSION Commercial antibacterial solutions vary significantly in their efficacy against MSSA biofilm. Efficacy globally decreased as biofilm maturity increased. Increased solution cost did not confer increased efficacy.
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Affiliation(s)
- Ajay Premkumar
- Hospital for Special Surgery, Adult Reconstruction & Joint Replacement, NY
| | | | | | | | - Alberto V Carli
- Hospital for Special Surgery, Adult Reconstruction & Joint Replacement, NY
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Christopher ZK, McQuivey KS, Deckey DG, Haglin J, Spangehl MJ, Bingham JS. Acute or chronic periprosthetic joint infection? Using the ESR ∕ CRP ratio to aid in determining the acuity of periprosthetic joint infections. J Bone Jt Infect 2021; 6:229-234. [PMID: 34159047 PMCID: PMC8209584 DOI: 10.5194/jbji-6-229-2021] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Accepted: 05/31/2021] [Indexed: 01/15/2023] Open
Abstract
Introduction: The gold standard for determining the duration of periprosthetic joint infection (PJI) is a thorough history. Currently, there are no well-defined objective criteria to determine the duration of PJI, and little evidence exists regarding the ratio between ESR (mm/h) and CRP (mg/L) in joint arthroplasty. This study suggests the ESR / CRP ratio will help differentiate acute from chronic PJI. Methods: Retrospective review of patients with PJI was performed. Inclusion criteria: patients > 18 years old who underwent surgical revision for PJI and had documented ESR and CRP values. Subjects were divided into two groups: PJI for greater (chronic) or less than (acute) 4 weeks and the ESR / CRP ratio was compared between them. Receiver-operating characteristic (ROC) curves were evaluated to determine the utility of the ESR / CRP ratio in characterizing the duration of PJI. Results: 147 patients were included in the study (81 acute and 66 chronic). The mean ESR / CRP ratio in acute patients was 0.48 compared to 2.87 in chronic patients ( p < 0.001 ). The ESR / CRP ROC curve demonstrated an excellent area under the curve (AUC) of 0.899. The ideal cutoff value was 0.96 for ESR / CRP to predict a chronic ( > 0.96 ) vs. acute ( < 0.96 ) PJI. The sensitivity at this value was 0.74 (95 % CI 0.62-0.83) and the specificity was 0.90 (95 % CI 0.81-0.94). Conclusions: The ESR / CRP ratio may help determine the duration of PJI in uncertain cases. This metric may give arthroplasty surgeons more confidence in defining the duration of the PJI and therefore aid in treatment selection.
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Affiliation(s)
| | - Kade S McQuivey
- Department of Orthopaedic Surgery, Mayo Clinic Arizona, Phoenix, AZ, USA
| | - David G Deckey
- Department of Orthopaedic Surgery, Mayo Clinic Arizona, Phoenix, AZ, USA
| | - Jack Haglin
- Department of Orthopaedic Surgery, Mayo Clinic Arizona, Phoenix, AZ, USA
| | - Mark J Spangehl
- Department of Orthopaedic Surgery, Mayo Clinic Arizona, Phoenix, AZ, USA
| | - Joshua S Bingham
- Department of Orthopaedic Surgery, Mayo Clinic Arizona, Phoenix, AZ, USA
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73
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Zhao D, He J, Wang X, Zhao X, Xia Y, Geng B. The role of fibrinogen in predicting reinfection after DAIR for periprosthetic joint infections. BMC Musculoskelet Disord 2021; 22:474. [PMID: 34030692 PMCID: PMC8146659 DOI: 10.1186/s12891-021-04357-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Accepted: 05/10/2021] [Indexed: 12/03/2022] Open
Abstract
Background Fibrinogen (FIB) has been found to be a promising marker in diagnosing periprosthetic joint infection (PJI), however, the value of FIB in predicting reinfection of PJI is unknown. The purpose of this study was to evaluate the value of FIB in predicting reinfection after debridement, antibiotics, and implant retention (DAIR) for PJI. Methods We retrospectively analyzed the clinical data of patients who were diagnosed with PJI and underwent DAIR from 2013 to 2019. The levels of the FIB, erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP) were measured before DAIR. After DAIR, patients were followed and reinfections were identified. For both acute and chronic PJI, the predictive value of FIB was evaluated by calculating the sensitivity, specificity, and area under the curve (AUC) of the receiver operating characteristic curve (ROC), and was compared with traditional inflammatory markers including ESR and CRP. Results The expression of FIB differed between patients reinfected and those not reinfected in both acute and chronic PJI (p < 0.05). In patients who underwent DAIR for acute PJI, the sensitivity and specificity of FIB were 81.82 and 83.33%, respectively, which were significantly higher than that of CRP (sensitivity, 72.73%; specificity, 50%; p < 0.05), while the specificity was higher than that of ESR (specificity, 41.67%; p < 0.05). In patients who underwent DAIR for chronic PJI, the sensitivity and specificity of FIB were 80.00 and 66.66%, respectively, which were significantly higher than that of CRP (sensitivity, 53.33%; specificity, 66.66%; p < 0.05) and ESR (sensitivity was 66.00%; specificity, 16.66%; p < 0.05). The ROC curves showed that FIB demonstrated the highest AUC among the biomarkers in both acute and chronic PJI. Conclusion FIB is a promising indicator in predicting reinfection after DAIR for both acute and chronic PJI, and it seems to perform better than ESR and CRP. Supplementary Information The online version contains supplementary material available at 10.1186/s12891-021-04357-8.
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Affiliation(s)
- Dacheng Zhao
- Department of Orthopaedics, Lanzhou University Second Hospital, Orthopaedics Key Laboratory of Gansu Province, Orthopaedics Clinical Research Center of Gansu Province, No. 82 of Cuiying Men, Lanzhou, 730030, Gansu, China
| | - Jinwen He
- Department of Orthopaedics, Lanzhou University Second Hospital, Orthopaedics Key Laboratory of Gansu Province, Orthopaedics Clinical Research Center of Gansu Province, No. 82 of Cuiying Men, Lanzhou, 730030, Gansu, China
| | - Xingwen Wang
- Department of Orthopaedics, Lanzhou University Second Hospital, Orthopaedics Key Laboratory of Gansu Province, Orthopaedics Clinical Research Center of Gansu Province, No. 82 of Cuiying Men, Lanzhou, 730030, Gansu, China
| | - Xiaobing Zhao
- Department of Orthopaedics, Lanzhou University Second Hospital, Orthopaedics Key Laboratory of Gansu Province, Orthopaedics Clinical Research Center of Gansu Province, No. 82 of Cuiying Men, Lanzhou, 730030, Gansu, China
| | - Yayi Xia
- Department of Orthopaedics, Lanzhou University Second Hospital, Orthopaedics Key Laboratory of Gansu Province, Orthopaedics Clinical Research Center of Gansu Province, No. 82 of Cuiying Men, Lanzhou, 730030, Gansu, China.
| | - Bin Geng
- Department of Orthopaedics, Lanzhou University Second Hospital, Orthopaedics Key Laboratory of Gansu Province, Orthopaedics Clinical Research Center of Gansu Province, No. 82 of Cuiying Men, Lanzhou, 730030, Gansu, China.
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74
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He R, Wang Q, Wang J, Tang J, Shen H, Zhang X. Better choice of the type of specimen used for untargeted metagenomic sequencing in the diagnosis of periprosthetic joint infections. Bone Joint J 2021; 103-B:923-930. [PMID: 33934659 DOI: 10.1302/0301-620x.103b5.bjj-2020-0745.r1] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
AIMS As a proven and comprehensive molecular technique, metagenomic next-generation sequencing (mNGS) has shown its potential in the diagnosis of pathogens in patients with periprosthetic joint infection (PJI), using a single type of specimen. However, the optimal use of mNGS in the management of PJI has not been explored. In this study, we evaluated the diagnostic value of mNGS using three types of specimen with the aim of achieving a better choice of specimen for mNGS in these patients. METHODS In this prospective study, 177 specimens were collected from 59 revision arthroplasties, including periprosthetic tissues, synovial fluid, and prosthetic sonicate fluid. Each specimen was divided into two, one for mNGS and one for culture. The criteria of the Musculoskeletal Infection Society were used to define PJI (40 cases) and aseptic failure (19 cases). RESULTS The sensitivity and specificity of mNGS in the diagnosis of PJI were 95% and 94.7%, respectively, for all types of specimen. The sensitivity and specificity were 65% and 100%, respectively, for periprosthetic tissues, 87.5% and 94.7%, respectively, for synovial fluid, and 92.5% and 94.7%, respectively, for prosthetic sonicate fluid. The mNGS of prosthetic sonicate fluid outperformed that for other types of specimen in the rates of detection of pathogens (84.6%), sequencing reads (> ten-fold) and the rate of genome coverage (> five-fold). CONCLUSION mNGS could serve as an accurate diagnostic tool in the detection of pathogens in patients with a PJI using three types of specimen. Due to its superior perfomance in identifying a pathogen, mNGS of prosthetic sonicate fluid provides the most value and may partly replace traditional tests such as bacteriological culture in these patients. Cite this article: Bone Joint J 2021;103-B(5):923-930.
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Affiliation(s)
- Renke He
- Department of Orthopaedics, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Qiaojie Wang
- Department of Orthopaedics, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Jin Wang
- Department of Orthopaedics, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Jin Tang
- Clinical Laboratory, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Hao Shen
- Department of Orthopaedics, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Xianlong Zhang
- Department of Orthopaedics, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai Jiao Tong University, Shanghai, China
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75
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Ene R, Nica M, Ene D, Cursaru A, Cirstoiu C. Review of calcium-sulphate-based ceramics and synthetic bone substitutes used for antibiotic delivery in PJI and osteomyelitis treatment. EFORT Open Rev 2021; 6:297-304. [PMID: 34150324 PMCID: PMC8183146 DOI: 10.1302/2058-5241.6.200083] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Infection in orthopaedic and trauma surgery remains a destructive complication with particularly challenging diagnosis and treatment due to bacterial antibiotic resistance and biofilm formation. Along with surgical debridement and systemic antibiotics, an important type of adjuvant therapy is local antibiotic delivery, with the purpose of eliminating bacterial colonization and biofilm development. Calcium sulphate, as a synthetic absorbable biomaterial used for local antibiotic delivery, has experienced an increasing popularity during the last decade, with multiple promoted advantages such as predictable antibiotic elution kinetics, complete and quick biodegradation, good biocompatibility, and limited associated complications. A series of commercially available antibiotic-delivery systems based on calcium sulphate are under investigation and in clinical use, with different presentations, compositions, and application techniques. The current article presents the main available calcium-sulphate-based products and the existing data about the clinical and preclinical research results, stemming from their implementation as local antibiotic carriers for surgical site and implant-associated infections treatment and prevention.
Cite this article: EFORT Open Rev 2021;6:297-304. DOI: 10.1302/2058-5241.6.200083
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Affiliation(s)
- Razvan Ene
- Carol Davila University of Medicine and Pharmacy, Orthopedics and Traumatology Department, Bucharest, Romania.,Bucharest Emergency Clinical Hospital, Romania
| | - Mihai Nica
- Carol Davila University of Medicine and Pharmacy, Orthopedics and Traumatology Department, Bucharest, Romania.,University Emergency Hospital Bucharest, Romania
| | - Dragos Ene
- Carol Davila University of Medicine and Pharmacy, Orthopedics and Traumatology Department, Bucharest, Romania.,Bucharest Emergency Clinical Hospital, Romania
| | - Adrian Cursaru
- Carol Davila University of Medicine and Pharmacy, Orthopedics and Traumatology Department, Bucharest, Romania.,University Emergency Hospital Bucharest, Romania
| | - Catalin Cirstoiu
- Carol Davila University of Medicine and Pharmacy, Orthopedics and Traumatology Department, Bucharest, Romania.,University Emergency Hospital Bucharest, Romania
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76
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Mu W, Xu B, Guo W, Ji B, Wahafu T, Cao L. Outcome of Irrigation and Debridement With Topical Antibiotics Delivery for the Management of Periprosthetic Joint Infection Occurring Within 3 Months Since the Primary Total Joint Arthroplasty. J Arthroplasty 2021; 36:1765-1771. [PMID: 33358609 DOI: 10.1016/j.arth.2020.11.033] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2020] [Revised: 11/21/2020] [Accepted: 11/23/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Irrigation and debridement with modular component exchange is appealing for surgeons to treat early-stage periprosthetic joint infection (PJI). However, the indication, perioperative protocol, and success rate remain controversial. This study is the first one to present results of debridement, antibiotics, and implant retention (DAIR) with integrated MIT (modular component exchange, povidone-iodine and topical antibiotics delivery) protocol for treating PJI occurring within 3 months since the primary total joint arthroplasty. METHODS We retrospectively analyzed patients who received DAIR with MIT protocol in our department between January 2011 and May 2018. Topical antibiotics were delivered in all cases. Topical antibiotics infusion was applied for those infected with multidrug-resistant bacteria, fungus, polymicrobial infection, and culture negative one. Failure was defined as additional surgical intervention for infection after DAIR; persistent sinus tract, drainage or excessive joint pain; need for suppressive antibiotics therapy due to the infection; infection relapse with the same pathogen; reinfection with different microorganism; and infection-related death. RESULTS A total of 73 patients with a mean age of 63.30 ± 10.97 years were included in this study, including 43 men and 30 women. There are 41 knees and 32 hips. Thirty patients had sinus tract. With a mean follow-up of 63.79 ± 18.57 months, there were 9 failures in total with an overall success rate of 87.67%. The success rate was 88.57% and 86.84% for those receiving topical antibiotics infusion postoperatively and those without. CONCLUSIONS DAIR with a standard MIT protocol is a viable and safe option for PJI occurring within 3 months since the primary total joint arthroplasty. LEVEL OF EVIDENCE Level 4, therapeutic study.
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Affiliation(s)
- Wenbo Mu
- Department of Orthopaedics, First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang, China
| | - Boyong Xu
- Department of Orthopaedics, First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang, China
| | - Wentao Guo
- Department of Orthopaedics, First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang, China
| | - Baochao Ji
- Department of Orthopaedics, First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang, China
| | - Tuerhongjiang Wahafu
- Department of Orthopaedics, First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang, China
| | - Li Cao
- Department of Orthopaedics, First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang, China
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Löwik CAM, Parvizi J, Jutte PC, Zijlstra WP, Knobben BAS, Xu C, Goswami K, Belden KA, Sousa R, Carvalho A, Martínez-Pastor JC, Soriano A, Wouthuyzen-Bakker M. Debridement, Antibiotics, and Implant Retention Is a Viable Treatment Option for Early Periprosthetic Joint Infection Presenting More Than 4 Weeks After Index Arthroplasty. Clin Infect Dis 2021; 71:630-636. [PMID: 31504331 DOI: 10.1093/cid/ciz867] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Accepted: 08/30/2019] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND The success of debridement, antibiotics, and implant retention (DAIR) in early periprosthetic joint infection (PJI) largely depends on the presence of a mature biofilm. At what time point DAIR should be disrecommended is unknown. This multicenter study evaluated the outcome of DAIR in relation to the time after index arthroplasty. METHODS We retrospectively evaluated PJIs occurring within 90 days after surgery and treated with DAIR. Patients with bacteremia, arthroscopic debridements, and a follow-up <1 year were excluded. Treatment failure was defined as (1) any further surgical procedure related to infection; (2) PJI-related death; or (3) use of long-term suppressive antibiotics. RESULTS We included 769 patients. Treatment failure occurred in 294 patients (38%) and was similar between time intervals from index arthroplasty to DAIR: the failure rate for Week 1-2 was 42% (95/226), the rate for Week 3-4 was 38% (143/378), the rate for Week 5-6 was 29% (29/100), and the rate for Week 7-12 was 42% (27/65). An exchange of modular components was performed to a lesser extent in the early post-surgical course compared with the late course (41% vs 63%, respectively; P < .001). The causative microorganisms, comorbidities, and durations of symptoms were comparable between time intervals. CONCLUSIONS DAIR is a viable option in patients with early PJI presenting more than 4 weeks after index surgery, as long as DAIR is performed within at least 1 week after the onset of symptoms and modular components can be exchanged.
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Affiliation(s)
- Claudia A M Löwik
- Department of Orthopaedic Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Javad Parvizi
- Department of Orthopaedic Surgery, Rothman Institute at Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Paul C Jutte
- Department of Orthopaedic Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Wierd P Zijlstra
- Department of Orthopaedic Surgery, Medical Center Leeuwarden, Leeuwarden, The Netherlands
| | - Bas A S Knobben
- Department of Orthopaedic Surgery, Martini Hospital, Groningen, The Netherlands
| | - Chi Xu
- Department of Orthopaedic Surgery, Rothman Institute at Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Karan Goswami
- Department of Orthopaedic Surgery, Rothman Institute at Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Katherine A Belden
- Department of Infectious Diseases, Sydney Kimmel Medical College at Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Ricardo Sousa
- Department of Orthopaedic Surgery, Centro Hospitalar do Porto, Porto, Portugal
| | - André Carvalho
- Department of Orthopaedic Surgery and Traumatology, University of Barcelona, Hospital Clinic of Barcelona, Barcelona, Spain
| | - Juan Carlos Martínez-Pastor
- Department of Orthopaedic Surgery and Traumatology, University of Barcelona, Hospital Clinic of Barcelona, Barcelona, Spain
| | - Alex Soriano
- Department of Infectious Diseases, University of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Hospital Clinic of Barcelona, Barcelona, Spain
| | - Marjan Wouthuyzen-Bakker
- Department of Medical Microbiology and Infection Prevention, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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78
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Collins KA. Periprosthetic Joint Infections of the Hip and Knee. PHYSICIAN ASSISTANT CLINICS 2021. [DOI: 10.1016/j.cpha.2020.11.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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79
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[Influence of timing of surgery on complication rates after cemented hemiarthroplasty for treatment of medial femoral neck fractures]. Unfallchirurg 2021; 124:990-999. [PMID: 33661345 DOI: 10.1007/s00113-021-00972-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/02/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND The optimal timing of the implantation of a cemented hemiarthroplasty in the management of displaced medial femoral neck fractures is still the subject of current research. According to the current recommendations, these cases should be surgically treated within 24 h. The aim of this study was to evaluate the impact of the timing of surgery on operation-specific and nonspecific complications, intensive care treatment as well as mortality. MATERIAL AND METHODS Overall, 152 cases were retrospectively investigated regarding several parameters (demographic data, comorbidities, surgery time, duration of hospital stay, intensive care treatment, general, bleeding, operation-specific and nonspecific complications). The statistical analysis was performed using the χ2-test and the unpaired Student's t‑test as well as logistic regression analyses. RESULTS A total of 152 patients were included and 71.1% of the operations were performed within 24 h and the remaining 28.9% after 24 h. All groups showed a similar profile of comorbidities. The analysis of the intensive care treatment showed no significant differences between the individual groups. The rate of postoperative pneumonia was moderately higher among the patients with a procedure after 24 h; however, with no severe courses. There were no significant differences regarding all other complications and the mortality rate between the individual time points of surgery. CONCLUSION The present study demonstrated that patients operated on after 24 h showed no disadvantages regarding other complications, intensive care treatment or mortality, except from an increased postoperative pneumonia rate. These results could be taken into consideration for the next update of the treatment guidelines.
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80
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Tan SHS, Hong CC, Saha S, Hey HWD, Murphy D, Hui JH. Optimum early orthopaedic surgery in COVID-19 patients. ANNALS OF THE ACADEMY OF MEDICINE, SINGAPORE 2021; 50:250-254. [PMID: 33855321 DOI: 10.47102/annals-acadmedsg.2020317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Affiliation(s)
- Si Heng Sharon Tan
- Department of Orthopaedic Surgery, National University Hospital, Singapore
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81
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Rossmann M, Minde T, Citak M, Gehrke T, Sandiford NA, Klatte TO, Abdelaziz H. High Rate of Reinfection With New Bacteria Following One-Stage Exchange for Enterococcal Periprosthetic Infection of the Knee: A Single-Center Study. J Arthroplasty 2021; 36:711-716. [PMID: 32863076 DOI: 10.1016/j.arth.2020.08.015] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 08/05/2020] [Accepted: 08/06/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND A wide range of success rates following the surgical management of enterococcal periprosthetic joint infection (PJI) with a tendency toward worse outcomes have been reported. However, the role of 1-stage exchange remains under-investigated. Therefore, we aimed to evaluate our results after the 1-stage knee exchange for enterococcal PJI. METHODS Forty patients were retrospectively included between 2002 and 2017 with a mean follow-up of survivors of 80 months (range 22-172; standard deviation [SD] = 5). Polymicrobial infections occurred in 45% (18/40) of patients. Patients' characteristics, joint-related data, and antibiotic therapy were recorded. Rates of enterococcal infection relapse, reinfection with new microorganisms, and re-revision for any reason were determined. Bivariate analysis was conducted to identify risk factors of infection recurrence. RESULTS Revision surgery was required in 22 cases (55%) with a mean time to revision surgery of 27 months (range 1-78; SD = 25). Indications for aseptic revisions (18%) included aseptic loosening (10%), periprosthetic fracture (5%), and patellar instability (3%). The most common cause of re-revision was a subsequent PJI (15/22; 68%) after a mean time of 22 months (range 1-77; SD = 24). Overall infection recurrence rate was 37.5% (15/40), substantially due to entirely non-enterococcal infections (9/15; 60%). Infection relapse with Enterococci occurred in 4 cases (10%) within 16 months postoperatively. Older patients (P = .05) and male gender (P = .05) were associated with a higher risk of infection recurrence. CONCLUSION Overcoming the Enterococci using the 1-stage exchange for knee PJI is achievable but the rate of reinfection due to new microorganisms is high . However, the overall infection recurrence rate is comparable to other treatment approaches.
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Affiliation(s)
- Markus Rossmann
- Department of Joint Replacement Surgery, Helios ENDO-Klinik Hamburg, Hamburg, Germany
| | - Thore Minde
- Department of Joint Replacement Surgery, Helios ENDO-Klinik Hamburg, Hamburg, Germany
| | - Mustafa Citak
- Department of Joint Replacement Surgery, Helios ENDO-Klinik Hamburg, Hamburg, Germany
| | - Thorsten Gehrke
- Department of Joint Replacement Surgery, Helios ENDO-Klinik Hamburg, Hamburg, Germany
| | | | - Till Orla Klatte
- Department of Trauma, Hand, and Reconstructive Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Hussein Abdelaziz
- Department of Joint Replacement Surgery, Helios ENDO-Klinik Hamburg, Hamburg, Germany
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Boyer B, Cazorla C. Methods and probability of success after early revision of prosthetic joint infections with debridement, antibiotics and implant retention. Orthop Traumatol Surg Res 2021; 107:102774. [PMID: 33321230 DOI: 10.1016/j.otsr.2020.102774] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Accepted: 06/15/2020] [Indexed: 02/03/2023]
Abstract
Prosthetic joint infection (PJI) is a rare-and dreaded-complication of arthroplasty requiring multidisciplinary care. Given the dual goal of treating the infection and maintaining satisfactory function, it is preferable to determine how and when the implanted components can be retained. Bacteria and fungi organize themselves into biofilms that shield them from antibiotics and the immune system. This biofilm is in place after 15 days of active infection. Some antibiotics have a better activity on biofilms. The following factors have a negative impact on the probability of a successful debridement, antibiotics and implant retention (DAIR) intervention: fracture or revision, use of cement, bacteremia, kidney and/or liver failure, immunosuppression and elevated CRP. Hematogenous infections have a worse prognosis than early postoperative infections. Using a decision algorithm increases the chances of DAIR being successful. The KLIC score applies to early postoperative infections (<4 weeks postoperative and<3 weeks from the first signs) while the CRIME-80 score applies to hematogenous infections (<3 weeks from the first signs). Arthroscopic treatments have no role here, whereas DAIR through an arthrotomy is well standardized. Wide spectrum antibiotic therapy, secondarily adapted to the causative microorganism, is indicated for a total of 3 months. The results against the infection are mixed, although following a decision algorithm resolves the infection in about 75% of cases. The functional outcomes and quality of life are close to those of patients who have undergone primary joint replacement. It is not recommended to carry out a second DAIR if the first one fails. It is logical to apply the principles set out for the hip and knee to other joint replacements, and to use the same algorithm. For the upper limb, and especially for reverse shoulder arthroplasty, one must be careful about Cutibacterium acnes infections as they are hard to diagnose. Surgeons should not hesitate to contact a referral center for any PJI, although it is preferable that early infections be treated at the facility that performed the implantation.
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Affiliation(s)
- Bertrand Boyer
- Prosthetic Joint Infection Referral Center of Saint Étienne University Hospital, France; Unité Inserm SAINBIOSE U1059-Laboratoire de Biologie du Tissu Ostéoarticulaire, France.
| | - Céline Cazorla
- Prosthetic Joint Infection Referral Center of Saint Étienne University Hospital, France; Groupe Immunité Muqueuse et Agents Pathogènes, EA 3064, CHU de Saint Etienne, 42055 Saint Étienne cedex 2, France
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Kuiper JWP, Hogervorst JMA, Herpers BL, Bakker AD, Klein-Nulend J, Nolte PA, Krom BP. The novel endolysin XZ.700 effectively treats MRSA biofilms in two biofilm models without showing toxicity on human bone cells in vitro. BIOFOULING 2021; 37:184-193. [PMID: 33615928 DOI: 10.1080/08927014.2021.1887151] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/27/2020] [Revised: 01/26/2021] [Accepted: 01/30/2021] [Indexed: 06/12/2023]
Abstract
In this in vitro study the effect of XZ.700, a new endolysin, on methicillin resistant Staphylococcus aureus (MRSA) biofilms grown on titanium was evaluated. Biofilms of S. aureus USA300 were grown statically and under flow, and treatment with XZ.700 was compared with povidone-iodine (PVP-I) and gentamicin. To evaluate the cytotoxic effects of XZ.700 and derived biofilm lysates, human osteocyte-like cells were exposed to biofilm supernatants, and metabolism and proliferation were quantified. XZ.700 showed a significant, concentration dependent reduction in biofilm viability, compared with carrier controls. Metabolism and proliferation of human osteocyte-like cells were not affected by XZ.700 or lysates, unlike PVP-I and gentamicin lysates which significantly inhibited proliferation. Using time-lapse microscopy, rapid biofilm killing and removal was observed for XZ.700. In comparison, PVP-I and gentamicin showed slower biofilm killing, with no apparent biofilm removal. In conclusion, XZ.700 reduced MRSA biofilms, especially under flow condition, without toxicity for surrounding bone cells.
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Affiliation(s)
- Jesse W P Kuiper
- Department of Orthopedic Surgery, Spaarne Gasthuis, Hoofddorp, The Netherlands
| | - Jolanda M A Hogervorst
- Department of Oral Cell Biology, Academic Centre for Dentistry Amsterdam (ACTA), University of Amsterdam and Vrije Universiteit Amsterdam, Amsterdam Movement Sciences, Amsterdam, The Netherlands
| | - Bjorn L Herpers
- Department of Medical Microbiology, Spaarne Gasthuis, Hoofddorp, The Netherlands
| | - Astrid D Bakker
- Department of Oral Cell Biology, Academic Centre for Dentistry Amsterdam (ACTA), University of Amsterdam and Vrije Universiteit Amsterdam, Amsterdam Movement Sciences, Amsterdam, The Netherlands
| | - Jenneke Klein-Nulend
- Department of Oral Cell Biology, Academic Centre for Dentistry Amsterdam (ACTA), University of Amsterdam and Vrije Universiteit Amsterdam, Amsterdam Movement Sciences, Amsterdam, The Netherlands
| | - Peter A Nolte
- Department of Orthopedic Surgery, Spaarne Gasthuis, Hoofddorp, The Netherlands
| | - Bastiaan P Krom
- Department of Preventive Dentistry, Academic Centre for Dentistry Amsterdam (ACTA), University of Amsterdam and Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
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Zhu MF, Kim K, Cavadino A, Coleman B, Munro JT, Young SW. Success Rates of Debridement, Antibiotics, and Implant Retention in 230 Infected Total Knee Arthroplasties: Implications for Classification of Periprosthetic Joint Infection. J Arthroplasty 2021; 36:305-310.e1. [PMID: 32868114 DOI: 10.1016/j.arth.2020.07.081] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 07/11/2020] [Accepted: 07/27/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Prosthetic joint infection (PJI) is the most common cause of failure following total knee arthroplasty (TKA). This study aimed to determine the success of debridement, antibiotics, and implant retention (DAIR) in a large cohort of TKA PJIs and assess the utility of current classification systems in predicting DAIR outcomes in early postoperative, late hematogenous, and chronic PJIs. METHODS In a multicenter review over 15 years, 230 patients underwent DAIR for first episode PJI following primary TKA. Patient demographics, disease and surgical factors, treatment regime, and outcomes were identified. Univariate and multivariate survival analyses were performed to identify factors associated with successful DAIR. Continuous variables with predictive value were further analyzed using receiver operating characteristic curves. The ability to predict DAIR outcomes of multiple classification systems was also assessed. RESULTS Patients were followed for an average of 6.9 years. The overall success rate of DAIR was 53.9%. On receiver operating characteristic analysis, 3 months (area under the curve = 0.63) and 1-year age (area under the curve = 0.66) of implant cut-offs was similarly predictive of outcomes. On multivariate survival analysis, DAIR was successful in 64% of "early" PJIs (implant <1 year) vs 38% of "late hematogenous" PJIs (implant >1 year; odds ratio [OR] 1.78, P = .01). For late PJIs (implant >1 year), Staphylococcus aureus (OR 4.70, P < .001) and gram-negative infections (OR 2.56, P = .031) were risk factors for DAIR failure. CONCLUSION DAIR has a high failure rate in all PJIs occurring more than a year post primary TKA, particularly when caused by S aureus or gram-negative bacteria. The age of implant is an important predictor of DAIR outcomes.
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Affiliation(s)
- Mark F Zhu
- School of Medicine, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand; Department of Orthopaedic Surgery, North Shore Hospital, Auckland, New Zealand
| | - Katy Kim
- School of Medicine, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand; Department of Orthopaedic Surgery, North Shore Hospital, Auckland, New Zealand
| | - Alana Cavadino
- School of Medicine, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Brendan Coleman
- Department of Orthopaedic Surgery, Middlemore Hospital, Auckland, New Zealand
| | - Jacob T Munro
- School of Medicine, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand; Department of Orthopaedic Surgery, Auckland City Hospital, Auckland, New Zealand
| | - Simon W Young
- School of Medicine, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand; Department of Orthopaedic Surgery, North Shore Hospital, Auckland, New Zealand
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85
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Vaz K, Scarborough M, Bottomley N, Kendrick B, Taylor A, Price A, Alvand A, Jackson W. Debridement, antibiotics and implant retention (DAIR) for the management of knee prosthetic joint infection. Knee 2020; 27:2013-2015. [PMID: 32950374 DOI: 10.1016/j.knee.2020.08.011] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 08/03/2020] [Accepted: 08/07/2020] [Indexed: 02/02/2023]
Abstract
BACKGROUND While two-stage revision arthroplasty is viewed as the gold standard for the treatment of knee periprosthetic joint infection (PJI) in terms of infection eradication, it is associated with significant cost along with patient morbidity and mortality. Debridement, antibiotics, and implant retention (DAIR) is an attractive option as it has demonstrated better patient outcomes, comparable implant longevity to primary arthroplasty, and significantly reduced cost when successful. Given the heterogeneity of what is defined as a DAIR the literature is highly variable in terms of its efficacy from the perspective of infection eradication. METHODS In the setting of a previously well-functioning, well-fixed arthroplasty with an acceptable soft tissue envelope and a treatable organism we report our methods for proceeding with a DAIR procedure, both unicompartmental and total knee. RESULTS With the above methods we have demonstrated improved patient outcomes when compared to one- or two-stage arthroplasty with lower patient morbidity. Implant longevity in the setting of a successful DAIR is equivalent to those of a primary arthroplasty. CONCLUSIONS With appropriate indications and good surgical technique as described we believe DAIR is an excellent option in the treatment of periprosthetic joint infection. We hope that with a well-defined protocol as outlined we can gain a better understanding of the efficacy of DAIR procedure with more homogeneity to the procedure to better define when they are most successful while improving patient outcomes and reducing cost.
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Affiliation(s)
- Kenneth Vaz
- Nuffield Orthopaedic Centre and University of Oxford, Botnar Research Centre, Old Road, Oxford OX3 7LD, United Kingdom.
| | - Matthew Scarborough
- Infectious Diseases, Microbiology, and General Medicine, Nuffield Orthopaedic Centre and University of Oxford, Botnar Research Centre, Old Road, Oxford OX3 7LD, United Kingdom
| | - Nicholas Bottomley
- Nuffield Orthopaedic Centre and University of Oxford, Botnar Research Centre, Old Road, Oxford OX3 7LD, United Kingdom
| | - Ben Kendrick
- Nuffield Orthopaedic Centre and University of Oxford, Botnar Research Centre, Old Road, Oxford OX3 7LD, United Kingdom
| | - Adrian Taylor
- Nuffield Orthopaedic Centre and University of Oxford, Botnar Research Centre, Old Road, Oxford OX3 7LD, United Kingdom
| | - Andrew Price
- Nuffield Orthopaedic Centre and University of Oxford, Botnar Research Centre, Old Road, Oxford OX3 7LD, United Kingdom
| | - Abtin Alvand
- Nuffield Orthopaedic Centre and University of Oxford, Botnar Research Centre, Old Road, Oxford OX3 7LD, United Kingdom
| | - William Jackson
- Nuffield Orthopaedic Centre and University of Oxford, Botnar Research Centre, Old Road, Oxford OX3 7LD, United Kingdom.
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Open Debridement is Superior to Arthroscopic Debridement for the Infected Total Knee Arthroplasty. J Arthroplasty 2020; 35:3716-3723. [PMID: 32713724 DOI: 10.1016/j.arth.2020.06.039] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Revised: 06/08/2020] [Accepted: 06/15/2020] [Indexed: 02/02/2023] Open
Abstract
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.
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Sabater Martos M, Hernandez Hermoso J, Garcia Oltra E, Molinos S, Martínez-Pastor J. Validity of the KLIC and CRIME80 scores in predicting failure in late acute infection treated by debridement and implant retention. Rev Esp Cir Ortop Traumatol (Engl Ed) 2020. [DOI: 10.1016/j.recote.2020.09.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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Schauberger A, Klug A, Hagebusch P, Kemmerer M, Hoffmann R, Gramlich Y. Explantation, Followed by Serial Debridement Without Antibiotic Spacers and Subsequent Revision With Cementless Components, Is Associated With High Remission Rates and Low Mortality in Periprosthetic Hip Joint Infections. J Arthroplasty 2020; 35:3274-3284. [PMID: 32624380 DOI: 10.1016/j.arth.2020.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Revised: 06/01/2020] [Accepted: 06/03/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND In difficult-to-treat cases, it is necessary to add debridement steps in prosthesis-free interval of 2-stage exchange. We aimed to analyze the functional and clinical outcome of patients treated with a multistage exchange of total hip arthroplasty without the use of spacers, rather only cementless implants. METHODS Between 2009 and 2018, 84 patients (mean age: 67.3 [39-90] years) suffering chronic late-onset periprosthetic joint infection (PJI) were treated using a multistage prosthesis exchange without spacers. The mean follow-up was 70 ± 45.3 [14-210] months. The treatment included prosthesis exchange and at least 1 additional revision step before a reimplantation, owing to ongoing acute infection in the prosthesis-free interval. High-efficiency antimicrobial therapy was administered in between, which was discontinued after cementless revision implantation. RESULTS The mean number of revisions between explantation and implantation was 2.6 (1-9). The most common microorganism was Staphylococcus epidermidis (53.6%) followed by Staphylococcus aureus (16.7%) and Cutibacterium acnes (11.9%). The bacterial load was more than one bacterium per patient in 38% of cases. All patients could be treated using a cementless implant. PJI remission was achieved in 92% of cases. Overall, 9 prostheses (11%) were replaced because of an ongoing PJI or fracture. The mean modified Harrison Hip Score was 63.4 (22-88) points. No patient died. CONCLUSION Multistage total hip arthroplasty exchange showed high remission rates and low mortality in difficult-to-treat cases. Spacer-free and multistage treatment had no negative effect on the success rate or functional outcome, consistent with the results of published 2-stage exchange studies. Implantation of an uncemented press-fit prosthesis was possible in all patients with no elevated periprosthetic fracture rate.
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Affiliation(s)
- Alice Schauberger
- Department of Trauma and Orthopedic Surgery, Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, Frankfurt am Main, Germany
| | - Alexander Klug
- Department of Trauma and Orthopedic Surgery, Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, Frankfurt am Main, Germany
| | - Paul Hagebusch
- Department of Trauma and Orthopedic Surgery, Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, Frankfurt am Main, Germany
| | - Matthias Kemmerer
- Department of Trauma and Orthopedic Surgery, Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, Frankfurt am Main, Germany
| | - Reinhard Hoffmann
- Department of Trauma and Orthopedic Surgery, Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, Frankfurt am Main, Germany
| | - Yves Gramlich
- Department of Trauma and Orthopedic Surgery, Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, Frankfurt am Main, Germany
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Svensson K, Rolfson O, Nauclér E, Lazarinis S, Sköldenberg O, Schilcher J, Johanson PE, Mohaddes M, Kärrholm J. Exchange of Modular Components Improves Success of Debridement, Antibiotics, and Implant Retention: An Observational Study of 575 Patients with Infection After Primary Total Hip Arthroplasty. JB JS Open Access 2020; 5:e20.00110. [PMID: 33376927 PMCID: PMC7757835 DOI: 10.2106/jbjs.oa.20.00110] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
Debridement, antibiotics, and implant retention (DAIR) is a surgical treatment for periprosthetic joint infection (PJI). DAIR is a desirable treatment option from an economic and patient perspective, if successful. The aim of this observational study was to compare the rates of success, defined as no additional reoperations due to PJI, between DAIR with exchange of modular components and DAIR without exchange in patients who had first-time PJI after primary total hip arthroplasty (THA). METHODS Patients with PJI at the site of a primary THA who were treated with DAIR in Sweden between January 1, 2009, and December 31, 2016, were identified in the Swedish Hip Arthroplasty Register. Supplementary questionnaires were sent to orthopaedic departments for additional variables of interest related to PJI. The primary end point was another reoperation due to PJI within 2 years after the first-time DAIR. DAIR with exchange was compared with DAIR without exchange using Kaplan-Meier survival analysis and Cox regression analysis. RESULTS A total of 575 patients treated with DAIR for a first-time PJI at the site of a primary THA were analyzed; 364 underwent component exchange and 211 did not. The exchange of components was associated with a lower rate of reoperations due to PJI after DAIR (28.0%) compared with non-exchange (44.1%). The Kaplan-Meier implant survival estimate for exchange was 71.4% (95% confidence interval [CI] = 66.9% to 76.3%) compared with 55.5% (95% CI = 49.1% to 62.7%) for non-exchange. With the analysis adjusted for confounders, DAIR with exchange was associated with a significantly decreased risk of another reoperation due to PJI compared with non-exchange (hazard ratio [HR] = 0.51 [95% CI = 0.38 to 0.68]). CONCLUSIONS In patients with a first-time PJI at the site of a primary THA, DAIR with exchange of modular components was superior to non-exchange DAIR. Surgeons should strive to exchange components when they perform DAIR, but there is a need to further identify how DAIR best should be practiced and which patients benefit from it. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Karin Svensson
- Department of Orthopedics, Institute of Clinical Sciences, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- The Swedish Hip Arthroplasty Register, Gothenburg, Sweden
| | - Ola Rolfson
- Department of Orthopedics, Institute of Clinical Sciences, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- The Swedish Hip Arthroplasty Register, Gothenburg, Sweden
| | - Emma Nauclér
- The Swedish Hip Arthroplasty Register, Gothenburg, Sweden
| | - Stergios Lazarinis
- Department of Orthopedics, Institute of Surgical Sciences, Uppsala University Hospital, Uppsala, Sweden
| | - Olof Sköldenberg
- Division of Orthopedics, Department of Clinical Sciences, Karolinska Institutet, Danderyd Hospital, Stockholm, Sweden
| | - Jörg Schilcher
- Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
| | - Per-Erik Johanson
- Department of Orthopedics, Institute of Clinical Sciences, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- The Swedish Hip Arthroplasty Register, Gothenburg, Sweden
| | - Maziar Mohaddes
- Department of Orthopedics, Institute of Clinical Sciences, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- The Swedish Hip Arthroplasty Register, Gothenburg, Sweden
| | - Johan Kärrholm
- Department of Orthopedics, Institute of Clinical Sciences, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- The Swedish Hip Arthroplasty Register, Gothenburg, Sweden
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90
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Lehner B, Omlor GW, Schwarze M. [Periprosthetic joint infections : Latest developments, strategies and treatment algorithms]. DER ORTHOPADE 2020; 49:648-659. [PMID: 32642942 DOI: 10.1007/s00132-020-03950-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Due to their multidimensional consequences, periprosthetic joint infections are a serious complication in arthroplasty. There are disagreements in the literature regarding their classification. At the same time, a consequence for the practical procedure cannot always be derived. THERAPEUTIC PROCEDURES In addition to debridement with antibiotics and implant retention, there are options for a one or two-stage change in the therapeutic procedure. Although the preservation of implants is only possible in the case of acute infections with a short duration of symptoms, prosthesis changes are indicated with a longer symptom duration. For both procedures, there are interinstitutional deviating indication criteria, weighing pros and cons. Both have specific problems, such as, in particular, the duration of the antibiotics course, the question of anchoring the prosthesis and, in the case of a two-stage procedure, the shape of the spacer.
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Affiliation(s)
- B Lehner
- Klinik für Orthopädie und Unfallchirurgie, Zentrum für Orthopädie, Unfallchirurgie und Paraplegiologie, Universitätsklinikum Heidelberg, Schlierbacher Landstraße 200a, 69118, Heidelberg, Deutschland.
| | - G-W Omlor
- Klinik für Orthopädie und Unfallchirurgie, Zentrum für Orthopädie, Unfallchirurgie und Paraplegiologie, Universitätsklinikum Heidelberg, Schlierbacher Landstraße 200a, 69118, Heidelberg, Deutschland
| | - M Schwarze
- Klinik für Orthopädie und Unfallchirurgie, Zentrum für Orthopädie, Unfallchirurgie und Paraplegiologie, Universitätsklinikum Heidelberg, Schlierbacher Landstraße 200a, 69118, Heidelberg, Deutschland
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Salvage procedure for chronic periprosthetic knee infection: the application of DAIR results in better remission rates and infection-free survivorship when used with topical degradable calcium-based antibiotics. Knee Surg Sports Traumatol Arthrosc 2020; 28:2823-2834. [PMID: 31321457 DOI: 10.1007/s00167-019-05627-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Accepted: 07/10/2019] [Indexed: 02/06/2023]
Abstract
PURPOSE Debridement, systemic antibiotics and implant retention (DAIR) is very successful for early periprosthetic joint infection (PJI), but can fail in late-onset cases. We selected patients with PJI who were unsuitable for two-stage exchange total knee arthroplasty (TKA) and compared the outcomes of DAIR with or without degradable calcium-based antibiotics. METHODS All patients fulfilled the criteria for late-onset PJI of TKA, as defined by an International Consensus Meeting in 2013, but were unsuitable for multistage procedures and TKA exchange due to operative risk. Fifty-six patients (mean age: 70.6 years, SD ± 10.8), in two historical collectives, were treated using a single-stage algorithm consisting of DAIR without antibiotics (control group, n = 33, 2012-2014), or by DAIR following the implantation of degradable antibiotics as indicated by an antibiogram (intervention group, n = 23, 2014-2017). OSTEOSET® (admixed vancomycin/tobramycin), and HERAFILL-gentamicin® were used as carrier systems. The primary endpoint was re-infection or surgical intervention after DAIR. RESULTS There were no significant differences between the two groups in terms of mean age, Charlson comorbidity index or the rate of mixed infections. Overall, 65.2% of patients achieved remission in the intervention group compared with only 18.2% in the control group (p < 0.001); 50% of re-infections in the intervention group even occurred after 36 months. Kaplan-Meier analysis showed that, compared with controls, the intervention group experienced significantly longer 3-year infection-free survival. CONCLUSION DAIR shows poor efficacy in difficult-to-treat cases, as demonstrated in our control group, which had a re-infection rate of 81.8%. In contrast, a DAIR group receiving topical calcium-based antibiotics showed significantly higher 3-year infection-free survival. Therefore, the combination of DAIR and degradable antibiogram-based local antibiotics is a reasonable salvage procedure for this body of patients. This is important as the number of severely sick patients who are too old for appropriate PJI treatment is estimated to increase significantly due to demographic change.
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Ghirardelli S, Fidanza A, Prati P, Iannotti F, Indelli PF. Debridement, antibiotic pearls, and retention of the implant in the treatment of infected total hip arthroplasty. Hip Int 2020; 30:34-41. [PMID: 32907425 DOI: 10.1177/1120700020929314] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
In this article the authors describe a modified surgical technique developed to enhance the classical irrigation and debridement procedure to improve the possibilities of retaining a total hip arthroplasty (THA) undergoing acute periprosthetic joint infection (PJI). This technique, debridement antibiotic pearls and retention of the implant (DAPRI), aims to remove the intra-articular biofilm allowing a higher and prolonged local antibiotic concentration by using calcium sulphate antibiotic-added beads. The combination of 3 different surgical techniques (tumour-like synovectomy, Argon Beam application and chlorhexidine gluconate brushing) might enhance the disruption and removal of the bacterial biofilm which is the main responsible of antibiotics and antibodies resistance. The timing of the diagnosis (6 weeks from the original surgery or 1 week from clinical symptoms appearance in the case of an hematogenous infection) and the preoperative isolation of the germ are fundamental in order to obtain a satisfactory outcome. A 12-week course of postoperative antibiotic therapy (6 weeks I.V. and 6 weeks oral) complete the postoperative protocol used by the authors.The DAPRI technique might represent a safe and more conservative treatment for acute and early hematogenous PJI.
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Affiliation(s)
- Stefano Ghirardelli
- Department of Orthopaedic Surgery and Bioengineering, Stanford University School of Medicine, Stanford, CA, USA
| | - Andrea Fidanza
- Department of Orthopaedic Surgery and Bioengineering, Stanford University School of Medicine, Stanford, CA, USA
| | - Paolo Prati
- ASST Bergamo Ovest, Treviglio Hospital, Treviglio, Italy
| | - Ferdinando Iannotti
- Department of Orthopaedic Surgery and Bioengineering, Stanford University School of Medicine, Stanford, CA, USA
| | - Pier F Indelli
- Department of Orthopaedic Surgery and Bioengineering, Stanford University School of Medicine, Stanford, CA, USA
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93
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94
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Wouthuyzen-Bakker M, Löwik CAM, Ploegmakers JJW, Knobben BAS, Dijkstra B, de Vries AJ, Mithoe G, Kampinga G, Zijlstra WP, Jutte PC. A Second Surgical Debridement for Acute Periprosthetic Joint Infections Should Not Be Discarded. J Arthroplasty 2020; 35:2204-2209. [PMID: 32192835 DOI: 10.1016/j.arth.2020.02.043] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Revised: 02/13/2020] [Accepted: 02/20/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND In acute periprosthetic joint infections (PJIs), a second surgical debridement (debridement, antibiotics, and implant retention [DAIR]) is generally not recommended after a failed first one. We identified the failure rate of a second DAIR and aimed to identify patients in whom an additional debridement might still be beneficial. METHODS Patients with acute PJI of the hip or knee and treated with DAIR between 2006 and 2016 were retrospectively evaluated. A second DAIR was routinely performed provided that the soft tissue was intact. Failure of a second DAIR was described as (1) the need for additional surgical intervention to achieve infection control, (2) the need for antibiotic suppressive therapy due to persistent clinical and/or biochemical signs of infection, or (3) PJI related death. RESULTS From the 455 cases treated with DAIR, 144 cases underwent a second debridement (34.6%). Thirty-seven cases failed (37/144, 25.7%). The implant needed to be removed in 23 cases (23/144, 16%). Positive cultures during the second DAIR (odds ratio 3.16, 95% confidence interval 1.29-7.74) and chronic renal insufficiency (odds ratio 13.6, 95% confidence interval 2.03-91.33) were independent predictors for failure in the multivariate analysis. No difference in failure was observed between persistent infection with the same microorganism and reinfection with a new microorganism (failure rate 31.6% vs 34.6%, P = .83). CONCLUSION A second DAIR had a low failure rate in our cohort of patients and the implant could be retained in the majority of them. Therefore, a second DAIR should not be discarded in acute PJIs.
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Affiliation(s)
- Marjan Wouthuyzen-Bakker
- Department of Medical Microbiology and Infection Prevention, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Claudia A M Löwik
- Department of Orthopaedic Surgery, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Joris J W Ploegmakers
- Department of Orthopaedic Surgery, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Bas A S Knobben
- Department of Orthopaedic Surgery, Martini Hospital, Groningen, the Netherlands
| | - Baukje Dijkstra
- Department of Orthopaedic Surgery, Medical Center Leeuwarden, Leeuwarden, the Netherlands
| | - Astrid J de Vries
- Department of Orthopaedic Surgery, Martini Hospital, Groningen, the Netherlands
| | - Glen Mithoe
- Department of Medical Microbiology, Certe, Groningen, the Netherlands
| | - Greetje Kampinga
- Department of Medical Microbiology and Infection Prevention, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Wierd P Zijlstra
- Department of Orthopaedic Surgery, Medical Center Leeuwarden, Leeuwarden, the Netherlands
| | - Paul C Jutte
- Department of Orthopaedic Surgery, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
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95
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Couderc AL, Alexandre A, Baudier A, Nouguerede E, Rey D, Pradel V, Argenson JN, Stein A, Lalys L, Villani P. Preoperative simplified geriatric assessment in planned hip and knee arthroplasty. Eur Geriatr Med 2020; 11:623-633. [PMID: 32681458 DOI: 10.1007/s41999-020-00364-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Accepted: 07/09/2020] [Indexed: 12/21/2022]
Abstract
INTRODUCTION Hip and knee arthroplasties are the most common planned orthopedic surgical procedures in older persons. It would be useful to identify frailties before surgery to improve the outcome of older patients. PURPOSE The objective of this work was to identify the criteria of a simplified comprehensive geriatric assessment (mini-CGA) that were associated with unplanned hospital readmission and postoperative complications within 3 months after the planned hip and/or knee arthroplasty in patients ≥ 65 years. METHODS This prospective study was carried out in the orthopedic department of Marseille University Hospital from January to May 2019. A mini-CGA was performed preoperatively. RESULTS One hundred four patients were included in the study. The rate of early readmission within 3 months after surgery was 12.5% and the rate of postoperative complications was 40.4%. In multivariate analysis, dependence in the activities of daily living (ADL ≤ 5) was the only factor associated with unplanned readmission (aOR = 9.9, 95% CI 1.9-50.8), and living alone was the only factor associated with postoperative complications (aOR = 3.2, 95% CI 1.2-8.8). CONCLUSIONS We found that the ADL score was associated with the risk of unplanned readmission in older patients undergoing planned arthroplasty, and that living alone was associated with postoperative complications. A preoperative mini-CGA appears essential to limit postoperative morbidity.
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Affiliation(s)
- Anne-Laure Couderc
- Internal Medicine, Geriatric and Therapeutic Unit, University Hospital of Marseille, AP-HM, 13009, Marseille, France.
- Aix-Marseille University, CNRS, EFS, ADES, Marseille, France.
| | - Anais Alexandre
- Infectious Diseases Unit, University Hospital of Infectiology IHU Mediterranée, AP-HM, Marseille, France
| | - Auriane Baudier
- Infectious Diseases Unit, University Hospital of Infectiology IHU Mediterranée, AP-HM, Marseille, France
| | - Emilie Nouguerede
- Internal Medicine, Geriatric and Therapeutic Unit, University Hospital of Marseille, AP-HM, 13009, Marseille, France
| | - Dominique Rey
- Internal Medicine, Geriatric and Therapeutic Unit, University Hospital of Marseille, AP-HM, 13009, Marseille, France
| | | | - Jean-Noël Argenson
- Orthopedic Surgery, Institute of Movement and Locomotor System IML, AP-HM, Marseille, France
- Aix-Marseille University, Marseille, France
| | - Andreas Stein
- Infectious Diseases Unit, University Hospital of Infectiology IHU Mediterranée, AP-HM, Marseille, France
- Aix-Marseille University, Marseille, France
| | - Loïc Lalys
- Aix-Marseille University, CNRS, EFS, ADES, Marseille, France
| | - Patrick Villani
- Internal Medicine, Geriatric and Therapeutic Unit, University Hospital of Marseille, AP-HM, 13009, Marseille, France
- Aix-Marseille University, CNRS, EFS, ADES, Marseille, France
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96
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Sabater-Martos M, Hernández Hermoso JA, García Oltra E, Molinos S, Martínez-Pastor JC. Validity of the KLIC and CRIME80 scores in predicting failure in late acute infection treated by debridement and implant retention. Rev Esp Cir Ortop Traumatol (Engl Ed) 2020; 64:415-420. [PMID: 32605849 DOI: 10.1016/j.recot.2020.05.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2020] [Revised: 04/29/2020] [Accepted: 05/09/2020] [Indexed: 11/24/2022] Open
Abstract
It is very important to treat prosthetic infections correctly in order to ensure a higher success rate. Debridement with implant retention (DAIR) is widely used in acute and late infections, however patients who fail after this surgery are known to have a higher risk of failure in subsequent surgeries. Therefore, it is important to find a scale that enables us to predict the risk of DAIR failure. Hence the KLIC and CRIME80 scores for acute and late acute infections, respectively. This study analysed the validity of both scores in acute late periprosthetic knee infections. We observed that the KLIC score has no predictive value for this type of infection, but the CRIME80 score does.
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Affiliation(s)
- M Sabater-Martos
- Servicio de Cirurgía Ortopédica y Traumatología. Hospital Universitari Germans Trias I Pujol, Badalona, España.
| | - J A Hernández Hermoso
- Servicio de Cirurgía Ortopédica y Traumatología. Hospital Universitari Germans Trias I Pujol, Badalona, España; Universidad Autónoma de Barcelona. Departamento de Cirugía, Barcelona, España
| | - E García Oltra
- Servicio de Cirurgía Ortopédica y Traumatología. Hospital Universitari Germans Trias I Pujol, Badalona, España
| | - S Molinos
- Servicio de Microbiología Hospital Universitari Germans Trias I Pujol, Badalona, España
| | - J C Martínez-Pastor
- Servicio de Cirurgía Ortopédica y Traumatología. Hospital Clínic de Barcelona, Barcelona, España
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Wouthuyzen-Bakker M, Sebillotte M, Huotari K, Escudero Sánchez R, Benavent E, Parvizi J, Fernandez-Sampedro M, Barbero JM, Garcia-Cañete J, Trebse R, Del Toro M, Diaz-Brito V, Sanchez M, Scarborough M, Soriano A. Lower Success Rate of Débridement and Implant Retention in Late Acute versus Early Acute Periprosthetic Joint Infection Caused by Staphylococcus spp. Results from a Matched Cohort Study. Clin Orthop Relat Res 2020; 478:1348-1355. [PMID: 32106134 PMCID: PMC7319375 DOI: 10.1097/corr.0000000000001171] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2019] [Accepted: 01/30/2020] [Indexed: 01/31/2023]
Abstract
BACKGROUND Surgical débridement, antibiotics and implant retention (DAIR) is currently recommended by international guidelines for both early acute (postsurgical) and late acute (hematogenous) periprosthetic joint infections (PJIs). However, due to a different pathogenesis of infection, a different treatment strategy may be needed. QUESTIONS/PURPOSES (1) Compared with early acute PJIs, are late acute PJIs associated with a higher risk of DAIR failure? (2) When stratified by microorganism, is the higher risk of failure in late acute PJI associated with Staphylocococcus aureus infection? (3) When analyzing patients with S. aureus infection, what factors are independently associated with DAIR failure? METHODS In this multicenter observational study, early acute and late acute PJIs treated with DAIR were retrospectively evaluated and matched according to treating center, year of diagnosis, and infection-causing microorganism. If multiple matches were available, the early acute PJI diagnosed closest to the late acute PJI was selected. A total of 132 pairs were included. Treatment success was defined as a retained implant during follow-up without the need for antibiotic suppressive therapy. RESULTS Late acute PJIs had a lower treatment success (46% [60 of 132]) compared with early acute PJIs (76% [100 of 132]), OR 3.9 [95% CI 2.3 to 6.6]; p < 0.001), but the lower treatment success of late acute PJIs was only observed when caused by Staphylococcus spp (S. aureus: 34% versus 75%; p < 0.001; coagulase-negative staphylococci: 46% versus 88%; p = 0.013, respectively). On multivariable analysis, late acute PJI was the only independent factor associated with an unsuccessful DAIR when caused by S. aureus (OR 4.52 [95% CI 1.79 to 11.41]; p < 0.001). CONCLUSIONS Although DAIR seems to be a successful therapeutic strategy in the management of early acute PJI, its use in late acute PJI should be reconsidered when caused by Staphylococcus spp. Our results advocate the importance of isolating the causative microorganism before surgery. LEVEL OF EVIDENCE Level III, therapeutic study.
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Affiliation(s)
- Marjan Wouthuyzen-Bakker
- M. Wouthuyzen-Bakker, Department of Medical Microbiology and Infection Prevention, University of Groningen, University Medical Center Groningen, the Netherlands
| | - Marine Sebillotte
- M. Sebillotte, Department of Infectious Diseases and Intensive Care Medicine, Rennes University Hospital, Rennes, France
| | - Kaisa Huotari
- K. Huotari, Inflammation center, Infectious Diseases, Peijas Hospital, Helsinki University Hospital and University of Helsinki, Finland
| | - Rosa Escudero Sánchez
- R. Escudero-Sánchez, Servicio de Enfermedades Infecciosas, Hospital Universitario Ramón y Cajal, IRYCIS, Madrid, Spain
| | - Eva Benavent
- E. Benavent, Infectious Disease Service, IDIBELL-Hospital Universitari Bellvitge, Barcelona, Spain
| | - Javad Parvizi
- J. Parvizi, Rothman Institute at Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Marta Fernandez-Sampedro
- M. Fernandez-Sampedro, Infectious Diseases Unit, Department of Medicine, Hospital Universitario Marques de Valdecilla-IDIVAL, Cantabria, Spain
| | - José Maria Barbero
- J. M. Barbero, Department of Internal Medicine, Hospital Universitario Principe de Asturias, Madrid, Spain
| | - Joaquín Garcia-Cañete
- J. Garcia-Cañete, Department of Internal Medicine-Emergency, IIS-Fundación Jiménez Díaz, UAM, Madrid, Spain
| | - Rihard Trebse
- R. Trebse, Service for Bone Infections, Valdoltra Orthopaedic Hospital, Ankaran, Slovenia
| | - Maria Del Toro
- M. Del Toro, Unidad Clínica de Enfermedades Infecciosas y Microbiología, Hospital Universitario Virgen Macarena, Universidad de Sevilla, Instituto de Biomedicina de Sevilla (IBIS), Sevilla, Spain
| | - Vicens Diaz-Brito
- V. Diaz-Brito, Infectious Diseases Unit, Parc Sanitari Sant Joan de Deu, Sant Boi, Barcelona, Spain
| | - Marisa Sanchez
- M. Sanchez, Infectious Diseases Section, Internal Medicine Service, Hospital Italiano de Buenos Aires, Argentina
| | - Matthew Scarborough
- M. Scarborough, Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, England
| | - Alex Soriano
- A. Soriano, Service of Infectious Diseases, Hospital Clínic, University of Barcelona, Barcelona, Spain
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98
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Wouthuyzen-Bakker M, Lora-Tamayo J, Soriano A. Antibiotic Use in Total Knee Arthroplasty Periprosthetic Joint Infection. Clin Infect Dis 2020; 70:1259-1260. [PMID: 31504318 DOI: 10.1093/cid/ciz631] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Affiliation(s)
- Marjan Wouthuyzen-Bakker
- Department of Medical Microbiology and Infection Prevention, University of Groningen, University Medical Center Groningen, The Netherlands
| | - Jaime Lora-Tamayo
- Department of Internal Medicine, Instituto de Investigación i+12, Hospital Universitario 12 de Octubre, Madrid
| | - Alex Soriano
- Service of Infectious Diseases, Hospital Clínic, University of Barcelona, Spain
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Abstract
Periprosthetic infection remains a frequent complication after total knee arthroplasty. The most common treatment is a two-stage procedure involving removal of all implants and cement, thorough débridement, insertion of some type of antibiotic spacer, and a course of antibiotic therapy of varying lengths. After some interval, and presumed eradication of the infection, new arthroplasty components are implanted in the second procedure. These knee spacers may be static or mobile spacers, with the latter presumably providing improved function for the patient and greater ease of surgical reimplantation. Numerous types of antibiotic cement spacers are available, including premolded cement components, surgical molds for intraoperative spacer fabrication, and the use of new metal and polyethylene knee components; all these are implanted with surgeon-prepared high-dose antibiotic cement. As there are advantages and disadvantages of both static and the various mobile spacers, surgeons should be familiar with several techniques. There is inconclusive data on the superiority of any antibiotic spacer. Both mechanical complications and postoperative renal failure may be associated with high-dose antibiotic cement spacers.
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100
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Crawford DA, Adams JB, Morris MJ, Berend KR, Lombardi AV. Partial 2-Stage Exchange for Infected Total Hip Arthroplasty: An Updated Report. J Arthroplasty 2019; 34:3048-3053. [PMID: 31353248 DOI: 10.1016/j.arth.2019.07.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Revised: 06/26/2019] [Accepted: 07/01/2019] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Management of an infected total hip arthroplasty (THA) is challenging. The eradication of infection as well as complications of component removal must all be considered. This study is an update on previous reports of treating periprosthetic infection of the hip with a partial 2-stage exchange with retention of the femoral component. METHODS A retrospective review of our practice's arthroplasty registry from 2000 to 2018 revealed 41 hips with 2-year minimum follow-up that were treated with a 2-stage partial exchange for an infected THA. All first-stage procedures allowed an articulating construct with 1 of 3 variations: cemented constrained liner (13 hips), StageOne Hip Cement Spacer Mold (14 hips), or an antibiotic polymethylmethacrylate head molded from a bulb syringe (14 hips). Of 41 cases, 34 were culture positive, with 3 cases having methicillin-resistant Staphylococcus. RESULTS Mean follow-up was 5.5 years (range, 1.5-18.5 years). The second-stage reimplantation was accomplished in 39 of the 41 hips (95%) at a mean interval of 9.2 weeks (range, 5-9 weeks). Two patients underwent repeat radical debridement with removal of all components before reimplantation for persistent clinical evidence of infection. Thirty-three of the 41 hips (81%) were infection free at most recent follow-up. The mean postoperative Harris hip score at most recent evaluation was 63.6 (range, 24-100). CONCLUSION Eradication of periprosthetic joint infections, while minimizing patient morbidity, continues to be a challenge. Partial 2-stage exchange may be considered in cases where removal of a well-fixed femoral component may result in significant bony destruction.
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Affiliation(s)
| | | | - Michael J Morris
- Joint Implant Surgeons, Inc, New Albany, OH; Mount Carmel Health System, New Albany, OH
| | - Keith R Berend
- Joint Implant Surgeons, Inc, New Albany, OH; Mount Carmel Health System, New Albany, OH
| | - Adolph V Lombardi
- Joint Implant Surgeons, Inc, New Albany, OH; Mount Carmel Health System, New Albany, OH; Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, OH
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