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Zhou W, Peng X, Ma Y, Hu Y, Wu Y, Lan F, Weir MD, Li M, Ren B, Oates TW, Xu HH, Zhou X, Cheng L. Two-staged time-dependent materials for the prevention of implant-related infections. Acta Biomater 2020; 101:128-140. [PMID: 31629895 DOI: 10.1016/j.actbio.2019.10.023] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Revised: 09/28/2019] [Accepted: 10/15/2019] [Indexed: 02/08/2023]
Abstract
Infection is a main cause of implant failure. Early implant-related infections often occur in the first 4 weeks post-operation. Inhibiting bacterial adhesion and biofilm formation at the early stage and promoting subsequent implant osseointegration are important for implant success. Our previous studies demonstrated that dimethylaminododecyl methacrylate (DMADDM) provided dental materials with antibacterial effects. In the present study, DMADDM and hydroxyapatite (HA) are loaded on to the titanium (Ti) surface via poly dopamine (PDA) self-polymerization. This local DMADDM-delivery Ti is referred as Ti-PHD. Here we report the two-staged capability of Ti-PHD: (1) in the first stage, releasing DMADDM during the high-infection-risk initial period post-implantation for 4 weeks; (2) then in the second stage, enhancing osteogenesis and promoting osseointegration. Ti-PHD has a porous surface with higher average roughness and greater hydrophilicity than pure Ti. Its biocompatibility is verified in vitro and in vivo. During the first 4 weeks of release, both DMADDM remaining on Ti surface and DMADDM released into the soaking medium greatly reduced the adherence and growth of pathogens. This is further confirmed by the prevention of bone destruction in a rat osteomyelitis model. After releasing DMADDM for 4 weeks, Ti-PHD promotes osteogenic differentiation of human bone marrow mesenchymal stem cells (hBMSCs) and new bone formation around the implants in vivo. This article represents the first report on the two-staged, time-dependent antibacterial and osteogenesis effects of Ti-PHD, demonstrating its potential for clinical applications to inhibit implant-associated infections. STATEMENT OF SIGNIFICANCE: The present study develops a two-staged time-dependent system for local dimethylaminododecyl methacrylate (DMADDM) delivery via Ti implant (referred to as Ti-PHD). DMADDM and hydroxyapatite (HA) are loaded on to the Ti surface with poly dopamine (PDA). Ti-PHD can release DMADDM during the high-risk period of infection in the first stage, and then promote osseointegration and new bone formation in the second stage. This bioactive and therapeutic Ti is promising to inhibit infections and enhance implant success.
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Lin ZX, Steed LL, Marculescu CE, Slone HS, Woolf SK. Cutibacterium acnes Infection in Orthopedics: Microbiology, Clinical Findings, Diagnostic Strategies, and Management. Orthopedics 2020; 43:52-61. [PMID: 31958341 DOI: 10.3928/01477447-20191213-02] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Accepted: 09/30/2019] [Indexed: 02/03/2023]
Abstract
Cutibacterium (formerly called Propionibacterium) acnes is a human skin flora often implicated in orthopedic infections. The unique characteristics of this microorganism make the diagnosis of infection difficult. The diagnosis often is made based on clinical evidence, radiographic signs, and laboratory and/or surgical findings combined. Treatment often involves both pharmacologic and surgical methods. In addition, formation of biofilms and increased resistance to drugs exhibited by the microorganism can require combined antimicrobial therapy. Prophylactic measures are particularly important, but no single method has been shown to fully eliminate the risk of C acnes infections. Previous reports have focused on C acnes infections involving surgical implants or after certain orthopedic procedures, particularly in the shoulder and spine. This article reviews current clinical, diagnostic, and treatment principles for C acnes in orthopedics in general. [Orthopedics. 2020; 43(1):52-61.].
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Berberich C, Sanz-Ruiz P. Risk assessment of antibiotic resistance development by antibiotic-loaded bone cements: is it a clinical concern? EFORT Open Rev 2019; 4:576-584. [PMID: 31754463 PMCID: PMC6836079 DOI: 10.1302/2058-5241.4.180104] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
Because of the risk of bacterial biofilm infections, prophylactic use of antibiotics in orthopaedic procedures involving the implantation of large prosthesis systems is considered mandatory. A strategy based on the rationale that local antibiotics released from bone cement or other carriers establish a second antibacterial frontline in and around the prosthesis is considered complementary to the administration of systemic antibiotics. Although less common as a consequence of the initially very high drug concentrations of local antibiotics in the tissues, a selection process of previous high resistance bacteria may occur, leading to antibiotic resistance. The use of antibiotic combinations in bone cement is generally accepted to improve antibiotic efficacy and minimizes the treatment failure risk due to antibiotic resistance. This is important in septic revisions and/or in patients at particularly high risk of infection. On an individual basis, the benefit of a lower infection probability with combined systemic and local antibiotic application should outweigh the risk of the selection of more resistant bacteria. Each prevented infection means that a complex and extended antibiotic therapy with risk of resistance development over time has been avoided. On an epidemiological level there is no clinical evidence that the routine use of bone cement impregnated with appropriate bactericidal antibiotics promotes the widespread development of antibiotic resistance and thereby puts the successful treatment of a prosthetic joint infection at higher risk.
Cite this article: EFORT Open Rev 2019;4:576-584. DOI: 10.1302/2058-5241.4.180104
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Affiliation(s)
- Christof Berberich
- Department of Medical Training and Education, Heraeus Medical GmbH, Wehrheim, Germany
| | - Pablo Sanz-Ruiz
- Department of Traumatology and Orthopaedic Surgery, General University Hospital Gregorio Marañón, Madrid, Spain
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Tyson Y, Rolfson O, Kärrholm J, Hailer NP, Mohaddes M. Uncemented or cemented revision stems? Analysis of 2,296 first-time hip revision arthroplasties performed due to aseptic loosening, reported to the Swedish Hip Arthroplasty Register. Acta Orthop 2019; 90:421-426. [PMID: 31154890 PMCID: PMC6746274 DOI: 10.1080/17453674.2019.1624336] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Background and purpose - Uncemented stems are increasingly used in revision hip arthroplasty, but only a few studies have analyzed the outcomes of uncemented and cemented revision stems in large cohorts of patients. We compared the results of uncemented and cemented revision stems. Patients and methods - 1,668 uncemented and 1,328 cemented revision stems used in first-time revisions due to aseptic loosening between 1999 and 2016 were identified in the Swedish Hip Arthroplasty Register. Kaplan-Meier analysis was used to investigate unadjusted implant survival with re-revision for any reason as the primary outcome. Hazard ratios (HR) for the risk of re-revision were calculated using a Cox regression model adjusted for sex, age, head size, concomitant cup revision, surgical approach at primary and at index revision surgery, and indication for primary total hip arthroplasty. Results - Unadjusted 10-year survival was 85% (95% CI 83-87) for uncemented and 88% (CI 86-90) for cemented revision stems. The adjusted HR for re-revision of uncemented revision stems during the first year after surgery was 1.3 (CI 1.0-1.6), from the second year the HR was 1.1 (CI 0.8-1.4). Uncemented stems were most often re-revised early due to infection and dislocation, whereas cemented stems were mostly re-revised later due to aseptic loosening. Interpretation - Both uncemented and cemented revision stems had satisfactory long-term survival but they differed in their modes of failure. Our conclusions are limited by the fact that femoral bone defect size could not be investigated within the setting of the current study.
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Affiliation(s)
- Yosef Tyson
- Section of Orthopedic Surgery, Department of Surgical Sciences, Uppsala University Hospital, Uppsala; ,The Swedish Hip Arthroplasty Register, Gothenburg; ,Correspondence:
| | - Ola Rolfson
- The Swedish Hip Arthroplasty Register, Gothenburg; ,Department of Orthopedics, Institute of Clinical Sciences, Sahlgrenska Academy, Sahlgrenska University Hospital, Mölndal, Sweden
| | - Johan Kärrholm
- The Swedish Hip Arthroplasty Register, Gothenburg; ,Department of Orthopedics, Institute of Clinical Sciences, Sahlgrenska Academy, Sahlgrenska University Hospital, Mölndal, Sweden
| | - Nils P Hailer
- Section of Orthopedic Surgery, Department of Surgical Sciences, Uppsala University Hospital, Uppsala; ,The Swedish Hip Arthroplasty Register, Gothenburg;
| | - Maziar Mohaddes
- The Swedish Hip Arthroplasty Register, Gothenburg; ,Department of Orthopedics, Institute of Clinical Sciences, Sahlgrenska Academy, Sahlgrenska University Hospital, Mölndal, Sweden
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Yayac M, Rondon AJ, Tan TL, Levy H, Parvizi J, Courtney PM. The Economics of Antibiotic Cement in Total Knee Arthroplasty: Added Cost with No Reduction in Infection Rates. J Arthroplasty 2019; 34:2096-2101. [PMID: 31122848 DOI: 10.1016/j.arth.2019.04.043] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Revised: 03/30/2019] [Accepted: 04/18/2019] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND To reduce the substantial clinical and financial burden of periprosthetic joint infection (PJI), some surgeons advocate for the use of antibiotic-loaded bone cement (ALBC) in primary total knee arthroplasty (TKA), although its effectiveness continues to be debated in the literature. The purpose of this study was to determine whether the routine use of ALBC is cost-effective in reducing PJI after primary TKA. METHODS We retrospectively reviewed a consecutive series of patients undergoing cemented primary TKA at two hospitals within our institution from 2015 to 2017. We compared demographics, comorbidities, costs, and PJI rates between patients receiving ALBC and plain cement. We performed a multivariate regression analysis to determine the independent effect of ALBC on PJI rate. We calculated readmission costs for PJI and reduction in PJI needed to justify the added cost of ALBC. RESULTS Of 2511 patients, 1077 underwent TKA with ALBC (43%), with no difference in PJI rates (0.56% vs 0.14%, P = .0662) or complications (1.2% vs 1.6%, P = .3968) but higher cement costs ($416 vs $117, P < .0001) and overall procedure costs ($6445 vs $5.968, P < .0001). ALBC had no effect on infection rate (P = .0894). Patients readmitted with PJI had higher overall 90-day episode-of-care claims costs ($49,341 vs $19,032, P < .001). To justify additional costs, ALBC would need to prevent infection in one of every 101 patients. CONCLUSION Routine use of ALBC in primary TKA is not cost-effective, adding $299 to the cost of episode of care without a reduction in PJI rate. Further study is needed to determine whether select use of ALBC would be justified in high-risk patients.
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Affiliation(s)
- Michael Yayac
- Rothman Institute at Thomas Jefferson University, Philadelphia, PA
| | | | - Timothy L Tan
- Rothman Institute at Thomas Jefferson University, Philadelphia, PA
| | - Hannah Levy
- Rothman Institute at Thomas Jefferson University, Philadelphia, PA
| | - Javad Parvizi
- Rothman Institute at Thomas Jefferson University, Philadelphia, PA
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van Vugt TAG, Arts JJ, Geurts JAP. Antibiotic-Loaded Polymethylmethacrylate Beads and Spacers in Treatment of Orthopedic Infections and the Role of Biofilm Formation. Front Microbiol 2019; 10:1626. [PMID: 31402901 PMCID: PMC6671866 DOI: 10.3389/fmicb.2019.01626] [Citation(s) in RCA: 106] [Impact Index Per Article: 21.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Accepted: 07/02/2019] [Indexed: 02/06/2023] Open
Abstract
Polymethylmethacrylate (PMMA) also referred as (acrylic) bone cement is a non-degradable biomaterial that has been used in clinical orthopedic practice for several decades. PMMA can be used in a plain formulation, but is often used in an antibiotic-loaded formulation in (primary and revision) arthroplasty and in treatment of orthopedic infections as prosthetic joint infections (PJI) and chronic osteomyelitis. In treatment of PJIs antibiotic-loaded PMMA is often used as a carrier material for local antibiotic delivery in addition to treatment with systemic antibiotics. In this case, the antibiotic-loaded PMMA is often used as a spacer or as a bead chain. Since the introduction of PMMA as an antibiotic carrier there is a tremendous amount of scientific and clinical papers published, which studied numerous different aspects of antibiotic-loaded PMMA. This paper will review the research regarding basic principles of antibiotic-loaded PMMA as mechanism of action, antibiotic-release capacities, choice of antibiotics and influences on mechanical properties of PMMA. Subsequently, concerns regarding the application of antibiotic-loaded PMMA, biofilm formation, antibiotic resistance and local or systemic toxicity will be discussed. In addition to these subjects, the role of antibiotic loaded PMMA in clinical treatment of PJIs and chronic osteomyelitis is discussed in the final part of this paper.
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Fillingham YA, Della Valle CJ, Suleiman LI, Springer BD, Gehrke T, Bini SA, Segreti J, Chen AF, Goswami K, Tan TL, Shohat N, Diaz-Ledezma C, Schwartz AJ, Parvizi J. Definition of Successful Infection Management and Guidelines for Reporting of Outcomes After Surgical Treatment of Periprosthetic Joint Infection: From the Workgroup of the Musculoskeletal Infection Society (MSIS). J Bone Joint Surg Am 2019; 101:e69. [PMID: 31318814 DOI: 10.2106/jbjs.19.00062] [Citation(s) in RCA: 75] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- Yale A Fillingham
- Department of Orthopaedic Surgery, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire
| | - Craig J Della Valle
- Departments of Orthopaedic Surgery (C.J.D.V.) and Infectious Disease (J.S.), Rush University Medical Center, Chicago, Illinois
| | - Linda I Suleiman
- Department of Orthopaedic Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Bryan D Springer
- Department of Orthopaedic Surgery, OrthoCarolina Hip and Knee Center, Charlotte, North Carolina
| | - Thorsten Gehrke
- Department of Orthopedic Surgery, Helios ENDO-Klinik Hamburg, Hamburg, Germany
| | - Stefano A Bini
- Department of Orthopaedic Surgery, University of California San Francisco, San Francisco, California
| | - John Segreti
- Departments of Orthopaedic Surgery (C.J.D.V.) and Infectious Disease (J.S.), Rush University Medical Center, Chicago, Illinois
| | - Antonia F Chen
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Karan Goswami
- The Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Timothy L Tan
- The Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Noam Shohat
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | | | - Adam J Schwartz
- Department of Orthopedic Surgery, Mayo Clinic, Phoenix, Arizona
| | - Javad Parvizi
- The Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
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Oliveira CLDT, Elias FA, Ribacionka ADS, Picado CHF, Garcia FL. DOES TOPICAL USE OF GENTAMICIN REDUCE THE INFECTION RATE IN PRIMARY TOTAL HIP ARTHROPLASTY? ACTA ORTOPEDICA BRASILEIRA 2019; 27:197-201. [PMID: 31452619 PMCID: PMC6699383 DOI: 10.1590/1413-785220192704219177] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To determine whether the topical use of gentamicin reduces periprosthetic joint infection rates in primary total hip arthroplasty (THA). METHODS We retrospectively evaluated two cohorts of patients who underwent primary THA in a university hospital, with a minimum of 1-year postoperative follow-up and full clinical, laboratory, and radiological documentation. Patients who underwent operation in the first 59 months of the study period (263 hips) received only intravenous cefazolin as antibiotic prophylaxis (Cef group), and those who underwent operation in the following 43 months (170 hips) received intravenous cefazolin plus topical gentamicin directly applied on the wound as antibiotic prophylaxis (Cef + Gen group). For the diagnosis of periprosthetic joint infection, we used the criteria of the Centers for Disease Control and Prevention. Data were analyzed using the Fisher exact test, and p values of <0.05 were considered significant. RESULTS Thirteen hips (4.9%) in the Cef group and eight hips (4.7%) in the Cef + Gen group presented periprosthetic joint infection. Statistical analysis revealed no difference between the infection rates (p = 1.0). CONCLUSION Topical gentamicin as used in this study did not reduce periprosthetic joint infection rates in primary THA. Level of Evidence III, Retrospective comparative study.
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Hanada M, Nishikino S, Hotta K, Furuhashi H, Hoshino H, Matsuyama Y. Intrawound vancomycin powder increases post-operative wound complications and does not decrease periprosthetic joint infection in primary total and unicompartmental knee arthroplasties. Knee Surg Sports Traumatol Arthrosc 2019; 27:2322-2327. [PMID: 30968239 DOI: 10.1007/s00167-019-05498-z] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Accepted: 03/27/2019] [Indexed: 02/07/2023]
Abstract
PURPOSE A frequent reason for revision surgery after total knee arthroplasty (TKA) and unicompartmental knee arthroplasty (UKA) is periprosthetic joint infection (PJI). The efficacy of intrawound VP in preventing PJI after primary TKA or UKA is rarely reported. The purpose of this study was to investigate the efficacy and side effects of local high-dose VP application to the joint to prevent PJI in TKA and UKA. METHODS From 2010 to 2017, 166 consecutive patients that underwent primary TKA or UKA were enrolled. Seventy-five patients (92 knees) did not receive VP (control group), while 90 patients (110 knees, VP group) received VP (intrawound, 1 g) before capsule closure during TKA and UKA. Aseptic wound complications, such as skin erosion, wound dehiscence, and prolonged wound healing, were evaluated within 3 months post-operatively. PJI was assessed within a year post-operatively. RESULTS Seven patients (7.6%) in the control group and five patients (4.5%) in the VP group had PJI. No significant differences existed in the PJI rates between the groups. Aseptic operative wound complications occurred in 4 patients (4.3%) and 13 patients (11.8%), whereas prolonged operative wound healing occurred in 3 patients (3.3%) and 14 patients (12.7%) of patients in the control and VP group, respectively. Operative wound complications were significantly frequent in the VP group. CONCLUSIONS Intrawound VP administration does not decrease PJI occurrence in primary TKA and significantly causes aseptic wound complications. The use of intrawound VP for the prevention of PJI after primary TKA and UKA is not recommended. LEVEL OF EVIDENCE Level II.
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Affiliation(s)
- Mitsuru Hanada
- Department of Orthopaedic Surgery, Hamamatsu University School of Medicine, 1-20-1 Handayama, Higashi-ku, Hamamatsu, 431-3192, Japan.
| | - Shoichi Nishikino
- Department of Orthopaedic Surgery, Hamamatsu University School of Medicine, 1-20-1 Handayama, Higashi-ku, Hamamatsu, 431-3192, Japan
| | - Kensuke Hotta
- Department of Orthopaedic Surgery, Hamamatsu University School of Medicine, 1-20-1 Handayama, Higashi-ku, Hamamatsu, 431-3192, Japan
| | - Hiroki Furuhashi
- Department of Orthopaedic Surgery, Hamamatsu University School of Medicine, 1-20-1 Handayama, Higashi-ku, Hamamatsu, 431-3192, Japan
| | - Hironobu Hoshino
- Department of Orthopaedic Surgery, Hamamatsu University School of Medicine, 1-20-1 Handayama, Higashi-ku, Hamamatsu, 431-3192, Japan
| | - Yukihiro Matsuyama
- Department of Orthopaedic Surgery, Hamamatsu University School of Medicine, 1-20-1 Handayama, Higashi-ku, Hamamatsu, 431-3192, Japan
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Martínez-Moreno J, Mir-Palomo S, Merino V, Nácher A, Merino-Sanjuán M. Development of antibiotic loaded biodegradable matrices to prevent superficial infections associated to total knee arthroplasty. Colloids Surf B Biointerfaces 2019; 181:1-5. [PMID: 31102726 DOI: 10.1016/j.colsurfb.2019.05.024] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Revised: 05/09/2019] [Accepted: 05/10/2019] [Indexed: 02/01/2023]
Abstract
Development of a pharmaceutical form for the superficial infections related with arthroplasties would be helpful for clinical practice. In this context, we set out to evaluate ciprofloxacin and gentamicin elution from systems based on chitosan. Films and semisolid hydrogels containing chitosan alone (2%) or in combination with gelatin (6%) or different proportions (from 12% to 36%) of tetrakis-(hydroxymethyl)-phosphonium-chloride (THPC) were tested as delivery systems. Different antibiotic doses were assayed (0.5 mg/cm2,1 mg/cm2 and 2 mg/cm2). Antibiotic release was studied for each formulation. In vitro cytocompatibility studies and a simulation exercise for bioactivity evaluation were performed. Samples containing chitosan or chitosan-gelatin released the antibiotics at very high rates. On the contrary, ciprofloxacin released was kept for 6 days from THPC-chitosan films and hydrogels. From hydrogel formulations release could be changed by varying the percentage of THPC. The system containing 12%-THPC-chitosan with 2 mg/cm2 of ciprofloxacin showed that 100% of patient would be covered during 72 h post-surgery. The concentration of 12%-THPC did not show cytotoxicity in NIH3T3 mouse fibroblasts after 48 h. THPC is suitable as crosslinker for chitosan when ciprofloxacin is incorporated showing a sustained release during 6 days.
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Affiliation(s)
- Javier Martínez-Moreno
- Departamento de Farmacia y Tecnología Farmacéutica y Parasitología, Facultad de Farmacia. Universitat de València. Av. Vicente Andrés Estelles s/n, Burjassot, Valencia, Spain; Instituto Interuniversitario de Investigación de Reconocimiento Molecular y Desarrollo Tecnológico (IDM), Universitat Politècnica de València, Universitat de València. Av. Vicente Andrés Estelles s/n, Burjassot, Valencia, Spain
| | - Silvia Mir-Palomo
- Departamento de Farmacia y Tecnología Farmacéutica y Parasitología, Facultad de Farmacia. Universitat de València. Av. Vicente Andrés Estelles s/n, Burjassot, Valencia, Spain
| | - Virginia Merino
- Departamento de Farmacia y Tecnología Farmacéutica y Parasitología, Facultad de Farmacia. Universitat de València. Av. Vicente Andrés Estelles s/n, Burjassot, Valencia, Spain; Instituto Interuniversitario de Investigación de Reconocimiento Molecular y Desarrollo Tecnológico (IDM), Universitat Politècnica de València, Universitat de València. Av. Vicente Andrés Estelles s/n, Burjassot, Valencia, Spain.
| | - Amparo Nácher
- Departamento de Farmacia y Tecnología Farmacéutica y Parasitología, Facultad de Farmacia. Universitat de València. Av. Vicente Andrés Estelles s/n, Burjassot, Valencia, Spain; Instituto Interuniversitario de Investigación de Reconocimiento Molecular y Desarrollo Tecnológico (IDM), Universitat Politècnica de València, Universitat de València. Av. Vicente Andrés Estelles s/n, Burjassot, Valencia, Spain
| | - Matilde Merino-Sanjuán
- Departamento de Farmacia y Tecnología Farmacéutica y Parasitología, Facultad de Farmacia. Universitat de València. Av. Vicente Andrés Estelles s/n, Burjassot, Valencia, Spain; Instituto Interuniversitario de Investigación de Reconocimiento Molecular y Desarrollo Tecnológico (IDM), Universitat Politècnica de València, Universitat de València. Av. Vicente Andrés Estelles s/n, Burjassot, Valencia, Spain
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Beuttel E, Bormann N, Pobloth AM, Duda GN, Wildemann B. Impact of Gentamicin-Loaded Bone Graft on Defect Healing in a Sheep Model. MATERIALS 2019; 12:ma12071116. [PMID: 30987272 PMCID: PMC6480073 DOI: 10.3390/ma12071116] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Revised: 04/01/2019] [Accepted: 04/02/2019] [Indexed: 01/23/2023]
Abstract
Infections of bone are severe complications, and an optimization of grafting material with antimicrobial drugs might be useful for prevention and treatment. This study aimed to investigate the influence of gentamicin-loaded bone graft on the healing of bone defects in a sheep model. Metaphyseal and diaphyseal drill hole defects (diameter: 6 mm, depth: 15 mm) were filled with graft or gentamicin-loaded graft (50 mg/g graft) or were left untreated. Analysis of regeneration after three and nine weeks, micro-computed tomography (μCT), and histology revealed a significant increase in bone formation in the drill hole defects, which began at the edges of the holes and grew over time into the defect center. The amount of graft decreased over time due to active resorption by osteoclasts, while osteoblasts formed new bone. No difference between the groups was seen after three weeks. After nine weeks, significantly less mineralized tissue was formed in the gentamicin-loaded graft group. Signs of inflammatory reactions were seen in all three groups. Even though the applied gentamicin concentration was based on the concentration of gentamicin mixed with cement, the healing process was impaired. When using local gentamicin, a dose-dependent, compromising effect on bone healing should be considered.
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Affiliation(s)
- Elisabeth Beuttel
- Julius Wolff Institute and Berlin-Brandenburg Center for Regenerative Therapies, Charité-Universitätmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, 13353 Berlin, Germany.
| | - Nicole Bormann
- Julius Wolff Institute and Berlin-Brandenburg Center for Regenerative Therapies, Charité-Universitätmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, 13353 Berlin, Germany.
| | - Anne-Marie Pobloth
- Julius Wolff Institute and Berlin-Brandenburg Center for Regenerative Therapies, Charité-Universitätmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, 13353 Berlin, Germany.
| | - Georg N Duda
- Julius Wolff Institute and Berlin-Brandenburg Center for Regenerative Therapies, Charité-Universitätmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, 13353 Berlin, Germany.
| | - Britt Wildemann
- Julius Wolff Institute and Berlin-Brandenburg Center for Regenerative Therapies, Charité-Universitätmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, 13353 Berlin, Germany.
- Experimental Trauma Surgery, University Hospital Jena, 07740 Jena, Germany.
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Johnson JD, Perry KI, Yuan BJ, Rose PS, Houdek MT. Outcomes of Endoprosthetic Replacement for Salvage of Failed Fixation of Malignant Pathologic Proximal Femur Fractures. J Arthroplasty 2019; 34:700-703. [PMID: 30606513 DOI: 10.1016/j.arth.2018.12.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2018] [Revised: 11/29/2018] [Accepted: 12/10/2018] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Internal fixation is often used to treat pathologic proximal femur fractures. However, nonunion and/or tumor progression may lead to hardware failure. In such cases, endoprosthetic replacement may be considered. The purpose of this study is to analyze the outcome of patients undergoing conversion to an endoprosthetic replacement following failed fixation of a pathological proximal femur fracture. METHODS We identified 26 patients who underwent conversion hip arthroplasty for salvage of failed fixation of a pathologic proximal femur fracture between 2000 and 2016. Previous surgical hardware included femoral nail (n = 18), dynamic hip screw (n = 5), proximal femoral locking plate (n = 1), blade plate (n = 1), and cannulated screws (n = 1). Twenty-one patients had metastatic disease, 4 myeloma, and 1 lymphoma. All received adjuvant or neoadjuvant radiotherapy at a mean dose of 30 Gy. RESULTS There were 15 males and 11 females with mean age 63 ± 11 years. Patients underwent conversion arthroplasty at a mean of 13 ± 12 months after initial fixation. At final follow-up, 19 patients had died, with 5-year overall survival of 35%. Conversion to arthroplasty was performed due to disease progression (n = 12), hardware failure (n = 8), and nonunion (n = 6). Eight hips required reoperation, most commonly for infection (n = 4). At last follow-up, the Harris Hip Scores (P < .001) and Musculoskeletal Tumor Society Scores (P < .001) significantly improved from a mean of 24 and 14 preoperatively to 68 and 59 postoperatively, respectively. CONCLUSION Conversion hip arthroplasty reliably provides improved quality of life and immediate weight bearing, making it an effective treatment for salvage of failed fixation of pathologic proximal femur fractures.
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Affiliation(s)
| | - Kevin I Perry
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN
| | - Brandon J Yuan
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN
| | - Peter S Rose
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN
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Maher S, Mazinani A, Barati MR, Losic D. Engineered titanium implants for localized drug delivery: recent advances and perspectives of Titania nanotubes arrays. Expert Opin Drug Deliv 2019; 15:1021-1037. [PMID: 30259776 DOI: 10.1080/17425247.2018.1517743] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
INTRODUCTION Therapeutics delivery to bones to treat skeletal diseases or prevent postsurgical infections is challenging due to complex and solid bone structure that limits blood supply and diffusion of therapeutics administered by systemic routes to reach effective concentration. Titanium (Ti) and their alloys are employed as mainstream implant materials in orthopedics and dentistry; having superior mechanical/biocompatibility properties which could provide an alternative solution to address this problem. AREAS COVERED This review presents an overview of recent development of Ti drug-releasing implants, with emphasis on nanoengineered Titania nanotubes (TNTs) structures, for solving key problems to improve implants osseointegration, overcome inflammation and infection together with providing localized drug delivery (LDD) for bone diseases including cancer. Critical analysis of the advantages/disadvantages of developed concepts is discussed, their drug loading/releasing performances and specific applications. EXPERT OPINION LDD to bones can address many disorders and postsurgical conditions such as inflammation, implants rejection and infection. To this end, TNTs-Ti implants represent a potential promise for the development of new generation of multifunctional implants with drug release functions. Even this concept is extensively explored recently, there is a strong need for more preclinical studies using animal models to confirm the long-term safety and stability of TNTs-Ti implants for real-life medical applications.
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Affiliation(s)
- Shaheer Maher
- a School of Chemical Engineering , The University of Adelaide , Adelaide , Australia
| | - Arash Mazinani
- a School of Chemical Engineering , The University of Adelaide , Adelaide , Australia
| | - Mohammad Reza Barati
- a School of Chemical Engineering , The University of Adelaide , Adelaide , Australia
| | - Dusan Losic
- a School of Chemical Engineering , The University of Adelaide , Adelaide , Australia
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Minimum 5 years’ follow-up after gentamicin- and clindamycin-loaded PMMA cement in total joint arthroplasty. J Med Microbiol 2019; 68:475-479. [DOI: 10.1099/jmm.0.000895] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
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65
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Hip and Knee Section, Prevention, Local Antimicrobials: Proceedings of International Consensus on Orthopedic Infections. J Arthroplasty 2019; 34:S289-S292. [PMID: 30343975 DOI: 10.1016/j.arth.2018.09.013] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
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Abblitt WP, Ascione T, Bini S, Bori G, Brekke AC, Chen AF, Courtney PM, Della Valle CJ, Diaz-Ledezma C, Ebied A, Fillingham YJ, Gehrke T, Goswami K, Grammatopoulos G, Marei S, Oliashirazi A, Parvizi J, Polkowski G, Saeed K, Schwartz AJ, Segreti J, Shohat N, Springer BD, Suleiman LI, Swiderek LK, Tan TL, Yan CH, Zeng YR. Hip and Knee Section, Outcomes: Proceedings of International Consensus on Orthopedic Infections. J Arthroplasty 2019; 34:S487-S495. [PMID: 30348557 DOI: 10.1016/j.arth.2018.09.035] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
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Gorvetzian JW, Kunkel RP, Demas CP. A Single Center Retrospective Evaluation of a Surgical Strategy to Combat Persistent Soft Tissue Wounds Utilizing Absorbable Antibiotic Beads. Adv Wound Care (New Rochelle) 2019; 8:49-57. [PMID: 30809422 PMCID: PMC6389768 DOI: 10.1089/wound.2018.0795] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2018] [Accepted: 08/30/2018] [Indexed: 12/19/2022] Open
Abstract
Objective: To determine whether use of absorbable antibiotic-imbued beads in chronic soft tissue wounds presents a viable therapeutic modality. Approach: Retrospective analysis of all cases utilizing calcium sulfate antibiotic beads was conducted. Cases comprised complex wound and breast reconstruction performed by the senior author (C.P.D.) over 4 years at the University of New Mexico Hospital. All-cause need for reoperation and reoperation for infection in the 90 days following bead-assisted surgery were compared to traditional surgical intervention in the 90-day period preceding bead-assisted surgery. Paired-samples t-test and corrected Cohen's d were calculated for outcome significance and effect size. Results: A total of 60 patients underwent 84 bead-assisted surgeries. There was a significant decrease in rate of reoperation following bead surgery (M = 0.32) compared with prebead surgery (M = 2.2), p < 0.001. Rate of reoperation for infection significantly decreased from 1.7 before bead surgery to 0.05 following bead surgery, p < 0.001. Results remained significant when stratified by complex wound or breast reconstruction, p < 0.01. Cohen's d ranged from 1.25 to 2.13, with probability of superiority between 80% and 93%. Innovation: Use of antibiotic-laden materials is well established in the orthopedic literature, but poorly characterized in soft tissue applications. Biofilms are increasingly implicated as a unifying pathologic foe underlying chronic wound infection and nonhealing. Antibiotic beads have demonstrated activity against biofilm in vitro. This study demonstrates diminished reoperative burden for these wounds following antibiotic bead surgery, possibly as a result of in vivo biofilm antagonism. Conclusion: Antibiotic bead-assisted surgery was associated with significantly decreased infectious and all-cause reoperations for chronic and infected wounds.
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Affiliation(s)
- Joseph W. Gorvetzian
- Health Sciences Center, University of New Mexico School of Medicine, Albuquerque, New Mexico
| | - Ryan P. Kunkel
- Division of Plastic Surgery, University of New Mexico Hospital, Albuquerque, New Mexico
| | - Christopher P. Demas
- Division of Plastic Surgery, University of New Mexico Hospital, Albuquerque, New Mexico
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Caravaggi P, Liverani E, Leardini A, Fortunato A, Belvedere C, Baruffaldi F, Fini M, Parrilli A, Mattioli‐Belmonte M, Tomesani L, Pagani S. CoCr porous scaffolds manufactured via selective laser melting in orthopedics: Topographical, mechanical, and biological characterization. J Biomed Mater Res B Appl Biomater 2019; 107:2343-2353. [DOI: 10.1002/jbm.b.34328] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Revised: 11/16/2018] [Accepted: 12/23/2018] [Indexed: 11/09/2022]
Affiliation(s)
- Paolo Caravaggi
- Movement Analysis LaboratoryIRCCS Istituto Ortopedico Rizzoli Bologna Italy
| | | | - Alberto Leardini
- Movement Analysis LaboratoryIRCCS Istituto Ortopedico Rizzoli Bologna Italy
| | | | - Claudio Belvedere
- Movement Analysis LaboratoryIRCCS Istituto Ortopedico Rizzoli Bologna Italy
| | - Fabio Baruffaldi
- Medical Technology LaboratoryIRCCS Istituto Ortopedico Rizzoli Bologna Italy
| | - Milena Fini
- Laboratory of Preclinical and Surgical StudiesIRCCS Istituto Ortopedico Rizzoli Bologna Italy
| | - Annapaola Parrilli
- Laboratory of Preclinical and Surgical StudiesIRCCS Istituto Ortopedico Rizzoli Bologna Italy
| | | | | | - Stefania Pagani
- Laboratory of Preclinical and Surgical StudiesIRCCS Istituto Ortopedico Rizzoli Bologna Italy
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Holleyman RJ, Deehan DJ, Walker L, Charlett A, Samuel J, Shirley MDF, Baker PN. Staphylococcal resistance profiles in deep infection following primary hip and knee arthroplasty: a study using the NJR dataset. Arch Orthop Trauma Surg 2019; 139:1209-1215. [PMID: 30877427 PMCID: PMC6687688 DOI: 10.1007/s00402-019-03155-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Indexed: 11/29/2022]
Abstract
INTRODUCTION This study aimed to (1) report the rates of resistance against a variety of antibiotics for pure Staphylococcal infections, and (2) examine the impact of ALBC use at primary surgery has on resistance patterns for patients undergoing first-time revision of primary hip and knee arthroplasty for indication of infection. MATERIALS AND METHODS Data from the National Joint Registry database for England and Wales were linked to microbiology data held by Public Health England to identify a consecutive series of 258 primary hip and knee arthroplasties performed between April 2003 and January 2014 that went on to have a revision for Staphylococcal deep periprosthetic infection. Multivariate binary logistic regression was used to study predictors of microorganism resistance to a range of antimicrobials. RESULTS After adjusting for patient and surgical factors, multivariate analysis showed the use of gentamicin-loaded bone cement at the primary surgery was associated with a significant increase in the risk of Staphylococcal gentamicin resistance (odds ratio 8.341, 95% CI 2.297-30.292, p = 0.001) and methicillin resistance (odds ratio 3.870, 95% CI 1.319-11.359, p = 0.014) at revision for infection. CONCLUSIONS Clinicians must anticipate the possibility of antibiotic resistance to ALBC utilised at primary surgery.
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Affiliation(s)
- Richard J. Holleyman
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, NE2 4HH UK ,Health Education North East, Newcastle upon Tyne, NE15 8NY UK
| | - David J. Deehan
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, NE2 4HH UK ,Newcastle upon Tyne NHS Foundation Trust, Newcastle upon Tyne, NE7 7DN UK
| | - Lucy Walker
- Health Education North East, Newcastle upon Tyne, NE15 8NY UK
| | - Andre Charlett
- Centre for Infectious Disease Surveillance and Control, Public Health England, London, NW9 5EQ UK
| | - Julie Samuel
- Newcastle upon Tyne NHS Foundation Trust, Newcastle upon Tyne, NE7 7DN UK
| | - Mark D. F. Shirley
- Biological, Clinical, and Environmental Systems Modelling Group, School of Biology, Newcastle University, Newcastle upon Tyne, NE1 7RU UK
| | - Paul N. Baker
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, NE2 4HH UK ,Department of Trauma and Orthopaedics, James Cook University Hospital, Middlebrough, TS4 3BW UK
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Klinder A, Zaatreh S, Ellenrieder M, Redanz S, Podbielski A, Reichel T, Bösebeck H, Mittelmeier W, Bader R. Antibiotics release from cement spacers used for two-stage treatment of implant-associated infections after total joint arthroplasty. J Biomed Mater Res B Appl Biomater 2018; 107:1587-1597. [PMID: 30312529 PMCID: PMC6586059 DOI: 10.1002/jbm.b.34251] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2018] [Revised: 08/29/2018] [Accepted: 09/08/2018] [Indexed: 12/13/2022]
Abstract
Two‐stage revision arthroplasty is the treatment of choice for periprosthetic infection, a serious complication after knee or hip arthroplasty. Our prospective clinical trial aimed to investigate the concentrations of gentamicin and vancomycin in wound exudate and tissue in two‐stage revision arthroplasty. Wound exudate and periprosthetic membrane samples were collected from 18 patients (10 hip and eight knee patients), who were due for two‐stage treatment after a periprosthetic joint infection. Samples were taken during insertion of antibiotic‐impregnated spacers and after their removal. The concentrations of gentamicin and vancomycin in wound exudates and adjacent tissue were analyzed using high‐performance liquid chromatography mass spectrometry. Average time period of spacer implantation was 13.6 weeks (9.3–22.6 weeks). The concentration of vancomycin in wound exudate decreased from a median of 43.28 μg/mL (0.28–261.22) after implantation to 0.46 μg/mL (0.13–37.47) after the removal of the spacer. In the adjacent tissue, vancomycin concentration was mainly undetectable prior to spacer implantation (0.003 μg/g [0.003–0.261]) and increased to 0.318 μg/g [0.024–484.16] at the time of spacer removal. This was also observed for gentamicin in the tissue of patients who previously had cement‐free implants (0.008 μg/g [0.008–0.087] vs. 0.164 μg/g [0.048–71.75]) while in the tissue of patients with previously cemented prosthesis, baseline concentration was already high (8.451 μg/g [0.152–42.926]). Despite the rapid decrease in antibiotics release from spacer cement observed in vitro, in vivo antibiotics are much longer detectable, especially in the adjacent soft tissue. © 2018 The Authors. Journal of Biomedical Materials Research Part B: Applied Biomaterials Published By Wiley Periodicals, Inc. J Biomed Mater Res B Part B, 2019. © 2018 Wiley Periodicals, Inc. J Biomed Mater Res Part B: Appl Biomater 107B: 1587–1597, 2019.
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Affiliation(s)
- Annett Klinder
- Biomechanics and Implant Technology Research Laboratory, Department of Orthopaedics, University Medicine Rostock, Rostock, Germany
| | - Sarah Zaatreh
- Biomechanics and Implant Technology Research Laboratory, Department of Orthopaedics, University Medicine Rostock, Rostock, Germany
| | - Martin Ellenrieder
- Biomechanics and Implant Technology Research Laboratory, Department of Orthopaedics, University Medicine Rostock, Rostock, Germany
| | - Sylvio Redanz
- Institute of Medical Microbiology, Virology and Hygiene, University Medicine Rostock, Rostock, Germany
| | - Andreas Podbielski
- Institute of Medical Microbiology, Virology and Hygiene, University Medicine Rostock, Rostock, Germany
| | | | | | - Wolfram Mittelmeier
- Biomechanics and Implant Technology Research Laboratory, Department of Orthopaedics, University Medicine Rostock, Rostock, Germany
| | - Rainer Bader
- Biomechanics and Implant Technology Research Laboratory, Department of Orthopaedics, University Medicine Rostock, Rostock, Germany
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Abstract
The treatment of superficial wound infections with local antibiotics is considered to be problematic as it is accompanied by an increased risk of resistance development and ineffectiveness in deeper regions. On the contrary, the local application of antibiotics is useful in arthroplasty and necessary if implants are utilized. The reason for this is the prevention of a rapid biofilm formation on foreign implants and a resulting infection may remain undiscovered until it becomes chronic. Apart from exogenous material, necrotic tissue (e. g. bone sequestra) provides suitable retreat areas for pathogens in the body. Because of the characteristics of bone and joint infections and an exceptional infection recurrence rate, a combined approach is required. Systemic antibiotic prophylaxis is able to reduce the number of pathogens acquired by perioperative contamination or hematogenic spread from another focus of infection; however, systemically applied antibiotics often fail to form an effective colonization barrier around the implant because their ability to penetrate the bone is relatively low. On the other hand, the high concentration of locally released antibiotics leads to an effective protection of the implant from bacteria in situ. Thus, for the treatment of implant-associated infections, systemic and local application of anti-infective agents is a reliable adjuvant measure that improves the therapeutic success. Polymethylmethacrylate (PMMA) bone cement is the most commonly used local drug carrier. Based on clinical and microbiological results, microbiologists and infectious disease experts together with the surgeon and pharmacist determine which anti-infective agents are indicated for systemic and local, PMMA cement-related application. Because there is no evident concept for the local application, unlike the recommendation for systemic use of anti-infective agents, this review article describes which aspects should be taken into account.
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Suleiman LI, Mesko DR, Nam D. Intraoperative Considerations for Treatment/Prevention of Prosthetic Joint Infection. Curr Rev Musculoskelet Med 2018; 11:401-408. [PMID: 29936680 PMCID: PMC6105485 DOI: 10.1007/s12178-018-9502-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
PURPOSE OF REVIEW Innovative measures have recently been proposed to prevent periprosthetic joint infection following total hip and knee arthroplasty. We sought to review these recent innovations to determine the reported reduction in periprosthetic joint infection. RECENT FINDINGS The most recent literature demonstrates promising results in regard to hydrofiber dressings as an independent risk factor for primary prosthetic joint infection reduction, which in turn is also linked with cost savings. As our understanding of safe yet effective concentrations of antiseptic solutions develops, dilute betadine in particular has demonstrated encouraging efficacy which warrants continued investigation through controlled trials. In summary, we found that the application of a hydrofiber dressing may prove beneficial in decreasing the risk of prosthetic joint infection following primary total hip and knee arthroplasty. The gold standard for an infection prevention protocol continues to be explored and optimized.
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Affiliation(s)
- Linda I Suleiman
- Department of Orthopaedic Surgery, Rush University Medical Center, 1611 West Harrison St, Chicago, IL, 60612, USA
| | - Daniel R Mesko
- Department of Orthopaedic Surgery, Rush University Medical Center, 1611 West Harrison St, Chicago, IL, 60612, USA
| | - Denis Nam
- Department of Orthopaedic Surgery, Rush University Medical Center, 1611 West Harrison St, Chicago, IL, 60612, USA.
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Martínez-Moreno J, Merino V, Nácher A, Rodrigo JL, Climente M, Merino-Sanjuán M. Antibiotic-loaded Bone Cement as Prophylaxis in Total Joint Replacement. Orthop Surg 2018; 9:331-341. [PMID: 29178309 DOI: 10.1111/os.12351] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2017] [Accepted: 06/10/2017] [Indexed: 12/14/2022] Open
Abstract
One of its most serious complications associated with arthroplasty is the development of infections. Although its prevalence is only between 0.5% and 3%, in some cases it can lead to death. Therefore, an important challenge in joint surgery is the prevention of infections when an arthroplasty is performed. The use of antibiotic-loaded cements could be a suitable tool due to numerous advantages. The main advantage of the use of antibiotic loading into bone cement derives directly from antibiotic release in the effect site, allowing achievement of high concentrations at the site of action, and minimal or no systemic toxicity. This route of administration was first described by Buchholz and Engelbrecht. In the case of infection treatment, this is an established method and its good results have been confirmed. However, its role in infection prevention, and, therefore, the use of these systems in clinical practice, has proved controversial because of the uncertainty about the development of possible antibiotic resistance after prolonged exposure time, their effectiveness, the cost of the systems, toxicity and loosening of mechanical properties. This review discusses all these topics, focusing on effectiveness and safety, antibiotic decisions, cement type, mixing method, release kinetics and future perspectives. The final objective is to provide the orthopaedic surgeons the right information in their clinical practice based on current evidence.
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Affiliation(s)
- Javier Martínez-Moreno
- Department of Pharmacy and Pharmaceutical Technology, Faculty of Pharmacy, Institute of Molecular Recognition and Technological Development, Mixed Center Polytechnic University of Valencia, University of Valencia, Valencia, Spain.,Pharmacy Service, University Hospital Doctor Peset of Valencia, Valencia, Spain
| | - Virginia Merino
- Department of Pharmacy and Pharmaceutical Technology, Faculty of Pharmacy, Institute of Molecular Recognition and Technological Development, Mixed Center Polytechnic University of Valencia, University of Valencia, Valencia, Spain
| | - Amparo Nácher
- Department of Pharmacy and Pharmaceutical Technology, Faculty of Pharmacy, Institute of Molecular Recognition and Technological Development, Mixed Center Polytechnic University of Valencia, University of Valencia, Valencia, Spain
| | - José Luis Rodrigo
- Traumatology Service, University Hospital Doctor Peset of Valencia, Valencia, Spain
| | - Mónica Climente
- Pharmacy Service, University Hospital Doctor Peset of Valencia, Valencia, Spain
| | - Matilde Merino-Sanjuán
- Department of Pharmacy and Pharmaceutical Technology, Faculty of Pharmacy, Institute of Molecular Recognition and Technological Development, Mixed Center Polytechnic University of Valencia, University of Valencia, Valencia, Spain
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van IJperen W, Van Quickenborne D, Buyl R, Scheerlinck T. Cement mantle thickness does not influence serum or local gentamicin concentrations in hybrid total hip arthroplasty: a randomised controlled trial. Hip Int 2018; 28:415-421. [PMID: 29734817 DOI: 10.1177/1120700018767335] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
INTRODUCTION We investigated the in vivo gentamicin elution kinetics of Hi-Fatigue Gentamicin Bone Cement (AAP Biomaterials GmbH) in serum and drain fluid after hybrid hip arthroplasty and the relationship with cement mantle thickness. METHODS We compared in a randomised, non-blinded prospective study, the local and systemic gentamicin concentrations in 2 groups. The thin cement mantle group ( n = 16) received a stem implanted line-to-line with the broach, whereas the thick group ( n = 14) had an undersized stem. Gentamicin concentrations were measured in drain fluid and serum at set intervals for 3 days postoperatively. RESULTS In both groups, local gentamicin concentrations were similar. After a high initial burst above the minimal inhibitory concentration (thin: 57.2 mg/L (SD 34.4), thick: 54.9 mg/L (SD 19.9), p = 0.823) local gentamicin concentrations declined rapidly. In both groups, serum concentrations never exceeded toxic levels (maximum 1.08 mg/L). CONCLUSION In hybrid total hip arthroplasty, Hi-Fatigue Gentamicin Bone Cement resulted in effective and safe gentamicin concentrations. Clinical trial protocol number: PMCI 12/02.
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Affiliation(s)
- Willem van IJperen
- 1 Department of Orthopaedic and Trauma Surgery, University Hospital Brussels (UZ Brussel), Jette, Belgium
| | - Damien Van Quickenborne
- 2 Department of Orthopaedic and Trauma Surgery, Gent University Hospital, (UGent), Ghent, Belgium
| | - Ronald Buyl
- 3 E-health and Medical Informatics, Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | - Thierry Scheerlinck
- 1 Department of Orthopaedic and Trauma Surgery, University Hospital Brussels (UZ Brussel), Jette, Belgium
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Prävention postoperativer Wundinfektionen. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 2018; 61:448-473. [PMID: 29589090 DOI: 10.1007/s00103-018-2706-2] [Citation(s) in RCA: 84] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Risitano S, Sabatini L, Atzori F, Massè A, Indelli PF. Static antibiotic spacers augmented by calcium sulphate impregnated beads in revision TKA: Surgical technique and review of literature. J Orthop 2018; 15:313-318. [PMID: 29556116 DOI: 10.1016/j.jor.2018.02.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2017] [Revised: 01/16/2018] [Accepted: 02/18/2018] [Indexed: 01/20/2023] Open
Abstract
Periprosthetic joint infection (PJI) is a serious complication in total knee arthroplasty (TKA) and represents one of the most common causes of revision. The challenge for surgeons treating an infected TKA is to quickly obtain an infection-free joint in order to re-implant, when possible, a new TKA. Recent literature confirms the role of local antibiotic-loaded beads as a strong bactericidal, allowing higher antibiotic elution when compared with antibiotic loaded spacers only. Unfortunately, classical Polymethylmethacrylate (PMMA) beads might allow bacteria adhesion, secondary development of antibiotic resistance and eventually surgical removal once antibiotics have eluted. This article describes a novel surgical technique using static, custom-made antibiotic loaded spacers augmented by calcium sulphate antibiotic-impregnated beads to improve the success rate of revision TKA in a setting of PJI. The use of calcium sulphate beads has several potential benefits, including a longer sustained local antibiotic release when compared with classical PMMA beads and, being resorbable, not requiring accessory surgical interventions.
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Affiliation(s)
- Salvatore Risitano
- Department of Orthopaedic Surgery and Traumatology, University of Turin, "Città della salute e della scienza"-CTO Hospital of Turin, Turin, ITA, Italy.,Department of Orthopaedic Surgery and Bioengineering, Stanford University School of Medicine and the Palo Alto Veterans Affairs Health Care System (PAVAHCS), Palo Alto, CA, USA
| | - Luigi Sabatini
- Department of Orthopaedic Surgery and Traumatology, University of Turin, "Città della salute e della scienza"-CTO Hospital of Turin, Turin, ITA, Italy
| | - Francesco Atzori
- Department of Orthopaedic Surgery, Cottolengo Hospital, Turin, Italy
| | - Alessandro Massè
- Department of Orthopaedic Surgery and Traumatology, University of Turin, "Città della salute e della scienza"-CTO Hospital of Turin, Turin, ITA, Italy
| | - Pier Francesco Indelli
- Department of Orthopaedic Surgery and Bioengineering, Stanford University School of Medicine and the Palo Alto Veterans Affairs Health Care System (PAVAHCS), Palo Alto, CA, USA
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Graves N, Wloch C, Wilson J, Barnett A, Sutton A, Cooper N, Merollini K, McCreanor V, Cheng Q, Burn E, Lamagni T, Charlett A. A cost-effectiveness modelling study of strategies to reduce risk of infection following primary hip replacement based on a systematic review. Health Technol Assess 2018; 20:1-144. [PMID: 27468732 DOI: 10.3310/hta20540] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND A deep infection of the surgical site is reported in 0.7% of all cases of total hip arthroplasty (THA). This often leads to revision surgery that is invasive, painful and costly. A range of strategies is employed in NHS hospitals to reduce risk, yet no economic analysis has been undertaken to compare the value for money of competing prevention strategies. OBJECTIVES To compare the costs and health benefits of strategies that reduce the risk of deep infection following THA in NHS hospitals. To make recommendations to decision-makers about the cost-effectiveness of the alternatives. DESIGN The study comprised a systematic review and cost-effectiveness decision analysis. SETTING 77,321 patients who had a primary hip arthroplasty in NHS hospitals in 2012. INTERVENTIONS Nine different treatment strategies including antibiotic prophylaxis, antibiotic-impregnated cement and ventilation systems used in the operating theatre. MAIN OUTCOME MEASURES Change in the number of deep infections, change in the total costs and change in the total health benefits in quality-adjusted life-years (QALYs). DATA SOURCES Literature searches using MEDLINE, EMBASE, Cumulative Index to Nursing and Allied Health Literature and the Cochrane Central Register of Controlled Trials were undertaken to cover the period 1966-2012 to identify infection prevention strategies. Relevant journals, conference proceedings and bibliographies of retrieved papers were hand-searched. Orthopaedic surgeons and infection prevention experts were also consulted. REVIEW METHODS English-language papers only. The selection of evidence was by two independent reviewers. Studies were included if they were interventions that reported THA-related deep surgical site infection (SSI) as an outcome. Mixed-treatment comparisons were made to produce estimates of the relative effects of competing infection control strategies. RESULTS Twelve studies, six randomised controlled trials and six observational studies, involving 123,788 total hip replacements (THRs) and nine infection control strategies, were identified. The quality of the evidence was judged against four categories developed by the National Institute for Health and Care Excellence Methods for Development of NICE Public Health Guidance ( http://publications.nice.org.uk/methods-for-the-development-of-nice-public-health-guidance-third-edition-pmg4 ), accessed March 2012. All evidence was found to fit the two highest categories of 1 and 2. Nine competing infection control interventions [treatments (Ts) 1-9] were used in a cohort simulation model of 77,321 patients who had a primary THR in 2012. Predictions were made for cases of deep infection and total costs, and QALY outcomes. Compared with a baseline of T1 (no systemic antibiotics, plain cement and conventional ventilation) all other treatment strategies reduced risk. T6 was the most effective (systemic antibiotics, antibiotic-impregnated cement and conventional ventilation) and prevented a further 1481 cases of deep infection, and led to the largest annual cost savings and the greatest gains to QALYs. The additional uses of laminar airflow and body exhaust suits indicate higher costs and worse health outcomes. CONCLUSIONS T6 is an optimal strategy for reducing the risk of SSI following THA. The other strategies that are commonly used among NHS hospitals lead to higher cost and worse QALY outcomes. Policy-makers, therefore, have an opportunity to save resources and improve health outcomes. The effects of laminar air flow and body exhaust suits might be further studied if policy-makers are to consider disinvesting in these technologies. LIMITATIONS A wide range of evidence sources was synthesised and there is large uncertainty in the conclusions. FUNDING The National Institute for Health Research Health Technology Assessment programme and the Queensland Health Quality Improvement and Enhancement Programme (grant number 2008001769).
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Affiliation(s)
- Nicholas Graves
- School of Public Health and Social Work, Queensland University of Technology, Brisbane, QLD, Australia
| | | | - Jennie Wilson
- College of Nursing, Midwifery and Healthcare, University of West London, London, UK
| | - Adrian Barnett
- School of Public Health and Social Work, Queensland University of Technology, Brisbane, QLD, Australia
| | - Alex Sutton
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Nicola Cooper
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Katharina Merollini
- School of Public Health and Social Work, Queensland University of Technology, Brisbane, QLD, Australia
| | - Victoria McCreanor
- School of Public Health and Social Work, Queensland University of Technology, Brisbane, QLD, Australia
| | - Qinglu Cheng
- School of Public Health and Social Work, Queensland University of Technology, Brisbane, QLD, Australia
| | - Edward Burn
- School of Public Health and Social Work, Queensland University of Technology, Brisbane, QLD, Australia
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Edmiston CE, Leaper D, Spencer M, Truitt K, Litz Fauerbach L, Graham D, Johnson HB. Considering a new domain for antimicrobial stewardship: Topical antibiotics in the open surgical wound. Am J Infect Control 2017; 45:1259-1266. [PMID: 28596018 DOI: 10.1016/j.ajic.2017.04.012] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2017] [Revised: 04/07/2017] [Accepted: 04/07/2017] [Indexed: 01/07/2023]
Abstract
The global push to combat the problem of antimicrobial resistance has led to the development of antimicrobial stewardship programs (ASPs), which were recently mandated by The Joint Commission and the Centers for Medicare and Medicaid Services. However, the use of topical antibiotics in the open surgical wound is often not monitored by these programs nor is it subject to any evidence-based standardization of care. Survey results indicate that the practice of using topical antibiotics intraoperatively, in both irrigation fluids and powders, is widespread. Given the risks inherent in their use and the lack of evidence supporting it, the practice should be monitored as a core part of ASPs, and alternative agents, such as antiseptics, should be considered.
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Affiliation(s)
| | - David Leaper
- University of Newcastle upon Tyne, Newcastle upon Tyne, UK
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Al Thaher Y, Perni S, Prokopovich P. Nano-carrier based drug delivery systems for sustained antimicrobial agent release from orthopaedic cementous material. Adv Colloid Interface Sci 2017; 249:234-247. [PMID: 28477865 DOI: 10.1016/j.cis.2017.04.017] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2016] [Revised: 04/25/2017] [Accepted: 04/26/2017] [Indexed: 12/22/2022]
Abstract
Total joint replacement (TJR), such as hip and knee replacement, is a popular procedure worldwide. Prosthetic joint infections (PJI) after this procedure have been widely reported, where treatment of such infections is complex with high cost and prolonged hospital stay. In cemented arthroplasties, the use of antibiotic loaded bone cement (ALBC) is a standard practice for the prophylaxis and treatment of PJI. Recently, the development of bacterial resistance by pathogenic microorganisms against most commonly used antibiotics increased the interest in alternative approaches for antimicrobial delivery systems such as nanotechnology. This review summarizes the efforts made to improve the antimicrobial properties of PMMA bone cements using nanotechnology based antibiotic and non-antibiotic delivery systems to overcome drawbacks of ALBC in the prophylaxis and treatment of PJIs after hip and knee replacement.
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Affiliation(s)
- Yazan Al Thaher
- School of Pharmacy and Pharmaceutical Science, Cardiff University, Cardiff, UK
| | - Stefano Perni
- School of Pharmacy and Pharmaceutical Science, Cardiff University, Cardiff, UK
| | - Polina Prokopovich
- School of Pharmacy and Pharmaceutical Science, Cardiff University, Cardiff, UK.
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80
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Salvage of Infected Nasal Reconstruction with a Polymethyl Methacrylate Spacer. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2017; 5:e1300. [PMID: 28831331 PMCID: PMC5548554 DOI: 10.1097/gox.0000000000001300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Total nasal reconstruction is a challenging multistage procedure. Infections can destroy the cartilage framework and seriously compromise the result. The use of polymethyl methacrylate with antibiotics as a spacer has been described in the treatment of skeletal infections. Using this same principle, the use of a polymethyl methacrylate with antibiotics spacer for an infected nasal reconstruction is reported in a clinical case.
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81
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In vivo serum concentration of vancomycin in antibiotic-loaded acrylic cement for the treatment and prevention of periprosthetic hip infection. J Orthop Sci 2017; 22:710-714. [PMID: 28342695 DOI: 10.1016/j.jos.2017.03.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2016] [Revised: 02/21/2017] [Accepted: 03/02/2017] [Indexed: 12/29/2022]
Abstract
BACKGROUND Although antibiotic-loaded acrylic cement (ALAC) is used to prevent and treat periprosthetic hip infection, it is unknown how much antibiotic is deposited in the body in vivo, how high the serum concentration rises, or how long its effects last. The aim of this study was firstly to determine the amount of vancomycin (VCM) deposited as ALAC in the body, and secondly to assess the safety and drug elution profile of VCM in ALAC. METHODS We administered VCM to prevent infection after total hip arthroplasty (THA) or to treat patients with methicillin-resistant Staphylococcus aureus. Patients were classified into two groups: a low-dose group (21 hips) that received primary THA for high-risk cases, revision THA without infection, or one-staged revision THA for infection; and a high-dose group (6 hips) that received cement beads during a two-staged revision THA. The amount of VCM placed as ALAC into the hip was calculated using the remaining ALAC. The serum concentrations of VCM and creatinine were evaluated at postoperative days 1, 4, 7, 14, and 28, and at 3 and 6 months. RESULTS The mean amount of VCM placed as ALAC into the hip was 0.9 g and 3.4 g for cemented THA and cement beads, respectively (P < 0.0001). The mean serum concentration of VCM from ALAC in the high-dose group was significantly increased compared with that in the low-dose group on postoperative days 1, 4, 7, 14, and 28 (P < 0.0001), but it remained within a clinically safe range. No significant differences were observed between the preoperative and postoperative serum creatinine levels of either group. CONCLUSION The average serum concentrations of VCM from ALAC were always less than the effective blood concentration, and were detectable until 6 months after surgery.
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Mühlhofer HML, Deiss L, Mayer-Kuckuk P, Pohlig F, Harrasser N, Lenze U, Gollwitzer H, Suren C, Prodinger P, VON Eisenhart-Rothe R, Schauwecker J. Increased Resistance of Skin Flora to Antimicrobial Prophylaxis in Patients Undergoing Hip Revision Arthroplasty. In Vivo 2017; 31:673-676. [PMID: 28652437 PMCID: PMC5566920 DOI: 10.21873/invivo.11111] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2017] [Revised: 05/07/2017] [Accepted: 05/08/2017] [Indexed: 12/16/2022]
Abstract
BACKGROUND/AIM Prosthetic joint infection (PJI) remains a major complication after total joint replacement and is the primary indication for revision arthroplasty. Specifically, coagulase-negative Staphylococci (CNS) can cause low-grade infections. Despite the use of cephalosporin-based antimicrobial prophylaxis (AMP) and antiseptic treatment at the surgical site, evidence suggests that a significant number of cases of dermal CNS results in low-grade PJI. Thus, this study examined the bacterial colonization and resistance patterns at the surgical site. We hypothesized that the bacteria developed resistance to antibiotics that are frequently used in primary and revision total hip arthroplasty (THA) procedures. PATIENTS AND METHODS Ninety patients, including 63 primary and 27 revision THA patients, were enrolled in this study. For each patient, a single swab of the skin at the surgical site was subjected to clinical microbiology to assess bacterial colonization. Furthermore, resistance to a sentinel panel of antibiotics (benzylpenicillin, erythromycin, tetracycline, oxacillin, fusidic acid, clindamycin, gentamicin, levofloxacin/moxifloxacin, rifampicin, linezolid and vancomycin) was tested. RESULTS In 96.7% of the patients, at least one bacterial strain was identified at the surgical site, with CNS strains comprising 93.1% of the total. The sentinel panel showed that 30.7% of the CNS strains exhibited maximal resistance to oxacillin, a commonly used cephalosporin. Additionally, oxacillin resistance increased 1.9-fold (p=0.042) between primary and revision THA. Notably, 8.1% of the CNS stains found on patients undergoing primary THA were resistant to gentamicin, an aminoglycoside, and this rate increased 4.7-fold (p=0.001) for patients undergoing revision THA. CONCLUSION CNS strains have significant resistance to standard AMP, particularly in individuals undergoing revision THA.
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Affiliation(s)
- Heinrich M L Mühlhofer
- Department of Orthopaedic Surgery, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - Lukas Deiss
- Department of Orthopaedic Surgery, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - Philipp Mayer-Kuckuk
- Department of Orthopaedic Surgery, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - Florian Pohlig
- Department of Orthopaedic Surgery, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - Norbert Harrasser
- Department of Orthopaedic Surgery, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - Ulrich Lenze
- Department of Orthopaedic Surgery, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - Hans Gollwitzer
- Department of Orthopaedic Surgery, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - Christian Suren
- Department of Orthopaedic Surgery, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - Peter Prodinger
- Department of Orthopaedic Surgery, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | | | - Johannes Schauwecker
- Department of Orthopaedic Surgery, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
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83
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Cossec CL, Colas S, Zureik M. Relative impact of hospital and surgeon procedure volumes on primary total hip arthroplasty revision: a nationwide cohort study in France. Arthroplast Today 2017; 3:176-182. [PMID: 28913403 PMCID: PMC5585819 DOI: 10.1016/j.artd.2017.03.010] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2017] [Revised: 03/08/2017] [Accepted: 03/25/2017] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Both surgeon and hospital procedure volumes have been found to be associated with total hip arthroplasty (THA) outcomes. However, little research has been conducted on the relative influence. We studied the association between THA survivorship and both hospital and surgeon procedure volumes, considering their relative impact. METHODS A population-based cohort included all patients aged ≥40 years having received a unilateral primary THA from 2010 to 2011, from the French National Health Insurance Database. Patients were followed up until the end of 2014. The outcome was THA revision. Exposures of interest were procedure volumes, divided into tertiles: <1.5, 1.5-4, >4 and <7, 7-15, >15 procedures per month defined as low, medium, and high volumes for surgeon and hospital, respectively. RESULTS The cohort had 62,906 patients, with mean age 69 years and women 57%. Mean surgeon and hospital volumes were 8 and 23 procedures per month, respectively, and 5%, 72%, 22% and 7%, 28%, 65% of THAs were implanted by a low-, medium-, and high-volume surgeon or in a low-, medium-, and high-volume hospital, respectively. Median follow-up was 45 months (range, 0-57 months). In multivariate analysis, adjusted for both surgeon and hospital volumes, for patient and THA characteristics, a lower surgeon volume was associated with poorer THA survivorship (adjusted hazard ratio [aHR] = 1.19; 95% confidence interval [CI], 1.07-1.34 and aHR = 1.70; 95% CI, 1.40-2.05, for medium- and low-volume surgeon, respectively, compared with that of high volume), whereas hospital volume was not. CONCLUSIONS This study brings evidence to support the notion that THAs performed by high-volume surgeons in French private hospitals have higher survivorship in the first 4 years.
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Affiliation(s)
| | - Sandrine Colas
- Corresponding author. 143-147 Boulevard Anatole France, F-93285 Saint-Denis Cedex, France. Tel.: +3 315 587 4152.143-147 Boulevard Anatole FranceF-93285 Saint-Denis CedexFrance
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84
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Han J, Yang Y, Lu J, Wang C, Xie Y, Zheng X, Yao Z, Zhang C. Sustained release vancomycin-coated titanium alloy using a novel electrostatic dry powder coating technique may be a potential strategy to reduce implant-related infection. Biosci Trends 2017; 11:346-354. [PMID: 28552898 DOI: 10.5582/bst.2017.01061] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
In order to tackle the implant-related infection, a novel way was developed in this study to coat vancomycin particles mixed with controlled release coating materials onto the surface of titanium alloy by using an electrostatic dry powder coating technique. To characterize this sustained release antibacterial coating, surface morphology, in vitro and in vivo drug release were sequentially evaluated. In vitro cytotoxicity was tested by Cell Counting Kit-8 (CCK-8) assay and cytological changes were observed by inverted microscope. The antibacterial properties against MRSA, including a bacterial growth inhibition assay and a colony-counting test by spread plate method were performed. Results indicated that the vancomycin-coated sample was biocompatible for Human osteoblast cell line MG-63 and displayed effective antibacterial ability against MRSA. The coating film was revealed uniform by scanning electron microscopy. Both the in vitro and in vivo drug release kinetics showed an initially high release rate, followed by an extended period of sustained drug release over 7 days. These results suggest that with good biocompatibility and antibacterial ability, the sustained release antibacterial coating of titanium alloy using our novel electrostatic dry powder coating process may provide a promising candidate for the treatment of orthopedic implant-related infection.
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Affiliation(s)
- Jing Han
- Department of Orthopaedic surgery, Zhongshan Hospital of Fudan University
| | - Yi Yang
- Department of Orthopaedic surgery, Zhongshan Hospital of Fudan University
| | - Junren Lu
- Department of Orthopaedic surgery, Zhongshan Hospital of Fudan University
| | - Chenzhong Wang
- Department of Orthopaedic surgery, Zhongshan Hospital of Fudan University
| | - Youtao Xie
- Key Laboratory of Inorganic Coating Materials, Chinese Academy of Sciences
| | - Xuebin Zheng
- Key Laboratory of Inorganic Coating Materials, Chinese Academy of Sciences
| | - Zhenjun Yao
- Department of Orthopaedic surgery, Zhongshan Hospital of Fudan University
| | - Chi Zhang
- Department of Orthopaedic surgery, Zhongshan Hospital of Fudan University
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George DA, Drago L, Scarponi S, Gallazzi E, Haddad FS, Romano CL. Predicting lower limb periprosthetic joint infections: A review of risk factors and their classification. World J Orthop 2017; 8:400-411. [PMID: 28567344 PMCID: PMC5434347 DOI: 10.5312/wjo.v8.i5.400] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2016] [Revised: 01/05/2017] [Accepted: 03/12/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To undertook a systematic review to determine factors that increase a patient's risk of developing lower limb periprosthetic joint infections (PJI). METHODS This systematic review included full-text studies that reviewed risk factors of developing either a hip or knee PJI following a primary arthroplasty published from January 1998 to November 2016. A variety of keywords were used to identify studies through international databases referencing hip arthroplasty, knee arthroplasty, infection, and risk factors. Studies were only included if they included greater than 20 patients in their study cohort, and there was clear documentation of the statistical parameter used; specifically P-value, hazard ratio, relative risk, or/and odds ratio (OR). Furthermore a quality assessment criteria for the individual studies was undertaken to evaluate the presence of record and reporting bias. RESULTS Twenty-seven original studies reviewing risk factors relating to primary total hip and knee arthroplasty infections were included. Four studies (14.8%) reviewed PJI of the hip, 3 (11.21%) of the knee, and 20 (74.1%) reviewed both joints. Nineteen studies (70.4%) were retrospective and 8 (29.6%) prospective. Record bias was identified in the majority of studies (66.7%). The definition of PJI varied amongst the studies but there was a general consensus to define infection by previously validated methods. The most significant risks were the use of preoperative high dose steroids (OR = 21.0, 95%CI: 3.5-127.2, P < 0.001), a BMI above 50 (OR = 18.3, P < 0.001), tobacco use (OR = 12.76, 95%CI: 2.47-66.16, P = 0.017), body mass index below 20 (OR = 6.00, 95%CI: 1.2-30.9, P = 0.033), diabetes (OR = 5.47, 95%CI: 1.77-16.97, P = 0.003), and coronary artery disease (OR = 5.10, 95%CI: 1.3-19.8, P = 0.017). CONCLUSION We have highlighted the need for the provider to optimise modifiable risk factors, and develop strategies to limit the impact of non-modifiable factors.
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Amerstorfer F, Fischerauer S, Sadoghi P, Schwantzer G, Kuehn KD, Leithner A, Glehr M. Superficial Vancomycin Coating of Bone Cement in Orthopedic Revision Surgery: A Safe Technique to Enhance Local Antibiotic Concentrations. J Arthroplasty 2017; 32:1618-1624. [PMID: 28111125 DOI: 10.1016/j.arth.2016.11.042] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2016] [Revised: 11/08/2016] [Accepted: 11/23/2016] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND The use of antibiotic-loaded cement has become a well-accepted method to develop high local antibiotic concentrations in revision surgery of infected arthroplasty. A new surgical technique has been established to further increase the local antibiotic concentration and thereby minimizes the risk of reinfection. Our study aim was to investigate the safety of additional superficial vancomycin coating (SVC) by analyzing postoperative joint and serum vancomycin concentrations, as well as the creatinine levels of patients with orthopedic revision surgery. METHODS A longitudinal case series was performed by reviewing collected data of patients who were treated by SVC during revision surgery (1- or 2-stage exchange) because of prosthetic joint infections. Vancomycin levels were obtained, local from drains and systemic from blood samples, on postoperative days 1 to 5. Furthermore, preoperative and postoperative serum creatinine levels were analyzed. RESULTS Highest median local vancomycin levels were documented on postoperative day 1 with 546.8 μg/mL (range, 44.4-1485 μg/mL) in the reimplantation group and 408.7 μg/mL (range, 24.7-1650 μg/mL) in the spacer group. Median serum vancomycin level was 4.4 μg/mL (range, <2.0-11.7 μg/mL) on the first postoperative day in the reimplantation group and <2.0 μg/mL (range, <2.0-3.9 μg/mL) in the spacer group, and lower than 2.0 μg/mL (range, <2.0-7.5 μg/mL) from postoperative day 2 to 5 in both groups. Neither an anaphylactic reaction nor other side effects to SVC were observed. CONCLUSION Our data showed that SVC of bone cement is an effective technique to enhance local concentrations of vancomycin without leading to systemic side effects.
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Affiliation(s)
| | | | - Patrick Sadoghi
- Department of Orthopedic Surgery, Medical University of Graz, Graz, Austria
| | - Gerold Schwantzer
- Institute for Medical Informatics, Statistics and Documentation, Medical University of Graz, Graz, Austria
| | - Klaus Dieter Kuehn
- Department of Orthopedic Surgery, Medical University of Graz, Graz, Austria
| | - Andreas Leithner
- Department of Orthopedic Surgery, Medical University of Graz, Graz, Austria
| | - Mathias Glehr
- Department of Orthopedic Surgery, Medical University of Graz, Graz, Austria
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Werthel JD, Lonjon G, Jo S, Cofield R, Sperling JW, Elhassan BT. Long-term outcomes of cemented versus cementless humeral components in arthroplasty of the shoulder. Bone Joint J 2017; 99-B:666-673. [DOI: 10.1302/0301-620x.99b5.bjj-2016-0910.r1] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2016] [Accepted: 01/18/2017] [Indexed: 11/05/2022]
Abstract
Aims In the initial development of total shoulder arthroplasty (TSA), the humeral component was usually fixed with cement. Cementless components were subsequently introduced. The aim of this study was to compare the long-term outcome of cemented and cementless humeral components in arthroplasty of the shoulder. Patients and Methods All patients who underwent primary arthroplasty of the shoulder at our institution between 1970 and 2012 were included in the study. There were 4636 patients with 1167 cemented humeral components and 3469 cementless components. Patients with the two types of fixation were matched for nine different covariates using a propensity score analysis. A total of 551 well-balanced pairs of patients with cemented and cementless components were available after matching for comparison of the outcomes. The clinical outcomes which were analysed included loosening of the humeral component determined at revision surgery, periprosthetic fractures, post-operative infection and operating time. Results The overall five-, ten-, 15- and 20-year rates of survival were 98.9%, 97.2%, 95.5%, and 94.4%, respectively. Survival without loosening at 20 years was 98% for cemented components and 92.4% for cementless components. After propensity score matching including fixation as determined by the design of the component, humeral loosening was also found to be significantly higher in the cementless group. Survival without humeral loosening at 20 years was 98.7% for cemented components and 91.0% for cementless components. There was no significant difference in the risk of intra- or post-operative fracture. The rate of survival without deep infection and the mean operating time were significantly higher in the cemented group. Conclusion Both types of fixation give rates of long-term survival of > 90%. Cemented components have better rates of survival without loosening but this should be weighed against increased operating time and the risk of bony destruction of the proximal humerus at the time of revision of a cemented humeral component. Cite this article: Bone Joint J 2017;99-B:666–73.
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Affiliation(s)
- J-D. Werthel
- Mayo Clinic, 200
First Street S.W, Rochester, Minnesota, USA
| | - G. Lonjon
- Hôpital Européen Georges Pompidou, 20
rue Leblanc, 75015 Paris, France
| | - S. Jo
- Mayo Clinic, 200
First Street S.W, Rochester, Minnesota, USA
| | - R. Cofield
- Mayo Clinic, 200
First Street S.W, Rochester, Minnesota, USA
| | - J. W. Sperling
- Mayo Clinic, 200
First Street S.W, Rochester, Minnesota, USA
| | - B. T. Elhassan
- Mayo Clinic, 200
First Street S.W, Rochester, Minnesota, USA
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Parvizi J, Shohat N, Gehrke T. Prevention of periprosthetic joint infection: new guidelines. Bone Joint J 2017; 99-B:3-10. [PMID: 28363888 DOI: 10.1302/0301-620x.99b4.bjj-2016-1212.r1] [Citation(s) in RCA: 107] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2016] [Accepted: 01/04/2017] [Indexed: 12/13/2022]
Abstract
The World Health Organization (WHO) and the Centre for Disease Control and Prevention (CDC) recently published guidelines for the prevention of surgical site infection. The WHO guidelines, if implemented worldwide, could have an immense impact on our practices and those of the CDC have implications for healthcare policy in the United States. Our aim was to review the strategies for prevention of periprosthetic joint infection in light of these and other recent guidelines. Cite this article: Bone Joint J 2017;99-B(4 Supple B):3-10.
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Affiliation(s)
- J Parvizi
- Thomas Jefferson University, Rothman Institute Sheridan Building, Suite 1000, 25 S 9th Street, Philadelphia, PA 19107, USA
| | - N Shohat
- Tel Aviv University, Tel Aviv, Israel and Thomas Jefferson University, Rothman Institute at Sheridan Building, Suite 1000, 125 S 9th Street, Philadelphia, PA 19107, USA
| | - T Gehrke
- HELIOS ENDO-Klinik Hamburg, Holstrenstraße 2, 22767 Hamburg, Germany
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Chirca I, Marculescu C. Prevention of Infection in Orthopedic Prosthetic Surgery. Infect Dis Clin North Am 2017; 31:253-263. [PMID: 28292539 DOI: 10.1016/j.idc.2017.01.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Total joint arthroplasty is a generally safe orthopedic procedure; however, infection is a potentially devastating complication. Multiple risk factors have been identified for development of prosthetic joint infections. Identification of patients at risk and preoperative correction of known risk factors, such as smoking, diabetes mellitus, anemia, malnutrition, and decolonization of Staphylococcus carriers, represent well-established actions to decrease the infection risk. Careful operative technique, proper draping and skin preparation, and appropriate selection and dosing of antimicrobials for perioperative prophylaxis are also very important in prevention of infection.
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Affiliation(s)
- Ioana Chirca
- Department of infectious Diseases, University Hospital, 1350 Walton Way, Augusta, GA 30909, USA
| | - Camelia Marculescu
- Division of Infectious Diseases, Medical University of South Carolina, 171 Ashley Avenue, Charleston, SC 29425, USA.
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Abstract
Implant-associated infections remain a major issue in orthopaedics and antimicrobial functionalization of the implant surface by antibiotics or other anti-infective agents have gained interest. The goal of this article is to identify antimicrobial coatings, for which clinical data are available and to review their clinical need, safety profile, and their efficacy to reduce infection rates. PubMed database of the National Library of Medicine was searched for clinical studies on antimicrobial coated implants for internal fracture fixation devices and endoprostheses for bone surgery, for which study design, level of evidence, biocompatibility, development of resistance, and effectiveness to reduce infection rates were analyzed. Four different coating technologies were identified: gentamicin poly(d, l-lactide) coating for tibia nails, one high (MUTARS®) and one low amount silver (Agluna) technology for tumor endoprostheses, and one povidone-iodine coating for titanium implants. There was a total of 9 published studies with 435 patients, of which 7 studies were case series (level IV evidence) and 2 studies were case control studies (level III evidence). All technologies were reported with good systemic and local biocompatibility, except the development of local argyria with blue to bluish grey skin discoloration after the use of silver MUTARS® megaendoprostheses. For the local use of gentamicin, there is contradictory data on the risk of emergence of gentamicin-resistance strains, a risk that does not seem to exist for silver and iodine based technologies. Regarding reduction of infection rates, one case control study showed a significant reduction of infection rates by Agluna silver coated tumor endoprostheses. Based on socio-economic data, there is a strong need for improvement of infection prevention and treatment strategies, including implant coatings, in fracture care, primary and revision arthroplasty, and bone tumor surgery. The reviewed gentamicin, silver Agluna, and povidone-iodine technologies have shown a good risk benefit ratio for patients. Further data from randomized control trials are desirable, although this will remain challenging in the context of infection prevention due to the required large sample size of such studies.
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Affiliation(s)
- Volker Alt
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Giessen-Marburg, Campus Giessen, Rudolf-Buchheim-Str. 7, Germany.
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91
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Frew NM, Cannon T, Nichol T, Smith TJ, Stockley I. Comparison of the elution properties of commercially available gentamicin and bone cement containing vancomycin with 'home-made' preparations. Bone Joint J 2017; 99-B:73-77. [PMID: 28053260 DOI: 10.1302/0301-620x.99b1.bjj-2016-0566.r1] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2016] [Accepted: 09/13/2016] [Indexed: 11/05/2022]
Abstract
AIMS Vancomycin is commonly added to acrylic bone cement during revision arthroplasty surgery. Proprietary cement preparations containing vancomycin are available, but are significantly more expensive. We investigated whether the elution of antibiotic from 'home-made' cement containing vancomycin was comparable with more expensive commercially available vancomycin impregnated cement. MATERIALS AND METHODS A total of 18 cement discs containing either proprietary CopalG+V; or 'home-made' CopalR+G with vancomycin added by hand, were made. Each disc contained the same amount of antibiotic (0.5 g gentamycin, 2 g vancomycin) and was immersed in ammonium acetate buffer in a sealed container. Fluid from each container was sampled at eight time points over a two-week period. The concentrations of gentamicin and vancomycin in the fluid were analysed using high performance liquid chromatography mass spectrometry. RESULTS The highest peak concentrations of antibiotic were observed from the 'home-made' cements containing vancomycin, added as in the operating theatre. The overall elution of antibiotic was, fivefold (vancomycin) and twofold (gentamicin) greater from the 'home-made' mix compared with the commercially mixed cement. The use of a vacuum during mixing had no significant effect on antibiotic elution in any of the samples. CONCLUSION These findings suggest that the addition of 2 g vancomycin powder to gentamicin-impregnated bone cement by hand significantly increases the elution of both antibiotics compared with commercially prepared cements containing vancomycin. We found no significant advantages of using expensive commercially produced vancomycin-impregnated cement and recommend the addition of vancomycin powder by hand in the operating theatre. Cite this article: Bone Joint J 2017;99-B:73-7.
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Affiliation(s)
- N M Frew
- Sheffield Teaching Hospitals NHS Foundation Trust, Herries Road, Sheffield, S5 7AU, UK
| | - T Cannon
- Sheffield Teaching Hospitals NHS Foundation Trust, Herries Road, Sheffield, S5 7AU, UK
| | - T Nichol
- Sheffield Hallam University, City Campus, Howard Street, Sheffield, S1 1WB, UK
| | - T J Smith
- Sheffield Hallam University, City Campus, Howard Street, Sheffield, S1 1WB, UK
| | - I Stockley
- Sheffield Teaching Hospitals NHS Foundation Trust, Herries Road, Sheffield, S5 7AU, UK
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Saeed K, Dryden M, Bassetti M, Bonnet E, Bouza E, Chan M, Cortes N, Davis JS, Esposito S, Giordano G, Gould I, Hartwright D, Lye D, Marin M, Morgan-Jones R, Lajara-Marco F, Righi E, Romano CL, Segreti J, Unal S, Williams RL, Yalcin AN. Prosthetic joints: shining lights on challenging blind spots. Int J Antimicrob Agents 2017; 49:153-161. [DOI: 10.1016/j.ijantimicag.2016.10.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2016] [Revised: 09/23/2016] [Accepted: 10/01/2016] [Indexed: 12/12/2022]
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Analysis of causative microorganism in 248 primary hip arthroplasties revised for infection: a study using the NJR dataset. Hip Int 2017; 26:82-9. [PMID: 26821692 DOI: 10.5301/hipint.5000313] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/22/2015] [Indexed: 02/04/2023]
Abstract
INTRODUCTION This study aimed to describe the epidemiology of the causative organism in a series of primary hip arthroplasties revised for a diagnosis of periprosthetic joint infection (PJI) in England and Wales. METHODS Patient data from the National Joint Registry (NJR) was linked to microbiology data held by Public Health England (PHE) which identified a series of 248 primary hip arthroplasties revised for PJI between 2003 and 2014. Definitive cultures, isolated at time of revision surgery, were available for all cases. Total hip arthroplasty (n = 239, 96%) and hip resurfacing (n = 5, 2%) were the most commonly performed primary procedures. A two-stage revision was the most common operative management (n = 174, 70%). RESULTS 202 (81%) cases were infected with a single genus microorganism and the most commonly implicated genus was Staphylococcus species (70% of all single genus infections). Staphylococcus species were also the most commonly identified microorganism in mixed genus infections (74% of patient's cultures). There was a significant difference in microorganism distribution when comparing uncemented vs cement implant fixation, with a higher incidence of Gram-negative infection observed in the uncemented group (p = 0.048, Chi-square). CONCLUSIONS Both prophylactic and therapeutic antibiotic regimes should be focused on targeting Staphylococci.
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94
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Henshaw RM. The Role of Surgery in the Multidisciplinary Care of Sarcoma. Sarcoma 2017. [DOI: 10.1007/978-3-319-43121-5_6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Abstract
Cements based on polymethyl methacrylate (PMMA) can be used without any problem in a variety of clinical augmentations. Cement-related complications in surgical procedures involving PMMA cements, such as embolism, thermal necrosis, toxicity and hypersensitivity, are often due to other causes. Knowledge about the properties of the cement helps the user to safely employ PMMA cements in augmentations. High radio-opacity is required in vertebral body augmentations and this is provided in particular by zirconium dioxide. In vertebral body augmentations, a low benzoyl peroxide (BPO) content can considerably prolong the liquid dough phase. In augmentations with cement fillings in the region of a tumor, a high BPO content can specifically increase the peak temperature of the PMMA cement. In osteosynthetic augmentations with PMMA, necrosis is rare because heat development in the presence of metallic implants is low due to heat conduction via the implant. Larger cement fillings where there is no heat conduction via metal implants can exhibit substantially higher peak temperatures. The flow properties of PMMA cements are of particular importance for the user to allow optimum handling of PMMA cements. In patients with hypersensitivity to antibiotics, there is no need to avoid the use of PMMA as there are sufficient PMMA-based alternatives. The PMMA cements are local drug delivery systems and antibiotics, antiseptics, antimycotics and also cytostatics can be mixed with the cement. Attention must be paid to antagonistic and synergistic effects.
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Affiliation(s)
- K-D Kühn
- Universitätsklinik für Orthopädie und Orthopädische Chirurgie, Medizinische Universität Graz, Auenbruggerplatz 5, 8036, Graz, Österreich,
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Voigt J, Mosier M, Darouiche R. Antibiotics and antiseptics for preventing infection in people receiving revision total hip and knee prostheses: a systematic review of randomized controlled trials. BMC Infect Dis 2016; 16:749. [PMID: 27955626 PMCID: PMC5153681 DOI: 10.1186/s12879-016-2063-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2016] [Accepted: 11/08/2016] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Infection rates in revision (second and subsequent) major joint arthroplasty continues to be a significant issue with rates 2-3 times those of primary procedures. The effect of antibiotic and antiseptic prophylaxis on outcomes for this type of surgery has not been adequately reviewed. METHODS A systematic search of the main databases for randomized controlled trials (RCTs) evaluating antibiotics and antiseptics was conducted to evaluate the predetermined endpoints of infection. RESULTS There were five (5) RCTs identified that examined the effects of antibiotic and antiseptic prophylaxis on infections after revision total hip arthroplasty [THA] (total of 304 participants) and total knee arthroplasty [TKA] (total of 206 participants). For TKA, preoperative systemic intravenous (IV) antibiotic prophylaxis plus antibiotic cement may be effective in reducing the incidence of infection in revision TKA at 8+ years. These results however should be interpreted with caution due to the significant biases. For revision THA, there is no RCT evidence that antibiotics/antiseptics have any effect on the infection rate. CONCLUSIONS There is a lack of high quality data demonstrating an effect of antibiotics or antiseptics on infection rates in revision THA/TKA. Considering the rate of infections in revisions is 2-3X that of primary procedures and; there is a consensus recommendation to use similar antibiotic and antiseptic regimens in both primary and revision procedures, there is a need for high quality studies in revision THA/TKA.
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Affiliation(s)
| | - Michael Mosier
- Washburn University, Morgan Hall, Room 250 J, 1700 SW College Ave, Topeka, KS, 66621, USA
| | - Rabih Darouiche
- Michael E. DeBakey Veterans Affairs Medical Center, 2002 Holcombe Blvd # 128, Houston, TX, 77030, USA
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McLawhorn AS, Nawabi DH, Ranawat AS. Management of Resistant, Atypical and Culture-negative Periprosthetic Joint Infections after Hip and Knee Arthroplasty. Open Orthop J 2016; 10:615-632. [PMID: 28503214 PMCID: PMC5408484 DOI: 10.2174/1874325001610010615] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2016] [Revised: 06/19/2016] [Accepted: 07/15/2016] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Periprosthetic joint infection (PJI) is a devastating complication following lower extremity total joint arthroplasty (TJA). It is a leading cause of morbidity and revision following TJA. As such, PJI is a significant driver of healthcare costs. The prevalence of PJI related to resistant and atypical organisms is increasing, and approximately 10-30% of PJIs are culture-negative. The purpose of this review is to summarize the current epidemiology, diagnostics, and management of PJI associated with resistant and atypical pathogens and of culture-negative PJIs. METHODS The published literature related to the epidemiology, diagnosis, and management of atypical, drug-resistant, and culture-negative PJI is reviewed. RESULTS The clinical diagnosis of PJI is often challenging, particularly when pathogens are fastidious or when antibiotics have been administered empirically. Molecular diagnostic studies, such as synovial α-defensin, may provide rapid, accurate identification of PJI, even in the setting of concurrent antibiotics administration or systemic inflammatory disease. Once PJI is diagnosed, two-stage exchange arthroplasty remains the gold standard for treating PJI with resistant microorganisms, since there is a high rate of treatment failure with irrigation and debridement and with one-stage exchange arthroplasty. CONCLUSION Additional research is needed to define the optimal treatment of PJIs associated with rare pathogens, such as fungi and mycobacteria. There is a need for inexpensive, reliable tests that rapidly detect specific microbial species and antimicrobial susceptibilities. Additional research is also required to define the specific organisms, clinical scenarios, surgical techniques, and antimicrobial regimens that allow for reproducible treatment success with prosthetic retention strategies.
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Affiliation(s)
- Alexander S McLawhorn
- Department of Orthopedic Surgery, Hospital for Special Surgery, 535 East 70 Street, New York, NY 10021, USA
| | - Danyal H Nawabi
- Department of Orthopedic Surgery, Hospital for Special Surgery, 535 East 70 Street, New York, NY 10021, USA
| | - Amar S Ranawat
- Department of Orthopedic Surgery, Hospital for Special Surgery, 535 East 70 Street, New York, NY 10021, USA
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98
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Chronic periprosthetic hip infection: micro-organisms responsible for infection and re-infection. INTERNATIONAL ORTHOPAEDICS 2016; 41:1131-1137. [PMID: 27858104 DOI: 10.1007/s00264-016-3341-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/26/2016] [Accepted: 11/07/2016] [Indexed: 02/06/2023]
Abstract
PURPOSE This study aimed to delineate the infecting micro-organisms identified at the first-time revision for infected THA, analyze pre-operative versus intra-operative findings, as well as intra-operative ones against re-infection micro-organisms. MATERIAL AND METHODS Microbiological laboratory findings were studied in 73 patients (mean age, 51.93 ± 10.9 years) with chronic periprosthetic hip infection pre-operatively and intra-operatively. Forty-three patients had a two-stage revision THA while 30 patients were treated with a modified resection arthroplasty using the Ilizarov apparatus. Re-infection developed in 29 cases. Its microbial species were identified. RESULTS Pre-operative findings on micro-organisms coincided 50.7 % with the intra-operative ones. Bacterial growth in the intra-operative tests was detected in 72 (98.5 %) cases. Gram-positive single genus infection was identified in 35 patients (48 %); microbe associations were present in 33 patients (45 %). Staphylococcus species prevailed. Gram-negative infection was detected in 5.5 % of cases. One case (1.5 %) did not have any microbe growth. Re-infection happened in 10 cases (23.2 %) in a two-stage revision THA. In the resection arthroplasty group, early re-infection was observed in 63.3 % of cases. Among a total of 29 re-infection cases, staphylococcus species were identified in 19 cases, present either in associations or as single germs. CONCLUSION Intra-operative microbiological tests at the first-time revision for infected THR detect a reliable spectrum of micro-organisms to assess microbial resistance to antibiotics, develop treatment protocols, and for prognostic purposes. Preventive measures at primary THR and strategies to fight periprosthetic infection and reinfection should be targeted on staphylococci.
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CORR Insights ®: What is the Intraarticular Concentration of Tobramycin Using Low-dose Tobramycin Bone Cement in TKA: An In Vivo Analysis? Clin Orthop Relat Res 2016; 474:2448-2450. [PMID: 27637615 PMCID: PMC5052221 DOI: 10.1007/s11999-016-5073-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2016] [Accepted: 09/06/2016] [Indexed: 01/31/2023]
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100
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Drexler M, Dwyer T, Kuzyk PRT, Kosashvilli Y, Abolghasemian M, Regev GJ, Kadar A, Rutenberg TF, Backstein D. The results of two-stage revision TKA using Ceftazidime-Vancomycin-impregnated cement articulating spacers in Tsukayama Type II periprosthetic joint infections. Knee Surg Sports Traumatol Arthrosc 2016; 24:3122-3130. [PMID: 26272061 DOI: 10.1007/s00167-015-3753-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2014] [Accepted: 08/07/2015] [Indexed: 11/24/2022]
Abstract
PURPOSE This study examined the success and factors associated with failure, of using cement spacers impregnated with high-dose Ceftazidime and Vancomycin when performing two-stage revision for infected total knee arthroplasty (TKA). METHODS A retrospective analysis was performed using a prospectively collected database of 82 patients (median age 68 years, range 39-87) with a confirmed deep TKA infection treated with a two-stage revision. All cement spacers were impregnated with high-dose Ceftazidime and Vancomycin. The rate of success was recorded-an association between failure of treatment, and patient factors, previous surgical treatment, and microbial characteristics was sought. RESULTS The mean time to infection from index arthroplasty was 45 months (range 3-240). The initial two-stage revision was successful in 70/82 patients (85.4 %), who remained free of infection at average follow-up of 36.2 months (range 24-85). A second two-stage revision for infection was required in 12/82 patients (14.6 %), which was successful in 4/12 (33 %). A third two-stage revision was performed in three patients, all of whom had a polymicrobial infection of which only one patient had successful eradication of infection. Recurrent infection was correlated with irrigation and debridement with implant retention prior to initial two-stage revision (p < 0.01), polymicrobial infections (p = 0.035), and infections presenting <6 months after index surgery (p = 0.031). No correlation was seen with age, BMI, type of organism, diabetes mellitus, or Charlson Comorbidity Index. CONCLUSION The findings of this study suggest that the combination of Ceftazidime and Vancomycin in cement spacers is as efficacious as other published single or combined antibiotic mixtures, which is clinically relevant to clinicians treating this difficult problem in the setting of patients with compromised renal function.
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Affiliation(s)
- Michael Drexler
- Mount Sinai Hospital, 600 University Avenue, Toronto, ON, M5G 1X5, Canada.
| | - Tim Dwyer
- Mount Sinai Hospital, 600 University Avenue, Toronto, ON, M5G 1X5, Canada
| | - Paul R T Kuzyk
- Mount Sinai Hospital, 600 University Avenue, Toronto, ON, M5G 1X5, Canada
| | - Yona Kosashvilli
- Mount Sinai Hospital, 600 University Avenue, Toronto, ON, M5G 1X5, Canada
| | | | - Gilad J Regev
- Tel-Aviv Sourasky Medical Center, Tel Aviv University, Waitzman 6 St, 6423906, Tel Aviv, Israel
| | - Assaf Kadar
- Tel-Aviv Sourasky Medical Center, Tel Aviv University, Waitzman 6 St, 6423906, Tel Aviv, Israel
| | - Tal Frenkel Rutenberg
- Tel-Aviv Sourasky Medical Center, Tel Aviv University, Waitzman 6 St, 6423906, Tel Aviv, Israel
| | - David Backstein
- Mount Sinai Hospital, 600 University Avenue, Toronto, ON, M5G 1X5, Canada
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