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Rızvanoglu İH, Sakarya B, Benlier N, Kökçü F. HMGB-1 Levels in Painful Knee Arthroplasty: Is it Possible to Distingue Periprosthetic Joint Infection and Aseptic Loosening? Indian J Orthop 2023; 57:1023-1031. [PMID: 37384002 PMCID: PMC10293519 DOI: 10.1007/s43465-023-00903-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2023] [Accepted: 04/27/2023] [Indexed: 06/30/2023]
Abstract
Introduction We investigated the efficiency of high mobility group box-1 protein (HMGB-1) in differentiation of asymptomatic knee prosthesis, and periprosthetic joint infection and aseptic loosening causing painful knee prosthesis. Materials and Methods The data of patients who consulted our clinic for checking after total knee arthroplasty surgery were recorded prospectively. Blood levels of CRP, ESR, WBC, and HMGB-1 were recorded. Patients whose examination and routine tests were within normal limits comprised group I, asymptomatic total knee arthroplasty (ATKA). Painful patients with abnormal test results underwent three phase bone scintigraphy for further investigation Patients with periprosthetic joint infection (PJI) and aseptic loosening (AL) according to scintigraphy comprised group II and group III, respectively. The mean values of HMGB-1 and cut-off values according to the groups and their correlations with other inflammatory parameters were determined. Results Seventy-three patients were included in the study. Significant differences were observed in three groups, in terms of CRP, ESR, WBC, and HMGB-1. The cut-off value of HMGB-1 was determined as 15.16 ng/ml between ATKA and PJI, 16.92 ng/ml between ATKA and AL, and 27.87 ng/ml between PJI and AL, respectively. Accordingly, the sensitivity, and specificity of HMGB-1 in differentiation of ATKA and PJI were 91%, 88%, and in differentiation of ATKA and AL were 91%, 96%, and in differentiation of PJI and AL were 81%, 73%, respectively. Conclusion HMGB-1 may be utilized as an additional blood test in the differential diagnosis of problematic knee prosthesis patients.
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Affiliation(s)
- İbrahim Halil Rızvanoglu
- Department of Orthopedics and Traumatology, NCR International Hospital, Mücahitler Neighborhood, No: 56. Şehitkamil, 27090 Gaziantep, Turkey
| | - Bülent Sakarya
- Department of Orthopedics and Traumatology, Mersin Toros Government Hospital, Cemalpaşa Neighborhood. 5314 Street, Akdeniz, Mersin, Turkey
| | - Necla Benlier
- Department of Medical Pharmacology, Sanko University School of Medicine, Ali Fuat Cebesoy Boulevard. No: 45, Şehitkamil, Gaziantep, Turkey
| | - Füsun Kökçü
- Department of Nuclear Medicine, Medical Park Gaziantep Hospital, Mücahitler Neighborhood, 52063 St., Şehitkamil, 27584 Gaziantep, Turkey
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Ciccullo C, Neri T, Farinelli L, Gigante A, Philippot R, Farizon F, Boyer B. Antibiotic Prophylaxis in One-Stage Revision of Septic Total Knee Arthroplasty: A Scoping Review. Antibiotics (Basel) 2023; 12:antibiotics12030606. [PMID: 36978473 PMCID: PMC10044675 DOI: 10.3390/antibiotics12030606] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 02/28/2023] [Accepted: 03/15/2023] [Indexed: 03/30/2023] Open
Abstract
BACKGROUND Total knee replacement (TKA) is becoming a routine procedure in orthopedic surgery. One of the possible complications of this surgery is periprosthetic joint infection (PJI). The purpose of this study is to identify, through a literature review, which antibiotic is used as prophylaxis for septic one-stage revision TKA and what is the rationale for its use. METHODS We searched: MEDLINE, Embase, PsycINFO on Ovid, the Cochrane Library, and the Google Scholar Database. The searches were limited by date (January 2005 to September 2022) and to the English language. All types of original research were considered, including prospective or retrospective longitudinal studies, cross-sectional studies, and randomized trials. The specific search terms were ((antibiotic [MeSH]) AND (prophylaxis)) and (TKA OR TKR OR "Arthroplasty, Replacement, Knee" [MeSH] OR ((knee) adj2 (replace* OR arthroplasty* OR prosthe*))). RESULTS Despite our research efforts, we found no article capable of answering the question of which antibiotic to use as surgical prophylaxis for a septic revision one-stage TKA. CONCLUSIONS Although the research results are inconclusive, we would recommend using the same antibiotic prophylaxis as for primary joint replacement, i.e., cefazolin, as it was recommended for its low side effect rate and relative effectiveness.
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Affiliation(s)
- Carlo Ciccullo
- Clinical Ortopaedics, Department of Clinical and Molecular Sciences, Università Politecnica delle Marche, 60121 Ancona, Italy
| | - Thomas Neri
- Department of Orthopaedic Surgery, University Hospital of Saint Etienne, Hôpital Nord, 42055 Saint-Étienne, France
- Laboratoire Interuniversitaire de Biologie de la Motricité, Université de Lyon, 69361 Lyon, France
| | - Luca Farinelli
- Clinical Ortopaedics, Department of Clinical and Molecular Sciences, Università Politecnica delle Marche, 60121 Ancona, Italy
| | - Antonio Gigante
- Clinical Ortopaedics, Department of Clinical and Molecular Sciences, Università Politecnica delle Marche, 60121 Ancona, Italy
| | - Rémi Philippot
- Department of Orthopaedic Surgery, University Hospital of Saint Etienne, Hôpital Nord, 42055 Saint-Étienne, France
- Laboratoire Interuniversitaire de Biologie de la Motricité, Université de Lyon, 69361 Lyon, France
| | - Frederic Farizon
- Department of Orthopaedic Surgery, University Hospital of Saint Etienne, Hôpital Nord, 42055 Saint-Étienne, France
- U 1059 Sainbiose, Mines Saint-Étienne, Universitè Jean Monnet, INSERM, 42023 Saint-Étienne, France
| | - Bertrand Boyer
- Department of Orthopaedic Surgery, University Hospital of Saint Etienne, Hôpital Nord, 42055 Saint-Étienne, France
- U 1059 Sainbiose, Mines Saint-Étienne, Universitè Jean Monnet, INSERM, 42023 Saint-Étienne, France
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Treatment outcomes of patients with Cutibacterium acnes-positive cultures during total joint replacement revision surgery: a minimum 2-year follow-up. Arch Orthop Trauma Surg 2022; 143:2951-2958. [PMID: 35759014 DOI: 10.1007/s00402-022-04489-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Accepted: 05/16/2022] [Indexed: 11/02/2022]
Abstract
INTRODUCTION Periprosthetic joint infection (PJI) is a devastating complication following total joint replacement (TJR). Cutibacterium acnes (C. acnes) is a low virulent skin commensal, commonly found during TJR revision surgery for "aseptic" causes. The purpose of the present study was to report the treatment outcomes of patients with C. acnes contamination or infection in the presence of a TJR treated with a revision surgery ± implant exchange ± prolonged (≥ 8 weeks) postoperative antibiotics. METHODS Medical records of patients with at least one positive C. acnes culture in intraoperative tissue samples or sonication fluid from a TJR revision surgery between January 2005 and December 2014 were retrospectively evaluated. The primary endpoint was infection eradication according to Delphi criteria. The diagnostic accuracy of preoperative TJR aspiration regarding the diagnosis of C. acnes PJI was also investigated. RESULTS A total of 52 TJR (28 shoulders, 17 hips, 7 knees) in 52 patients (35 males, 17 females) with an average age of 63 ± 11 (33-86) years were included. At an average follow-up of 67 ± 33 (24-127) months, the infection eradication of C. acnes PJI was 97% regardless of the surgical treatment or administration of prolonged postoperative antibiotics. The incidence of unsuspected C. acnes PJI was 28.8%. The sensitivity and specificity of preoperative joint aspiration in detecting C. acnes PJI were 59% and 88%, whereas the PPV and NNV were 83% and 67%, respectively. CONCLUSION Infection eradication of C. acnes PJI was very high at a minimum follow-up of 24 months, suggesting that C. acnes PJI could be adequately treated with a combination of revision surgery and prolonged postoperative antibiotics. The preoperative diagnosis of C. acnes PJI might be challenging with more than one-quarter of patients presenting without suspicion of C. acnes PJI. The appropriate treatment of patients with a single positive culture remains still unclear. A negative TJR aspiration should not rule out a C. acnes PJI, especially in the presence of clinical correlates of infection. LEVEL OF EVIDENCE Retrospective case-control study, Level III. IRB APPROVAL Kantonale Ethikkommission Zürich, BASEC Nr.:2017-00567.
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Renz N, Trampuz A. Synoviaveränderungen bei Infektion. ARTHROSKOPIE 2022. [DOI: 10.1007/s00142-022-00526-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Buchhorn T, Baumbach SF, Böcker W, Szymski D, Polzer H. [Salvage options following failed total ankle arthroplasty]. Unfallchirurg 2022; 125:211-218. [PMID: 35091802 DOI: 10.1007/s00113-022-01141-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/03/2022] [Indexed: 10/19/2022]
Abstract
The number of patients with osteoarthritis of the ankle, which are treated by arthroplasty, has continuously increased in recent years. The survival time of these implants is far below the results following hip and knee arthroplasty. In some cases a failure rate of approximately 1% per year or a survival rate of 70% after 10 years has been reported. The most frequent reasons for revision of an ankle prosthesis are aseptic loosening, technical implantation errors and persisting pain. For the revision of an ankle prosthesis there are basically two treatment options. For a long time, ankle arthrodesis was considered the gold standard after a failed prosthesis. In recent years, there has been an increasing trend towards re-implantation of an ankle prosthesis, as this preserves the functionality and mobility of the ankle joint as far as possible. Depending on the reason for failure and the size of the bony defect, a decision must be made regarding a one-stage and a two-stage procedure with bone augmentation. This article presents the advantages and disadvantages of arthrodesis and revision arthroplasty after failed primary ankle arthroplasty and highlights the special features of surgery.
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Affiliation(s)
- T Buchhorn
- Sporthopädicum Straubing-Regensburg-Berlin, 94315, Straubing, Deutschland
| | - S F Baumbach
- Klinik für Orthopädie und Unfallchirurgie, Muskuloskelettales Universitätszentrum München (MUM), Klinikum der Universität München, LMU München, Ziemssenstr. 5, 80336, München, Deutschland
| | - W Böcker
- Klinik für Orthopädie und Unfallchirurgie, Muskuloskelettales Universitätszentrum München (MUM), Klinikum der Universität München, LMU München, Ziemssenstr. 5, 80336, München, Deutschland
| | - D Szymski
- Sporthopädicum Straubing-Regensburg-Berlin, 94315, Straubing, Deutschland.,Klinik und Poliklinik für Unfallchirurgie, Universitätsklinikum Regensburg, 93053, Regensburg, Deutschland
| | - H Polzer
- Klinik für Orthopädie und Unfallchirurgie, Muskuloskelettales Universitätszentrum München (MUM), Klinikum der Universität München, LMU München, Ziemssenstr. 5, 80336, München, Deutschland.
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Stephan A, Thürmer A, Glauche I, Nowotny J, Zwingenberger S, Stiehler M. Does preoperative antibiotic prophylaxis affect sonication-based diagnosis in implant-associated infection? J Orthop Res 2021; 39:2646-2652. [PMID: 33620104 DOI: 10.1002/jor.25015] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Revised: 02/15/2021] [Accepted: 02/21/2021] [Indexed: 02/04/2023]
Abstract
As culture-negative implant-associated infection denote a diagnostic challenge, sonicate fluid cultures of the explanted endoprosthesis and osteosynthesis components are frequently used. However, the effect of antibiotic treatment on pathogen detection by sonication fluid cultures in implant-associated infection has not been investigated. Thus, the aim of this study was to evaluate the influence of preoperative antibiotic prophylaxis (PAP) and antibiotic therapy (AT) on sonicate fluid cultures in patients with implant-associated infection. In this retrospective study three groups were compared: (i) standard PAP, (ii) AT for at least one day, and (iii) no antibiotics before surgery. For the inclusion criteria, an established diagnostic protocol for implant-associated infection was used. Sonicate fluid cultures were validated by corresponding microbiological and histopathological samples. In 90 patients with single and multiple infections, 114 pathogens were detected. The detection rate by sonicate fluid cultures in patients receiving PAP (n = 27, 29 pathogens), AT before surgery (n = 33, 48 pathogens) and no antibiotics before surgery (n = 30, 37 pathogens) were 86.2%, 81.3%, and 86.5% (p = .778), respectively. Eleven of 114 infectious agents were detected exclusively by sonicate fluid cultures, while conventional tissue culture failed in these cases. PAP and AT do not affect intraoperative cultures in implant-associated infection. It is therefore not recommended to omit antibiotic prophylaxis in patients with implant-associated infection. Algorithms including both sonicate fluid cultures and tissue samples should be used for appropriate microbiological diagnosis of implant-associated infections.
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Affiliation(s)
- Anna Stephan
- University Centre for Orthopaedics, Traumatology and Plastic Surgery, Dresden, Germany
| | - Alexander Thürmer
- University Centre for Orthopaedics, Traumatology and Plastic Surgery, Dresden, Germany
| | | | - Jörg Nowotny
- University Centre for Orthopaedics, Traumatology and Plastic Surgery, Dresden, Germany
| | - Stefan Zwingenberger
- University Centre for Orthopaedics, Traumatology and Plastic Surgery, Dresden, Germany
| | - Maik Stiehler
- University Centre for Orthopaedics, Traumatology and Plastic Surgery, Dresden, Germany
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Diagnosis of Chronic Infection at Total Hip Arthroplasty Revision Is a Question of Definition. BIOMED RESEARCH INTERNATIONAL 2021; 2021:8442435. [PMID: 34840982 PMCID: PMC8626185 DOI: 10.1155/2021/8442435] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Accepted: 11/01/2021] [Indexed: 12/03/2022]
Abstract
Purpose Contradicting definitions of periprosthetic joint infection (PJI) are in use. Joint aspiration is performed before total hip arthroplasty (THA) revision. This study investigated the influence of PJI definition on PJI prevalence at THA revision. Test quality of prerevision aspiration was evaluated for the different PJI definitions. Methods 256 THA revisions were retrospectively classified to be infected or not infected. Classification was performed according to the 4 different definitions proposed by the Musculoskeletal Infection Society (MSIS), the Infectious Diseases Society of America (IDSA), the International Consensus Meeting (ICM), and the European Bone and Joint Infection Society (EBJIS). Only chronic PJIs were included. Results PJI prevalence at revision significantly correlated with the applied PJI definition (p = 0.01, Cramer's V = 0.093). PJI prevalence was 20.7% for the MSIS, 25.4% for the ICM, 28.1% for the IDSA, and 32.0% for the EBJIS definition. For synovial fluid white blood cell count, the best ROC-AUC for predicting PJI was 0.953 in combination with the MSIS definition. Conclusion PJI definition significantly influences the rate of diagnosed PJIs at THA revision. Synovial fluid white blood cell count is a reliable means to rule out PJI. In cases with a borderline high synovial white blood cell count before THA revision as the only sign of chronic PJI, an extended diagnostic work-up should be considered.
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Macke C, Lenhof S, Graulich T, Örgel M, Omar-Pacha T, Stübig T, Krettek C, Omar M. Low Diagnostic Value of Synovial Aspiration Culture Prior to Reimplantation in Periprosthetic Joint Infection. In Vivo 2021; 35:2409-2416. [PMID: 34182524 DOI: 10.21873/invivo.12518] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 03/26/2021] [Accepted: 04/12/2021] [Indexed: 11/10/2022]
Abstract
BACKGROUND/AIM We aimed to determine the diagnostic value of the synovial aspiration culture prior to reimplantation in two- (or more) stage exchange of periprosthetic joint infection. PATIENTS AND METHODS This was a retrospective study, spanning over ten years including all synovial cultures of patients with two- (or more) stage exchange due to periprosthetic joint infection. RESULTS A total of 183 patients were included, mean age was 66.6 years (range=12.8-93.4 years). Overall sensitivity of synovial aspiration cultures before reimplantation was 56.6%, specificity 84.6%, negative predictive value (NPV) 63.8%, positive predictive value (PPV) 80.2%, area under the curve (AUC) 70.6%. Sensitivity of the knee in comparison to the hip culture was significantly higher, as well as the NPV and the AUC (p=0.038). In case of complete removal of prosthesis, the sensitivity and AUC were significantly reduced, whereas the specificity was comparable with prosthesis in situ, partial removal or complete removal. CONCLUSION Due to the low sensitivity, obtaining several synovial cultures in the prosthesis-free interval to exclude persistence of infection, does not seem reasonable.
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Affiliation(s)
- Christian Macke
- Trauma Department, Hannover Medical School (MHH), Hannover, Germany
| | - Stefan Lenhof
- Trauma Department, Hannover Medical School (MHH), Hannover, Germany
| | - Tilman Graulich
- Trauma Department, Hannover Medical School (MHH), Hannover, Germany
| | - Marcus Örgel
- Trauma Department, Hannover Medical School (MHH), Hannover, Germany
| | - Tarek Omar-Pacha
- Trauma Department, Hannover Medical School (MHH), Hannover, Germany
| | - Timo Stübig
- Trauma Department, Hannover Medical School (MHH), Hannover, Germany
| | | | - Mohamed Omar
- Trauma Department, Hannover Medical School (MHH), Hannover, Germany
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Ghanem M, Schneider I, Zajonz D, Pempe C, Goralski S, Fakler JKM, Heyde CE, Roth A. Management of Modular Mega-Implant Infection of the Lower Extremity. ZEITSCHRIFT FUR ORTHOPADIE UND UNFALLCHIRURGIE 2021; 160:317-323. [PMID: 33540460 DOI: 10.1055/a-1340-0890] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
INTRODUCTION Revision arthroplasty involving mega-implants is associated with a high complication rate. In particular, infection is a serious complication of revision arthroplasty of hip and knee joints and has been reported to have an average rate of 18%, and for mega-implants, the range is from 3 to 36%. This study was designed to analyze the strategy of treatment of infection of mega-endoprostheses of the lower extremities in our patient cohort, particularly the management of chronic infection. MATERIAL AND METHODS This was a retrospective study that focused on the results of the treatment of periprosthetic infections of mega-implants of the lower extremities. We identified 26 cases with periprosthetic infections out of 212 patients with 220 modular mega-endoprostheses of the lower extremities who were treated in our department between September 2013 and September 2019. As a reinfection or recurrence, we defined clinical and microbiological recurrences of local periprosthetic joint infections after an antibiotic-free period. RESULTS In this study, 200 cases out of 220 were investigated. The average follow-up period was approximately 18 months (6 months to 6 years). Endoprosthesis infections after implantation of mega-implants occurred in 26 cases (13%). This group comprised 2 early infections (within the first 4 weeks) and 24 chronic infections (between 10 weeks and 6 years after implantation). Nineteen cases out of the identified 26 cases with infection (73.1%) belong to the group of patients who were operated on due to major bone loss following explantation of endoprosthetic components due to previous periprosthetic joint infection. The remaining seven cases with infection comprised four cases following management of periprosthetic fracture, two cases following treatment of aseptic loosening, and one case following tumor resection. All infections were treated surgically. In all cases, the duration of continuous antibiotic treatment did not exceed 6 weeks. Both cases with early infection were treated by exchanging polyethylene inlays and performing debridement with lavage (two cases). In two (7.7%) cases with chronic infection, one-stage surgery was performed. In all remaining cases with chronic infection (22 cases; 84.6%), explantation of all components and temporary implantation of cement spacers were carried out prior to reimplantation. CONCLUSION There is still no gold standard therapeutic regimen for the management of periprosthetic infection of mega-implants, though radical surgical debridement and lavage accompanied by systemic antibiotic therapy are the most important therapeutic tools in all cases of periprosthetic infections, regardless of the time of onset. Further studies are needed to standardize management strategies of such infections. Nevertheless, it is not uncommon for compromises to be made based on the particular condition of the individual.
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Affiliation(s)
- Mohamed Ghanem
- Klinik für Orthopädie, Unfallchirurgie und Plastische Chirurgie, Universitätsklinikum Leipzig AöR, Leipzig, Germany
| | - Isabell Schneider
- Klinik für Orthopädie, Unfallchirurgie und Plastische Chirurgie, Universitätsklinikum Leipzig AöR, Leipzig, Germany
| | - Dirk Zajonz
- Klinik für Orthopädie und Unfallchirurgie, Zeisigwaldkliniken Bethanien Chemnitz, Chemnitz, Germany
| | - Christina Pempe
- Klinik für Orthopädie, Unfallchirurgie und Plastische Chirurgie, Universitätsklinikum Leipzig AöR, Leipzig, Germany
| | - Szymon Goralski
- Klinik für Orthopädie, Unfallchirurgie und Plastische Chirurgie, Universitätsklinikum Leipzig AöR, Leipzig, Germany
| | - Johannes K M Fakler
- Klinik für Orthopädie, Unfallchirurgie und Plastische Chirurgie, Universitätsklinikum Leipzig AöR, Leipzig, Germany
| | - Christoph-Eckhard Heyde
- Klinik für Orthopädie, Unfallchirurgie und Plastische Chirurgie, Universitätsklinikum Leipzig AöR, Leipzig, Germany
| | - Andreas Roth
- Klinik für Orthopädie, Unfallchirurgie und Plastische Chirurgie, Universitätsklinikum Leipzig AöR, Leipzig, Germany
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Zippelius T, Bürger J, Schömig F, Putzier M, Matziolis G, Strube P. Clinical presentation and diagnosis of acute postoperative spinal implant infection (PSII). JOURNAL OF SPINE SURGERY 2020; 6:765-771. [PMID: 33447681 DOI: 10.21037/jss-20-587] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Acute postoperative infections after surgical interventions on the spinal column are associated with prolonged treatment duration, poor patient outcomes, and a high socioeconomic burden. In the field of joint replacement, guidelines have been established with recommendations for the diagnosis and treatment of such complications, but in spinal surgery there are no definitions permitting distinction between early and late infections and no specific instructions for their management. Various factors increase the risk of acute postoperative infection, including blood transfusions, leakage of cerebrospinal fluid, urinary tract infection, injury of the dura mater, an American Society of Anesthesiologists (ASA) score >2, obesity, diabetes mellitus, and surgical revision. We suggest defining all infections occurring within the first 4 weeks after spinal surgery as early infections. The symptoms are pain at rest, on motion, and/or pressure pain, abnormal warmth, local erythema, circumscribed swelling of the wound, and newly occurring secretion. Together with laboratory parameters such as C-reactive protein (CRP) and leukocytes, a central role is played by imaging in the form of magnetic resonance imaging (MRI), although diagnosis can be hampered by the presence of postoperative fluid collections such as edema or hematoma or by artifacts from an implant. Once an infection has been confirmed, immediate wound revision with debridement and rinsing (sodium hypochlorite) is essential. Intraoperatively it may prove advantageous to use jet lavage and administer vancomycin. We recommend leaving the implant in place in cases of acute postoperative infection. Patients who are not conditional for surgery can first receive antibiotic suppression treatment before surgery at a later date. In such cases initial computed tomography (CT)-guided aspiration or drain insertion can take place.
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Affiliation(s)
- Timo Zippelius
- Orthopaedic Professorship of the University Hospital Jena, Orthopaedic Department of the Waldkliniken Eisenberg, Eisenberg, Germany
| | - Justus Bürger
- Center for Musculoskeletal Surgery, Charité University Medicine Berlin, Berlin, Germany
| | - Friederike Schömig
- Center for Musculoskeletal Surgery, Charité University Medicine Berlin, Berlin, Germany
| | - Michael Putzier
- Center for Musculoskeletal Surgery, Charité University Medicine Berlin, Berlin, Germany
| | - Georg Matziolis
- Orthopaedic Professorship of the University Hospital Jena, Orthopaedic Department of the Waldkliniken Eisenberg, Eisenberg, Germany
| | - Patrick Strube
- Orthopaedic Professorship of the University Hospital Jena, Orthopaedic Department of the Waldkliniken Eisenberg, Eisenberg, Germany
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Schulz P, Dlaska CE, Perka C, Trampuz A, Renz N. Preoperative synovial fluid culture poorly predicts the pathogen causing periprosthetic joint infection. Infection 2020; 49:427-436. [PMID: 33141393 PMCID: PMC8159841 DOI: 10.1007/s15010-020-01540-2] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Accepted: 10/12/2020] [Indexed: 11/09/2022]
Abstract
Purpose We investigated the value of preoperative pathogen detection and evaluated its concordance with intraoperative cultures in patients with culture-positive periprosthetic joint infection (PJI). Methods Culture-positive PJI episodes with available preoperative (synovial fluid) and intraoperative cultures (periprosthetic tissue, synovial or sonication fluid) were analyzed. The pathogen detection rate in preoperative and intraoperative cultures was compared using Fisher’s exact test and their concordance was calculated. Results Among 167 included PJI episodes, 150 were monomicrobial with coagulase-negative staphylococci (n = 55, 37%), S. aureus (n = 34, 23%), and streptococci (n = 21, 14%) being the most common pathogens. Seventeen episodes (10%) were polymicrobial infections. The pathogen(s) grew in preoperative culture in 110 and in intraoperative cultures in 153 episodes (66% vs. 92%, p < 0.001). The pathogen detection rate was lower in preoperative compared to intraoperative cultures for low-virulent pathogens (40% vs. 94%, p < 0.001), polymicrobial infections (59% vs. 100%, p = 0.007), and in delayed and late PJI (63% vs. 94%, and 66% vs. 91%, respectively, p < 0.001). Full concordance of preoperative and intraoperative cultures was found in 87 episodes (52%). The pathogen was detected solely preoperatively in 14 episodes (8%) and solely intraoperatively in 57 cases (34%); an additional pathogen was found in 3 episodes (2%) preoperatively and in 6 episodes (4%) intraoperatively. Conclusion The concordance of preoperative and intraoperative cultures was poor (52%). The sole or an additional pathogen was found exclusively in intraoperative cultures in 38% of PJI episodes, hence preoperative synovial fluid cultures are considered unreliable for pathogen detection in PJI.
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Affiliation(s)
- Philipp Schulz
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Center for Musculoskeletal Surgery (CMSC), Charitéplatz 1, 10117, Berlin, Germany
| | - Constantin E Dlaska
- Orthopaedic Research Institute of Queensland, 7 Turner Street, Pimlico, Townsville, QLD, 4812, Australia
| | - Carsten Perka
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Center for Musculoskeletal Surgery (CMSC), Charitéplatz 1, 10117, Berlin, Germany
| | - Andrej Trampuz
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Center for Musculoskeletal Surgery (CMSC), Charitéplatz 1, 10117, Berlin, Germany
| | - Nora Renz
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Center for Musculoskeletal Surgery (CMSC), Charitéplatz 1, 10117, Berlin, Germany.
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Infection control and outcome of staged reverse shoulder arthroplasty for the management of shoulder infections. JSES Int 2020; 4:959-963. [PMID: 33345240 PMCID: PMC7738577 DOI: 10.1016/j.jseint.2020.08.012] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
Background The treatment of septic arthritis, caused by either hematogenous seeding, injections, or surgery, can be challenging. Staged reverse shoulder arthroplasty (RSA) with temporary implantation of an antibiotic-loaded spacer is widely accepted but still discussed controversially. This study investigated the shoulder-specific bacterial spectrum, infection control rate, functional outcome, and infection-free survival rate after staged RSA in the mid- to long-term follow-up. It was hypothesized that staged RSA would show a high infection-free survival rate. Methods A total of 39 patients treated with staged RSA for primary septic arthritis (n = 8), secondary infection (n = 8), or periprosthetic infection (n = 23) were retrospectively included. The infection control rate was calculated based on cultures taken intraoperatively at spacer removal and RSA implantation. Infection-free survival was defined as no revision due to infection. The minimum follow-up period for functional outcome assessment was 2 years (n = 14; mean, 76 months; range, 31-128 months). Results Cutibacterium (26%) and coagulase-negative staphylococci (23%) were the predominant pathogens. The infection control rate was 90%. The cumulative infection-free survival rate was 91% after 128 months. Follow-up examinations showed a mean Constant score of 48 (range, 7-85), a mean QuickDASH (short version of Disabilities of the Arm, Shoulder and Hand questionnaire) score of 40.0 (range, 11.4-93.3), and a mean pain score of 1.6 (range, 0-7). Conclusion Staged RSA implantation was confirmed to be a reliable treatment option for primary, secondary, and periprosthetic infections of the shoulder. The infection control rate and infection-free survival rate are satisfactory. However, patients and surgeons must be aware of functional impairment even after successful treatment of infections.
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Declercq P, Neyt J, Depypere M, Goris S, Van Wijngaerden E, Verhaegen J, Wauters J, Spriet I. Preoperative joint aspiration culture results and causative pathogens in total hip and knee prosthesis infections: mind the gap. Acta Clin Belg 2020; 75:284-292. [PMID: 31057053 DOI: 10.1080/17843286.2019.1611718] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
OBJECTIVES In prosthetic joint infections (PJIs), there is no consensus about the utility of the preoperative joint aspiration culture to guide antimicrobial treatment. The main objective of this retrospective study was to investigate the value of these preoperative samples to narrow immediate postoperative empirical antimicrobial treatment in patients with a knee or hip PJI. METHODS Adult patients admitted for an exchange procedure between June 2007 and July 2016 for whom a preoperative joint aspiration within 6 months prior to the procedure was available and with an antibiotic-free interval before sampling, were eligible. Per PJI, taking both preoperative joint aspiration and intraoperative deep samples into account, causative pathogen(s) were assessed by the current Infectious Diseases Society of America (IDSA) guidelines. Per PJI, agreement of preoperative joint aspiration cultures corresponding to the causative pathogen(s) was investigated both on species and on Gram/fungi level. RESULTS From the 85 PJIs, on species level, the total agreement was found in 58 (68%) PJIs. On Gram/fungi level, when preoperative joint aspiration cultures yielded exclusively Gram-positive microorganisms (n = 61), a 100% predictive value for Gram positive causing pathogens was attained. Insufficient predictive value was observed in PJIs with preoperative joint aspiration yielding Gram-negative microorganisms (n = 4), a fungus (n = 1) or with sterile results (n = 19). CONCLUSION In the immediate postoperative setting, the treating team might consider a broad spectrum empirical antibiotic regime, guided by the local epidemiology and susceptibility, which can be narrowed to Gram-positive coverage if preoperative joint aspiration cultures yield exclusively Gram-positive microorganisms.
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Affiliation(s)
- Peter Declercq
- Pharmacy Dpt. and Department of Pharmaceutical and Pharmacological Sciences, Clinical Pharmacology and Pharmacotherapy, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | - Jeroen Neyt
- Department of Orthopedic Surgery, Head Division Septic Orthopedic and Trauma Surgery, Faculty of Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Melissa Depypere
- Department of Microbiology and Immunology, Laboratory of Clinical Bacteriology and Mycology, University Hospitals Leuven, Leuven, Belgium
| | - Stefanie Goris
- Pharmacy Dpt. and Department of Pharmaceutical and Pharmacological Sciences, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | - Eric Van Wijngaerden
- Department of General Internal Medicine, Faculty of Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Jan Verhaegen
- Department of Microbiology and Immunology, Laboratory of Clinical Bacteriology and Mycology, University Hospitals Leuven, Leuven, Belgium
| | - Joost Wauters
- Department of General Internal Medicine, Faculty of Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Isabel Spriet
- Pharmacy Dpt. and Department of Pharmaceutical and Pharmacological Sciences, Clinical Pharmacology and Pharmacotherapy, University Hospitals Leuven, KU Leuven, Leuven, Belgium
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Margaryan D, Renz N, Bervar M, Zahn R, Onken J, Putzier M, Vajkoczy P, Trampuz A. Spinal implant-associated infections: a prospective multicentre cohort study. Int J Antimicrob Agents 2020; 56:106116. [PMID: 32726675 DOI: 10.1016/j.ijantimicag.2020.106116] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 05/19/2020] [Accepted: 07/21/2020] [Indexed: 12/17/2022]
Abstract
This study evaluated the clinical, laboratory, microbiological, radiological and treatment characteristics of patients with early-onset and late-onset spinal implant-associated infections. Patients diagnosed with spinal implant-associated infection between 2015-2019 were prospectively included and treated according to a standardised algorithm. Infections were classified as early-onset (≤6 weeks) and late-onset (>6 weeks). Among 250 patients, 152 (61%) had early-onset and 98 (39%) had late-onset infection. Local inflammatory signs was the most common manifestation in early-onset infections (84%), whereas late-onset infections presented mainly with persisting or increasing local pain (71%). Sonication fluid was more often positive than peri-implant tissue samples (90% vs. 79%; P = 0.016), particularly in late-onset infections (92% vs. 75%; P = 0.005). Predominant pathogens were coagulase-negative staphylococci, Staphylococcus aureus and Cutibacterium spp. Debridement and implant retention was the most common surgical approach in early-onset infections (85%), whereas partial or complete implant exchange was mainly performed in late-onset infections (62%). Of the 250 patients, 220 (88%) received biofilm-active antibiotics, and median treatment duration was 11.7 weeks. Moreover, 49 patients (20%) needed more than one revision for infection and six patients (2.4%) died during hospital stay. Concluding, most spinal implant-associated infections were acquired during surgery and presented within 6 weeks of surgery. Infections presented mainly with local inflammatory signs in early-onset and with persisting or increasing pain in late-onset infections. Sonication was the most sensitive microbiological method, particularly in late-onset infections. Debridement and implant retention was used in well-integrated implants without loosening, independent of the time of infection onset.
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Affiliation(s)
- Donara Margaryan
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Center for Musculoskeletal Surgery (CMSC), Berlin, Germany
| | - Nora Renz
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Center for Musculoskeletal Surgery (CMSC), Berlin, Germany
| | - Maja Bervar
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Center for Musculoskeletal Surgery (CMSC), Berlin, Germany
| | - Robert Zahn
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Center for Musculoskeletal Surgery (CMSC), Berlin, Germany
| | - Julia Onken
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Neurosurgery, Berlin, Germany
| | - Michael Putzier
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Center for Musculoskeletal Surgery (CMSC), Berlin, Germany
| | - Peter Vajkoczy
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Neurosurgery, Berlin, Germany
| | - Andrej Trampuz
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Center for Musculoskeletal Surgery (CMSC), Berlin, Germany.
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Low-Grade-Infektionen in der Wirbelsäulenchirurgie – Ein Chamäleon? DER ORTHOPADE 2020; 49:669-678. [DOI: 10.1007/s00132-020-03947-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Mühlhofer HML, Feihl S, Suren C, Banke IJ, Pohlig F, von Eisenhart-Rothe R. Implantatassoziierte Gelenkinfektionen. DER ORTHOPADE 2020; 49:277-286. [DOI: 10.1007/s00132-020-03877-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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Fritzsche H, Goronzy J, Schaser KD, Hofbauer C, Postler AE, Günther KP. [Complication profile and revision concepts for megaprosthetic reconstruction following tumour resection at the hip]. DER ORTHOPADE 2020; 49:123-132. [PMID: 32006053 DOI: 10.1007/s00132-020-03879-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND Tumourous destruction of the periacetabular region and the proximal femur is a typical consequence of either primary malignant bone tumour manifestation or skeletal metastatic diseases. Pathological fractures of the proximal femur and periacetabular regions due to primary manifestation or metastatic disorders are frequent. OBJECTIVES Presentation of the most common complications of tumour endoprostheses at the hip and a description of management strategies, including therapeutic recommendations and concepts for complication avoidance. MATERIALS AND METHODS The current knowledge and our own experience of complication management with the use of megaprostheses around the hip are presented. RESULTS Compared to elective/primary total hip arthroplasty, megaprosthetic reconstructions following tumour resections have an increased rate of postoperative deep infections, dislocations, incidence of pathological and periprosthetic fractures and of deep vein thrombosis. The postoperative mortality and local tumour recurrence along with deep infections represent the most serious complications. CONCLUSIONS In comparison to primary arthroplasty, the risk of failure and complications following tumour-endoprosthetic replacement is increased. Precise surgical planning and careful selection and preoperative preparation of suitable patients should be performed in close interdisciplinary cooperation with final decision-making on an interdisciplinary tumour board. Wide resection and advanced reconstruction, as well as complicated palliative stabilization due to malignant bone tumour growth around the hip joint should be performed in musculoskeletal tumour centres with profound expertise in osteosynthetic and endoprosthetic reconstruction and consecutive complication management of the pelvis and the proximal femur.
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Affiliation(s)
- H Fritzsche
- UniversitätsCentrum für Orthopädie & Unfallchirurgie, Universitätsklinikum Carl Gustav Carus an der Technischen Universität Dresden, Fetscherstraße 74, 01307, Dresden, Deutschland.
| | - J Goronzy
- UniversitätsCentrum für Orthopädie & Unfallchirurgie, Universitätsklinikum Carl Gustav Carus an der Technischen Universität Dresden, Fetscherstraße 74, 01307, Dresden, Deutschland
| | - K-D Schaser
- UniversitätsCentrum für Orthopädie & Unfallchirurgie, Universitätsklinikum Carl Gustav Carus an der Technischen Universität Dresden, Fetscherstraße 74, 01307, Dresden, Deutschland
| | - C Hofbauer
- UniversitätsCentrum für Orthopädie & Unfallchirurgie, Universitätsklinikum Carl Gustav Carus an der Technischen Universität Dresden, Fetscherstraße 74, 01307, Dresden, Deutschland
| | - A E Postler
- UniversitätsCentrum für Orthopädie & Unfallchirurgie, Universitätsklinikum Carl Gustav Carus an der Technischen Universität Dresden, Fetscherstraße 74, 01307, Dresden, Deutschland
| | - K P Günther
- UniversitätsCentrum für Orthopädie & Unfallchirurgie, Universitätsklinikum Carl Gustav Carus an der Technischen Universität Dresden, Fetscherstraße 74, 01307, Dresden, Deutschland
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Fritzsche H, Hofbauer C, Winkler D, Günther KP, Goronzy J, Lützner J, Kisel W, Schaser KD. Komplikationsmanagement nach Tumorendoprothesen. DER ORTHOPADE 2019; 48:588-597. [DOI: 10.1007/s00132-019-03756-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Pérez-Prieto D, Portillo ME, González-Lucena G, Ginés-Cespedosa A. Foot and ankle infections: Debridement, early fixation and rifampicin provide earlier recovery of function and quality of life. Foot Ankle Surg 2019; 25:13-18. [PMID: 29409262 DOI: 10.1016/j.fas.2017.07.644] [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] [Received: 05/21/2017] [Revised: 06/28/2017] [Accepted: 07/21/2017] [Indexed: 02/04/2023]
Abstract
BACKGROUND Infection after foot and ankle fractures is a major concern for orthopedic surgeons. It is widely believed that final osteosynthesis should be delayed until the infection is cured. However, there is no literature that supports this practice. In addition, the delay impairs patient function and quality of life (QoL). METHODS In the present study, four cases of ankle infection treated with aggressive debridement, early fixation and antibiofilm antibiotics are described. It is thought that, like other implant related infections, ankle infections can be rapidly treated with the definitive fixation and by curing the infection to make for a fast recovery of QoL and function. RESULTS The infections were caused by MSSA and Pseudomonas aeruginosa in case 1, MSSA in case 2 and MRSA as well as K. pneumonia in case 3. Case 4 was a culture negative infection. They were susceptible to antibiofilm antibiotics (the gram-negative bacilli susceptible to ciprofloxacin and the gram-positive cocci susceptible to rifampicin). Cases 1, 3 and 4 were treated with a tibio-talo-calcaneal arthrodesis and case 2 was treated with a de-rotational fibular osteotomy and a medial closing wedge supramalleolar osteotomy. All cases improved at a median time of 4 weeks in terms of quality of life (SF-36) and function (AOFAS). At 2-years follow-up, no recurrence of infection was observed in any of the cases. All the cases achieved fusion or osteotomy healing at final follow-up. CONCLUSIONS Early fixation after debridement combined with antibiofilm antibiotics can be performed in foot and ankle inflections to provide early recovery of QoL and function in patients.
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Affiliation(s)
- Daniel Pérez-Prieto
- Orthopedic Department, Hospital del Mar - Universitat Autònoma de Barcelona, Barcelona, Spain.
| | - María E Portillo
- Microbiology Department, Complejo Hospitalario de Navarra, Pamplona, Spain
| | - Gemma González-Lucena
- Orthopedic Department, Hospital del Mar - Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Alberto Ginés-Cespedosa
- Orthopedic Department, Hospital del Mar - Universitat Autònoma de Barcelona, Barcelona, Spain
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Bosch P, van den Kieboom J, Plate JDJ, IJpma FFA, Houwert RM, Huisman A, Hietbrink F, Leenen LPH, Govaert GAM. Limited Predictive Value of Serum Inflammatory Markers for Diagnosing Fracture-Related Infections: results of a large retrospective multicenter cohort study. J Bone Jt Infect 2018; 3:130-137. [PMID: 30013894 PMCID: PMC6043470 DOI: 10.7150/jbji.26492] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Accepted: 05/12/2018] [Indexed: 01/09/2023] Open
Abstract
Introduction: Diagnosing Fracture-Related Infections (FRI) based on clinical symptoms alone can be challenging and additional diagnostic tools such as serum inflammatory markers are often utilized. The aims of this study were 1) to determine the individual diagnostic performance of three commonly used serum inflammatory markers: C-Reactive Protein (CRP), Leukocyte Count (LC) and Erythrocyte Sedimentation Rate (ESR), and 2) to determine the diagnostic performance of a combination of these markers, and the additional value of including clinical parameters predictive of FRI. Methods: This cohort study included patients who presented with a suspected FRI at two participating level I academic trauma centers between February 1st 2009 and December 31st 2017. The parameters CRP, LC and ESR, determined at diagnostic work-up of the suspected FRI, were retrieved from hospital records. The gold standard for diagnosing or ruling out FRI was defined as: positive microbiology results of surgically obtained tissue samples, or absence of FRI at a clinical follow-up of at least six months. The diagnostic accuracy of the individual serum inflammatory markers was assessed. Analyses were done with both dichotomized values using hospital thresholds as well as with continuous values. Multivariable logistic regression analyses were performed to obtain the discriminative performance (Area Under the Receiver Operating Characteristic, AUROC) of (1) the combined inflammatory markers, and (2) the added value of these markers to clinical parameters. Results: A total of 168 patients met the inclusion criteria and were included for analysis. CRP had a 38% sensitivity, 34% specificity, 42% positive predictive value (PPV) and 78% negative predictive value (NPV). For LC this was 39%, 74%, 46% and 67% and for ESR 62%, 64%, 45% and 76% respectively. The diagnostic accuracy was 52%, 61% and 80% respectively. The AUROC was 0.64 for CRP, 0.60 for LC and 0.58 for ESR. The AUROC of the combined inflammatory markers was 0.63. Serum inflammatory markers combined with clinical parameters resulted in AUROC of 0.66 as opposed to 0.62 for clinical parameters alone. Conclusion: The added value of CRP, LC and ESR for diagnosing FRI is limited. Clinicians should be cautious when interpreting the results of these tests in patients with suspected FRI.
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Affiliation(s)
- Paul Bosch
- Department of General Surgery, Subdivision of Trauma Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Janna van den Kieboom
- Department of Trauma Surgery, University of Utrecht, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Joost D J Plate
- Department of Trauma Surgery, University of Utrecht, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Frank F A IJpma
- Department of General Surgery, Subdivision of Trauma Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - R Marijn Houwert
- Department of Trauma Surgery, University of Utrecht, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Albert Huisman
- Department of Clinical Chemistry and Haematology, University Utrecht, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Falco Hietbrink
- Department of Trauma Surgery, University of Utrecht, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Luke P H Leenen
- Department of Trauma Surgery, University of Utrecht, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Geertje A M Govaert
- Department of Trauma Surgery, University of Utrecht, University Medical Center Utrecht, Utrecht, The Netherlands
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Boelch SP, Weissenberger M, Spohn F, Rudert M, Luedemann M. Insufficient sensitivity of joint aspiration during the two-stage exchange of the hip with spacers. J Orthop Surg Res 2018; 13:7. [PMID: 29321073 PMCID: PMC5763577 DOI: 10.1186/s13018-017-0703-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2017] [Accepted: 12/26/2017] [Indexed: 12/18/2022] Open
Abstract
Background Evaluation of infection persistence during the two-stage exchange of the hip is challenging. Joint aspiration before reconstruction is supposed to rule out infection persistence. Sensitivity and specificity of synovial fluid culture and synovial leucocyte count for detecting infection persistence during the two-stage exchange of the hip were evaluated. Methods Ninety-two aspirations before planned joint reconstruction during the two-stage exchange with spacers of the hip were retrospectively analyzed. Results The sensitivity and specificity of synovial fluid culture was 4.6 and 94.3%. The sensitivity and specificity of synovial leucocyte count at a cut-off value of 2000 cells/μl was 25.0 and 96.9%. C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) values were significantly higher before prosthesis removal and reconstruction or spacer exchange (p = 0.00; p = 0.013 and p = 0.039; p = 0.002) in the infection persistence group. Receiver operating characteristic area under the curve values before prosthesis removal and reconstruction or spacer exchange for ESR were lower (0.516 and 0.635) than for CRP (0.720 and 0.671). Conclusions Synovial fluid culture and leucocyte count cannot rule out infection persistence during the two-stage exchange of the hip.
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Affiliation(s)
- Sebastian Philipp Boelch
- Department of Orthopaedic Surgery, Julius-Maximilians University Wuerzburg, Koenig-Ludwig-Haus, 11 Brettreichstrasse, 97074, Wuerzburg, Germany.
| | - Manuel Weissenberger
- Department of Orthopaedic Surgery, Julius-Maximilians University Wuerzburg, Koenig-Ludwig-Haus, 11 Brettreichstrasse, 97074, Wuerzburg, Germany
| | - Frederik Spohn
- Department of Orthopaedic Surgery, Julius-Maximilians University Wuerzburg, Koenig-Ludwig-Haus, 11 Brettreichstrasse, 97074, Wuerzburg, Germany
| | - Maximilian Rudert
- Department of Orthopaedic Surgery, Julius-Maximilians University Wuerzburg, Koenig-Ludwig-Haus, 11 Brettreichstrasse, 97074, Wuerzburg, Germany
| | - Martin Luedemann
- Department of Orthopaedic Surgery, Julius-Maximilians University Wuerzburg, Koenig-Ludwig-Haus, 11 Brettreichstrasse, 97074, Wuerzburg, Germany
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Evaluation of the use of sonication of retrieved implants for the diagnosis of prosthetic joint infection in a routine setting. Eur J Clin Microbiol Infect Dis 2017; 37:715-722. [PMID: 29270861 DOI: 10.1007/s10096-017-3164-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2017] [Accepted: 12/07/2017] [Indexed: 12/11/2022]
Abstract
In order to evaluate the usefulness of sonication of retrieved implants for the diagnosis of prosthetic joint infection (PJI) in a large group of patients in a routine setting, we designed a 3-year retrospective study. Patients were classified into two groups: those meeting the clinical criteria of PJI and those that did not (control group). Two hundred patients and 276 samples were included. The types of infection were early (n = 44), delayed (n = 53), positive intraoperative cultures (n = 13) and late-acute (n = 8). The culture sensitivities of sonicate fluid, periprosthetic tissue, synovial fluid and combination of periprosthetic tissue and/or synovial fluid were 69.5, 52.8, 54.8 and 60.2%, respectively. The specificities were 97.6, 90.3, 93.0 and 89.9%, respectively. Sonicate fluid culture of implants was more sensitive than peri-implant tissue, synovial fluid and combination of periprosthetic tissue and/or synovial fluid for all infection types, though it was especially useful in delayed infection: 91.3% vs. 60.0% (p = 0.0015), 63.2% (p = 0.0005) and 66.7% (p = 0.0001), respectively. When sonicate fluid culture of implants was performed in addition to conventional cultures, the sensitivity increased significantly in total (from 60.2 to 77.1%) and delayed PJI (from 45.1 to 71.7%). On the other hand, for early PJI, sonicate fluid culture of prosthesis was not superior to conventional diagnostic methods.
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[Aseptic loosening of total ankle replacement and conversion to ankle arthrodesis]. OPERATIVE ORTHOPADIE UND TRAUMATOLOGIE 2017; 29:207-219. [PMID: 28444407 DOI: 10.1007/s00064-017-0492-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/23/2016] [Revised: 01/25/2017] [Accepted: 02/12/2017] [Indexed: 02/01/2023]
Abstract
OBJECTIVE To remove loosened prosthesis components, to perform augmentation, to address osseous defects, to perform neutrally aligned ankle arthrodesis, and to achieve postoperative pain relief. INDICATIONS Symptomatic, aseptic loosening of total ankle replacement (TAR) with/without substantial bone defect of the tibial and/or talar bone stock. CONTRAINDICATIONS General surgical or anesthesiological risks, periprosthetic infection, local or systemic infection, nonmanageable soft tissue problems. SURGICAL TECHNIQUE Removal of both prosthesis components using the previous incision (mostly using anterior ankle approach). Careful debridement of bone stock at the tibial and talar side. Osseous augmentation of defects using autologous or homologous cancellous bone, if needed, using structural allografts. POSTOPERATIVE MANAGEMENT A soft wound dressing is used. Thromboprophylaxis is recommended. Patient mobilization starts on postoperative day 1 with 15 kg partial weight bearing using a stabilizing walking boot or cast for 6-8 weeks. Following clinical and radiographic follow-up at 6 weeks, full weight bearing is initiated gradually after progressive osseous healing has been confirmed. RESULTS Between January 2007 and December 2012, ankle arthrodesis was performed in 9 patients with failed TAR (6 men and 3 women, mean age 56.4 ± 7.0 years, range 47.8-66.0 years). The mean time between the initial TAR and revision surgery was 4.5 ± 2.4 years (range 1.2-7.9 years). In one patient irrigation and debridement was performed due to superficial wound infection. Another patient had a delayed osseous healing 11 months after the revision surgery.
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C-reactive protein may misdiagnose prosthetic joint infections, particularly chronic and low-grade infections. INTERNATIONAL ORTHOPAEDICS 2017; 41:1315-1319. [DOI: 10.1007/s00264-017-3430-5] [Citation(s) in RCA: 69] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/19/2016] [Accepted: 02/12/2017] [Indexed: 02/08/2023]
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