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McQuinn MW, Moreno SD, Perez L, Burkes JN. Management of Intraoperative Contamination of the Custom Total Temporomandibular Joint Prosthesis. J Oral Maxillofac Surg 2023; 81:17-23. [PMID: 36279938 DOI: 10.1016/j.joms.2022.09.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Revised: 08/25/2022] [Accepted: 09/15/2022] [Indexed: 01/11/2023]
Abstract
Management of intraoperative contamination of a custom total temporomandibular joint prosthesis has not been reported in the literature. As this complication is rare, it can be unsettling for the surgeon. Improper management may lead to a complicated treatment course and financial consequences. Prevention is the primary strategy for avoidance and appropriate management is dependent on many variables. The purpose of this report is to identify a unique complication associated with placement of a custom temporomandibular joint prosthesis and offer an algorithm for management.
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Affiliation(s)
- Michael W McQuinn
- Staff Surgeon, Department of Oral and Maxillofacial Surgery, Naval Dental Center, Camp Lejeune, NC.
| | - Stephen D Moreno
- Fellow, Pediatric Craniofacial Surgery, Department of Oral and Maxillofacial Surgery, University of Florida-Jacksonville College of Medicine, Jacksonville, FL
| | - Leonel Perez
- Program Director and Staff Surgeon, Department of Oral and Maxillofacial Surgery, Walter Reed National Military Medical Center, Bethesda, MD
| | - Jason N Burkes
- President of the Medical Staff and Staff Surgeon, Department of Oral and Maxillofacial Surgery, Walter Reed National Military Medical Center, Bethesda, MD
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2
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Ferro FP, Bessa FS, Miyahara H, Ejnisman L, Vicente JR, Croci AT. Multiple deep tissue cultures in primary total hip arthroplasty: prognostic value for periprosthetic infection. Hip Int 2022; 32:45-50. [PMID: 32538159 DOI: 10.1177/1120700020932110] [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] [Indexed: 02/04/2023]
Abstract
BACKGROUND The risk of infection after total hip replacement (THR) is significant, with negative impact on quality of life and high costs. Bacteria can contaminate the surgical site despite aseptic techniques; however, there is debate regarding the benefit of identifying bacteria during the primary procedure. Although taking multiple samples for culture is a well-established practice in revision arthroplasty, doing so in primary cases remains controversial. We aimed to investigate whether there is a prognostic value in the culture of samples taken during primary THR, seeking a correlation between the positivity of the cultures and subsequent prosthetic joint infection (PJI). METHODS Deep samples (capsule, femoral and acetabular bone) were collected from 426 patients undergoing elective primary THR. Follow-up was at least 3 years. Microbiological profiles of cultures were analysed. Patient data were reviewed for the identification of risk factors presumably associated with a higher risk of PJI. RESULTS 54 surgeries (12.6%) had positive cultures. 16 cases (3.8%) developed infection, of which 5 had a positive culture in the primary surgery. Infection rate was 9.3% in patients with positive culture and 3% in those with negative culture (p < 0.05), with an odds ratio of 3.34 (95% CI, 1.09-10.24). Patients with previous hip surgery had an infection rate of 8.5%, compared to 2.9% in patients with no previous surgery (p < 0.05). CONCLUSIONS Routinely harvesting microbiologic samples in primary THR is not justified, as it has no consequence in clinical decision for most patients. It might be recommended in selected cases that are suspected to be at high risk for infection, especially previously operated patients (conversion arthroplasty).
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Affiliation(s)
- Fernando P Ferro
- Institute of Orthopedics and Traumatology, Hospital das Clínicas, Faculty of Medicine, University of São Paulo, Brazil
| | - Felipe S Bessa
- Institute of Orthopedics and Traumatology, Hospital das Clínicas, Faculty of Medicine, University of São Paulo, Brazil
| | - Hélder Miyahara
- Institute of Orthopedics and Traumatology, Hospital das Clínicas, Faculty of Medicine, University of São Paulo, Brazil
| | - Leandro Ejnisman
- Institute of Orthopedics and Traumatology, Hospital das Clínicas, Faculty of Medicine, University of São Paulo, Brazil
| | - Jose Rn Vicente
- Institute of Orthopedics and Traumatology, Hospital das Clínicas, Faculty of Medicine, University of São Paulo, Brazil
| | - Alberto T Croci
- Institute of Orthopedics and Traumatology, Hospital das Clínicas, Faculty of Medicine, University of São Paulo, Brazil
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Rivera A, Sánchez A, Luque S, Mur I, Puig L, Crusi X, González JC, Sorlí L, González A, Horcajada JP, Navarro F, Benito N. Intraoperative Bacterial Contamination and Activity of Different Antimicrobial Prophylaxis Regimens in Primary Knee and Hip Replacement. Antibiotics (Basel) 2020; 10:antibiotics10010018. [PMID: 33375415 PMCID: PMC7823842 DOI: 10.3390/antibiotics10010018] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Revised: 12/22/2020] [Accepted: 12/23/2020] [Indexed: 02/05/2023] Open
Abstract
Surgical antimicrobial prophylaxis (SAP) is important for the prevention of prosthetic joint infections (PJIs) and must be effective against the microorganisms most likely to contaminate the surgical site. Our aim was to compare different SAP regimens (cefazolin, cefuroxime, or vancomycin, alone or combined with gentamicin) in patients undergoing total knee (TKA) and hip (THA) arthroplasty. In this preclinical exploratory analysis, we analyzed the results of intraoperative sample cultures, the ratio of plasma antibiotic levels to the minimum inhibitory concentrations (MICs) for bacteria isolated at the surgical wound and ATCC strains, and serum bactericidal titers (SBT) against the same microorganisms. A total of 132 surgical procedures (68 TKA, 64 THA) in 128 patients were included. Cultures were positive in 57 (43.2%) procedures (mostly for coagulase-negative staphylococci and Cutibacterium spp.); the rate was lower in the group of patients receiving combination SAP (adjusted OR 0.475, CI95% 0.229-0.987). The SAP regimens evaluated achieved plasma levels above the MICs in almost all of intraoperative isolates (93/94, 98.9%) and showed bactericidal activity against all of them (SBT range 1:8-1:1024), although SBTs were higher in patients receiving cefazolin and gentamicin-containing regimens. The potential clinical relevance of these findings in the prevention of PJIs remains to be determined.
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Affiliation(s)
- Alba Rivera
- Department of Microbiology, Hospital de la Santa Creu i Sant Pau—Institut d’Investigació Biomèdica Sant Pau, 08025 Barcelona, Spain; (A.R.); (A.S.); (F.N.)
- Department of Genetic and Microbiology, Universitat Autònoma de Barcelona, 08193 Barcelona, Spain
| | - Alba Sánchez
- Department of Microbiology, Hospital de la Santa Creu i Sant Pau—Institut d’Investigació Biomèdica Sant Pau, 08025 Barcelona, Spain; (A.R.); (A.S.); (F.N.)
- Department of Genetic and Microbiology, Universitat Autònoma de Barcelona, 08193 Barcelona, Spain
| | - Sonia Luque
- Department of Pharmacy, Hospital del Mar—Hospital del Mar Medical Research Institute (IMIM), 08003 Barcelona, Spain;
| | - Isabel Mur
- Department of Medicine, Faculty of Medicine, Universitat Autònoma de Barcelona, 08193 Barcelona, Spain; (I.M.); (J.P.H.)
- Infectious Disease Unit, Department of Internal Medicine, Hospital de la Santa Creu i Sant Pau—Institut d’Investigació Biomèdica Sant Pau, 08025 Barcelona, Spain
- Bone and Joint Infection Study Group of the Spanish Society of Infectious Diseases and Clinical Microbiology (GEIO-SEIMC), 28003 Madrid, Spain;
| | - Lluís Puig
- Department of Orthopedic Surgery and Traumatology, Hospital del Mar—Hospital del Mar Medical Research Institute (IMIM), 08003 Barcelona, Spain;
| | - Xavier Crusi
- Department of Orthopedic Surgery and Traumatology, Hospital de la Santa Creu i Sant Pau—Institut d’Investigació Biomèdica Sant Pau, 08025 Barcelona, Spain; (X.C.); (J.C.G.); (A.G.)
| | - José Carlos González
- Department of Orthopedic Surgery and Traumatology, Hospital de la Santa Creu i Sant Pau—Institut d’Investigació Biomèdica Sant Pau, 08025 Barcelona, Spain; (X.C.); (J.C.G.); (A.G.)
| | - Luisa Sorlí
- Bone and Joint Infection Study Group of the Spanish Society of Infectious Diseases and Clinical Microbiology (GEIO-SEIMC), 28003 Madrid, Spain;
- Department of Infectious Diseases, Hospital del Mar—Hospital del Mar Medical Research Institute (IMIM), 08003 Barcelona, Spain
- Department of Experimental and Health Sciences, Universitat Pompeu Fabra, 08003 Barcelona, Spain
| | - Aránzazu González
- Department of Orthopedic Surgery and Traumatology, Hospital de la Santa Creu i Sant Pau—Institut d’Investigació Biomèdica Sant Pau, 08025 Barcelona, Spain; (X.C.); (J.C.G.); (A.G.)
| | - Juan Pablo Horcajada
- Department of Medicine, Faculty of Medicine, Universitat Autònoma de Barcelona, 08193 Barcelona, Spain; (I.M.); (J.P.H.)
- Department of Infectious Diseases, Hospital del Mar—Hospital del Mar Medical Research Institute (IMIM), 08003 Barcelona, Spain
| | - Ferran Navarro
- Department of Microbiology, Hospital de la Santa Creu i Sant Pau—Institut d’Investigació Biomèdica Sant Pau, 08025 Barcelona, Spain; (A.R.); (A.S.); (F.N.)
- Department of Genetic and Microbiology, Universitat Autònoma de Barcelona, 08193 Barcelona, Spain
| | - Natividad Benito
- Department of Medicine, Faculty of Medicine, Universitat Autònoma de Barcelona, 08193 Barcelona, Spain; (I.M.); (J.P.H.)
- Infectious Disease Unit, Department of Internal Medicine, Hospital de la Santa Creu i Sant Pau—Institut d’Investigació Biomèdica Sant Pau, 08025 Barcelona, Spain
- Bone and Joint Infection Study Group of the Spanish Society of Infectious Diseases and Clinical Microbiology (GEIO-SEIMC), 28003 Madrid, Spain;
- Correspondence:
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Justesen T, Olsen JB, Hesselvig AB, Mørup-Petersen A, Odgaard A. Does intraoperative contamination during primary knee arthroplasty affect patient-reported outcomes for patients who are uninfected 1 year after surgery? A prospective cohort study of 714 patients. Acta Orthop 2020; 91:750-755. [PMID: 32867557 PMCID: PMC8023922 DOI: 10.1080/17453674.2020.1811552] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Background and purpose - It is well recognized that some knee arthroplasty (KA) patients present with prolonged postoperative inflammation and some develop persistent pain. It can reasonably be speculated that some of these problems develop because of low-grade infections with low virulence bacteria caused by intraoperative contamination. This prospective study was performed to investigate whether intraoperative contamination results in lower patient-reported outcomes (PRO) for patients who were clinically uninfected in the first year after surgery. Patients and methods - We combined data from 2 major prospective studies on patients undergoing primary KA at 2 Danish hospitals between September 2016 and January 2018. Pre- and postoperative (1.5, 3, 6, and 12 months) PROs and intraoperative microbiological cultures were obtained on a total of 714 patients who were included in the study. Based on the microbiological cultures, the patients were divided into 2 groups, contaminated and non-contaminated, and differences in PROs between the 2 groups were analyzed. Results - 84 of 714 (12%) patients were intraoperatively contaminated; none of the 714 patients developed clinical infection. The preoperative Oxford Knee Score was 24 and 23 for contaminated and non-contaminated patients, respectively, improving to 40 and 39 at 1 year (p = 0.8). 1-year AUC for Oxford Knee Score and absolute improvement at each postoperative time point for Forgotten Joint Score and EQ-5D-5L also were similar between contaminated and non-contaminated patients. Interpretation - Patient-reported outcomes from 714 patients do not indicate that intraoperative contamination affects the knee-specific or general health-related quality of life in primary KA patients who are clinically uninfected 1 year after surgery.
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Affiliation(s)
- Tobias Justesen
- Department of Orthopedic Surgery, Copenhagen University Hospital Herlev-Gentofte, Copenhagen, Denmark,Correspondence:
| | - Jakob B Olsen
- Department of Orthopedic Surgery, Copenhagen University Hospital Herlev-Gentofte, Copenhagen, Denmark
| | - Anne B Hesselvig
- Department of Orthopedic Surgery, Copenhagen University Hospital Herlev-Gentofte, Copenhagen, Denmark
| | - Anne Mørup-Petersen
- Department of Orthopedic Surgery, Copenhagen University Hospital Herlev-Gentofte, Copenhagen, Denmark
| | - Anders Odgaard
- Department of Orthopedic Surgery, Copenhagen University Hospital Herlev-Gentofte, Copenhagen, Denmark
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Jonsson EÖ, Johannesdottir H, Robertsson O, Mogensen B. Bacterial contamination of the wound during primary total hip and knee replacement. Median 13 years of follow-up of 90 replacements. Acta Orthop 2014; 85:159-64. [PMID: 24650025 PMCID: PMC3967258 DOI: 10.3109/17453674.2014.899848] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND AND PURPOSE Previous work has shown that despite preventive measures, intraoperative contamination of joint replacements is still common, although most of these patients seem to do well in follow-up of up to 5 years. We analyzed the prevalence and bacteriology of intraoperative contamination of primary joint replacement and assessed whether its presence is related to periprosthetic joint infection (PJI) on long-term follow-up. PATIENTS AND METHODS 49 primary total hip replacements (THRs) and 41 total knee replacements (TKRs) performed between 1990 and 1991 were included in the study. 4 bacterial swabs were collected intraoperatively during each procedure. Patients were followed up for joint-related complications until March 2011. RESULTS 19 of 49 THRs and 22 of 41 TKRs had at least 1 positive culture. Coagulase-negative staphylococci and Staphylococcus aureus were the most common organisms, contaminating 28 and 9 operations respectively. Where information was available, bacteria from 27 of 29 contaminated operations were susceptible to the prophylactic antibiotic administered. 13% of samples gathered before 130 min of surgery were contaminated, as compared to 35% collected after that time. 2 infections were diagnosed, both in TKRs. 1 of them may have been related to intraoperative contamination. INTERPRETATION Intraoperative contamination was common but few infections occurred, possibly due to the effect of prophylactic antibiotics. The rate of contamination was higher with longer duration of surgery. It appears that positive results from intraoperative swabs do not predict the occurrence of PJI.
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Affiliation(s)
- Eythor Örn Jonsson
- Department of Orthopedic Surgery, Landspitali University Hospital, Iceland.
| | | | - Otto Robertsson
- Department of Orthopedic Surgery, Landspitali University Hospital, Iceland.
| | - Brynjolfur Mogensen
- Faculty of Medicine, University of Iceland, Iceland.,Department of Emergency Medicine, Landspitali University Hospital, Reykjavik, Iceland.
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Lindeque B, Hartman Z, Noshchenko A, Cruse M. Infection after primary total hip arthroplasty. Orthopedics 2014; 37:257-65. [PMID: 24762833 DOI: 10.3928/01477447-20140401-08] [Citation(s) in RCA: 76] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2013] [Accepted: 09/30/2013] [Indexed: 02/03/2023]
Abstract
The number of primary total hip arthroplasties (THAs) performed in the United States each year continues to climb, as does the incidence of infectious complications. The changing profile of antibiotic-resistant bacteria has made preventing and treating primary THA infections increasingly complex. The goal of this review was to summarize (1) the published data concerning the risk of surgical site infection (SSI) after primary THA by type of bacteria and (2) the effect of potentially modifying factors. The Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects, EMBASE, Web of Science, and PubMed were searched. Studies dated between 2001 and 2011 examining primary THA in adults were included. Meta-analysis of the collected data was performed. The pooled SSI rate was 2.5% (95% confidence interval [Cl], 1.4%-4.4%; P<.001; n=28,883). The pooled deep prosthetic joint infection (PJI) rate was 0.9% (95% Cl, 0.4%-2.2%; P<.001; n=28,883). The pooled rate of methicillin-resistant Staphylococcus aureus SSI was 0.5% (95% Cl, 0.2%-1.5%; P<.001; n=26,703). This is approximately 20% of all SSI cases. The pooled rate of intraoperative bacterial wound contamination was 16.9% (95% Cl, 6.6%-36.8%; P=.003; n=2180). All these results had significant heterogeneity. The postoperative risk of SSI was significantly associated with intraoperative bacterial surgical wound contamination (pooled rate ratio, 2.5; 95% Cl, 1.4%-4.6%; P=.001; n=19,049).
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Abolghasemian M, Sternheim A, Shakib A, Safir OA, Backstein D. Is arthroplasty immediately after an infected case a risk factor for infection? Clin Orthop Relat Res 2013; 471:2253-8. [PMID: 23389803 PMCID: PMC3676593 DOI: 10.1007/s11999-013-2827-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2012] [Accepted: 01/25/2013] [Indexed: 02/06/2023]
Abstract
BACKGROUND It is common practice in many centers to avoid performing a clean case in a room in which an infected procedure has just taken place. No studies of which we are aware speak to the necessity of this precaution. QUESTIONS/PURPOSES The purposes of this study were to identify (1) the risk of infection in a group of patients who underwent arthroplasties performed immediately after a first-stage arthroplasty for joint infection; and (2) the risk of superficial and deep infections in these patients compared with a matched group of patients who underwent arthroplasties not performed after an infected surgery. METHODS Eighty-three patients (85 arthroplasties) who underwent arthroplasties (primary or revision) immediately after patients with known infections underwent surgery in the same operating room (OR) were analyzed for 12 months after surgery to determine the incidence of infection. They were matched for demographic factors and surgery type with a control group of 321 patients (354 arthroplasties) who underwent surgery in an OR that had not just been used for surgery involving patients with infections. We compared the risk of superficial and deep infections between the groups. RESULTS Patients in the study group were not more likely to have infections develop than those in the control group. One patient in the study group (1.17%) and three in the control group (0.84%) had deep infections develop; the infection in the patient in the study group was caused by a different organism than that of the patient with an infection whose surgery preceded in the OR. Two superficial infections (2.35%) were detected in the study group and 17 (4.8%) were detected in the control group. CONCLUSIONS With the numbers available, we found that a deep infection was not more likely to occur in a patient without an infection after an arthroplasty that followed surgery on a patient with an infection than in one who had surgery after a clean case. Although sample size was a potential issue in this study, the results may serve as hypothesis generating for future studies. LEVEL OF EVIDENCE Level III, prognostic study. See Guidelines for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Mansour Abolghasemian
- Division of Orthopedic Surgery, Department of Surgery, University of Toronto, 600 University Avenue, Suite 476 (A), Toronto, Ontario M5G 1X5 Canada
| | - Amir Sternheim
- Division of Orthopedic Surgery, Department of Surgery, University of Toronto, 600 University Avenue, Suite 476 (A), Toronto, Ontario M5G 1X5 Canada
| | - Alireza Shakib
- Division of Orthopedic Surgery, Department of Surgery, University of Toronto, 600 University Avenue, Suite 476 (A), Toronto, Ontario M5G 1X5 Canada
| | - Oleg A. Safir
- Division of Orthopedic Surgery, Department of Surgery, University of Toronto, 600 University Avenue, Suite 476 (A), Toronto, Ontario M5G 1X5 Canada
| | - David Backstein
- Division of Orthopedic Surgery, Department of Surgery, University of Toronto, 600 University Avenue, Suite 476 (A), Toronto, Ontario M5G 1X5 Canada
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Flores X, Corona PS, Cortina J, Guerra E, Amat C. Temporary cement tectoplasty: a technique to improve prefabricated hip spacer stability in two-stage surgery for infected hip arthroplasty. Arch Orthop Trauma Surg 2012; 132:719-24. [PMID: 22258179 DOI: 10.1007/s00402-012-1461-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2011] [Indexed: 02/09/2023]
Abstract
This technical note describes an intraoperatively custom-made, antibiotic-loaded bone cement roof, used in conjunction with a prefabricated hip spacer to improve component stability, as part of the first stage of a two-stage procedure for an infected hip implant. This technique was successfully used in seven cases who presented with extensive superior and/or posterio-superior acetabular defect, which created a risk of spacer dislocation. With this technique we were able to avoid any further dislocation in these seven cases. We believe that the technique may reduce postoperative spacer dislocation in cases with extensive acetabular defects, while improving clinical outcomes.
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Affiliation(s)
- X Flores
- Reconstruction and Septic Division, Department of Orthopedic Surgery, Hospital Universitario Vall d'Hebron, Barcelona 08035, Spain
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