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Haeberle AL, Greenwood-Quaintance KE, Zar S, Johnson S, Patel R, Willett JLE. Genotypic and phenotypic characterization of Enterococcus faecalis isolates from periprosthetic joint infections. Microbiol Spectr 2024; 12:e0056524. [PMID: 38912797 PMCID: PMC11302728 DOI: 10.1128/spectrum.00565-24] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2024] [Accepted: 05/09/2024] [Indexed: 06/25/2024] Open
Abstract
Over 2.5 million prosthetic joint implantation surgeries occur annually in the United States. Periprosthetic joint infections (PJIs), though occurring in only 1-2% of patients receiving replacement joints, are challenging to diagnose and treat and are associated with significant morbidity. The Gram-positive bacterium Enterococcus faecalis, which can be highly antibiotic-resistant and is a robust biofilm producer on indwelling medical devices, accounts for 2-11% of PJIs. E. faecalis PJIs are understudied compared to those caused by other pathogens, such as Staphylococcus aureus. This motivates the need to generate a comprehensive understanding of E. faecalis PJIs to guide future treatments for these infections. To address this, we describe a panel of E. faecalis strains isolated from the surface of prosthetic joints in a cohort of individuals treated at the Mayo Clinic in Rochester, MN. Here, we present the first complete genome assemblage of E. faecalis PJI isolates. Comparative genomics shows differences in genome size, virulence factors, antimicrobial resistance genes, plasmids, and prophages, underscoring the genetic diversity of these strains. These isolates have strain-specific differences in in vitro biofilm biomass, biofilm burden, and biofilm morphology. We measured robust changes in biofilm architecture and aggregation for all isolates when grown in simulated synovial fluid (SSF). Finally, we evaluated the antibiotic efficacy of these isolates and found strain-specific changes across all strains when grown in SSF. Results of this study highlight the existence of genetic and phenotypic heterogeneity among E. faecalis PJI isolates which will provide valuable insight and resources for future E. faecalis PJI research. IMPORTANCE Periprosthetic joint infections (PJIs) affect ~1-2% of those who undergo joint replacement surgery. Enterococcus faecalis is a Gram-positive opportunistic pathogen that causes ~10% of PJIs in the United States each year, but our understanding of how and why E. faecalis causes PJIs is limited. E. faecalis infections are typically biofilm-associated and can be difficult to clear with antibiotic therapy. Here, we provide complete genomes for four E. faecalis PJI isolates from the Mayo Clinic. These isolates have strain-specific differences in biofilm formation, aggregation, and antibiotic susceptibility in simulated synovial fluid. These results provide important insight into the genomic and phenotypic features of E. faecalis isolates from PJI.
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Affiliation(s)
- Amanda L. Haeberle
- Department of Microbiology & Immunology, University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Kerryl E. Greenwood-Quaintance
- Division of Clinical Microbiology, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Sarah Zar
- Department of Microbiology & Immunology, University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Stephen Johnson
- Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota, USA
| | - Robin Patel
- Division of Clinical Microbiology, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
- Division of Public Health, Infectious Diseases, and Occupational Medicine, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Julia L. E. Willett
- Department of Microbiology & Immunology, University of Minnesota Medical School, Minneapolis, Minnesota, USA
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Zhao Y, Fan S, Wang Z, Yan X, Luo H. Systematic review and meta-analysis of single-stage vs two-stage revision for periprosthetic joint infection: a call for a prospective randomized trial. BMC Musculoskelet Disord 2024; 25:153. [PMID: 38373976 PMCID: PMC10875807 DOI: 10.1186/s12891-024-07229-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Accepted: 01/24/2024] [Indexed: 02/21/2024] Open
Abstract
BACKGROUND Periprosthetic joint infection (PJI) is a severe complication of joint arthroplasty that causes significant pain and economic loss. This study aimed to determine whether the current evidence supports single-stage revision for PJI based on reinfection and reoperation rates. METHODS We searched the PubMed, EBSCO, Medline, and Cochrane Library databases from inception to 30 May 2023 to identify studies that compared single-stage revision and two-stage revision for PJI. Data on reinfection and reoperation rates were pooled. RESULTS This meta-analysis included a total of 40 studies with 8711 patients. Overall, there was no significant difference between single- and two-stage revision regarding the postoperative reinfection rate and reoperation rate. Subgroup analysis by surgery period and different surgical sites revealed no difference between the two groups in the reinfection and reoperation rates. CONCLUSIONS Based on the available evidence, our study did not identify a significant difference in reinfection and reoperation rates between single- and two-stage revision for PJI. Given the limitations in inclusion/exclusion criteria and the observed heterogeneity, we acknowledge the complexity of drawing strong conclusions. Therefore, we suggest that the choice between single- and two-stage revision should be carefully considered on an individual basis, taking into account patient-specific factors and further research developments.
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Affiliation(s)
- Yong Zhao
- Department of Orthopedics, Shanghai Fengxian District Central Hospital, Shanghai, 201400, China
| | - Shaohua Fan
- Department of Orthopedics, Taizhou Hospital of Zhejiang Province affiliated to Wenzhou Medical University, Taizhou, 317000, Zhejiang, China
| | - Zhangfu Wang
- Department of Orthopedics, Taizhou Hospital of Zhejiang Province affiliated to Wenzhou Medical University, Taizhou, 317000, Zhejiang, China
| | - Xueli Yan
- Department of Orthopedics, Taizhou Hospital of Zhejiang Province affiliated to Wenzhou Medical University, Taizhou, 317000, Zhejiang, China
| | - Hua Luo
- Department of Orthopedics, Taizhou Hospital of Zhejiang Province affiliated to Wenzhou Medical University, Taizhou, 317000, Zhejiang, China.
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Haeberle A, Greenwood-Quaintance K, Zar S, Johnson S, Patel R, Willett JLE. Genotypic and phenotypic characterization of Enterococcus faecalis isolates from periprosthetic joint infections. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2024:2024.02.06.579140. [PMID: 38370742 PMCID: PMC10871183 DOI: 10.1101/2024.02.06.579140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/20/2024]
Abstract
Over 2.5 million prosthetic joint implantation surgeries occur annually in the United States. Periprosthetic joint infections (PJIs), though occurring in only 1-2% of patients receiving replacement joints, are challenging to diagnose and treat and are associated with significant morbidity. The Gram-positive bacterium Enterococcus faecalis, which can be highly antibiotic resistant and is a robust biofilm producer on indwelling medical devices, accounts for 2-11% of PJIs. E. faecalis PJIs are understudied compared to those caused by other pathogens, such as Staphylococcus aureus. This motivates the need to generate a comprehensive understanding of E. faecalis PJIs to guide future treatments for these infections. To address this, we describe a panel of E. faecalis strains isolated from the surface of prosthetic joints in a cohort of individuals treated at Mayo Clinic in Rochester, MN. Here, we present the first complete genome assemblage of E. faecalis PJI isolates. Comparative genomics shows differences in genome size, virulence factors, antimicrobial resistance genes, plasmids, and prophages, underscoring the genetic diversity of these strains. These isolates have strain-specific differences in in vitro biofilm biomass, biofilm burden, and biofilm morphology. We measured robust changes in biofilm architecture and aggregation for all isolates when grown in simulated synovial fluid (SSF). Lastly, we evaluated antibiotic efficacy of these isolates and found strain specific changes across all strains when grown in SSF. Results of this study highlight the existence of genetic and phenotypic heterogeneity among E. faecalis PJI isolates which will provide valuable insight and resources for future E. faecalis PJI research.
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Affiliation(s)
- Amanda Haeberle
- Department of Microbiology & Immunology, University of Minnesota Medical School, Minneapolis, Minnesota USA
| | - Kerryl Greenwood-Quaintance
- Division of Clinical Microbiology, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Sarah Zar
- Department of Microbiology & Immunology, University of Minnesota Medical School, Minneapolis, Minnesota USA
| | - Stephen Johnson
- Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota, USA
| | - Robin Patel
- Division of Clinical Microbiology, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
- Division of Public Health, Infectious Diseases, and Occupational Medicine, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Julia L. E. Willett
- Department of Microbiology & Immunology, University of Minnesota Medical School, Minneapolis, Minnesota USA
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Wellauer H, Bansal-Zweifel V, Benninger E, Wahl P. Successful Implant Retention in a Chronified Hematogenous Bilateral Periprosthetic Hip Joint Infection With Enterococcus faecalis. Arthroplast Today 2024; 25:101313. [PMID: 38292147 PMCID: PMC10825227 DOI: 10.1016/j.artd.2023.101313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Revised: 12/08/2023] [Accepted: 12/10/2023] [Indexed: 02/01/2024] Open
Abstract
We present a case with bilateral hematogenous hip periprosthetic joint infection with Enterococci which could be treated successfully with implant retention despite chronification and partial loosening. A debridement and replacement of the modular components was carried out with replacement of a loose acetabular cup on the right side. Considering poor local infection control, antibiotic treatment was enhanced by local application of vancomycin. In the present case, treatment of chronic enterococcal periprosthetic joint infection while preserving the implants was successful despite unfavorable odds. Considering the duration of infection, causative microorganism, and loosening of one of the implants, staged exchange of both hip replacements would have been the standard procedure. This case illustrates that some concepts have to be challenged from time to time.
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Affiliation(s)
- Hanna Wellauer
- Division of Orthopaedics and Traumatology, Cantonal Hospital Winterthur, Winterthur, Switzerland
- Department of Orthopaedic and Trauma Surgery, HFR Fribourg – Cantonal Hospital, Fribourg, Switzerland
| | - Vineeta Bansal-Zweifel
- Division of Internal Medicine, Division of Infectiology, Cantonal Hospital Winterthur, Winterthur, Switzerland
| | - Emanuel Benninger
- Division of Orthopaedics and Traumatology, Cantonal Hospital Winterthur, Winterthur, Switzerland
| | - Peter Wahl
- Division of Orthopaedics and Traumatology, Cantonal Hospital Winterthur, Winterthur, Switzerland
- Faculty of Medicine, University of Berne, Berne, Switzerland
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Kim BI, Wixted CM, Schwartz AM, Jiranek WA, Ryan SP, Seyler TM. Risk factors for failure after rotational muscle flap coverage for prosthetic knee infections. J Orthop Surg (Hong Kong) 2024; 32:10225536241230349. [PMID: 38279963 DOI: 10.1177/10225536241230349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2024] Open
Abstract
INTRODUCTION Soft tissue defects are a devastating complication of prosthetic joint infections (PJI) after total knee arthroplasty (TKA). Rotational flaps are commonly utilized to address these defects with variable reports of success. This study aimed to identify predictors of poor outcomes in rotational muscle flap placement after prosthetic knee infections. The authors hypothesized that outcomes may vary based on infecting pathogen and treatment characteristics. METHODS 44 cases of rotational muscle flaps for prosthetic knee infection were retrospectively evaluated at a tertiary referral hospital from 2007 to 2020. Muscle flap types included 39 medial and four lateral gastrocnemius, and one anterior tibialis. Minimum follow-up was 1 year (median: 3.4 years). Primary outcome was flap-related complications. Secondary outcomes included recurrent infection requiring additional surgery, final joint outcomes, and mortality. RESULTS One-year complication-free flap survivorship was 83.9%, recurrent infection-free survivorship was 65.7%, and amputation-free survivorship was 79%. Multivariable cox regression revealed that rheumatoid arthritis diagnosis (HR: 3.4; p = .028) and methicillin-resistant Staphylococcus aureus-positive culture (HR: 4.0; p = .040) had increased risk, while Coagulase-negative Staphylococcus infections had reduced risk for recurrent or persistent infection (HR: 0.2; p = .023). Final joint outcome was retained TKA implant in 18 (40.9%), amputation in 15 (34.1%) patients, and definitive treatment with articulating spacer in 10 (22.7%). 5-years survivorship from death was 71.4%. CONCLUSION Rotational muscle flaps for soft tissue coverage of the knee are often performed in limb salvage situations with poor survivorship from flap complications, reinfections, and amputation. When considering surgical options for limb salvage, patients should be counseled on these risks.
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Affiliation(s)
- Billy I Kim
- Department of Orthopaedic Surgery, Duke University, Durham, NC, USA
| | - Colleen M Wixted
- Department of Orthopaedic Surgery, Duke University, Durham, NC, USA
| | | | | | - Sean P Ryan
- Department of Orthopaedic Surgery, Duke University, Durham, NC, USA
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Chang Y, Li Y, Fan T, Jiang K, Lv J, Huang J. Pathogenic bacteria characteristics and drug resistance in acute, delayed, and chronic periprosthetic joint infection: A retrospective analysis of 202 patients. Int Wound J 2023; 20:3315-3323. [PMID: 37186450 PMCID: PMC10502290 DOI: 10.1111/iwj.14212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Revised: 04/13/2023] [Accepted: 04/13/2023] [Indexed: 05/17/2023] Open
Abstract
To assist orthopaedic surgeons in choosing appropriate antibiotics, this study attempted to identify the common microorganisms that cause periprosthetic joint infection (PJI) and their respective drug resistance spectrums. The clinical data of 202 patients with PJI after primary hip and knee arthroplasty between January 2017 and December 2021 were retrospectively analysed. There were 84 males and 118 females, aged (63.03 ± 13.10) years (range: 24-89 years). A total of 102 and 100 patients underwent total hip and total knee arthroplasty, respectively. Based on the time of postoperative infection, the patients were divided into acute (25 cases), delayed (91 cases), and chronic (86 cases) PJI groups. The results of pathogen species, composition ratio, and drug susceptibility tests were collected. Gram-positive bacteria were the primary causative pathogens of PJI (58.91%, 119/202), and their culture-positive rates in patients with acute, delayed, and chronic PJI were 32.00% (8/25), 62.64% (57/91), and 62.79% (54/86), respectively. Staphylococcus epidermidis and Staphylococcus aureus were the major gram-positive bacteria detected, followed by gram-negative bacteria (29/202, 14.36%), and fungi (4/202, 1.98%). Gram-positive bacteria showed higher resistance to penicillin (81.25%), oxacillin (63.33%), erythromycin (61.17%), and clindamycin (48.35%) and 100% sensitivity to linezolid, vancomycin, daptomycin, and tigecycline. In gram-negative bacteria, the drug resistance rates to cefazolin, gentamicin, furantoin, cefuroxime, ticacillin/clavulanic acid, ceftriaxone, ciprofloxacin, and tobramycin were >50%. However, no vancomycin-resistant bacteria were discovered in the current study. The drug resistance rate to carbapenems was low, ranging from 0% to 3.57%. Gram-positive bacteria are the main causative pathogens of PJI, and the resistance rate of pathogens of chronic PJI is higher than those of delayed and acute PJI. Use of cefuroxime and clindamycin in patients with PJIs should proceed with caution because of the high drug resistance rate. Vancomycin can be used as a first-line antibiotic against gram-positive bacteria. Carbapenems can be used as the first choice against gram-negative bacteria because of to their high sensitivity.
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Affiliation(s)
- Yu Chang
- Department of Clinical PharmacyHonghui Hospital, Xi'an Jiaotong UniversityXi'anShaanxiPeople's Republic of China
| | - Yongsheng Li
- Department of Clinical PharmacyHonghui Hospital, Xi'an Jiaotong UniversityXi'anShaanxiPeople's Republic of China
| | - Ting Fan
- Department of Clinical PharmacyHonghui Hospital, Xi'an Jiaotong UniversityXi'anShaanxiPeople's Republic of China
| | - Kai Jiang
- Department of Clinical PharmacyHonghui Hospital, Xi'an Jiaotong UniversityXi'anShaanxiPeople's Republic of China
| | - Jing Lv
- Department of Clinical LaboratoryHonghui Hospital, Xi'an Jiaotong UniversityXi'anShaanxiPeople's Republic of China
| | - Jing Huang
- Department of Clinical PharmacyHonghui Hospital, Xi'an Jiaotong UniversityXi'anShaanxiPeople's Republic of China
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Maurille C, Michon J, Isnard C, Rochcongar G, Verdon R, Baldolli A. Interest in the combination of antimicrobial therapy for orthopaedic device-related infections due to Enterococcus spp. Arch Orthop Trauma Surg 2023; 143:5515-5526. [PMID: 36988713 DOI: 10.1007/s00402-023-04848-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Accepted: 03/14/2023] [Indexed: 03/30/2023]
Abstract
INTRODUCTION The objective of this study was to evaluate the management of orthopaedic device-related infections (ODRIs) due to Enterococcus spp. MATERIALS AND METHODS We performed a retrospective cohort study in a French tertiary university hospital. Patients with prosthetic joint- or osteosynthesis-associated infections caused by enterococci from 2013 to 2020 were included. Patients who died within 5 days after surgery; who were in palliative care; or who had osteosynthesis of the hand, foot or vertebra were excluded. RESULTS Thirty-six patients were included, with 24 in the arthroplasty group and 12 in the osteosynthesis material group. Most infections were polymicrobial (63.9%, n = 23). Debridement, antibiotics and implant retention (DAIR) was performed in 30.6% (n = 11), withdrawal of material in 16.7% (n = 6), one-stage exchange in 30.6% (n = 11) and two-stage exchange in 22.2% of cases (n = 8). The antibiotic regimen was amoxicillin in 41.6% (n = 15), rifampicin in 27.8% (n = 10), linezolid in 25% (n = 9) and/or fluoroquinolones in 30.6% (n = 11). Clinical success at 1 year was 67% (18/27). The only variable statistically associated with a decreased risk of clinical failure was a duration of antibiotic therapy of 12 weeks (p = 0.04). Patients with a lower body mass index and age tended to decrease the risk of clinical failure (p = 0.05 and 0.06 respectively). CONCLUSIONS The management of enterococcal ODRIs is complex, and ODRI patients are at high risk for relapse. In our small study, a better outcome was not demonstrated for patients with combination therapy and rifampicin use. Further studies are needed to improve the medico-surgical strategy for treating these infections.
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Affiliation(s)
- Charles Maurille
- Department of Infectious Diseases, Normandie University, UNICAEN, CHU de Caen Normandie, 14000, Caen, France.
- Normandie Univ, UNICAEN, UNIROUEN, Inserm UMR 1311 DynaMicURe, 14000, Caen, France.
| | - Jocelyn Michon
- Department of Infectious Diseases, Normandie University, UNICAEN, CHU de Caen Normandie, 14000, Caen, France
| | - Christophe Isnard
- Normandie Univ, UNICAEN, UNIROUEN, Inserm UMR 1311 DynaMicURe, 14000, Caen, France
- Microbiology Department, Normandie University, UNICAEN, CHU de Caen Normandie, 14000, Caen, France
| | - Goulven Rochcongar
- Orthopaedics and Traumatology Department, Normandie University, UNICAEN, CHU de Caen Normandie, 14000, Caen, France
| | - Renaud Verdon
- Department of Infectious Diseases, Normandie University, UNICAEN, CHU de Caen Normandie, 14000, Caen, France
- Normandie Univ, UNICAEN, UNIROUEN, Inserm UMR 1311 DynaMicURe, 14000, Caen, France
| | - Aurélie Baldolli
- Department of Infectious Diseases, Normandie University, UNICAEN, CHU de Caen Normandie, 14000, Caen, France
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Karczewski D, Schönnagel L, Hipfl C, Akgün D, Hardt S. Periprosthetic knee infection in octogenarians: a single institution experience at midterm outcome. Arch Orthop Trauma Surg 2023; 143:4317-4322. [PMID: 36750492 PMCID: PMC10293346 DOI: 10.1007/s00402-023-04796-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Accepted: 01/22/2023] [Indexed: 02/09/2023]
Abstract
PURPOSE Periprosthetic joint infections (PJI) of total knee arthroplasties (TKAs) in the elderly is among the clinically most challenging scenarios given multimorbidity combined with poor bone and soft tissue quality. Despite increasing prevalence, limited is known on PJI among this unique group of patients. As such, this study analyzed PJI characteristics, implant survivorship and non-surgical complications of octogenarians revised PJI for the knee. METHODS We identified 31 patients that were revised for PJIs of the knee between 2010 and 2019 using a single university-based registry. Mean age was 83 years (range 80-87), 48% were females, and mean BMI was 29 kg/m2. Mean age adjusted Charlson Comorbidity Index was 7, and mean ASA score was 3. Major causative pathogens included Coagulase-negative Staphylococci (26%), Staphylococcus aureus (13%), and Streptococci (13%). Two-stage exchange was performed in 30 patients, permanent resection arthroplasty in one joint. Kaplan-Meier survivorship analyses were performed. Mean follow-up was 4 years. RESULTS The 2-year survivorship free of any recurrent PJI was 96%, and there was one PJI relapse noted at 6 months. Moreover, there were three additional revisions for aseptic loosening, and one further revision for fracture. As such, the 2-year survivorship free of any revision was 87%. In addition to the aforementioned revisions, there was one additional plate osteosynthesis for a Vancouver C fracture, resulting in a 79% survivorship free of any reoperation at 2 years. Mean perioperative complication score according to the Clavien-Dindo classification was 2 out of 5. A total of three patients died: one patient 40 days after resection arthroplasty, two others 4 months and 8 months after reimplantation. CONCLUSIONS Octogenarians revised for PJI of the knee are at low risk of recurrent infection and overall revision at 2 years. However, moderate rates of perioperative complications and mortality at short term must acknowledge before deciding upon procedure. LEVEL OF EVIDENCE Therapeutic level IV.
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Affiliation(s)
- Daniel Karczewski
- Department of Orthopaedic Surgery, Musculoskeletal Oncology Service, Massachusetts General Hospital-Harvard Medical School, 55 Fruit Street, Boston, MA, 02114, USA.
- Department of Orthopaedic Surgery and Traumatology, Charité Berlin, University Hospital, Chariteplatz 1, 10117, Berlin, Germany.
| | - Lukas Schönnagel
- Department of Orthopaedic Surgery, Musculoskeletal Oncology Service, Massachusetts General Hospital-Harvard Medical School, 55 Fruit Street, Boston, MA, 02114, USA
| | - Christian Hipfl
- Department of Orthopaedic Surgery, Musculoskeletal Oncology Service, Massachusetts General Hospital-Harvard Medical School, 55 Fruit Street, Boston, MA, 02114, USA
| | - Doruk Akgün
- Department of Orthopaedic Surgery, Musculoskeletal Oncology Service, Massachusetts General Hospital-Harvard Medical School, 55 Fruit Street, Boston, MA, 02114, USA
| | - Sebastian Hardt
- Department of Orthopaedic Surgery, Musculoskeletal Oncology Service, Massachusetts General Hospital-Harvard Medical School, 55 Fruit Street, Boston, MA, 02114, USA
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Jeong S, Yang A, Rubin LE, Arsoy D. Management of Bilateral Synchronous Knee Prosthetic Joint Infection in a Patient with Infected Heart Transplant: A Case Report. JBJS Case Connect 2023; 13:01709767-202309000-00019. [PMID: 37506219 DOI: 10.2106/jbjs.cc.23.00182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/30/2023]
Abstract
CASE A 74-year-old man presented with septic shock with infection of his heart transplant and bilateral prosthetic knee joints simultaneously. He underwent bilateral knee resection arthroplasties with placement of articulating spacers. At 3-year follow-up, the patient was alive and ambulating independently. CONCLUSION This case represents the first report of bilateral hematogenous prosthetic knee infections associated with concomitant enterococcal endocarditis of a heart transplant treated successfully and definitively with radical debridement and placement of articulating spacer with regular implants.
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Affiliation(s)
- Seongho Jeong
- Department of Orthopaedics and Rehabilitation, Yale New Haven Hospital, New Haven, Connecticut
| | - Ally Yang
- Department of Orthopaedics and Rehabilitation, Yale New Haven Hospital, New Haven, Connecticut
| | - Lee E Rubin
- Department of Orthopaedics and Rehabilitation, Yale New Haven Hospital, New Haven, Connecticut
| | - Diren Arsoy
- Rothman Orthopaedic Institute, New York, New York
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Migliorini F, Weber CD, Bell A, Betsch M, Maffulli N, Poth V, Hofmann UK, Hildebrand F, Driessen A. Bacterial pathogens and in-hospital mortality in revision surgery for periprosthetic joint infection of the hip and knee: analysis of 346 patients. Eur J Med Res 2023; 28:177. [PMID: 37208700 DOI: 10.1186/s40001-023-01138-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Accepted: 05/09/2023] [Indexed: 05/21/2023] Open
Abstract
INTRODUCTION The management of periprosthetic joint infections (PJI) of the lower limb is challenging, and evidence-based recommendations are lacking. The present clinical investigation characterized the pathogens diagnosed in patients who underwent revision surgery for PJI of total hip arthroplasty (THA) and total knee arthroplasty (TKA). METHODS The present study follows the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE). The institutional databases of the RWTH University Medical Centre of Aachen, Germany, were accessed. The OPS (operation and procedure codes) 5-823 and 5-821 and the ICD (International Statistical Classification of Diseases and Related Health Problems) codes T84.5, T84.7 or T84.8 were used. All patients with PJI of a previous THA and TKA who underwent revision surgery were retrieved and included for analysis. RESULTS Data from 346 patients were collected (181 THAs and 165 TKAs). 44% (152 of 346 patients) were women. Overall, the mean age at operation was 67.8 years, and the mean BMI was 29.2 kg/m2. The mean hospitalization length was 23.5 days. 38% (132 of 346) of patients presented a recurrent infection. CONCLUSION PJI remain a frequent cause for revisions after total hip and knee arthroplasty. Preoperative synovial fluid aspiration was positive in 37%, intraoperative microbiology was positive in 85%, and bacteraemia was present in 17% of patients. Septic shock was the major cause of in-hospital mortality. The most common cultured pathogens were Staph. epidermidis, Staph. aureus, Enterococcus faecalis, and Methicillin-resistant Staph aureus (MRSA). An improved understanding of PJI pathogens is important to plan treatment strategies and guide the choice of empirical antibiotic regimens in patients presenting with septic THAs and TKAs. LEVEL OF EVIDENCE Level III, retrospective cohort study.
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Affiliation(s)
- Filippo Migliorini
- Department of Orthopaedic, Trauma, and Reconstructive Surgery, RWTH University Hospital, Pauwelsstraße 30, 52074, Aachen, Germany.
- Department of Orthopaedic and Trauma Surgery, Eifelklinik St. Brigida, 52152, Simmerath, Germany.
| | - Christian David Weber
- Department of Orthopaedic, Trauma, and Reconstructive Surgery, RWTH University Hospital, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Andreas Bell
- Department of Orthopaedic and Trauma Surgery, Eifelklinik St. Brigida, 52152, Simmerath, Germany
| | - Marcel Betsch
- Department of Orthopaedic and Trauma Surgery, University Hospital of Erlangen, 91054, Erlangen, Germany
| | - Nicola Maffulli
- Department of Medicine, Surgery and Dentistry, University of Salerno, 84081, Baronissi, Italy.
- School of Pharmacy and Bioengineering, Faculty of Medicine, Keele University, Stoke On Trent, ST4 7QB, UK.
- Centre for Sports and Exercise Medicine, Barts and the London School of Medicine and Dentistry, Mile End Hospital, Queen Mary University of London, 275 Bancroft Road, London, E1 4DG, UK.
| | - Vanessa Poth
- Department of Orthopaedic, Trauma, and Reconstructive Surgery, RWTH University Hospital, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Ulf Krister Hofmann
- Department of Orthopaedic, Trauma, and Reconstructive Surgery, RWTH University Hospital, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Frank Hildebrand
- Department of Orthopaedic, Trauma, and Reconstructive Surgery, RWTH University Hospital, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Arne Driessen
- Department of Orthopaedic, Trauma, and Reconstructive Surgery, RWTH University Hospital, Pauwelsstraße 30, 52074, Aachen, Germany
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11
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Martin A, Loubet P, Salipante F, Laffont-Lozes P, Mazet J, Lavigne JP, Cellier N, Sotto A, Larcher R. Clinical Features and Outcomes of Enterococcal Bone and Joint Infections and Factors Associated with Treatment Failure over a 13-Year Period in a French Teaching Hospital. Microorganisms 2023; 11:1213. [PMID: 37317187 DOI: 10.3390/microorganisms11051213] [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: 04/14/2023] [Revised: 05/01/2023] [Accepted: 05/04/2023] [Indexed: 06/16/2023] Open
Abstract
Enterococcal bone and joint infections (BJIs) are reported to have poor outcomes, but there are conflicting results. This study aimed to describe the clinical characteristics and outcomes of patients with enterococcal BJI and to assess the factors associated with treatment failure. We conducted a retrospective cohort study at Nimes University Hospital from January 2007 to December 2020. The factors associated with treatment failure were assessed using a Cox model. We included 90 consecutive adult patients, 11 with native BJIs, 40 with prosthetic joint infections and 39 with orthopedic implant-associated infections. Two-thirds of patients had local signs of infection, but few (9%) had fever. Most BJIs were caused by Enterococcus faecalis (n = 82, 91%) and were polymicrobial (n = 75, 83%). The treatment failure rate was 39%, and treatment failure was associated with coinfection with Staphylococcus epidermidis (adjusted hazard ratio = 3.04, confidence interval at 95% [1.31-7.07], p = 0.01) and with the presence of local signs of inflammation at the time of diagnosis (aHR = 2.39, CI 95% [1.22-4.69], p = 0.01). Our results confirm the poor prognosis of enterococcal BJIs, prompting clinicians to carefully monitor for local signs of infection and to optimize the medical-surgical management in case of coinfections, especially with S. epidermidis.
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Affiliation(s)
- Aurélie Martin
- Infectious and Tropical Diseases Department, Nimes University Hospital, 30000 Nimes, France
| | - Paul Loubet
- Infectious and Tropical Diseases Department, Nimes University Hospital, 30000 Nimes, France
- VBIC (Bacterial Virulence and Chronic Infection), INSERM (French Institute of Health and Medical Research), Montpellier University, 30908 Nimes, France
| | - Florian Salipante
- Department of Biostatistics, Epidemiology, Public Health, and Innovation in Methodology (BESPIM), Nimes University Hospital, 30000 Nimes, France
| | - Paul Laffont-Lozes
- Infectious and Tropical Diseases Department, Nimes University Hospital, 30000 Nimes, France
- Department of Pharmacy, Nimes University Hospital, 30000 Nimes, France
| | - Julien Mazet
- Infectious and Tropical Diseases Department, Nimes University Hospital, 30000 Nimes, France
| | - Jean-Philippe Lavigne
- VBIC (Bacterial Virulence and Chronic Infection), INSERM (French Institute of Health and Medical Research), Montpellier University, 30908 Nimes, France
- Department of Microbiology and Hospital Hygiene, Nimes University Hospital, 30000 Nimes, France
| | - Nicolas Cellier
- Department of Orthopedic Surgery and Traumatology, Nimes University Hospital, 30000 Nimes, France
| | - Albert Sotto
- Infectious and Tropical Diseases Department, Nimes University Hospital, 30000 Nimes, France
- VBIC (Bacterial Virulence and Chronic Infection), INSERM (French Institute of Health and Medical Research), Montpellier University, 30908 Nimes, France
| | - Romaric Larcher
- Infectious and Tropical Diseases Department, Nimes University Hospital, 30000 Nimes, France
- PhyMedExp (Physiology and Experimental Medicine), INSERM (French Institute of Health and Medical Research), CNRS (French National Centre for Scientific Research), University of Montpellier, 34090 Montpellier, France
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12
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Deckey DG, Christopher ZK, Bingham JS, Spangehl MJ. Principles of mechanical and chemical debridement with implant retention. ARTHROPLASTY 2023; 5:16. [PMID: 37020248 PMCID: PMC10077701 DOI: 10.1186/s42836-023-00170-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2022] [Accepted: 01/17/2023] [Indexed: 04/07/2023] Open
Abstract
BACKGROUND Periprosthetic joint infection (PJI) is one of the most common causes of early revision for total hip and knee arthroplasty. Mechanical and chemical debridement typically referred to as debridement, antibiotics, and implant retention (DAIR) can be a successful technique to eradicate PJI in acute postoperative or acute hematogenous infections. This review will focus specifically on the indications, techniques, and outcomes of DAIR. DISCUSSION The success of mechanical and chemical debridement, or a DAIR operation, is reliant on a combination of appropriate patient selection and meticulous technique. There are many technical considerations to take into consideration. One of the most important factors in the success of the DAIR procedure is the adequacy of mechanical debridement. Techniques are surgeon-specific and perhaps contribute to the large variability in the literature on the success of DAIR. Factors that have been shown to be associated with success include the exchange of modular components, performing the procedure within seven days or less of symptom onset, and possibly adjunctive rifampin or fluoroquinolone therapy, though this remains controversial. Factors that have been associated with failure include rheumatoid arthritis, age greater than 80 years, male sex, chronic renal failure, liver cirrhosis, and chronic obstructive pulmonary disease. CONCLUSIONS DAIR is an effective treatment option for the management of an acute postoperative or hematogenous PJI in the appropriately selected patient with well-fixed implants.
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Affiliation(s)
- David G Deckey
- Department of Orthopaedic Surgery, Mayo Clinic, Phoenix, AZ, 85054, USA
| | | | - Joshua S Bingham
- Department of Orthopaedic Surgery, Mayo Clinic, Phoenix, AZ, 85054, USA
| | - Mark J Spangehl
- Department of Orthopaedic Surgery, Mayo Clinic, Phoenix, AZ, 85054, USA.
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13
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Brooks JR, Chonko DJ, Pigott M, Sullivan AC, Moore K, Stoodley P. Mapping bacterial biofilm on explanted orthopedic hardware: An analysis of 14 consecutive cases. APMIS 2023; 131:170-179. [PMID: 36656746 PMCID: PMC10012203 DOI: 10.1111/apm.13295] [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: 01/12/2023] [Accepted: 01/18/2023] [Indexed: 01/20/2023]
Abstract
Hardware implanted during primary total joint arthroplasty carries a serious risk for periprosthetic joint infection (PJI). The formation of bacterial biofilms, which are highly tolerant of antibiotics and host immunity, is recognized as being a major barrier to treatment. It is not known whether some components and their surface features are more prone to biofilm than others. This study attempted to map biofilm on different components and features of orthopedic hardware recovered during revision. Implant surface culture (ISC) was used on 53 components from 14 hip and knee revisions. ISC achieves a thin agar coating over components, followed by incubation and observation for colony outgrowth over 9 days. Recovered organisms were identified by selective culture and 16s rRNA sequencing. Outcomes were compared with clinical culturing and PJI diagnosis based on 2013 Musculoskeletal Infection Society criteria. ISC paralleled clinical culturing with a sensitivity of 100% and a specificity of 57.1%. When compared to Musculoskeletal Infection Society criteria, sensitivity remained at 100% while specificity was 80%. Biofilm accumulation was patchy and heterogeneous throughout different prostheses, though notably the non-articulating surfaces between the tibial tray and polyethylene insert showed consistent growth. On individual components, ridges and edges consistently harbored biofilm, while growth elsewhere was case dependent. ISC successfully identified microbial growth with high sensitivity while also revealing that biofilm growth was commonly localized to particular locations. Understanding where biofilm formation occurs most often on implanted hardware will help guide debridement, retention choices, and implant design.
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Affiliation(s)
- Jacob R Brooks
- Medical Student Research Program, The Ohio State University College of Medicine, Columbus, Ohio, USA.,Department of Microbial Infection and Immunity, Wexner Medical Center, The Ohio State University, Columbus, Ohio, USA
| | - Douglas J Chonko
- Department of Orthopaedics, Wexner Medical Center, The Ohio State University, Columbus, Ohio, USA
| | - Matthew Pigott
- Department of Orthopaedics, Wexner Medical Center, The Ohio State University, Columbus, Ohio, USA
| | - Anne C Sullivan
- Department of Orthopaedics, Wexner Medical Center, The Ohio State University, Columbus, Ohio, USA
| | - Kelly Moore
- Department of Microbial Infection and Immunity, Wexner Medical Center, The Ohio State University, Columbus, Ohio, USA
| | - Paul Stoodley
- Department of Microbial Infection and Immunity, Wexner Medical Center, The Ohio State University, Columbus, Ohio, USA.,Department of Orthopaedics, Wexner Medical Center, The Ohio State University, Columbus, Ohio, USA
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14
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Diagnostic Role of mNGS in Polymicrobial Periprosthetic Joint Infection. J Clin Med 2023; 12:jcm12051838. [PMID: 36902625 PMCID: PMC10003677 DOI: 10.3390/jcm12051838] [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: 10/24/2022] [Revised: 02/02/2023] [Accepted: 02/21/2023] [Indexed: 03/03/2023] Open
Abstract
OBJECTIVES The purpose of this study was to explore the clinical value of metagenomic next-generation sequencing (mNGS) in the diagnosis of polymicrobial periprosthetic joint infection (PJI). METHODS Patients with complete data who underwent surgery at our hospital between July 2017 and January 2021 for suspected periprosthetic joint infection (PJI), according to the 2018 ICE diagnostic criteria, were enrolled, and all patients underwent microbial culture and mNGS detection, which were performed on the BGISEQ-500 platform. Microbial cultures were performed on two samples of synovial fluid, six samples of tissue, and two samples of prosthetic sonicate fluid for each patient. The mNGS was performed on 10 tissues, 64 synovial fluid samples, and 17 prosthetic sonicate fluid samples. The results of mNGS testing were based on the interpretation of mNGS results in the previous literature and the assertions of microbiologists and orthopedic surgeons. The diagnostic efficacy of mNGS in polymicrobial PJI was assessed by comparing the results of conventional microbial cultures and mNGS. RESULTS A total of 91 patients were finally enrolled in this study. The sensitivity, specificity, and accuracy of conventional culture for the diagnosis of PJI were 71.0%, 95.4%, and 76.9%, respectively. The sensitivity, specificity, and accuracy of mNGS for the diagnosis of PJI were 91.3%, 86.3%, and 90.1%, respectively. The sensitivity, specificity, and accuracy of conventional culture for the diagnosis of polymicrobial PJI were 57.1%, 100%, and 91.3%, respectively. mNGS had a sensitivity, specificity, and accuracy of 85.7%, 60.0%, and 65.2%, respectively, for the diagnosis of polymicrobial PJI. CONCLUSIONS mNGS can improve the diagnosis efficiency of polymicrobial PJI, and the combination of culture and mNGS is a promising method to diagnose polymicrobial PJI.
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15
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Karczewski D, Schönnagel L, Hipfl C, Akgün D, Hardt S. Periprosthetic hip infection in octogenarians : a single institution experience of 33 cases. Bone Joint J 2023; 105-B:135-139. [PMID: 36722065 DOI: 10.1302/0301-620x.105b2.bjj-2022-1035.r1] [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] [Indexed: 02/02/2023]
Abstract
AIMS Periprosthetic joint infection (PJI) in total hip arthroplasty in the elderly may occur but has been subject to limited investigation. This study analyzed infection characteristics, surgical outcomes, and perioperative complications of octogenarians undergoing treatment for PJI in a single university-based institution. METHODS We identified 33 patients who underwent treatment for PJIs of the hip between January 2010 and December 2019 using our institutional joint registry. Mean age was 82 years (80 to 90), with 19 females (57%) and a mean BMI of 26 kg/m2 (17 to 41). Mean American Society of Anesthesiologists (ASA) grade was 3 (1 to 4) and mean Charlson Comorbidity Index was 6 (4 to 10). Leading pathogens included coagulase-negative Staphylococci (45%) and Enterococcus faecalis (9%). Two-stage exchange was performed in 30 joints and permanent resection arthroplasty in three. Kaplan-Meier survivorship analyses were performed. Mean follow-up was five years (3 to 7). RESULTS The two-year survivorship free of any recurrent PJI was 72% (95% confidence interval (CI) 56 to 89; 18 patients at risk). There were a total of nine recurrent PJIs at a mean of one year (16 days to eight years), one for the same pathogen as at index infection. One additional surgical site infection was noted at two weeks, resulting in a 69% (95% CI 52 to 86; 17 patients at risk) survivorship free of any infection at two years. There were two additional revisions for dislocations at one month each. As such, the two-year survivorship free of any revision was 61% (95% CI 42 to 80; 12 patients at risk). In addition to the aforementioned revisions, there was one additional skin grafting for a decubitus ulcer, resulting in a survivorship free of any reoperation of 54% (95% CI 35 to 73; ten patients at risk) at two years. Mean Clavien-Dindo score of perioperative complications was two out of five, with one case of perioperative death noted at six days. CONCLUSION Octogenarians undergoing surgery for PJI of the hip are at low risk of acute mortality, but are at moderate risk of other perioperative complications. One in two patients will undergo a reoperation within two years, with 70% attributable to recurrent infections.Cite this article: Bone Joint J 2023;105-B(2):135-139.
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Affiliation(s)
- Daniel Karczewski
- Department of Orthopaedic Surgery, Musculoskeletal Oncology Service, Massachusetts General Hospital-Harvard Medical School, Boston, Massachusetts, USA.,Department of Orthopaedic Surgery and Traumatology, Charité Berlin, University Hospital, Berlin, Germany
| | - Lukas Schönnagel
- Department of Orthopaedic Surgery, Musculoskeletal Oncology Service, Massachusetts General Hospital-Harvard Medical School, Boston, Massachusetts, USA
| | - Christian Hipfl
- Department of Orthopaedic Surgery, Musculoskeletal Oncology Service, Massachusetts General Hospital-Harvard Medical School, Boston, Massachusetts, USA
| | - Doruk Akgün
- Department of Orthopaedic Surgery, Musculoskeletal Oncology Service, Massachusetts General Hospital-Harvard Medical School, Boston, Massachusetts, USA
| | - Sebastian Hardt
- Department of Orthopaedic Surgery, Musculoskeletal Oncology Service, Massachusetts General Hospital-Harvard Medical School, Boston, Massachusetts, USA
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16
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Prosthetic Knee Infection With Coagulase-Negative Staphylococcus: A Harbinger of Poor Outcomes. J Arthroplasty 2022; 37:S313-S320. [PMID: 35196567 DOI: 10.1016/j.arth.2022.02.050] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Revised: 02/10/2022] [Accepted: 02/11/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Coagulase-negative staphylococci (CoNS) are biofilm-producing pathogens whose role in periprosthetic joint infection (PJI) is increasing. There is little data on the prognosis and treatment considerations in the setting of PJI. We sought to evaluate the clinical characteristics, outcomes, and complications in these patients. METHODS This is a retrospective cohort study of adult patients at a single tertiary medical center from 2009 to 2020 with culture-proven CoNS PJI after total knee arthroplasty, as diagnosed by Musculoskeletal Infection Society criteria. The primary outcome was treatment success, with failure defined as recurrent CoNS PJI, recurrent PJI with a new pathogen, and/or chronic oral antibiotic suppression at one year postoperatively. RESULTS We identified 55 patients with a CoNS total knee arthroplasty PJI with a mean follow-up of 29.8 months (SD: 16.3 months). The most commonly isolated organism was Staphylococcus epidermidis (n = 36, 65.5%). The overall prevalence of methicillin resistance was 63%. Surgical treatment included surgical debridement, antibiotics, and implant retention in 25 (45.5%) cases and two-stage revision (22 articulating and eight static antibiotic-impregnated spacers). At one-year follow-up, only 47% of patients had successful management of their infection. The surgical debridement, antibiotics, and implant retention cohort had the higher rate of treatment failure (60.0%) compared to two-stage revision (46.7%). CONCLUSION These results indicate a poor rate of success in treating CoNS PJI. This likely represents the interplay of inherent virulence through biofilm formation and decreased antibiotic efficacy.
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17
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Le Vavasseur B, Zeller V. Antibiotic Therapy for Prosthetic Joint Infections: An Overview. Antibiotics (Basel) 2022; 11:486. [PMID: 35453237 PMCID: PMC9025623 DOI: 10.3390/antibiotics11040486] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Revised: 03/29/2022] [Accepted: 04/02/2022] [Indexed: 02/04/2023] Open
Abstract
Prosthetic joint infection (PJI) is a severe complication after arthroplasty. Its management combines surgical intervention, whose type depends on the clinical situation, and prolonged high-dose antibiotics adapted to the responsible microorganism(s) and the patient. Antibiotics are only one part of the therapeutic regimen and are closely related to the surgical strategy. Their efficacy depends to a large extent on the choice and quality of the surgical procedure, and the quality of the microbiological diagnosis. Although guidelines have been published, many aspects of antibiotic therapy remain poorly established. Choosing the optimal agent(s) is one aspect, with others being optimization of drugs' pharmacokinetic/pharmacodynamic parameters, the choice of administration route, use of monotherapy or combination regimens, therapeutic drug-monitoring and patient education to improve compliance and tolerance. Herein, we address PJI management based on recent literature data, guidelines and the experience of our referral center for complex bone-and-joint infections.
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Affiliation(s)
- Benjamin Le Vavasseur
- Referral Center for Complex Bone and Joint Infections, Diaconesses Croix Saint-Simon Hospital, 75020 Paris, France;
- Department of Internal Medicine and Infectious Diseases, Diaconesses Croix Saint-Simon Hospital, 75020 Paris, France
| | - Valérie Zeller
- Referral Center for Complex Bone and Joint Infections, Diaconesses Croix Saint-Simon Hospital, 75020 Paris, France;
- Department of Internal Medicine and Infectious Diseases, Diaconesses Croix Saint-Simon Hospital, 75020 Paris, France
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18
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Lev K, Kunz Coyne AJ, Kebriaei R, Morrisette T, Stamper K, Holger DJ, Canfield GS, Duerkop BA, Arias CA, Rybak MJ. Evaluation of Bacteriophage-Antibiotic Combination Therapy for Biofilm-Embedded MDR Enterococcus faecium. Antibiotics (Basel) 2022; 11:antibiotics11030392. [PMID: 35326855 PMCID: PMC8944492 DOI: 10.3390/antibiotics11030392] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 02/22/2022] [Accepted: 03/05/2022] [Indexed: 02/03/2023] Open
Abstract
Multidrug-resistant (MDR) Enterococcus faecium is a challenging pathogen known to cause biofilm-mediated infections with limited effective therapeutic options. Lytic bacteriophages target, infect, and lyse specific bacterial cells and have anti-biofilm activity, making them a possible treatment option. Here, we examine two biofilm-producing clinical E. faecium strains, daptomycin (DAP)-resistant R497 and DAP-susceptible dose-dependent (SDD) HOU503, with initial susceptibility to E. faecium bacteriophage 113 (ATCC 19950-B1). An initial synergy screening was performed with modified checkerboard MIC assays developed by our laboratory to efficiently screen for antibiotic and phage synergy, including at very low phage multiplicity of infection (MOI). The data were compared by one-way ANOVA and Tukey (HSD) tests. In 24 h time kill analyses (TKA), combinations with phage-DAP-ampicillin (AMP), phage-DAP-ceftaroline (CPT), and phage-DAP-ertapenem (ERT) were synergistic and bactericidal compared to any single agent (ANOVA range of mean differences 3.34 to 3.84 log10 CFU/mL; p < 0.001). Furthermore, phage-DAP-AMP and phage-DAP-CPT prevented the emergence of DAP and phage resistance. With HOU503, the combination of phage-DAP-AMP showed the best killing effect, followed closely by phage-DAP-CPT; both showed bactericidal and synergistic effects compared to any single agent (ANOVA range of mean differences 3.99 to 4.08 log10 CFU/mL; p < 0.001).
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Affiliation(s)
- Katherine Lev
- Anti-Infective Research Laboratory, College of Pharmacy and Health Sciences, Wayne State University, Detroit, MI 48201, USA; (K.L.); (A.J.K.C.); (R.K.); (K.S.); (D.J.H.)
| | - Ashlan J. Kunz Coyne
- Anti-Infective Research Laboratory, College of Pharmacy and Health Sciences, Wayne State University, Detroit, MI 48201, USA; (K.L.); (A.J.K.C.); (R.K.); (K.S.); (D.J.H.)
| | - Razieh Kebriaei
- Anti-Infective Research Laboratory, College of Pharmacy and Health Sciences, Wayne State University, Detroit, MI 48201, USA; (K.L.); (A.J.K.C.); (R.K.); (K.S.); (D.J.H.)
| | - Taylor Morrisette
- Department of Pharmacy and Clinical Services, Medical University of South Carolina College of Pharmacy, Charleston, SC 29208, USA;
| | - Kyle Stamper
- Anti-Infective Research Laboratory, College of Pharmacy and Health Sciences, Wayne State University, Detroit, MI 48201, USA; (K.L.); (A.J.K.C.); (R.K.); (K.S.); (D.J.H.)
| | - Dana J. Holger
- Anti-Infective Research Laboratory, College of Pharmacy and Health Sciences, Wayne State University, Detroit, MI 48201, USA; (K.L.); (A.J.K.C.); (R.K.); (K.S.); (D.J.H.)
| | - Gregory S. Canfield
- Department of Immunology and Microbiology, University of Colorado School of Medicine, Aurora, CO 80045, USA; (G.S.C.); (B.A.D.)
- Department of Infectious Diseases, University of Colorado School of Medicine, Aurora, CO 80045, USA
| | - Breck A. Duerkop
- Department of Immunology and Microbiology, University of Colorado School of Medicine, Aurora, CO 80045, USA; (G.S.C.); (B.A.D.)
| | - Cesar A. Arias
- Division of Infectious Diseases, Houston Methodist Hospital, Houston, TX 77030, USA;
- Center for Infectious Diseases Research, Houston Methodist Research Institute, Houston, TX 77030, USA
| | - Michael J. Rybak
- Anti-Infective Research Laboratory, College of Pharmacy and Health Sciences, Wayne State University, Detroit, MI 48201, USA; (K.L.); (A.J.K.C.); (R.K.); (K.S.); (D.J.H.)
- School of Medicine, Wayne State University, Detroit, MI 48201, USA
- Correspondence:
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19
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Russo A, Cavagnaro L, Chiarlone F, Alessio-Mazzola M, Felli L, Burastero G. Predictors of failure of two-stage revision in periprosthetic knee infection: a retrospective cohort study with a minimum two-year follow-up. Arch Orthop Trauma Surg 2022; 142:481-490. [PMID: 34812921 DOI: 10.1007/s00402-021-04265-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Accepted: 11/14/2021] [Indexed: 10/19/2022]
Abstract
PURPOSE Despite the standardization of two-stage knee revision protocols, a high percentage of failures still occurs. Identifying the predictors of failure is necessary to determine appropriate management and counsel for patients with a periprosthetic knee infection. This study aimed to identify risk factors predicting the failure, to describe implant survival, and to report the mid-term clinical outcomes of patients undergoing two-stage revision for periprosthetic knee infection. METHODS Data of patients who underwent two-stage knee revision from 2012 to 2016 were analyzed, and 108 patients were included. The mean age was 66.6 ± 9.2 years. The mean follow-up was 52.9 ± 15.6 months. Logistic regression was conducted to identify predictors of treatment failure. Kaplan-Meier curves were generated to assess implant survival. Preoperative functional outcomes were compared to those registered at the final follow-up. RESULTS Difficult-to-treat infections (OR = 4.2, 95% CI 1.2-14.5, p = 0.025), the number of previous surgeries (OR = 1.8, 95% CI 1.2-2.6, p = 0.005), and the level of tibial bone defect (OR = 2.3, 95% CI 1.1-4.7, p = 0.027) significantly predicted the failure of two-stage knee revision. Survivorship of implants was significantly lower for patients presenting these risk factors (p < 0.05). Mean Knee Society Score improved from 49.0 ± 12.0 to 80.2 ± 13.6 (p < 0.001). Mean Oxford Knee Score improved from 22.2 ± 4.9 to 36.1 ± 6.0 points (p < 0.001). CONCLUSION Difficult-to-treat pathogens, the number of previous surgeries, and the level of tibial bone defect were independent risk factors of two-stage knee revision failure. Overall, the two-stage protocol provided a good survival rate and functional outcome.
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Affiliation(s)
- Antonio Russo
- Orthopaedic Clinic, Ospedale Policlinico San Martino, Largo R. Benzi 10, 16132, Genoa, Italy.,Department of Surgical Sciences and Integrated Diagnostic (DISC), University of Genoa, Viale Benedetto XV 6, 16132, Genoa, Italy
| | - Luca Cavagnaro
- Joint Arthroplasty Unit, Orthopaedic and Traumatology 2, Santa Corona Hospital, Viale 25 Aprile 38, 17027, Pietra Ligure, Italy
| | - Francesco Chiarlone
- Joint Arthroplasty Unit, Orthopaedic and Traumatology 2, Santa Corona Hospital, Viale 25 Aprile 38, 17027, Pietra Ligure, Italy
| | - Mattia Alessio-Mazzola
- Orthopaedic Clinic, Ospedale Policlinico San Martino, Largo R. Benzi 10, 16132, Genoa, Italy.,Department of Surgical Sciences and Integrated Diagnostic (DISC), University of Genoa, Viale Benedetto XV 6, 16132, Genoa, Italy
| | - Lamberto Felli
- Orthopaedic Clinic, Ospedale Policlinico San Martino, Largo R. Benzi 10, 16132, Genoa, Italy.,Department of Surgical Sciences and Integrated Diagnostic (DISC), University of Genoa, Viale Benedetto XV 6, 16132, Genoa, Italy
| | - Giorgio Burastero
- Prosthetic Surgery Centre, IRCCS Istituto Ortopedico Galeazzi, Via Riccardo Galeazzi 4, 20161, Milan, Italy.
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20
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Sotiriou D, Stigbrand H, Ullmark G. Is two-stage revision surgery for infected hip arthroplasty worth the suffering, resources and results compared to one-stage? Hip Int 2022; 32:205-212. [PMID: 32777947 DOI: 10.1177/1120700020949162] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
PURPOSE Periprosthetic joint infection (PJI) is the most serious complication of total hip arthroplasty. The treatment is usually revision in either 1 or 2 stages. This study analyses revision with impaction bone grafting for periprosthetic joint infection of the hip and compares 1- and 2-stage strategies. PATIENTS AND METHODS We reviewed 55 consecutive cases (54 patients) of revision arthroplasty for PJI carried out at our hospital between 2002 and 2016. Of these, 46 were 2-stage procedures. 21 had vancomycin mixed in with the bone graft, and all had gentamycin-containing bone cement. The total perioperative blood loss, duration of operation, and length of hospital stay were recorded. Clinical and radiological results were analysed for 48 hips at 2-16 years follow-up. RESULTS No PJI remained at follow-up. 3 patients (6%) had undergone revision for all causes. 1 had radiological signs of mechanical loosening but was not revised. 2-stage procedures had a significantly longer operating time (409 vs. 238 min) and hospital stay (34 vs. 13 days), greater blood loss (2764 vs. 1638 ml), and lower mean functional hip score (15.9 vs. 17.5) at follow-up than the one-stage procedures. INTERPRETATION Revision total hip arthroplasty for PJI with vancomycin-loaded impaction bone grafting is a safe method that achieves both the restoration of bone stock and resolution of the infection. This single-stage procedure could therefore be the new gold standard for treatment of non-complicated PJI in the hip.
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Affiliation(s)
- Dimitrios Sotiriou
- Department of Orthopaedics, Gävle Hospital and Centre for Research and Development Uppsala University/County Council of Gävleborg, Sweden
| | - Hampus Stigbrand
- Department of Orthopaedics, Gävle Hospital and Centre for Research and Development Uppsala University/County Council of Gävleborg, Sweden
| | - Gösta Ullmark
- Department of Orthopaedics, Gävle Hospital and Centre for Research and Development Uppsala University/County Council of Gävleborg, Sweden
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21
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The Fate of Periprosthetic Joint Infection With Corynebacterium striatum: A Rare but Catastrophic Causative Organism. J Arthroplasty 2022; 37:142-149. [PMID: 34624507 DOI: 10.1016/j.arth.2021.09.023] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Revised: 09/24/2021] [Accepted: 09/28/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND The virulence and antibiotic resistance profile of an infecting organism have been shown to impact the outcomes of periprosthetic joint infection (PJI). However, there are no existing data on the outcomes of PJI caused by Corynebacterium striatum, a rare organism. Thus, our objective is to ascertain: (1) the treatment success of PJI caused by this rare organism and (2) patient characteristics in the setting of C striatum PJI. METHODS A retrospective review was conducted on 741 consecutive PJIs managed at 2 hospital facilities by 8 surgeons (February 4, 2015 to October 30, 2019). The inclusion criteria represented the presence of minimum 1 positive culture of C. striatum. After excluding 1 patient with no follow-up, 15 patients were finally analyzed (9 hips/6 knees). Out of 15 patients, 9 underwent explantation with spacer insertion, 5 underwent irrigation and debridement with polyexchange (I&D), and 1 underwent Girdlestone. Out of 9 explanted patients, only 6 cleared infection and were reimplanted. The clinical staging system for PJI was determined using McPherson classification. The mean follow-ups for I&D and explantation were 35 and 23.5 months, respectively. Success of reimplantation was determined using Delphi criteria. RESULTS Out of 5 I&D patients, 40% had to be reoperated because of persistent infection. Out of 6 explanted patients who were reimplanted, 67% failed. According to McPherson, 40% of I&D and 22.2% of explanted patients were significantly compromised hosts. CONCLUSION C. striatum PJI has a high-treatment failure rate in patient undergoing I&D or 2-stage revision surgery. Surgeons should be aware of the difficulty controlling this PJI and advise patients accordingly.
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22
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Lee SH, Chang CH, Hu CC, Chang Y, Hsieh PH, Lin YC. The Risk Factor and Outcome of Metachronous Periprosthetic Joint Infections: A Retrospective Analysis With a Minimum Ten-Year Follow-Up. J Arthroplasty 2021; 36:3734-3740. [PMID: 34419315 DOI: 10.1016/j.arth.2021.07.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Revised: 07/20/2021] [Accepted: 07/29/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Patients with multiple prosthetic joints are at risk of developing periprosthetic joint infections (PJIs). We aimed to determine whether PJI development at one site may lead to infection at another prosthetic joint site and assess the risk factors leading to this subsequent infection. METHODS We reviewed all cases (294 patients with first-time PJI [159 hips, 135 knees]) with PJI treated at our institute between January 1994 and December 2020. The average follow-up period was 11.2 years (range 10.1-23.2). Patients were included if they had at least one other prosthetic joint at the time of developing a single PJI (96 patients). Patients with synchronous PJI were excluded from the study. The incidence of metachronous PJI was assessed, and the risk factors were determined by comparing different characteristics between patients without metachronous PJI. RESULTS Of the 96 patients, 19.79% developed metachronous PJI. The identified causative pathogen was the same in 63.16% of the patients. The time to developing a second PJI was 789.84 days (range 10-3386). The identified risk factors were PJI with systemic inflammatory response syndrome, ≥3 stages of resection arthroplasty, and PJI caused by methicillin-resistant Staphylococcus aureus. CONCLUSION PJI may predispose patients to subsequent PJI in another prosthesis with identified risks. Most causative organisms of metachronous PJI were the same species as those of the first PJI. We believe that bacteremia may be involved in pathogenesis, but further research is required.
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Affiliation(s)
- Sheng-Hsun Lee
- Department of Orthopaedic Surgery, Chang Gung Memorial Hospital (CGMH), Taoyuan, Taiwan; Bone and Joint Research Center, Chang Gung Memorial Hospital (CGMH), Taoyuan, Taiwan; College of Medicine, Chang Gung University (CGU), Taoyuan, Taiwan
| | - Chih-Hsiang Chang
- Department of Orthopaedic Surgery, Chang Gung Memorial Hospital (CGMH), Taoyuan, Taiwan; Bone and Joint Research Center, Chang Gung Memorial Hospital (CGMH), Taoyuan, Taiwan; College of Medicine, Chang Gung University (CGU), Taoyuan, Taiwan
| | - Chih-Chien Hu
- Department of Orthopaedic Surgery, Chang Gung Memorial Hospital (CGMH), Taoyuan, Taiwan; Bone and Joint Research Center, Chang Gung Memorial Hospital (CGMH), Taoyuan, Taiwan; College of Medicine, Chang Gung University (CGU), Taoyuan, Taiwan
| | - Yuhan Chang
- Department of Orthopaedic Surgery, Chang Gung Memorial Hospital (CGMH), Taoyuan, Taiwan; Bone and Joint Research Center, Chang Gung Memorial Hospital (CGMH), Taoyuan, Taiwan; College of Medicine, Chang Gung University (CGU), Taoyuan, Taiwan
| | - Pang-Hsin Hsieh
- Department of Orthopaedic Surgery, Chang Gung Memorial Hospital (CGMH), Taoyuan, Taiwan; Bone and Joint Research Center, Chang Gung Memorial Hospital (CGMH), Taoyuan, Taiwan; College of Medicine, Chang Gung University (CGU), Taoyuan, Taiwan
| | - Yu-Chih Lin
- Department of Orthopaedic Surgery, Chang Gung Memorial Hospital (CGMH), Taoyuan, Taiwan; Bone and Joint Research Center, Chang Gung Memorial Hospital (CGMH), Taoyuan, Taiwan; College of Medicine, Chang Gung University (CGU), Taoyuan, Taiwan
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Eckers F, Laux CJ, Schaller S, Berli M, Achermann Y, Fucentese SF. Risk factor analysis for above-knee amputation in patients with periprosthetic joint infection of the knee: a case-control study. BMC Musculoskelet Disord 2021; 22:884. [PMID: 34663297 PMCID: PMC8525022 DOI: 10.1186/s12891-021-04757-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 09/28/2021] [Indexed: 11/29/2022] Open
Abstract
Background Periprosthetic joint infection (PJI) is a severe complication following knee arthroplasty. Therapeutic strategies comprise a combination of surgical and antibiotic treatment modalities and aim to eradicate the infection. Sometimes control of the disease can only be attained by above-knee amputation (AKA). While a vast amount of literature exists illuminating predisposing factors for PJI, risk factors favoring the endpoint AKA in this context are sparsely known. Methods The purpose of this investigation was to delineate whether patients with PJI of the knee present specific risk factors for AKA. In a retrospective case-control study 11 cases of PJI treated with AKA were compared to 57 cases treated with limb salvage (LS). The minimum follow-up was 2 years. Comorbidities, signs and symptoms of the current infection, factors related to previous surgeries and the implant, microbiology, as well as therapy related factors were recorded. Comparative analysis was performed using student’s t-test, chi-square test or Fisher’s exact test. Binary differences were calculated using odds ratio (OR). Reoperation frequency was compared using Mann-Whitney U test. In-depth descriptive analysis of 11 amputees was carried out. Results A total of 68 cases aged 71 ± 11.2 years were examined, 11 of which underwent AKA and 57 had LS. Severe comorbidities (p = 0.009), alcohol abuse (p = 0.015), and preoperative anemia (p = 0.022) were more frequently associated with AKA. Preoperative anemia was found in all 11 amputees (100%) and in 33 of 57 LS patients (58%) with an average preoperative hemoglobin of 99.9 ± 15.1 g/dl compared to 118.2 ± 19.9 g/dl (p = 0.011). No other parameters differed significantly. AKA patients underwent a median of eight (range 2–24) reoperations, LS patients a median of five (range 2–15). Conclusion Factors potentially influencing the outcome of knee PJI are diverse. The indication of AKA in this context remains a rarity and a case-by-case decision. Patient-intrinsic systemic factors such as alcohol abuse, severe comorbidities and preoperative anemia may elevate the individual risk for AKA in the setting of PJI. We recommend that anemia, being a condition well amenable to therapeutic measures, should be given special consideration in management of PJI patients. Trial registration This study was registered with Kantonale Ethikkommission Zürich, (BASEC-No. 2016–01048).
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Affiliation(s)
- Franziska Eckers
- Department of Orthopaedics, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008, Zurich, Switzerland.
| | - Christoph J Laux
- Department of Orthopaedics, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008, Zurich, Switzerland
| | - Sebastian Schaller
- Department of Orthopaedics, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008, Zurich, Switzerland
| | - Martin Berli
- Department of Orthopaedics, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008, Zurich, Switzerland
| | - Yvonne Achermann
- Department of Infectious Diseases and Hospital Epidemiologie, University Hospital Zurich, University of Zurich, Rämistrasse 100, 8091, Zurich, Switzerland
| | - Sandro F Fucentese
- Department of Orthopaedics, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008, Zurich, Switzerland
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Tuecking LR, Silligmann J, Savov P, Omar M, Windhagen H, Ettinger M. Detailed Revision Risk Analysis after Single- vs. Two-Stage Revision Total Knee Arthroplasty in Periprosthetic Joint Infection: A Retrospective Tertiary Center Analysis. Antibiotics (Basel) 2021; 10:antibiotics10101177. [PMID: 34680758 PMCID: PMC8533002 DOI: 10.3390/antibiotics10101177] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2021] [Revised: 09/13/2021] [Accepted: 09/23/2021] [Indexed: 01/03/2023] Open
Abstract
Periprosthetic joint infection (PJI) remains one of the most common causes of revision knee arthroplasty. Controversy continues to surround the proper operative technique of PJI in knee arthroplasty with single- or two-stage replacement. Significant variations are seen in the eradication rates of PJI and in implant survival rates. This detailed retrospective analysis of a single tertiary center is intended to provide further data and insight comparing single- and two-stage revision surgery. A retrospective analysis of all revision total knee arthroplasty (TKA) surgeries from 2013 to 2019 was performed and screened with respect to single- or two-stage TKA revisions. Single- and two-stage revisions were analyzed with regard to implant survival, revision rate, microbiological spectrum, and other typical demographic characteristics. A total of 63 patients were included, with 15 patients undergoing single-stage revision and 48 patients undergoing two-stage revision. The mean follow-up time was 40.7 to 43.7 months. Statistically, no difference was found between both groups in overall survival (54.4% vs. 70.1%, p = 0.68) and implant survival with respect to reinfection (71.4% vs. 82.4%, p = 0.48). Further, high reinfection rates were found for patients with difficult-to-treat organisms and low- to semi-constrained implant types, in comparison to constrained implant types. A statistically comparable revision rate for recurrence of infection could be shown for both groups, although a tendency to higher reinfection rate for single-stage change was evident. The revision rate in this single-center study was comparably high, which could be caused by the high comorbidity and high proportion of difficult-to-treat bacteria in patients at a tertiary center. In this patient population, the expectation of implant survival should be critically discussed with patients.
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Affiliation(s)
- Lars-Rene Tuecking
- Department of Orthopaedic Surgery, Hannover Medical School, Diakovere Annastift, Anna-von-Borries-Str. 1-7, 30625 Hannover, Germany; (L.-R.T.); (J.S.); (P.S.); (H.W.)
| | - Julia Silligmann
- Department of Orthopaedic Surgery, Hannover Medical School, Diakovere Annastift, Anna-von-Borries-Str. 1-7, 30625 Hannover, Germany; (L.-R.T.); (J.S.); (P.S.); (H.W.)
| | - Peter Savov
- Department of Orthopaedic Surgery, Hannover Medical School, Diakovere Annastift, Anna-von-Borries-Str. 1-7, 30625 Hannover, Germany; (L.-R.T.); (J.S.); (P.S.); (H.W.)
| | - Mohamed Omar
- Department of Trauma Surgery, Hannover Medical School, Carl-Neuberg-Strasse 1, 30625 Hanover, Germany;
| | - Henning Windhagen
- Department of Orthopaedic Surgery, Hannover Medical School, Diakovere Annastift, Anna-von-Borries-Str. 1-7, 30625 Hannover, Germany; (L.-R.T.); (J.S.); (P.S.); (H.W.)
| | - Max Ettinger
- Department of Orthopaedic Surgery, Hannover Medical School, Diakovere Annastift, Anna-von-Borries-Str. 1-7, 30625 Hannover, Germany; (L.-R.T.); (J.S.); (P.S.); (H.W.)
- Correspondence: ; Tel.: +49-511-5354-0
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Superinfection with Difficult-to-Treat Pathogens Significantly Reduces the Outcome of Periprosthetic Joint Infections. Antibiotics (Basel) 2021; 10:antibiotics10101145. [PMID: 34680726 PMCID: PMC8532792 DOI: 10.3390/antibiotics10101145] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Revised: 09/16/2021] [Accepted: 09/18/2021] [Indexed: 12/21/2022] Open
Abstract
Periprosthetic joint infection (PJI) is a serious complication after total joint arthroplasty. In the course of a PJI, superinfections with pathogens that do not match the primary infecting micro-organism may occur. To our knowledge, there are no published data on the outcome of such infections in the literature. The aim of this study was to assess the outcome of PJI with superinfections with a difficult-to-treat (DTT) pathogen. Data of 169 consecutive patients with PJI were retrospectively analyzed in this single-center study. Cases were categorized into: Group 1 including non-DTT-PJI without superinfection, Group 2 DTT-PJI without superinfection, Group 3 non-DTT-PJI with DTT superinfection, and Group 4 non-DTT-PJI with non-DTT superinfection. Group 3 comprised 24 patients and showed, after a mean follow-up of 13.5 ± 10.8 months, the worst outcome with infection resolution in 17.4% of cases (p = 0.0001), PJI-related mortality of 8.7% (p = 0.0001), mean revision rate of 6 ± 3.6 (p < 0.0001), and duration of antibiotic treatment of 71.2 ± 45.2 days (p = 0.0023). PJI caused initially by a non-DTT pathogen with a superinfection with a DTT pathogen is significantly associated with the worst outcome in comparison to non-DTT-PJI, PJI caused initially by a DTT pathogen, and to non-DTT-PJI with a non-DTT superinfection.
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Boyle KK, Kapadia M, Chiu YF, Khilnani T, Miller AO, Henry MW, Lyman S, Carli AV. The James A. Rand Young Investigator's Award: Are Intraoperative Cultures Necessary If the Aspiration Culture Is Positive? A Concordance Study in Periprosthetic Joint Infection. J Arthroplasty 2021; 36:S4-S10. [PMID: 33676815 DOI: 10.1016/j.arth.2021.01.073] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 01/14/2021] [Accepted: 01/26/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND The concordance between preoperative synovial fluid culture and multiple intraoperative tissue cultures for identifying pathogenic microorganisms in periprosthetic joint infection (PJI) remains unknown. Our aim is to determine the diagnostic performance of synovial fluid culture for early organism identification. METHODS A total of 363 patients who met Musculoskeletal Infection Society criteria for PJI following primary total joint arthroplasty were identified from a retrospective joint infection database. Inclusion criteria required a positive preoperative intra-articular synovial fluid sample within 90 days of intraoperative tissue culture(s) at revision surgery. Concordance was defined as matching organism(s) in aspirate and intraoperative specimens. RESULTS Concordance was identified in 279 (76.8%) patients with similar rates among total hip arthroplasties (77.2%) and total knee arthroplasties (76.4%, P = .86). Culture discordance occurred in 84 (23.1%) patients; 37 (10.2%) had no intraoperative culture growth and 33 (90.1%) were polymicrobial. Monomicrobial Staphylococcal PJI cases had high sensitivity (0.96, 95% confidence interval [CI] 0.92-0.98) and specificity (0.85, 95% CI 0.80-0.90). Polymicrobial infections had the lowest sensitivity (0.06, 95% CI 0.01-0.19). CONCLUSION Aspiration culture has favorable sensitivity and specificity when compared to tissue culture for identifying the majority of PJI organisms. Clinicians can guide surgical treatment and postoperative antibiotics based on monomicrobial aspiration results, but they should strongly consider collecting multiple tissue cultures to maximize the chance of identifying an underlying polymicrobial PJI. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- K Keely Boyle
- Department of Orthopaedics, Joint Replacement & Reconstruction, University at Buffalo, SUNY, Buffalo, NY
| | - Milan Kapadia
- Department of Infectious Diseases, Hospital for Special Surgery, New York, NY
| | - Yu-Fen Chiu
- Healthcare Research Institute, Hospital for Special Surgery, New York, NY
| | | | - Andy O Miller
- Department of Infectious Diseases, Hospital for Special Surgery, New York, NY
| | - Michael W Henry
- Department of Infectious Diseases, Hospital for Special Surgery, New York, NY
| | - Stephen Lyman
- Healthcare Research Institute, Hospital for Special Surgery, New York, NY; Department of Orthopedic Surgery, Adult Reconstruction and Joint Replacement, Hospital for Special Surgery, New York, NY
| | - Alberto V Carli
- Department of Orthopedic Surgery, Adult Reconstruction and Joint Replacement, Hospital for Special Surgery, New York, NY
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Buchalter DB, Teo GM, Kirby DJ, Schwarzkopf R, Aggarwal VK, Long WJ. Does the Organism Profile of Periprosthetic Joint Infections Change With a Topical Vancomycin Powder and Dilute Povidone-Iodine Lavage Protocol? J Arthroplasty 2021; 36:S314-S319. [PMID: 33526397 DOI: 10.1016/j.arth.2020.12.036] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2020] [Revised: 12/14/2020] [Accepted: 12/22/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND While vancomycin powder and dilute povidone-iodine (VIP) is associated with fewer total joint arthroplasty (TJA) periprosthetic joint infections (PJI), its effect on PJI organism profiles is unclear. This study evaluates primary TJA PJI organism profiles before and after the implementation of a VIP protocol. METHODS In total, 18,299 primary TJAs performed at a university-affiliated, not-for-profit orthopedic hospital from before (1/2012-12/2013) and after (1/2016-12/2019) a VIP protocol was initiated were reviewed to identify deep PJIs that occurred within 90 days of the index arthroplasty as defined by the Musculoskeletal Infection Society guidelines. Demographics, overall organism incidence (n/TJAs), and relative organism incidence (n/PJIs) from the two cohorts were compared. RESULTS In total, 103 TJA PJIs were identified (pre-VIP: 32/3982; VIP: 71/14,317). Following the introduction of VIP, the overall and relative incidence of coagulase-negative staphylococcal TJA PJIs significantly decreased (overall: 0.20% to 0.04%, P = .004; relative: 25.00% to 8.45%, P = .031). In response, the relative incidence of MSSA TJA PJIs significantly increased (18.75% to 40.85%, P = .042). Broken down by arthroplasty type, VIP was associated with a significantly lower overall incidence of coagulase-negative staphylococcal total knee arthroplasty (TKA) PJIs (0.27% to 0.06%, P = .015), a significantly lower overall incidence of MRSA TKA PJIs (0.18% to 0.03%, P = .031), and a nonsignificant decrease in the overall incidence of gram-negative TKA PJIs (0.18% to 0.04%, P = .059). No organism profile changes were found in total hip arthroplasty PJIs. CONCLUSION VIP is not associated with more difficult to treat primary TJA PJIs. While promising, these findings require a prospective randomized controlled trial for confirmation. LEVEL OF EVIDENCE Level III, Retrospective cohort study.
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Affiliation(s)
| | - Greg M Teo
- Department of Orthopedic Surgery, NYU Langone Health, New York, NY
| | - David J Kirby
- Department of Orthopedic Surgery, NYU Langone Health, New York, NY
| | - Ran Schwarzkopf
- Department of Orthopedic Surgery, NYU Langone Health, New York, NY
| | - Vinay K Aggarwal
- Department of Orthopedic Surgery, NYU Langone Health, New York, NY
| | - William J Long
- Department of Orthopedic Surgery, NYU Langone Health, New York, NY
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Rossmann M, Minde T, Citak M, Gehrke T, Sandiford NA, Klatte TO, Abdelaziz H. High Rate of Reinfection With New Bacteria Following One-Stage Exchange for Enterococcal Periprosthetic Infection of the Knee: A Single-Center Study. J Arthroplasty 2021; 36:711-716. [PMID: 32863076 DOI: 10.1016/j.arth.2020.08.015] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 08/05/2020] [Accepted: 08/06/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND A wide range of success rates following the surgical management of enterococcal periprosthetic joint infection (PJI) with a tendency toward worse outcomes have been reported. However, the role of 1-stage exchange remains under-investigated. Therefore, we aimed to evaluate our results after the 1-stage knee exchange for enterococcal PJI. METHODS Forty patients were retrospectively included between 2002 and 2017 with a mean follow-up of survivors of 80 months (range 22-172; standard deviation [SD] = 5). Polymicrobial infections occurred in 45% (18/40) of patients. Patients' characteristics, joint-related data, and antibiotic therapy were recorded. Rates of enterococcal infection relapse, reinfection with new microorganisms, and re-revision for any reason were determined. Bivariate analysis was conducted to identify risk factors of infection recurrence. RESULTS Revision surgery was required in 22 cases (55%) with a mean time to revision surgery of 27 months (range 1-78; SD = 25). Indications for aseptic revisions (18%) included aseptic loosening (10%), periprosthetic fracture (5%), and patellar instability (3%). The most common cause of re-revision was a subsequent PJI (15/22; 68%) after a mean time of 22 months (range 1-77; SD = 24). Overall infection recurrence rate was 37.5% (15/40), substantially due to entirely non-enterococcal infections (9/15; 60%). Infection relapse with Enterococci occurred in 4 cases (10%) within 16 months postoperatively. Older patients (P = .05) and male gender (P = .05) were associated with a higher risk of infection recurrence. CONCLUSION Overcoming the Enterococci using the 1-stage exchange for knee PJI is achievable but the rate of reinfection due to new microorganisms is high . However, the overall infection recurrence rate is comparable to other treatment approaches.
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Affiliation(s)
- Markus Rossmann
- Department of Joint Replacement Surgery, Helios ENDO-Klinik Hamburg, Hamburg, Germany
| | - Thore Minde
- Department of Joint Replacement Surgery, Helios ENDO-Klinik Hamburg, Hamburg, Germany
| | - Mustafa Citak
- Department of Joint Replacement Surgery, Helios ENDO-Klinik Hamburg, Hamburg, Germany
| | - Thorsten Gehrke
- Department of Joint Replacement Surgery, Helios ENDO-Klinik Hamburg, Hamburg, Germany
| | | | - Till Orla Klatte
- Department of Trauma, Hand, and Reconstructive Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Hussein Abdelaziz
- Department of Joint Replacement Surgery, Helios ENDO-Klinik Hamburg, Hamburg, Germany
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29
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Theil C, Stock ME, Gosheger G, Moellenbeck B, Schwarze J, Schmidt-Braekling T. Gastrocnemius Muscle Flaps for Soft Tissue Coverage in Periprosthetic Knee Joint Infection. J Arthroplasty 2020; 35:3730-3736. [PMID: 32694027 DOI: 10.1016/j.arth.2020.06.074] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Revised: 06/17/2020] [Accepted: 06/25/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Soft tissue deficiency in total knee arthroplasty infection is a potentially devastating complication. Gastrocnemius muscle flaps can be used to address this problem. We aim at reporting survival rates of these reconstructions and identify risk factors for failure. METHODS A retrospective evaluation of all flaps performed at a single center between 2006 and 2019 was performed. Clinical and microbiological results were assessed in 43 cases after a median follow-up period of 53 months (25%-75% interquartile range 18-79). Function was assessed using the Oxford Knee Score. We analyzed the infection-free survival and identified risk factors using survival comparison and (non-)parametric testing. RESULTS Infection-free survival was 71% at 2 years and 63% at 5 years. The rate of subsequent amputation was 16% with a mortality rate of 26% during follow-up. Four patients did not undergo reimplantation and 11 patients received an arthrodesis implant. There were no failures of the flap itself. The Charlson Comorbidity index was the only relevant risk factor for reinfection. Coagulase-negative staphylococci were most common organisms identified. Postoperative function was limited with a mean Oxford Knee Score of 20. CONCLUSION Gastrocnemius flap coverage is a valid option for soft tissue reconstruction in periprosthetic infections to retain a functioning limb despite a high complication rate and the risk of subsequent amputation.
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Affiliation(s)
- Christoph Theil
- Department of Orthopedics and Tumor Orthopedics, Muenster University Hospital, Muenster, Germany
| | - Maren E Stock
- Department of Orthopedics and Tumor Orthopedics, Muenster University Hospital, Muenster, Germany
| | - Georg Gosheger
- Department of Orthopedics and Tumor Orthopedics, Muenster University Hospital, Muenster, Germany
| | - Burkhard Moellenbeck
- Department of Orthopedics and Tumor Orthopedics, Muenster University Hospital, Muenster, Germany
| | - Jan Schwarze
- Department of Orthopedics and Tumor Orthopedics, Muenster University Hospital, Muenster, Germany
| | - Tom Schmidt-Braekling
- Department of Orthopedics and Tumor Orthopedics, Muenster University Hospital, Muenster, Germany
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Stoodley P, Brooks J, Peters CW, Jiang N, Delury CP, Laycock PA, Aiken SS, Dusane DH. Prevention and Killing Efficacy of Carbapenem Resistant Enterobacteriaceae (CRE) and Vancomycin Resistant Enterococci (VRE) Biofilms by Antibiotic-Loaded Calcium Sulfate Beads. MATERIALS 2020; 13:ma13153258. [PMID: 32707995 PMCID: PMC7436038 DOI: 10.3390/ma13153258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Revised: 07/14/2020] [Accepted: 07/17/2020] [Indexed: 11/17/2022]
Abstract
Carbapenem-resistant Enterobacteriaceae (CRE) and vancomycin-resistant Enterococci (VRE) have emerged as multidrug-resistant (MDR) pathogens associated with periprosthetic joint infections (PJI). In this study, we evaluated the efficacy of antibiotic-loaded calcium sulfate beads (ALCSB) in inhibiting bacterial growth, encouraging biofilm formation and killing preformed biofilms of CRE and VRE. Three strains of Klebsiella pneumoniae (KP) and a strain of Enterococcus faecalis (EF) were used. ALCSB of 4.8-mm diameter were loaded with vancomycin (V) and gentamicin (G), V and rifampicin (R), V and tobramycin (T) or R and meropenem (M), and placed onto tryptic soy agar (TSA), spread with one of the test strains and incubated for 24 h at 37 °C. Beads were transferred daily onto fresh TSA spread plates and the zone of inhibition (ZOI) was recorded until no inhibition was observed. ALCSB containing R + M or R + V produced the most extensive ZOI up to 5 weeks. Biofilm prevention efficacy was investigated by challenging ALCSB daily with 5 × 105 CFU/mL bacterial cells and analyzing for biofilm formation at challenges 1, 2 and 3. In the biofilm killing experiments, ALCSB were added to pre-grown 3-day biofilms of KP and EF strains, which were then analyzed at days 1 and 3 post-exposure. The CFU counts and confocal images of the attached cells showed that ALCSB treatment reduced colonization and biofilm formation significantly (5–7 logs) with combinations of R + M or R + V, compared to unloaded beads. This study provides evidence that the local release of antibiotics from ALCSB may be useful in treating the biofilms of multidrug-resistant strains of CRE and VRE.
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Affiliation(s)
- Paul Stoodley
- Department of Microbial Infection and Immunity, The Ohio State University, Columbus, OH 43210, USA; (P.S.); (J.B.); (C.W.P.); (N.J.)
- National Centre for Advanced Tribology, Faculty of Engineering and Institute for Life Sciences, University of Southampton, Southampton SO17 1BJ, UK
- Department of Orthopaedic, The Ohio State University, Columbus, OH 43210, USA
| | - Jacob Brooks
- Department of Microbial Infection and Immunity, The Ohio State University, Columbus, OH 43210, USA; (P.S.); (J.B.); (C.W.P.); (N.J.)
| | - Casey W. Peters
- Department of Microbial Infection and Immunity, The Ohio State University, Columbus, OH 43210, USA; (P.S.); (J.B.); (C.W.P.); (N.J.)
| | - Nan Jiang
- Department of Microbial Infection and Immunity, The Ohio State University, Columbus, OH 43210, USA; (P.S.); (J.B.); (C.W.P.); (N.J.)
| | - Craig P. Delury
- Biocomposites Ltd., Keele Science Park, Keele, Staffordshire ST5 5NL, UK; (C.P.D.); (P.A.L.); (S.S.A.)
| | - Phillip A. Laycock
- Biocomposites Ltd., Keele Science Park, Keele, Staffordshire ST5 5NL, UK; (C.P.D.); (P.A.L.); (S.S.A.)
| | - Sean S. Aiken
- Biocomposites Ltd., Keele Science Park, Keele, Staffordshire ST5 5NL, UK; (C.P.D.); (P.A.L.); (S.S.A.)
| | - Devendra H. Dusane
- Department of Microbial Infection and Immunity, The Ohio State University, Columbus, OH 43210, USA; (P.S.); (J.B.); (C.W.P.); (N.J.)
- Center for Clinical and Translational Research, The Research Institute at Nationwide Children′s Hospital, 700 Children′s Drive, Columbus, OH 43205, USA
- Correspondence:
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Ohlmeier M, Filitarin S, Delgado G, Frings J, Abdelaziz H, Salber J, Frommelt L, Gehrke T, Citak M. Improved treatment strategies can result in better outcomes following one-stage exchange surgery for MRSA periprosthetic joint infection. J Med Microbiol 2020; 69:1100-1104. [PMID: 32639225 DOI: 10.1099/jmm.0.001229] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Introduction. Periprosthetic joint infections caused by methicillin-resistant Staphylococcus aureus (MRSA-PJIs) are rare, with only a few studies reporting the treatment outcomes and even fewer reporting outcomes with one-stage exchange.Aim. This study aims to analyse the outcomes of one-stage exchange in the management of MRSA-PJIs.Methodology. Patients with MRSA-PJI of the hip and knee, who were treated with a one-stage exchange between 2001 and 2018 were enrolled in this study. The final cohort comprised of 29 patients, which included 23 hips and six knees. The mean follow-up was 5.3 years (1-9 years). Reinfection and complications rates after the one-stage exchange were analysed.Results. Overall infection control could be achieved in 93.1 % (27 out of 29 patients). The overall revision rate was 31.0% (9 patients), with three patients requiring an in-hospital revision (10.3 %). Six patients had to be revised after hospital discharge (20.7 %). Of the two reinfections, one had a growth of MRSA while the other was of methicillin-sensitive Staphyloccocus epidermidis.Conclusion. One-stage exchange surgery using current techniques could improve surgical outcomes with excellent results in the management of MRSA-PJIs.
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Affiliation(s)
- Malte Ohlmeier
- Department of Joint Surgery, Helios ENDO-Klinik Hamburg, Holstenstrasse 2, 22767 Hamburg, Germany
| | - Sergei Filitarin
- Department of Joint Surgery, Helios ENDO-Klinik Hamburg, Holstenstrasse 2, 22767 Hamburg, Germany
| | - Giorgio Delgado
- Department of Orthopedics, Philippine General Hospital, University of the Philippines Manila, Taft Avenue, Manila 1000, Philippines
| | - Jannik Frings
- Department of Joint Surgery, Helios ENDO-Klinik Hamburg, Holstenstrasse 2, 22767 Hamburg, Germany
| | - Hussein Abdelaziz
- Department of Joint Surgery, Helios ENDO-Klinik Hamburg, Holstenstrasse 2, 22767 Hamburg, Germany
| | - Jochen Salber
- Department of Surgery, Ruhr-University Bochum, Germany
| | - Lars Frommelt
- Department of Infectious Diseases, Clinical Microbiology and Infection Control, Helios ENDO-Klinik Hamburg, Holstenstrasse 2, 22767 Hamburg, Germany
| | - Thorsten Gehrke
- Department of Joint Surgery, Helios ENDO-Klinik Hamburg, Holstenstrasse 2, 22767 Hamburg, Germany
| | - Mustafa Citak
- Department of Joint Surgery, Helios ENDO-Klinik Hamburg, Holstenstrasse 2, 22767 Hamburg, Germany
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Miller R, Higuera CA, Wu J, Klika A, Babic M, Piuzzi NS. Periprosthetic Joint Infection. JBJS Rev 2020; 8:e1900224. [DOI: 10.2106/jbjs.rvw.19.00224] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
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Wimmer MD, Hischebeth GTR, Randau TM, Gathen M, Schildberg FA, Fröschen FS, Kohlhof H, Gravius S. Difficult-to-treat pathogens significantly reduce infection resolution in periprosthetic joint infections. Diagn Microbiol Infect Dis 2020; 98:115114. [PMID: 32712505 DOI: 10.1016/j.diagmicrobio.2020.115114] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Revised: 06/10/2020] [Accepted: 06/10/2020] [Indexed: 01/17/2023]
Abstract
Periprosthetic joint infection (PJI) is a feared complication after arthroplasty. Our hypothesis was that PJI caused by difficult-to-treat (DTT) pathogens has a worse outcome compared with non-DTT PJI. Routine clinical data on 77 consecutive patients with confirmed PJI treated with 2-stage exchange arthroplasty were placed in DTT and non-DTT PJI groups and analyzed. The main outcome variable was that the patient was definitively free of infection after 2 years. We found definitive infection resolution in 31 patients in the DTT group (68.9%) and 28 patients (87.5%) in the non-DTT group (P < 0.05). The necessity for revision surgery until assumed resolution of infection was significantly more frequent in the DTT group with 4.72 ± 3.03 operations versus 2.41 ± 3.02 operations in the non-DTT group (P < 0.05). PJI caused by DTT bacteria is associated with significantly higher numbers of revision operations and significantly inferior definitive infection resolution.
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Affiliation(s)
- Matthias D Wimmer
- Clinic for Orthopedics and Trauma Surgery, University Hospital Bonn, Bonn, Germany
| | - Gunnar T R Hischebeth
- Institute of Medical Microbiology, Immunology and Parasitology, University Hospital Bonn, Bonn, Germany.
| | - Thomas M Randau
- Clinic for Orthopedics and Trauma Surgery, University Hospital Bonn, Bonn, Germany
| | - Martin Gathen
- Clinic for Orthopedics and Trauma Surgery, University Hospital Bonn, Bonn, Germany
| | - Frank A Schildberg
- Clinic for Orthopedics and Trauma Surgery, University Hospital Bonn, Bonn, Germany
| | - Frank S Fröschen
- Clinic for Orthopedics and Trauma Surgery, University Hospital Bonn, Bonn, Germany
| | - Hendrik Kohlhof
- Clinic for Orthopedics and Trauma Surgery, University Hospital Bonn, Bonn, Germany
| | - Sascha Gravius
- Clinic for Orthopedics and Trauma Surgery, University Hospital Bonn, Bonn, Germany; Department of Orthopaedics and Trauma Surgery, University Medical Center Mannheim of the University of Heidelberg, Mannheim, Germany
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Renz N, Trebse R, Akgün D, Perka C, Trampuz A. Enterococcal periprosthetic joint infection: clinical and microbiological findings from an 8-year retrospective cohort study. BMC Infect Dis 2019; 19:1083. [PMID: 31881851 PMCID: PMC6935141 DOI: 10.1186/s12879-019-4691-y] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2019] [Accepted: 12/08/2019] [Indexed: 12/16/2022] Open
Abstract
Background Treatment of enterococcal periprosthetic joint infections (PJI) is challenging due to non-standardized management strategies and lack of biofilm-active antibiotics. The optimal surgical and antimicrobial therapy are unknown. Therefore, we evaluated characteristics and outcome of enterococcal PJI. Methods Consecutive patients with enterococcal PJI from two specialized orthopedic institutions were retrospectively analyzed. Both institutions are following the same diagnostic and treatment concepts. The probability of relapse-free survival was estimated using Kaplan-Meier survival curves and compared by log-rank test. Treatment success was defined by absence of relapse or persistence of PJI due to enterococci or death related to enterococcal PJI. Clinical success was defined by the infection-free status, no subsequent surgical intervention for persistent or perioperative infection after re-implantation and no PJI-related death within 3 months. Results Included were 75 enterococcal PJI episodes, involving 41 hip, 30 knee, 2 elbow and 2 shoulder prostheses. PJI occurred postoperatively in 61 episodes (81%), hematogenously in 13 (17%) and by contiguous spread in one. E. faecalis grew in 64 episodes, E. faecium in 10 and E. casseliflavus in one episode(s). Additional microorganism(s) were isolated in 38 patients (51%). Enterococci were susceptible to vancomycin in 73 of 75 isolates (97%), to daptomycin in all 75 isolates, and to fosfomycin in 21 of 22 isolates (96%). The outcome data was available for 66 patients (88%). The treatment success after 3 years was 83.7% (95% confidence interval [CI]; 76.1–96.7%) and the clinical success was 67.5% (95% CI; 57.3–80.8%). In 11 patients (17%), a new PJI episode caused by a different pathogen occurred. All failures occurred within 3 years after surgery. Conclusion About half of enterococcal PJI were polymicrobial infections. The treatment success was high (84%). All treatment failures occurred within the first 3 years after revision surgery. Interestingly, 17% of patients experienced a new PJI caused by another pathogen at a later stage. Trial registration The study was retrospectively registered with the public clinical trial identification NCT0253022 at https://www.clinicaltrials.gov on 15 July 2015.
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Affiliation(s)
- Nora Renz
- Center for Musculoskeletal Surgery (CMSC), Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Charitéplatz 1, 10117, Berlin, Germany
| | - Rihard Trebse
- Orthopaedic Hospital Valdoltra, SI-6280, Ankaran, Slovenia
| | - Doruk Akgün
- Center for Musculoskeletal Surgery (CMSC), Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Charitéplatz 1, 10117, Berlin, Germany
| | - Carsten Perka
- Center for Musculoskeletal Surgery (CMSC), Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Charitéplatz 1, 10117, Berlin, Germany
| | - Andrej Trampuz
- Center for Musculoskeletal Surgery (CMSC), Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Charitéplatz 1, 10117, Berlin, Germany.
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Wang X, Zhang W. [Research progress of two-stage revision for periprosthetic joint infection after hip and knee arthroplasties]. ZHONGGUO XIU FU CHONG JIAN WAI KE ZA ZHI = ZHONGGUO XIUFU CHONGJIAN WAIKE ZAZHI = CHINESE JOURNAL OF REPARATIVE AND RECONSTRUCTIVE SURGERY 2019; 33:1566-1571. [PMID: 31823560 DOI: 10.7507/1002-1892.201901098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Objective To summarize the research progress of two-stage revision for periprosthetic joint infection (PJI) after hip and knee arthroplasties. Methods The related literature on two-stage revision for PJI was summarized, and the new progress in the choice of spacers, systemic antibiotic therapy, and risk factors were analyzed. Results Two-stage revision is a common way to treat infection after hip and knee arthroplasties. The types of spacers used in the one-stage operation are diverse and each has its own advantages and disadvantages. Non-articular spacers are mainly used for the patients with poor soft tissue conditions around the joints and severe bone defects. But the joint mobility is not good after the placement of the spacer. Articular spacers can restore the affected joint movement after operation, which is beneficial to the joint mobility after two-stage operation. The use of antibiotics is an indispensable part of the treatment process, and the effectiveness of short-term antibiotic treatment is similar to long-term treatment. Identifying the relevant risk factors that influence the prognosis of the two-stage revision can help preoperative management and reduce the recurrence rate of infection. Conclusion There are still controversies about the choice of spacers and systemic antibiotic therapy during the two-stage revision and treatment of PJI. The factors affecting the prognosis of the two-stage revision need to be explored and the further high-quality research is needed.
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Affiliation(s)
- Xiangxuan Wang
- Department of Orthopedics, the First Affiliated Hospital of Fujian Medical University, Fuzhou Fujian, 350000, P.R.China
| | - Wenming Zhang
- Department of Orthopedics, the First Affiliated Hospital of Fujian Medical University, Fuzhou Fujian, 350000,
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Thompson O, Rasmussen M, Stefánsdóttir A, Christensson B, Åkesson P. A population-based study on the treatment and outcome of enterococcal prosthetic joint infections. A consecutive series of 55 cases. J Bone Jt Infect 2019; 4:285-291. [PMID: 31966959 PMCID: PMC6960026 DOI: 10.7150/jbji.35683] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2019] [Accepted: 06/23/2019] [Indexed: 02/01/2023] Open
Abstract
AIM: Enterococci cause 2-11% of all prosthetic joint infections (PJI) and are generally considered difficult to treat. However, study-results are not consistent. In this study we present a population-based case series of 55 cases with enterococcal PJI, investigating treatment and outcome, as well as describing the affected patient population regarding demography and co-morbidities. METHODS: We identified all enterococcal PJIs in the Region of Skåne, Sweden, during a five-year period (2011-2015) and reviewed the patients' medical records. RESULTS: Fifty-five enterococcal PJIs were found. Enterococcus faecalis was the most frequently isolated species (84%), and poly-microbial infections were common (64%). Treatment with intention to cure was given to 43 (78%) cases. Debridement with retention of the implant and antibiotics (DAIR) was the most common surgical treatment strategy (71%), with a cure-rate of 72%. Overall cure-rate was 67%, and in cases where cure was intended, this was achieved in 80%. CONCLUSIONS: When cure is aimed for, the prognosis for enterococcal PJI is not so poor, and DAIR treatment can provide adequate results in many cases.
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Affiliation(s)
- Olof Thompson
- Lund University, Department of Clinical Sciences Lund, Division of Infection Medicine and Skåne University Hospital, Department of Infectious Diseases, Lund, Sweden
| | - Magnus Rasmussen
- Lund University, Department of Clinical Sciences Lund, Division of Infection Medicine and Skåne University Hospital, Department of Infectious Diseases, Lund, Sweden
| | - Anna Stefánsdóttir
- Lund University, Department of Clinical Sciences Lund, Division of Orthopedics and Skåne University Hospital, Department of Orthopedics, Lund, Sweden
| | - Bertil Christensson
- Lund University, Department of Clinical Sciences Lund, Division of Infection Medicine and Skåne University Hospital, Department of Infectious Diseases, Lund, Sweden
| | - Per Åkesson
- Lund University, Department of Clinical Sciences Lund, Division of Infection Medicine and Skåne University Hospital, Department of Infectious Diseases, Lund, Sweden
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Jacobs AME, Valkering LJJ, Bénard M, Meis JF, Goosen JHM. Evaluation One Year after DAIR Treatment in 91 Suspected Early Prosthetic Joint Infections in Primary Knee and Hip Arthroplasty. J Bone Jt Infect 2019; 4:238-244. [PMID: 31700773 PMCID: PMC6831808 DOI: 10.7150/jbji.37757] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Accepted: 09/24/2019] [Indexed: 01/08/2023] Open
Abstract
INTRODUCTION Early recognition and appropriate initial treatment with debridement, antibiotics and implant retention (DAIR) if a suspicion of an early prosthetic joint infection (PJI) is present can eradicate infection on first attempt and prevent implant failure. We evaluated the outcome after 1 year of patients treated with DAIR after primary total knee arthroplasty (TKA) or total hip arthroplasty (THA). Furthermore, we determined preoperative, microbiology, and treatment factors related to failure after DAIR. METHODS A retrospective cohort study was assembled with 91 patients undergoing DAIR with a high suspicion of an early PJI. Records were reviewed for demographics, preoperative laboratory results, microbiological data, given treatment and postoperative follow-up. The primary outcome was infection-free implant survival at 1 year. Repeated DAIR was not considered as treatment failure. RESULTS The rate of infection-free implant survival following DAIR in a suspected early PJI was 85% (95% confidence intervals (CI) 78-91). Cultures remained negative in 20 patients, with no occurrence of infection during follow-up. A higher failure rate was seen in early PJI caused by Enterococcus faecalis (p=0.04). Multivariate analysis showed a statistically significant association between treatment failure and high C-reactive protein level (CRP >100) (odds ratio 10.0, 95% CI [1.5-70]) and multiple DAIR procedures (≥2) (odds ratio 5.0, 95%CI [1.1-23]). CONCLUSION If an early PJI is suspected DAIR is the appointed treatment with up to 2 debridement procedures. Since culture-negative DAIRs were not related to any complications during follow-up, overtreatment of suspected PJI seems to do no significant harm with respect to implant failure.
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Affiliation(s)
- Anouk M E Jacobs
- Department of Orthopaedic Surgery, Prosthetic Joint Infection Unit, Sint Maartenskliniek, Nijmegen, the Netherlands.,Sint Maartenskliniek Research, Sint Maartenskliniek, Nijmegen, the Netherlands
| | - Lucia J J Valkering
- Department of Orthopaedic Surgery, Prosthetic Joint Infection Unit, Sint Maartenskliniek, Nijmegen, the Netherlands
| | - Menno Bénard
- Sint Maartenskliniek Research, Sint Maartenskliniek, Nijmegen, the Netherlands
| | - Jacques F Meis
- Department of Medical Microbiology and Infectious Diseases, Canisius-Wilhelmina Ziekenhuis, Nijmegen, the Netherlands.,Department of Medical Microbiology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Jon H M Goosen
- Department of Orthopaedic Surgery, Prosthetic Joint Infection Unit, Sint Maartenskliniek, Nijmegen, the Netherlands
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What are the Factors Associated with Re-revision After One-stage Revision for Periprosthetic Joint Infection of the Hip? A Case-control Study. Clin Orthop Relat Res 2019; 477:2258-2263. [PMID: 31135547 PMCID: PMC6999925 DOI: 10.1097/corr.0000000000000780] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Despite increased interest in one-stage revision arthroplasty for periprosthetic joint infection (PJI) of the hip, the reported infection-free proportions after the one-stage approach are still comparable to that of two-stage revision. However, we still lack studies that analyze factors associated with any re-revision after one-stage revision arthroplasty for PJI. QUESTIONS/PURPOSES After one-stage revision arthroplasty for PJI of the hip, what factors were associated with an increased risk of re-revision, and what factors were associated with an increased risk of reinfection? METHODS We performed a single-center retrospective case-control analysis. Patients who underwent one-stage revision arthroplasty for PJI of the hip in our hospital between 2009 and 2017, and who were subsequently re-revised due to any reason, including reinfection, were identified from our electronic medical records. A total of 121 patients who underwent repeat revision for any reason after one-stage exchange for PJI of the hip were identified. The re-revision procedures were performed after a mean of 407 days. The primary reasons for re-revision were repeated hip dislocation in 53 of 121 patients (44%), reinfection including both new and persistent infections in 40 of 121 patients (33%), and aseptic loosening in 16 patients (13%). Forty-three patients underwent another revision procedure after the re-revision procedure (43 of 121; 36%). More than 40 potential patient-, joint- and surgery-related risk factors were investigated and compared with a 1:1 matched control participants by age, sex and year of the one-stage revision. Similar to the re-revision patients, controls were treated for PJI with one-stage revision arthroplasty; however, they did not undergo subsequent revision for any reason by the latest followup examination. The mean followup of the control group was 66 months (range, 17-119 months). The mean length of hospital stay was 26 days in the re-revised group (SD, 11.6 days) compared with 22 days for the controls (SD, 6.6 days). All analyses were performed to identify factors associated with general re-revision and reinfection. RESULTS The independent factors associated with repeat revision for any reason were persistent wound drainage for at least 1 week (odds ratio [OR], 7.4; 95% CI, 2.6-20.6; p < 0.001), isolation of enterococci (OR, 4.8; 95% CI, 1.4-15.7; p = 0.010), and prior surgery due to infection before the one-stage hip revision (OR, 3.6; 95% CI, 2.0-6.4; p < 0.001). The factors associated with reinfection including both new and persistent infections were prolonged wound drainage (OR, 6.9; 95% CI, 2.2-21.5; p = 0.001) and prior surgery due to infection (OR, 4.3; 95% CI, 1.9-9.5; p < 0.001). CONCLUSIONS Prolonged wound drainage after the one-stage revision arthroplasty for PJI of the hip must be treated rigorously. Patients with a history of a prior surgical procedure due to hip infection should be informed about the risk of further re-revision when deciding for the one-stage exchange. In case of enterococcal isolation, surgeons may consider another treatment approach rather than the one-stage exchange. Furthermore, we recommend the use of dual mobility cups when performing the one-stage revision hip arthroplasty to reduce the risk of dislocation.Level of Evidence Level III, therapeutic study.
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Müller M, Winkler T, Märdian S, Trampuz A, Renz N, Perka C, Karczewski D. The worst-case scenario: treatment of periprosthetic femoral fracture with coexistent periprosthetic infection-a prospective and consecutive clinical study. Arch Orthop Trauma Surg 2019; 139:1461-1470. [PMID: 31432205 DOI: 10.1007/s00402-019-03263-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Indexed: 12/14/2022]
Abstract
BACKGROUND The simultaneous occurrence of periprosthetic fracture (PPF) and periprosthetic joint infection (PJI) is among the most devastating complications in arthroplasty and carries the risk of limb loss. For the first time, this study will describe the characteristics, treatment concepts, and outcomes of this complication. METHODS Patients were consecutively included who were treated at our specialized interdisciplinary department between 2015 and 2016 with a PJI and an additional PPF of the hip. The treatment algorithm followed a three-step procedure: the complete removal of any foreign material (step 1), fracture stabilization by plate, intramedullary rod osteosynthesis or cerclages using an additional spacer (step 2), and reimplantation of a new prosthesis (step 3). RESULTS Overall, eight cases [four male, four female, mean age 77 years (55-91)] were included. The mean follow-up was 34 ± 8 months. The fractures included one PPF Vancouver B1, three B2/3, and four type C. Most frequent microbes were CNS (Coagulase-negative staphylococci) (n = 4), Cutibacterium (n = 2) and Staphylococcus aureus (n = 2). Mixed infections (≥ 2 microorganisms) occurred in five cases. The time between explanation and reimplantation was 42 ± 34 (range 7-123) days. A re-infection took place in one, a re-revision in four cases, and in five cases fracture healing was noticed. In all eight cases, freedom from the infection and limb preservation could be achieved. CONCLUSION PPF in the case of a PJI is a devastating situation and a huge challenge. Extremity preservation should be the primary goal. The described procedure offers a possible solution.
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Affiliation(s)
- Michael Müller
- Department of Orthopaedics, Center for Musculoskeletal Surgery, Charité-University Medicine, Charitéplatz 1, 10117, Berlin, Germany
| | - Tobias Winkler
- Department of Orthopaedics, Center for Musculoskeletal Surgery, Charité-University Medicine, Charitéplatz 1, 10117, Berlin, Germany.,Julius Wolff Institute and Berlin Brandenburg Center for Regenerative Therapies, Charité-University Medicine, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Sven Märdian
- Department of Orthopaedics, Center for Musculoskeletal Surgery, Charité-University Medicine, Charitéplatz 1, 10117, Berlin, Germany
| | - Andrej Trampuz
- Department of Orthopaedics, Center for Musculoskeletal Surgery, Charité-University Medicine, Charitéplatz 1, 10117, Berlin, Germany
| | - Nora Renz
- Department of Orthopaedics, Center for Musculoskeletal Surgery, Charité-University Medicine, Charitéplatz 1, 10117, Berlin, Germany
| | - Carsten Perka
- Department of Orthopaedics, Center for Musculoskeletal Surgery, Charité-University Medicine, Charitéplatz 1, 10117, Berlin, Germany
| | - Daniel Karczewski
- Department of Orthopaedics, Center for Musculoskeletal Surgery, Charité-University Medicine, Charitéplatz 1, 10117, Berlin, Germany.
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Citak M, Friedenstab J, Abdelaziz H, Suero EM, Zahar A, Salber J, Gehrke T. Risk Factors for Failure After 1-Stage Exchange Total Knee Arthroplasty in the Management of Periprosthetic Joint Infection. J Bone Joint Surg Am 2019; 101:1061-1069. [PMID: 31220022 DOI: 10.2106/jbjs.18.00947] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND One-stage exchange arthroplasty in the management of periprosthetic joint infection was introduced at our institution. The purpose of this study was to analyze the risk factors of failure after periprosthetic joint infection following total knee arthroplasty treated with 1-stage exchange. METHODS Ninety-one patients who underwent failed treatment following 1-stage exchange total knee arthroplasty due to periprosthetic joint infection from January 2008 to December 2017 were included. From the same period, we randomly selected a 1:1 matched control group without a subsequent revision surgical procedure. Bivariate analyses, including preoperative, intraoperative, and postoperative factors, as well as logistic regression, were performed to identify risk factors for failure. RESULTS Bivariate analysis yielded 10 predictors (variables with significance at p < 0.05) for failure involving re-revision for any reason and 11 predictors for failure involving re-revision for reinfection. The binary logistic regression model revealed the following risk factors for re-revision for any reason: history of a 1-stage exchange for infection (odds ratio [OR], 26.706 [95% confidence interval (CI), 5.770 to 123.606]; p < 0.001), history of a 2-stage exchange (OR, 3.948 [95% CI, 1.869 to 8.339]; p < 0.001), and isolation of enterococci (OR, 16.925 [95% CI, 2.033 to 140.872]; p = 0.009). The risk factors for reinfection in the binary logistic regression analysis were history of 1-stage or 2-stage exchange arthroplasty, isolation of enterococci, and isolation of streptococci (OR, 6.025 [95% CI, 1.470 to 24.701]; p = 0.013). CONCLUSIONS We identified several risk factors of failure after 1-stage exchange arthroplasty for periprosthetic joint infection, most of which were not related to the patient comorbidities. Among them, previous exchange due to periprosthetic joint infection and the isolation of Enterococcus or Streptococcus species were associated with a higher risk of failure. Besides a multidisciplinary approach, being aware of the identified risk factors when evaluating patients with periprosthetic joint infection could lead to better outcomes. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Mustafa Citak
- Department of Orthopaedic Surgery, Helios ENDO-Klinik Hamburg, Hamburg, Germany
| | - Jasmin Friedenstab
- Department of Orthopaedic Surgery, Helios ENDO-Klinik Hamburg, Hamburg, Germany.,Department of Surgery, Ruhr-University Hospital, Bochum, Germany
| | - Hussein Abdelaziz
- Department of Orthopaedic Surgery, Helios ENDO-Klinik Hamburg, Hamburg, Germany
| | - Eduardo M Suero
- Department of General, Trauma and Reconstructive Surgery, Ludwig-Maximilians-University München, München, Germany
| | - Akos Zahar
- Department of Orthopaedic Surgery, Helios ENDO-Klinik Hamburg, Hamburg, Germany
| | - Jochen Salber
- Department of Surgery, Ruhr-University Hospital, Bochum, Germany
| | - Thorsten Gehrke
- Department of Orthopaedic Surgery, Helios ENDO-Klinik Hamburg, Hamburg, Germany
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41
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Garrigues GE, Zmistowski B, Cooper AM, Green A. Proceedings from the 2018 International Consensus Meeting on Orthopedic Infections: management of periprosthetic shoulder infection. J Shoulder Elbow Surg 2019; 28:S67-S99. [PMID: 31196516 DOI: 10.1016/j.jse.2019.04.015] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2019] [Accepted: 04/20/2019] [Indexed: 02/05/2023]
Abstract
The Second International Consensus Meeting on Orthopedic Infections was held in Philadelphia, Pennsylvania, in July 2018. A multidisciplinary team of international experts from all 9 subspecialties of orthopedic surgery and allied fields of infectious disease, microbiology, and epidemiology was assembled to form the International Consensus Group. The following consensus proceedings from the International Consensus Meeting involve 30 questions pertaining to the management of periprosthetic shoulder infection.
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Affiliation(s)
- Grant E Garrigues
- Division of Sports Medicine, Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, IL, USA.
| | - Benjamin Zmistowski
- Department of Orthopaedic Surgery, Rothman Institute at Thomas Jefferson University, Philadelphia, PA, USA
| | - Alexus M Cooper
- Department of Orthopaedic Surgery, Rothman Institute at Thomas Jefferson University, Philadelphia, PA, USA
| | - Andrew Green
- Division of Shoulder and Elbow Surgery, Department of Orthopaedic Surgery, Warren Alpert Medical School, Brown University, Providence, RI, USA
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Boyle KK, Kuo FC, Horcajada JP, Hughes H, Cavagnaro L, Marculescu C, McLaren A, Nodzo SR, Riccio G, Sendi P, Silibovsky R, Stammers J, Tan TL, Wimmer M. General Assembly, Treatment, Antimicrobials: Proceedings of International Consensus on Orthopedic Infections. J Arthroplasty 2019; 34:S225-S237. [PMID: 30360976 DOI: 10.1016/j.arth.2018.09.074] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [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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Anemüller R, Belden K, Brause B, Citak M, Del Pozo JL, Frommelt L, Gehrke T, Hewlett A, Higuera CA, Hughes H, Kheir M, Kim KI, Konan S, Lausmann C, Marculescu C, Morata L, Ramirez I, Rossmann M, Silibovsky R, Soriano A, Suh GA, Vogely C, Volpin A, Yombi J, Zahar A, Zimmerli W. Hip and Knee Section, Treatment, Antimicrobials: Proceedings of International Consensus on Orthopedic Infections. J Arthroplasty 2019; 34:S463-S475. [PMID: 30348582 DOI: 10.1016/j.arth.2018.09.032] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [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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44
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Carijo JH, Courtney PM, Goswami K, Groff H, Kendoff D, Matos J, Sandiford NA, Scheper H, Schmaltz CAS, Shubnyakov I, Tan TL, Wouthuyzen-Bakker M. Hip and Knee Section, Pathogen Factors: Proceedings of International Consensus on Orthopedic Infections. J Arthroplasty 2019; 34:S381-S386. [PMID: 30343968 DOI: 10.1016/j.arth.2018.09.022] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [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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45
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Argenson JN, Arndt M, Babis G, Battenberg A, Budhiparama N, Catani F, Chen F, de Beaubien B, Ebied A, Esposito S, Ferry C, Flores H, Giorgini A, Hansen E, Hernugrahanto KD, Hyonmin C, Kim TK, Koh IJ, Komnos G, Lausmann C, Loloi J, Lora-Tamayo J, Lumban-Gaol I, Mahyudin F, Mancheno-Losa M, Marculescu C, Marei S, Martin KE, Meshram P, Paprosky WG, Poultsides L, Saxena A, Schwechter E, Shah J, Shohat N, Sierra RJ, Soriano A, Stefánsdóttir A, Suleiman LI, Taylor A, Triantafyllopoulos GK, Utomo DN, Warren D, Whiteside L, Wouthuyzen-Bakker M, Yombi J, Zmistowski B. Hip and Knee Section, Treatment, Debridement and Retention of Implant: Proceedings of International Consensus on Orthopedic Infections. J Arthroplasty 2019; 34:S399-S419. [PMID: 30348550 DOI: 10.1016/j.arth.2018.09.025] [Citation(s) in RCA: 94] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Key Words
- acute periprosthetic joint infection (PJI)
- antibiotic combination
- antibiotic duration
- antibiotic therapy
- antibiotic treatment
- biofilm
- chronic obstructive pulmonary disease (COPD)), and C-reactive protein (CRP) >115 mg/L (C), rheumatoid arthritis (R), indication prosthesis (I), male (M), exchange of mobile components (E), age > 80 years (80) (CRIME80) scores
- chronic renal failure (K), liver cirrhosis (L), index surgery (I), cemented prosthesis (C), and C-reactive protein (CRP) >115 mg/L (KLIC) score
- contraindications
- debridement antibiotics and retention of the prosthesis
- debridement, antibiotics, implant retention (DAIR)
- emergency management
- exchange of modular components
- failed debridement, antibiotics, implant retention (DAIR) management
- fluoroquinolone
- gram-negative acute periprosthetic joint infection (PJI)
- indications
- infection recurrence
- intra-articular antibiotic infusion
- irrigation
- irrigation and debridement
- irrigation solution
- length of antibiotics
- megaprosthesis
- methicillin-resistant Staphylococcus aureus (MRSA)
- pathogen identification
- patient optimization
- periprosthetic joint infection (PJI) recurrence
- povidone-iodine
- rifampicin
- risk stratification
- surgical factors
- surgical intervention
- surgical outcome
- surgical outcomes
- surgical site infection (SSI) recurrence
- surgical timing
- treatment failure
- treatment success
- two-stage exchange arthroplasty
- unicompartmental knee arthroplasty debridement, antibiotics, implant retention (DAIR)
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General Assembly, Diagnosis, Pathogen Isolation: Proceedings of International Consensus on Orthopedic Infections. J Arthroplasty 2019; 34:S207-S214. [PMID: 30348573 DOI: 10.1016/j.arth.2018.09.072] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [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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47
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Tsai TT, Huang TH, Chen CA, Ho NYJ, Chou YJ, Chen CF. Development a stacking pad design for enhancing the sensitivity of lateral flow immunoassay. Sci Rep 2018; 8:17319. [PMID: 30470789 PMCID: PMC6251899 DOI: 10.1038/s41598-018-35694-9] [Citation(s) in RCA: 58] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2018] [Accepted: 11/09/2018] [Indexed: 11/20/2022] Open
Abstract
Lateral flow immunoassays (LFIAs) have wide application in point-of-care testing, particularly in resource-poor settings. To achieve signal amplification in a gold nanoparticle-based lateral flow assay without an additional procedure or the need for complex fabrication, a new and simple method was developed for using a “stacking pad” configuration that adds an additional membrane between the conjugation pad and test pad to the conventional AuNP-based LFIA format. This design helps to accumulate the antibody and antigen on the stacking pad, hence extending the antigen/antibody binding interactions to enhance the test’s detection sensitivity. With the enhanced lateral flow assay, as low as 1 ng/mL of Protein A and 15.5 ng/mL of C-reactive protein can be visualized with the naked eye. We also successfully applied the stacking pad system in the analysis of C-reactive protein in human serum and synovial fluid samples. These results suggest that this stacking pad LFIA can provide sensitive and on-site prognosis for detection in synovial fluid and serum samples in resource-limited settings.
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Affiliation(s)
- Tsung-Ting Tsai
- Department of Orthopaedic Surgery, Bone and Joint Research Center, Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taoyuan, 333, Taiwan
| | - Tse-Hao Huang
- Department of Orthopaedic Surgery, Bone and Joint Research Center, Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taoyuan, 333, Taiwan.,Institute of Applied Mechanics, National Taiwan University, Taipei, 106, Taiwan
| | - Chung-An Chen
- Department of Orthopaedic Surgery, Bone and Joint Research Center, Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taoyuan, 333, Taiwan.,Institute of Applied Mechanics, National Taiwan University, Taipei, 106, Taiwan
| | - Natalie Yi-Ju Ho
- Department of Orthopaedic Surgery, Bone and Joint Research Center, Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taoyuan, 333, Taiwan
| | - Yi-Ju Chou
- Institute of Applied Mechanics, National Taiwan University, Taipei, 106, Taiwan
| | - Chien-Fu Chen
- Institute of Applied Mechanics, National Taiwan University, Taipei, 106, Taiwan.
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48
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Fagotti L, Tatka J, Salles MJC, Queiroz MC. Risk Factors and Treatment Options for Failure of a Two-Stage Exchange. Curr Rev Musculoskelet Med 2018; 11:420-427. [PMID: 29934884 PMCID: PMC6105486 DOI: 10.1007/s12178-018-9504-1] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
PURPOSE OF REVIEW Although a two-stage exchange revision is reported to have a high success rate, this strategy may fail as a treatment for prosthetic joint infection (PJI). When it does, resection arthroplasty, arthrodesis, amputation, and chronic antibiotic suppression may play a role. The purpose of this review is to determine which are the main risk factors for a two-stage exchange failure and to analyze the indications and results of resection arthroplasty, arthrodesis, amputation, and antibiotic chronic suppression for PJI. RECENT FINDINGS Recent literature demonstrates that the main risk factors for a two-stage exchange failure are as follows: hemodialysis, obesity, multiple previous procedures, diabetes mellitus, corticosteroid therapy, hypoalbuminemia, immunosuppression, rheumatological conditions, coagulation disorders, and infection due to multidrug-resistant (MDR) bacteria or fungal species. Regarding microorganisms, besides Staphylococcus aureus, Streptococcus spp., Enterobacteriaceae species such as Klebsiella pneumoniae and Enterobacter sp., Pseudomonas aeruginosa, or Acinetobacter baumannii, and fungus including Candida sp. are also considered risk factors for a two-stage exchange failure. Resection arthroplasty, arthrodesis, and amputation have a limited role. Chronic suppression is an option for high-risk patients or unfeasible reconstruction. In summary, we report the main risk factors for a two-stage exchange failure and alternative procedures when it occurs. Future research on patient-specific risk factors for a two-stage exchange may aid surgical decision-making and optimization of outcomes.
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Affiliation(s)
| | - Jakub Tatka
- Steadman Philippon Research Institute, Vail, CO, USA
| | - Mauro Jose Costa Salles
- Division of Infectious Diseases, Department of Internal Medicine, Santa Casa de São Paulo School of Medical Sciences, São Paulo, Brazil
| | - Marcelo C Queiroz
- Department of Orthopaedic Surgery, Santa Casa de São Paulo School of Medical Sciences, São Paulo, Brazil.
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Predictors of Treatment Failure After 2-Stage Reimplantation for Infected Total Knee Arthroplasty: A 2- to 10-Year Follow-Up. J Arthroplasty 2018; 33:2234-2239. [PMID: 29572036 DOI: 10.1016/j.arth.2018.02.007] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2017] [Revised: 01/26/2018] [Accepted: 02/02/2018] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND The aim of this study is to identify risk factors which may lead to treatment failure following 2-stage reimplantation for chronic infected total knee arthroplasty (TKA). METHODS We retrospectively reviewed 106 patients (108 knees) who underwent consecutive 2-stage revision for chronic PJI of the knee at our institution between January 2005 and December 2015. A total of 31 risk factors, including patient characteristics, comorbidities, surgical variables, and microbiology data, were collected. Kaplan-Meier survival and Cox regression analyses were used to calculate survival rates and adjusted hazard ratios (HRs) of treatment failure. RESULTS Within the cohort, 16 of the 108 2-stage reimplantations (14.8%) had treatment failure. The treatment success for 2-stage reimplantation was 91% (95% confidence interval [CI] 0.8-1.0) at 2 years and 84% (95% CI 0.8-0.9) at 5 and 10 years. Multivariate analysis provided the strongest predictors of treatment failure, including body mass index ≥30 kg/m2 (adjusted HR 9.3, 95% CI 2.7-31.8, P < .001), operative time >4 hours (adjusted HR 11.3, 95% CI 3.9-33.1, P < .001), gout (adjusted HR 13.8, 95% CI 2.9-66.1, P = .001), and the presence of Enterococcus species during resection arthroplasty (adjusted HR 14.1, 95% CI 2.6-76.3, P = .002). CONCLUSION Our study identified 4 potential risk factors that may predict treatment failure following 2-stage revision for chronic knee PJI. This finding may be useful when counseling patients regarding the treatment success and prognosis of 2-stage reimplantation for infected TKA.
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50
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Sousa R, Abreu MA. Treatment of Prosthetic Joint Infection with Debridement, Antibiotics and Irrigation with Implant Retention - a Narrative Review. J Bone Jt Infect 2018; 3:108-117. [PMID: 30013891 PMCID: PMC6043472 DOI: 10.7150/jbji.24285] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2017] [Accepted: 05/04/2018] [Indexed: 12/12/2022] Open
Abstract
Prosthetic joint infection usually requires combined medical and surgical therapy. While revision surgery is widely considered to be the gold standard surgical procedure, debridement, antibiotics and irrigation with implant retention is a very appealing alternative. There is however great controversy regarding its real worth with success rates ranging from 0% to over 90%. A number of different patient and host related variables as well as specific aspects of surgical and medical management have been described as relevant for the final outcome. Along this paper, the authors will provide the readers with a critical narrative review of the currently available literature while trying to provide concise and practical treatment recommendations regarding adequate patient selection criteria, proper surgical technique and optimal antibiotic therapy.
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Affiliation(s)
- Ricardo Sousa
- Department of Orthopaedics, Centro Hospitalar do Porto, Porto, Portugal
- Grupo TrofaSaude - Hospital em Alfena, Valongo, Portugal
| | - Miguel Araújo Abreu
- Department of Infectious Diseases, Centro Hospitalar do Porto, Porto, Portugal
- Grupo TrofaSaude - Hospital em Alfena, Valongo, Portugal
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