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Nourie BO, Cozzarelli NF, Krueger CA, Donnelly PC, Fillingham YA. Antibiotic Laden Bone Cement Does Not Reduce Acute Periprosthetic Joint Infection Risk in Primary Total Knee Arthroplasty. J Arthroplasty 2024; 39:S229-S234. [PMID: 38703925 DOI: 10.1016/j.arth.2024.04.068] [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: 09/28/2023] [Revised: 04/22/2024] [Accepted: 04/23/2024] [Indexed: 05/06/2024] Open
Abstract
BACKGROUND Periprosthetic joint infection (PJI) can be a serious complication of total knee arthroplasty (TKA). A method believed to decrease the incidence of PJI is antibiotic-laden bone cement (ALBC). Current clinical practice guidelines do not recommend ALBC in primary TKA. The purpose of this study was to compare ALBC to plain cement (PC) in preventing PJI in primary TKA. METHODS This retrospective analysis included 109,242 Medicare patients in the American Joint Replacement Registry who underwent a cemented primary TKA from January 2017 to March 2021, and had at least 1 year of follow-up. Patients who received ALBC were compared to patients who received PC. Demographic and case-specific variables such as age, sex, race, body mass index, Charlson Comorbidity Index, anesthesia type, and operative time were used to create propensity scores. A logistic regression was run to predict the probability of receiving ALBC. Also, a multivariate model was run on the full unstratified population, using the same covariates as were used to create the propensity model. The primary outcome was differences in PJI rates. RESULTS Logistic regression analysis showed that a higher preoperative diagnosis of osteoarthritis, higher Charlson Comorbidity Index, higher body mass index, women, race, and anesthesia requirements increased a patient's probability of receiving ALBC. In the full unstratified multivariate model, ALBC did not show a statistically significant difference in risk of revision for infection compared to PC. CONCLUSIONS The use of ALBC in primary TKA has not been shown to be more efficacious in preventing PJI within the population of Medicare patients in the United States. However, this study is limited given it is a retrospective database study that may inherently have biases and the large dataset has a potential for overpowering the findings.
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Affiliation(s)
- Blake O Nourie
- Department of Orthopedic Surgery, Albany Medical Center, Albany, New York
| | - Nicholas F Cozzarelli
- Department of Orthopedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Chad A Krueger
- Department of Orthopedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | | | - Yale A Fillingham
- Department of Orthopedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
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Kittinger C, Stadler J, Kühn KD. Evaluation of Gentamicin Release of PMMA Cements Using Different Methods: HPLC, Elution and Inhibition Zone Testing. Antibiotics (Basel) 2024; 13:754. [PMID: 39200054 PMCID: PMC11350647 DOI: 10.3390/antibiotics13080754] [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: 07/02/2024] [Revised: 07/26/2024] [Accepted: 08/07/2024] [Indexed: 09/01/2024] Open
Abstract
(1) Background: There is an ongoing discussion on the elution efficacy of antibiotic-impregnated cements. Our experiments were intended to clarify if there are differences in the antibiotic elution of HPLC compared with inhibition zone testing using eluates or PMMA discs. (2) Materials and Methods: Two cement brands with different concentrations of the active ingredient were tested in antimicrobial Kirby-Bauer (disc diffusion) assays. Cement platelets were directly applied on the agar plates and their zone of inhibition was measured. In parallel, the platelets were incubated in phosphate buffered saline (PBS) and at distinct points of time transferred into new buffer. At these time points, 50 µL of the bone cement eluates was used for zone of inhibition testing. Standard gentamicin sulfate solutions served as a control in the same test setup. To verify the microbiological investigations, the antibiotic content of the eluates was also measured via high-performance liquid chromatography (HPLC). (3) Results: The experiments with cement eluates showed better differentiable results than the direct application of the cement discs. The results were also comparable to investigations with HPLC and gentamicin sulfate standard solutions. (4) Conclusions: The results of elution rates are influenced by the test system and the period of observation chosen. The microbial test systems reflect the results of HPLC to the same degree and give evidence of the efficacy of the antibiotics. The HPLC tests on eluates were more suitable in representing differences in release characteristics.
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Affiliation(s)
- Clemens Kittinger
- D&R Insitute of Hygiene, Microbiology and Environmental Medicine, Medical University of Graz, Neue Stiftingtalstraße 6/III 1, 8036 Graz, Austria;
| | - Johannes Stadler
- Department of Orthopaedics and Trauma, Medical University of Graz, 8036 Graz, Austria;
| | - Klaus Dieter Kühn
- Department of Orthopaedics and Trauma, Medical University of Graz, 8036 Graz, Austria;
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3
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Kittinger C, Eder-Halbedl M, Kühn KD. Impact of Manual Addition of Vancomycin to Polymethylmethacrylate (PMMA) Cements. Antibiotics (Basel) 2024; 13:721. [PMID: 39200021 PMCID: PMC11350699 DOI: 10.3390/antibiotics13080721] [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: 07/01/2024] [Revised: 07/26/2024] [Accepted: 07/30/2024] [Indexed: 09/01/2024] Open
Abstract
(1) Background: The addition of antibiotics to bone cements is a common practice in the treatment of periprosthetic joint infections. In revision cases, the amount and type of antibiotic is often insufficient and additional antibiotics must be added. The addition, however, changes the product itself, and the surgeon becomes the "manufacturer" of the bone cement. PMMAe wished to clarify whether the admixture of antibiotics changes the mechanical stability of the bone cements used and if the added antibiotics were still functional and released in sufficient quantities. (2) Methods: We compared two industrially manufactured vancomycin-containing PMMA cements; the low-viscous VancogenX® (TECRES, Sommacampagna, Italy) and the high-viscous Copal® G+V (Heraeus Medical GmbH, Wehrheim, Germany), with two PMMA cements loaded with aminoglycosides, to which 2.0 g of vancomycin (Hexal CT1631) were manually added-the high-viscous Smartset® GHV and the medium-viscous Antibiotic Simplex with Tobramycin (antibiotic Simplex® T). Test specimens of the bone cements were used to determine mechanical stability (bending strength and bending module), and the release of the antibiotics was determined by HLPC and modified Kirby-Bauer assays. (3) Results: All tested bone cements showed an initial high release within the first hours. Repeated testing after 24 h showed a reduced efficacy of VancogenX® and Smartset® GHV in Kirby-Bauer assays. Long-time release over days showed a release of functional antimicrobial active ingredients over this period of time in anti-microbial assays, but no activity of VancogenX® from day 21 onward. No significant differences in the ISO bending modules could be detected, but in contrast to the bending module, the ISO bending strength was substantially reduced by 10-15 mPal in comparison to both cements of the reference group. The Simplex®T met just the ISO 5833; the Smartset® GHV did not after adding vancomycin. (4) Conclusions: In conclusion, the manual addition of 2 g of vancomycin to 40 g of PMMA powder is recommended for the treatment of methicillin-resistant staphylococci. Vancomycin is released over a period of 42 days with concentrations above the MIC for typical staphylococci. The mechanical properties of the PMMA just met, or did not fulfill, ISO mechanical specification. Copal® G+V showed a better elution than VancogenX® over time.
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Affiliation(s)
- Clemens Kittinger
- Development and Research Insitute of Hygiene, Microbiology and Environmental Medicine, Hygiene Medical University of Graz, Neue Stiftingtalstraße 6/III 1, 8010 Graz, Austria;
| | - Michael Eder-Halbedl
- Department of Orthopedics and Trauma, LKH-Feldbach, Ottokar-Kernstock-Straße 18, 8330 Feldbach, Austria;
| | - Klaus Dieter Kühn
- Department of Orthopaedics and Trauma, Medical University of Graz, 8010 Graz, Austria
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4
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Zhao Y, Mannala GK, Youf R, Rupp M, Alt V, Riool M. Development of a Galleria mellonella Infection Model to Evaluate the Efficacy of Antibiotic-Loaded Polymethyl Methacrylate (PMMA) Bone Cement. Antibiotics (Basel) 2024; 13:692. [PMID: 39199992 PMCID: PMC11350861 DOI: 10.3390/antibiotics13080692] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2024] [Revised: 07/21/2024] [Accepted: 07/22/2024] [Indexed: 09/01/2024] Open
Abstract
Prosthetic joint infections (PJIs) can have disastrous consequences for patient health, including removal of the device, and placement of cemented implants is often required during surgery to eradicate PJIs. In translational research, in vivo models are widely used to assess the biocompatibility and antimicrobial efficacy of antimicrobial coatings and compounds. Here, we aim to utilize Galleria mellonella implant infection models to assess the antimicrobial activity of antibiotic-loaded bone cement (ALBC) implants. Therefore, we used commercially available bone cement loaded with either gentamicin alone (PALACOS R+G) or with a combination of gentamicin and vancomycin (COPAL G+V), compared to bone cement without antibiotics (PALACOS R). Firstly, the in vitro antimicrobial activity of ALBC was determined against Staphylococcus aureus. Next, the efficacy of ALBC implants was analyzed in both the G. mellonella hematogenous and early-stage biofilm implant infection model, by monitoring the survival of larvae over time. After 24 h, the number of bacteria on the implant surface and in the tissue was determined. Larvae receiving dual-loaded COPAL G+V implants showed higher survival rates compared to implants loaded with only gentamicin (PALACOS R+G) and the control implants without antibiotics (PALACOS R). In conclusion, G. mellonella larvae infection models with antibiotic-loaded bone cements are an excellent option to study (novel) antimicrobial approaches.
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Affiliation(s)
| | | | | | | | | | - Martijn Riool
- Department of Trauma Surgery, University Hospital Regensburg, Franz-Josef-Strauß-Allee 11, 93053 Regensburg, Germany; (Y.Z.); (G.K.M.); (R.Y.); (M.R.); (V.A.)
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Hamoudi C, Hamon M, Reiter-Schatz A, Debordes PA, Gaudias J, Rondé-Oustau C, Jenny JY. Cement loaded with high-dose gentamicin and clindamycin does not reduce the risk of subsequent infection after aseptic total hip or knee revision arthroplasty: a preliminary study. J Orthop Traumatol 2024; 25:37. [PMID: 39048851 PMCID: PMC11269536 DOI: 10.1186/s10195-024-00775-1] [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: 01/23/2024] [Accepted: 06/15/2024] [Indexed: 07/27/2024] Open
Abstract
PURPOSE The aim of this study was to quantify the prophylactic effect of high-dose gentamicin and clindamycin antibiotic-loaded bone cement (ALBC) during revision total hip (rTHA) or knee (rTKA) arthroplasty for aseptic reasons. The hypothesis was that the raw surgical site infection (SSI) rate is lower when this particular cement is used in comparison with cement loaded with standard-dose gentamicin during rTHA or rTKA for aseptic reasons. METHODS This retrospective study included 290 consecutive patients undergoing aseptic rTHA or rTKA. Two consecutive cohorts were defined: the first (control group) involved 145 patients where ALBC with gentamicin only was used; the second (study group) involved 145 patients where ALBC with high-dose gentamicin and clindamycin was used. The primary endpoint was the raw SSI rate after 24 months. RESULTS The raw SSI rate was 8/145 (6%) in the control group and 13/145 (9%) in the study group (odds ratio 0.62, p = 0.26). There was a significant impact of the presence of any risk factor on the SSI rate (15/100 versus 6/169, odds ratio = 4.25, p = 0.002), but no significant impact of any individual risk factor. No complication or side effect related to ALBC was observed in either group. CONCLUSION These results do not support the routine use of gentamicin and clindamycin ALBC for fixation of revision implants after rTHA and rTKA for aseptic reasons.
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Affiliation(s)
- Ceyran Hamoudi
- Department of Orthopaedic Surgery, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Marie Hamon
- Department of Pharmacy, CHU de Caen, Caen, France
| | - Aurélie Reiter-Schatz
- Department of Orthopaedic Surgery, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Pierre-Antoine Debordes
- Department of Orthopaedic Surgery, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Jeannot Gaudias
- Department of Orthopaedic Surgery, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Cécile Rondé-Oustau
- Department of Orthopaedic Surgery, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Jean-Yves Jenny
- Department of Orthopaedic Surgery, Hôpitaux Universitaires de Strasbourg, Strasbourg, France.
- Clinique Sainte-Odile, Groupe Elsan, Haguenau, France.
- Impulse-Ortho, 3 Rue de la Redoute, F-67500, Haguenau, France.
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Prats-Peinado L, Fernández-Fernández T, Márquez-Gómez M, Matas-Diaz JA, Sánchez-Somolinos M, de la Villa-Martínez S, Vaquero-Martín J, Sanz-Ruiz P. Do High Doses of Multiple Antibiotics Loaded into Bone Cement Spacers Improve the Success Rate in Staphylococcal Periprosthetic Joint Infection When Rifampicin Cannot Be Employed? Antibiotics (Basel) 2024; 13:538. [PMID: 38927204 PMCID: PMC11200406 DOI: 10.3390/antibiotics13060538] [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: 04/07/2024] [Revised: 05/21/2024] [Accepted: 06/05/2024] [Indexed: 06/28/2024] Open
Abstract
Rifampicin is one of the mainstays in treating staphylococcal prosthetic joint infection (PJI). However, discontinuation due to intolerance, drug interactions, and adverse events is common. Two-stage revision surgery remains the gold standard, with the number of revision arthroplasties steadily increasing. This study aims to evaluate the effectiveness and safety of a novel two-stage revision protocol for staphylococcal prosthetic joint infection (PJI) utilizing bone cement spacers loaded with multiple high doses of antibiotics. Additionally, it seeks to analyze outcomes in patients ineligible for rifampicin treatment. A retrospective review of 43 cases of staphylococcal hip and knee prosthetic joint infections (PJIs) from 2012 to 2020 was conducted. In all instances, a commercial cement containing 1 g of gentamicin and 1 g of clindamycin, augmented with 4 g of vancomycin and 2 g of ceftazidime, was employed to cast a spacer manually after thorough surgical debridement. We report an eradication rate of 82%, with no significant differences observed (p = 0.673) between patients treated with (84%, n = 19) and without rifampicin (79%, n = 24). There were no disparities in positive culture rates (7%), spacer replacement (18%), or survival analysis (p = 0.514) after an average follow-up of 68 months (range 10-147) in the absence of systemic toxicity and surgical complications superimposable to those previously reported. In conclusion, two-stage revision with local high doses of ceftazidime, vancomycin, gentamicin, and clindamycin demonstrates high effectiveness in treating staphylococcal PJIs. Notably, systemic rifampicin does not influence the outcomes. This protocol, with multiple high doses of antibiotics loaded into the bone cement spacer, is presented as a viable and safe alternative for patients unsuitable for rifampicin treatment.
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Affiliation(s)
- Lourdes Prats-Peinado
- Department of Orthopedic Surgery, General University Hospital Gregorio Marañón, 28007 Madrid, Spain; (L.P.-P.); (T.F.-F.); (M.M.-G.); (J.A.M.-D.); (J.V.-M.)
| | - Tanya Fernández-Fernández
- Department of Orthopedic Surgery, General University Hospital Gregorio Marañón, 28007 Madrid, Spain; (L.P.-P.); (T.F.-F.); (M.M.-G.); (J.A.M.-D.); (J.V.-M.)
| | - Miguel Márquez-Gómez
- Department of Orthopedic Surgery, General University Hospital Gregorio Marañón, 28007 Madrid, Spain; (L.P.-P.); (T.F.-F.); (M.M.-G.); (J.A.M.-D.); (J.V.-M.)
| | - José Antonio Matas-Diaz
- Department of Orthopedic Surgery, General University Hospital Gregorio Marañón, 28007 Madrid, Spain; (L.P.-P.); (T.F.-F.); (M.M.-G.); (J.A.M.-D.); (J.V.-M.)
| | - Mar Sánchez-Somolinos
- Department of Microbiology, General University Hospital Gregorio Marañón, 28007 Madrid, Spain; (M.S.-S.); (S.d.l.V.-M.)
| | - Sofía de la Villa-Martínez
- Department of Microbiology, General University Hospital Gregorio Marañón, 28007 Madrid, Spain; (M.S.-S.); (S.d.l.V.-M.)
| | - Javier Vaquero-Martín
- Department of Orthopedic Surgery, General University Hospital Gregorio Marañón, 28007 Madrid, Spain; (L.P.-P.); (T.F.-F.); (M.M.-G.); (J.A.M.-D.); (J.V.-M.)
- Surgery Department, School of Medicine, Complutense University of Madrid, 28040 Madrid, Spain
| | - Pablo Sanz-Ruiz
- Department of Orthopedic Surgery, General University Hospital Gregorio Marañón, 28007 Madrid, Spain; (L.P.-P.); (T.F.-F.); (M.M.-G.); (J.A.M.-D.); (J.V.-M.)
- Surgery Department, School of Medicine, Complutense University of Madrid, 28040 Madrid, Spain
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7
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Xin B, Cao S, Bai G, Huang X, Ye C, Hu R, Gao X, Zou W, Liu T. Risk Factors for Postoperative Surgical Site Infection in Patients Undergoing Spinal Tumor Surgery. Clin Spine Surg 2023; 36:E478-E483. [PMID: 37448177 DOI: 10.1097/bsd.0000000000001494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Accepted: 06/21/2023] [Indexed: 07/15/2023]
Abstract
STUDY DESIGN A retrospective comparative case-control study. OBJECTIVE The aim of this study was to determine the risk factors for postoperative surgical site infection (SSI) in patients with spinal tumors requiring reoperation during the perioperative period. SUMMARY OF BACKGROUND DATA SSI is a common postoperative complication of spinal surgery. The occurrence of SSI not only increases the mortality rate but prolongs the patient's hospital stay and increases the medical cost. METHODS Included in this study were 202 patients with spinal tumors who received surgical treatment between January 2008 and December 2018, of whom 101 patients who developed SSI and underwent secondary surgery were used as the SSI group, and the other 101 patients with no SSI who were matched with the SSI group by age (±10), pathologic diagnosis (malignant/no-malignant), tumor site (C/T/L/S), surgical approach (anterior/posterior/combined), and surgical team were used as the control group. The clinical data of the 202 patients in both groups were analyzed by logistic regression modeling to identify SSI-associated risk factors. RESULTS Multivariate logistic regression analysis showed that the revision status ( B =1.430, P =0.028), the number of spinal levels fused ≥4 ( B =0.963, P =0.006), and the use of bone cement ( B =0.739, P =0.046) were significantly associated with the increased risk of developing postoperative SSI. CONCLUSIONS This study identified the revision status, the number of spinal levels fused ≥4, and the use of bone cement as independent risk factors for SSI in patients with spinal tumors who underwent reoperation during the perioperative period.
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Affiliation(s)
- Baoquan Xin
- School of Health Science and Engineering, University of Shanghai for Science and Technology
- Departments of Orthopaedic Oncology
| | | | - Guangjian Bai
- School of Health Science and Engineering, University of Shanghai for Science and Technology
- Departments of Orthopaedic Oncology
| | | | - Chen Ye
- Departments of Orthopaedic Oncology
| | | | - Xin Gao
- Departments of Orthopaedic Oncology
| | - Weiwei Zou
- Medical Imaging, Changzheng Hospital, Navy Medical University, Shanghai, China
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Bos PK, Spekenbrink-Spooren A, Croughs P, Bierma-Zeinstra SMA, Reijman M, Van Oldenrijk J. Risk for re-revision and type of antibiotic-loaded bone cement in hip or knee arthroplasty revisions: report of the Dutch Arthroplasty Register. Acta Orthop 2023; 94:471-476. [PMID: 37728200 PMCID: PMC10510150 DOI: 10.2340/17453674.2023.18645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2023] [Accepted: 08/17/2023] [Indexed: 09/21/2023] Open
Abstract
BACKGROUND AND PURPOSE High-dose dual antibiotic-loaded bone cement (ALBC) may reduce the risk of revision after total hip and knee replacements. The aim of our study therefore was to determine the risk of re-revision following first time aseptic hip or knee revision using single versus dual ALBC. PATIENTS AND METHODS Patients from the Dutch Arthroplasty Register treated from 2007 to 2018 with first time cemented aseptic hip (n = 2,529) or knee revisions (n = 7,124) were incorporated into 2 datasets. The primary endpoint of this observational cohort study was subsequent all-cause re-revision. Multivariable Cox proportional hazard and competing risk was analyzed for both groups. RESULTS There was no difference in re-revision rate (any reason) with single versus dual ALBC (hazard ratio 1.06, 95% confidence interval [CI] 0.83-1.35 for hip and 0.93, CI 0.80-1.07 for knee revisions). The 10-year crude cumulative re-revision rate also showed no differences for single versus dual ALBC use. The crude cumulative 7-year THA re-revision and 9-year TKA re-revision rates did not show any difference in implant survival for common cement types used. CONCLUSION We could not confirm the potential benefit of using dual ALBC compared with single ALBC for aseptic hip and knee revisions.
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Affiliation(s)
- Pieter K Bos
- Department of Orthopedics and Sports Medicine, Erasmus MC University Medical Center, Rotterdam.
| | | | - Peter Croughs
- Department of Medical Microbiology and Infectious Diseases, Erasmus MC University Medical Center, Rotterdam
| | - Sita M A Bierma-Zeinstra
- Department of Orthopedics and Sports Medicine, Erasmus MC University Medical Center, Rotterdam; Department of General Practice, Erasmus MC University Center Rotterdam, Rotterdam, the Netherlands
| | - Max Reijman
- Department of Orthopedics and Sports Medicine, Erasmus MC University Medical Center, Rotterdam
| | - Jakob Van Oldenrijk
- Department of Orthopedics and Sports Medicine, Erasmus MC University Medical Center, Rotterdam
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Sánchez-Somolinos M, Díaz-Navarro M, Benjumea A, Matas J, Vaquero J, Muñoz P, Sanz-Ruíz P, Guembe M. In Vitro Efficacy of Dalbavancin as a Long-Acting Anti-Biofilm Agent Loaded in Bone Cement. Antibiotics (Basel) 2023; 12:1445. [PMID: 37760741 PMCID: PMC10525811 DOI: 10.3390/antibiotics12091445] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Revised: 08/24/2023] [Accepted: 09/07/2023] [Indexed: 09/29/2023] Open
Abstract
Based on previous studies by our group in which we demonstrated that dalbavancin loaded in bone cement had good elution capacity for the treatment of biofilm-related periprosthetic infections, we now assess the anti-biofilm activity of dalbavancin and compare it with that of vancomycin over a 3-month period. We designed an in vitro model in which we calculated the percentage reduction in log cfu/mL counts of sonicated steel discs contaminated with staphylococci and further exposed to bone cement discs loaded with 2.5% or 5% vancomycin and dalbavancin at various timepoints (24 h, 48 h, 1 week, 2 weeks, 6 weeks, and 3 months). In addition, we tested the anti-biofilm activity of eluted vancomycin and dalbavancin at each timepoint based on a 96-well plate model in which we assessed the percentage reduction in metabolic activity. We observed a significant decrease in the dalbavancin concentration from 2 weeks of incubation, with sustained anti-biofilm activity up to 3 months. In the case of vancomycin, we observed a significant decrease at 1 week. The concentration gradually increased, leading to significantly lower anti-biofilm activity. The percentage reduction in cfu/mL counts was higher for dalbavancin than for vancomycin at both the 2.5% and the 5% concentrations. The reduction in log cfu/mL counts was higher for S. epidermidis than for S. aureus and was particularly more notable for 5% dalbavancin at 3 months. In addition, the percentage reduction in metabolic activity also decreased at 3 months in 5% dalbavancin and 5% vancomycin, with more notable values recorded for the latter.
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Affiliation(s)
- Mar Sánchez-Somolinos
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, 28007 Madrid, Spain; (M.S.-S.); (M.D.-N.)
| | - Marta Díaz-Navarro
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, 28007 Madrid, Spain; (M.S.-S.); (M.D.-N.)
- Instituto de Investigación Sanitaria Gregorio Marañón, 28007 Madrid, Spain; (J.V.); (P.M.); (P.S.-R.)
| | - Antonio Benjumea
- Department of Orthopaedic Surgery and Traumatology, Hospital General Universitario Gregorio Marañón, 28007 Madrid, Spain; (A.B.); (J.M.)
| | - José Matas
- Department of Orthopaedic Surgery and Traumatology, Hospital General Universitario Gregorio Marañón, 28007 Madrid, Spain; (A.B.); (J.M.)
| | - Javier Vaquero
- Instituto de Investigación Sanitaria Gregorio Marañón, 28007 Madrid, Spain; (J.V.); (P.M.); (P.S.-R.)
- Department of Orthopaedic Surgery and Traumatology, Hospital General Universitario Gregorio Marañón, 28007 Madrid, Spain; (A.B.); (J.M.)
- School of Medicine, Traumatology Department, Universidad Complutense de Madrid, 28040 Madrid, Spain
| | - Patricia Muñoz
- Instituto de Investigación Sanitaria Gregorio Marañón, 28007 Madrid, Spain; (J.V.); (P.M.); (P.S.-R.)
- Department of Orthopaedic Surgery and Traumatology, Hospital General Universitario Gregorio Marañón, 28007 Madrid, Spain; (A.B.); (J.M.)
- School of Medicine, Traumatology Department, Universidad Complutense de Madrid, 28040 Madrid, Spain
- School of Medicine, Microbiology Department, Universidad Complutense de Madrid, 28040 Madrid, Spain
- CIBER Enfermedades Respiratorias-CIBERES (CB06/06/0058), 28029 Madrid, Spain
| | - Pablo Sanz-Ruíz
- Instituto de Investigación Sanitaria Gregorio Marañón, 28007 Madrid, Spain; (J.V.); (P.M.); (P.S.-R.)
- Department of Orthopaedic Surgery and Traumatology, Hospital General Universitario Gregorio Marañón, 28007 Madrid, Spain; (A.B.); (J.M.)
- School of Medicine, Traumatology Department, Universidad Complutense de Madrid, 28040 Madrid, Spain
| | - María Guembe
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, 28007 Madrid, Spain; (M.S.-S.); (M.D.-N.)
- Instituto de Investigación Sanitaria Gregorio Marañón, 28007 Madrid, Spain; (J.V.); (P.M.); (P.S.-R.)
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Blersch BP, Barthels M, Schuster P, Fink B. A Low Rate of Periprosthetic Infections after Aseptic Knee Prosthesis Revision Using Dual-Antibiotic-Impregnated Bone Cement. Antibiotics (Basel) 2023; 12:1368. [PMID: 37760665 PMCID: PMC10525338 DOI: 10.3390/antibiotics12091368] [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: 08/02/2023] [Revised: 08/22/2023] [Accepted: 08/24/2023] [Indexed: 09/29/2023] Open
Abstract
AIM The incidence of periprosthetic joint infections (PJI) following aseptic knee revision arthroplasty lies between 3% and 7.5%. The aim of this study was to verify the hypothesis that the use of dual-antibiotic-impregnated cement in knee revision arthroplasty leads to a lower rate of periprosthetic joint infections. METHODS We retrospectively reviewed 403 aseptic revision knee arthroplasties performed between January 2013 and March 2021 (148 revisions of a unicompartmental prosthesis, 188 revisions of a bicondylar total knee arthroplasty (TKA), 41 revisions of an axis-guided prosthesis, and 26 revisions of only one component of a surface replacement prosthesis). The bone cement Copal G+C (Heraeus Medical, Wertheim, Germany) with two antibiotics-gentamycin and clindamycin-was used for the fixation of the new implant. The follow-up period was 53.4 ± 27.9 (4.0-115.0) months. RESULTS Five patients suffered from PJI within follow-up (1.2%). The revision rate for any reason was 8.7%. Survival for any reason was significantly different between the types of revision (p = 0.026, Log-Rank-test), with lower survival rates after more complex surgical procedures. The 5-year survival rate with regard to revision for any reason was 91.3% [88.2-94.4%] and with regard to revision for PJI 98.2% [98.7-99.9%], respectively. CONCLUSION The use of the dual-antibiotic-impregnated bone cement Copal G+C results in a lower rate of periprosthetic infections after aseptic knee prosthesis replacement than that reported in published prosthesis revisions using only one antibiotic in the bone cement.
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Affiliation(s)
- Benedikt Paul Blersch
- Department of Joint Replacement, General and Rheumatic Orthopaedics, Orthopaedic Clinic Markgröningen gGmbH, Kurt-Lindemann-Weg 10, 71706 Markgröningen, Germany; (B.P.B.); (M.B.); (P.S.)
| | - Michael Barthels
- Department of Joint Replacement, General and Rheumatic Orthopaedics, Orthopaedic Clinic Markgröningen gGmbH, Kurt-Lindemann-Weg 10, 71706 Markgröningen, Germany; (B.P.B.); (M.B.); (P.S.)
| | - Philipp Schuster
- Department of Joint Replacement, General and Rheumatic Orthopaedics, Orthopaedic Clinic Markgröningen gGmbH, Kurt-Lindemann-Weg 10, 71706 Markgröningen, Germany; (B.P.B.); (M.B.); (P.S.)
- Department of Orthopaedics and Traumatology, Paracelsus Medical University, Prof. Ernst Nathan Straße 1, 90419 Nuremberg, Germany
| | - Bernd Fink
- Department of Joint Replacement, General and Rheumatic Orthopaedics, Orthopaedic Clinic Markgröningen gGmbH, Kurt-Lindemann-Weg 10, 71706 Markgröningen, Germany; (B.P.B.); (M.B.); (P.S.)
- Orthopaedic Department, University Hospital Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany
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11
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Szymski D, Walter N, Krull P, Melsheimer O, Lang S, Grimberg A, Alt V, Steinbrück A, Rupp M. The Prophylactic Effect of Single vs. Dual Antibiotic-Loaded Bone Cement against Periprosthetic Joint Infection Following Hip Arthroplasty for Femoral Neck Fracture: An Analysis of the German Arthroplasty Registry. Antibiotics (Basel) 2023; 12:antibiotics12040732. [PMID: 37107094 PMCID: PMC10135143 DOI: 10.3390/antibiotics12040732] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2023] [Revised: 03/31/2023] [Accepted: 04/07/2023] [Indexed: 04/29/2023] Open
Abstract
BACKGROUND Antibiotic-loaded bone cement in arthroplasties is currently experiencing increased usage. Therefore, single and double antibiotic-loaded bone cements are commercially available and used in orthopedic surgery. The aim of this investigation was to compare the clinical use of single compared to dual antibiotic-loaded bone cement for implant fixation after femoral neck fracture. Further infection rates were to be compared in (partial) arthroplasty for the treatment of femoral neck fracture for both treatment options. METHODS On the basis of the German Arthroplasty Registry (EPRD), all cases of femoral neck fracture treated with hemiarthroplasty (HA), or total hip arthroplasty (THA) with single and dual antibiotic-loaded bone cement, were included into the data analysis. The infection risk was compared using Kaplan-Meier estimates. RESULTS In total, 26,845 cases (HA 76.3%-THA: 23.7%) with femoral neck fracture were included. Within recent years, an increasing usage of dual antibiotic-loaded cement in Germany, with a current proportion of 7.30% in arthroplasty procedures for femoral neck fracture treatment, has been observed. In patients treated with HA, the proportion of dual antibiotic-loaded cement was 7.86%, while in those treated with THA, 5.46% of all prostheses were fixated with a two antibiotic component cement. For all arthroplasty procedures using single antibiotic-loaded bone cement after six months 1.8%, after one year 1.9%, and after five years 2.3%, of the cases failed due to periprosthetic joint infection (PJI), while in the same time period, in cases with dual antibiotic-loaded bone cement 1.5%, 1.5% and 1.5% suffered from infection (p = 0.34). A infection rate of 1.1% after HA with dual antibiotic-loaded bone cement was reported, compared to a 2.1% infection rate whilst using single antibiotic-loaded bone cement after five years (p = 0.098). The number required for treatment when using HA was 91. CONCLUSIONS The use of dual antibiotic-loaded bone cement is increasingly used in arthroplasty procedures after femoral neck fractures. It demonstrates a reduction of PJI after HA and seems, therefore, to be a useful method for the prevention of infection, especially in patients with increased risk factors for PJI.
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Affiliation(s)
- Dominik Szymski
- Department for Trauma Surgery, University Hospital Regensburg, 93053 Regensburg, Germany
| | - Nike Walter
- Department for Trauma Surgery, University Hospital Regensburg, 93053 Regensburg, Germany
| | - Paula Krull
- Deutsches Endoprothesenregister (EPRD) gGmbH, 10623 Berlin, Germany
| | | | - Siegmund Lang
- Department for Trauma Surgery, University Hospital Regensburg, 93053 Regensburg, Germany
| | | | - Volker Alt
- Department for Trauma Surgery, University Hospital Regensburg, 93053 Regensburg, Germany
| | - Arnd Steinbrück
- Deutsches Endoprothesenregister (EPRD) gGmbH, 10623 Berlin, Germany
- Orthopädisch Chirurgisches Kompetenzzentrum Augsburg (OCKA), 86152 Augsburg, Germany
| | - Markus Rupp
- Department for Trauma Surgery, University Hospital Regensburg, 93053 Regensburg, Germany
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12
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Determination of the Elution Capacity of Dalbavancin in Bone Cements: New Alternative for the Treatment of Biofilm-Related Peri-Prosthetic Joint Infections Based on an In Vitro Study. Antibiotics (Basel) 2022; 11:antibiotics11101300. [PMID: 36289958 PMCID: PMC9598415 DOI: 10.3390/antibiotics11101300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Revised: 09/21/2022] [Accepted: 09/21/2022] [Indexed: 11/17/2022] Open
Abstract
Antibiotic-loaded bone cement is the most widely used approach for the treatment of biofilm-induced septic sequelae in orthopedic surgery. Dalbavancin is a lipoglycopeptide that acts against Gram-positive bacteria and has a long half-life, so we aimed to assess whether it could be a new alternative drug in antibiotic-loaded bone cement for the treatment of periprosthetic joint infections. We assessed the elution capacity of dalbavancin and compared it with that of vancomycin in bone cement. Palacos®R (Heraeus Medical GmbH, Wehrheim, Germany) bone cement was manually mixed with each of the antibiotics studied at 2.5% and 5%. Three cylinders were obtained from each of the mixtures; these were weighed and incubated in 5 mL phosphate-buffered saline at 37°C under shaking for 1 h, 2 h, 4 h, 8 h, 24 h, 48 h, 168 h, and 336 h. PBS was replenished at each time point. The samples were analyzed using high-performance liquid chromatography (vancomycin) and mass cytometry (dalbavancin). Elution was higher than the minimum inhibitory concentration (MIC)90 for both antibiotics after 14 days of study. The release of vancomycin at 14 days was higher than of dalbavancin at each concentration tested (p = 0.05, both). However, the cumulative release of 5% dalbavancin was similar to that of 2.5% vancomycin (p = 0.513). The elution capacity of dalbavancin reached a cumulative concentration similar to that of vancomycin. Moreover, considering that the MIC90 of dalbavancin is one third that of vancomycin (0.06 mg/L and 2 mg/L, respectively) and given the long half-life of dalbavancin, it may be a new alternative for the treatment of biofilm-related periprosthetic infections when loaded in bone cement.
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13
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Berberich C, Josse J, Ruiz PS. Patients at a high risk of PJI: Can we reduce the incidence of infection using dual antibiotic-loaded bone cement? ARTHROPLASTY 2022; 4:41. [PMID: 36068617 PMCID: PMC9450350 DOI: 10.1186/s42836-022-00142-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Accepted: 06/26/2022] [Indexed: 11/10/2022] Open
Abstract
AbstractProsthetic joint infection (PJI) is one of the most devastating complications of orthopedic surgery. However, not all patients are equally at the risk of severe infection. The incidences of PJI vary with the host and surgery-related risk factors. It is now generally accepted that some important medical comorbidities may predispose the patients to a high risk of PJI. Time-consuming and invasive surgical procedures, such as revision arthroplasties, are also associated with a high incidence of PJI, presumably due to the increased risk of surgical site contamination. Effective infection-preventing strategies should begin with identifying and optimizing the patients at a high risk of infection prior to surgery. Optimizing the operating room environment and antibiotic prophylaxis are also essential strategies that help minimize the overall incidence of infection in orthopedic surgery. The ideal antibiotic prophylaxis is still under debate, and discussions have emerged about whether variations or adjustments to the standard protocol are justified in patients at a high risk of infection. This also includes evaluating the possible benefits and risks of using high-dose dual antibiotic-loaded bone cement instead of low-dose single antibiotic-loaded bone cement in arthroplasty. This review summarizes the evidence showing that the combination of two local antibiotics in bone cement exerts a strong and longer-lasting antimicrobial effect against PJI-associated pathogens. This conclusion is consistent with the preliminary clinical studies showing a low incidence of PJI in high-risk patients undergoing cemented hemiarthroplasty, cemented revision, and primary arthroplasty if dual ALBC is used. These results may encourage clinicians to consolidate this hypothesis in a wider clinical range.
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Crego-Vita D, Aedo-Martín D, Garcia-Cañas R, Espigares-Correa A, Sánchez-Pérez C, Berberich CE. Periprosthetic joint infections in femoral neck fracture patients treated with hemiarthroplasty – should we use antibiotic-loaded bone cement? World J Orthop 2022; 13:150-159. [PMID: 35317403 PMCID: PMC8891664 DOI: 10.5312/wjo.v13.i2.150] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Revised: 08/16/2021] [Accepted: 01/20/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Hemiarthroplasty is the most common treatment in elderly patients with displaced intra-capsular femoral neck fracture (FNF). Prosthetic joint infection (PJI) is one of the most feared and frequent complications post-surgery because of the frail health status of these patients and the need for fast track surgery. Therefore, priorities should lie in effective preventive strategies to mitigate this burden.
AIM To determine how much the implementation of the routine use of antibiotic-loaded bone cement (ALBC) as a relatively easy-to-apply amendment to the surgical practice reduces the infection rate in our hemiarthroplasty cohort.
METHODS We retrospectively assessed all demographic, health status and treatment-related data of our FNF patients undergoing cemented hemiarthroplasty in the period from 2011 to 2017; 241 patients were further analyzed after exclusion of patients with cancer-related sequelae and those who died before the end of the 1-year observation period. The PJI rate as diagnosed on basis of the Musculoskeletal Infection Society (MSIS) criteria 2011 was determined for each included patient and compared in function of the bone cement used for hip stem fixation. Patients were split into a group receiving a plain bone cement in the period from January 2011 to June 2013 (non-ALBC group) and into a group receiving an ALBC in the period July 2013 to December 2017 (ALBC group). Data analysis was performed with statistical software. We further calculated the cost-efficacy of the implementation of routine use of ALBC in the second group balancing the in-hospital infection related treatment costs with the extra costs of use of ALBC.
RESULTS In total 241 FNF patients who received cemented hemiarthroplasty in the period from January 2011 to January 2017 were eligible for inclusion in this retrospective study. There were 8 PJI cases identified in the ALBC group among n = 94 patients, whereas 28 PJI cases were observed in the non-ALBC group among n = 147 patients. The statistical analysis showed an infection risk reduction of 55.3% (in particular due to the avoidance of chronic delayed infections) in the ALBC group (95%CI: 6.2%-78.7%; P = 0.0025). The cost-evaluation analysis demonstrated a considerable cost saving of 3.500 € per patient, related to the implementation of routine use of ALBC in this group.
CONCLUSION Use of ALBC is a potent infection preventive factor in FNF patients receiving cemented hemiarthroplasties. It was further found to be highly cost-effective.
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Affiliation(s)
- Diana Crego-Vita
- Department of Orthopaedic and Trauma Surgery, Hospital Central de la Defensa Gómez Ulla, Madrid 28047, Spain
| | - Daniel Aedo-Martín
- Department of Orthopaedic and Trauma Surgery, Hospital Universitario del Henares, Universidad Francisco de Vitoria, Coslada 28822, Madrid, Spain
| | - Rafael Garcia-Cañas
- Department of Orthopaedic and Trauma Surgery, Hospital Central de la Defensa Gómez Ulla, Madrid 28047, Spain
| | - Andrea Espigares-Correa
- Department of Orthopeadic and Trauma Surgery, Hospital Central de la Defensa Gómez Ulla, Madrid 28047, Spain
| | - Coral Sánchez-Pérez
- Department of Orthopeadic and Trauma Surgery, General University Hospital Gregorio Maranon, Madrid 28007, Spain
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15
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Roman MD, Russu O, Mohor C, Necula R, Boicean A, Todor A, Mohor C, Fleaca SR. Outcomes in revision total knee arthroplasty (Review). Exp Ther Med 2022; 23:29. [PMID: 34824637 PMCID: PMC8611497 DOI: 10.3892/etm.2021.10951] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Indexed: 11/06/2022] Open
Abstract
Revision total knee arthroplasty (TKA) is a challenging surgical procedure. Although good results are presented, the outcomes are worse in comparison with those of primary TKA, with a higher failure rate. The main reasons for the failure of revision TKA include: sepsis, loosening and instability. There are multiple variables linked to these results, and it is difficult to determinate the exact cause as it is often a multifactorial issue. These variables may be related to the quality of the index-procedure (TKA), to the revision procedure or to patient characteristics. The purpose of this review was to highlight the outcomes of revision knee arthroplasty and main factors that may influence the results. Considerable progress has been made during the last 30 years regarding infection treatment and prevention, complex revision prosthetic design and surgical technique development. Although the outcomes have improved over time, patients who undergo revision TKA may need further re-operations in the future.
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Affiliation(s)
- Mihai Dan Roman
- Department of Orthopedic and Trauma Surgery, ‘Lucian Blaga’ University, 550276 Sibiu, Romania
| | - Octav Russu
- Department of Orthopedic Surgery, ‘George Emil Palade’ University of Medicine, Pharmacy, Science and Technology, 540142 Targu Mures, Romania
| | - Calin Mohor
- Department of Orthopedic and Trauma Surgery, ‘Lucian Blaga’ University, 550276 Sibiu, Romania
| | - Radu Necula
- Department of Orthopedic Surgery, ‘Transilvania’ University, 500036 Brasov, Romania
| | - Adrian Boicean
- Department of Orthopedic and Trauma Surgery, ‘Lucian Blaga’ University, 550276 Sibiu, Romania
| | - Adrian Todor
- Department of Orthopedic Surgery, ‘Iuliu Hatieganu’ University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania
| | - Cosmin Mohor
- Department of Orthopedic and Trauma Surgery, ‘Lucian Blaga’ University, 550276 Sibiu, Romania
| | - Sorin Radu Fleaca
- Department of Orthopedic and Trauma Surgery, ‘Lucian Blaga’ University, 550276 Sibiu, Romania
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16
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Jenny JY, Hamon M, Klein S, Reiter-Schatz A, Rondé-Oustau C, Boéri C, Wisniewski S, Gaudias J. Cement Loaded With High-Dose Gentamicin and Clindamycin Reduces the Risk of Subsequent Infection After One-Stage Hip or Knee Arthroplasty Exchange for Periprosthetic Infection: A Preliminary Study. J Arthroplasty 2021; 36:3973-3978. [PMID: 34511281 DOI: 10.1016/j.arth.2021.08.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 07/21/2021] [Accepted: 08/13/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND The use of antibiotic-loaded acrylic cement for treating periprosthetic joint infections remains controversial. We hypothesized that the raw rate of surgical site infection (SSI) is lower after using cement loaded with high-dose gentamicin and clindamycin than after using cement loaded with standard-dose gentamicin for implant fixation during 1-stage hip and knee revision arthroplasty for infection. METHODS One hundred seventy-one continuous patients operated by 2 experienced surgeons during a 2-year period were included in the study. All patients were followed for 24 months. The primary endpoint was the raw rate of SSI after 2 years of follow-up time. RESULTS The raw rate of SSI after 2 years of follow-up time was significantly lower in the study group (13%) than in the control group (26%) (P = .03) with an odds ratio of 0.42 (P = .03). These SSIs were new infections rather than a recurrence/persistence of the initial infection. CONCLUSION The cement used in the study group significantly reduced the risk of SSI relative to the cement used in the control group. Routine use of this high-dose dual antibiotic-loaded cement can be considered during 1-stage knee or hip revision arthroplasty for infection.
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Affiliation(s)
| | - Marie Hamon
- Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Stéphane Klein
- Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | | | | | - Cyril Boéri
- Hôpitaux Universitaires de Strasbourg, Strasbourg, France
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17
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Xi W, Hegde V, Zoller SD, Park HY, Hart CM, Kondo T, Hamad CD, Hu Y, Loftin AH, Johansen DO, Burke Z, Clarkson S, Ishmael C, Hori K, Mamouei Z, Okawa H, Nishimura I, Bernthal NM, Segura T. Point-of-care antimicrobial coating protects orthopaedic implants from bacterial challenge. Nat Commun 2021; 12:5473. [PMID: 34531396 PMCID: PMC8445967 DOI: 10.1038/s41467-021-25383-z] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Accepted: 07/29/2021] [Indexed: 11/24/2022] Open
Abstract
Implant related infections are the most common cause of joint arthroplasty failure, requiring revision surgeries and a new implant, resulting in a cost of $8.6 billion annually. To address this problem, we created a class of coating technology that is applied in the operating room, in a procedure that takes less than 10 min, and can incorporate any desired antibiotic. Our coating technology uses an in situ coupling reaction of branched poly(ethylene glycol) and poly(allyl mercaptan) (PEG-PAM) polymers to generate an amphiphilic polymeric coating. We show in vivo efficacy in preventing implant infection in both post-arthroplasty infection and post-spinal surgery infection mouse models. Our technology displays efficacy with or without systemic antibiotics, the standard of care. Our coating technology is applied in a clinically relevant time frame, does not require modification of implant manufacturing process, and does not change the implant shelf life.
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Affiliation(s)
- Weixian Xi
- Department of Chemical and Biomolecular Engineering, University of California Los Angeles, Los Angeles, CA, United States
- Department of Orthopaedic Surgery, Orthopaedic Hospital Research Center, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, CA, United States
| | - Vishal Hegde
- Department of Orthopaedic Surgery, Orthopaedic Hospital Research Center, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, CA, United States
| | - Stephen D Zoller
- Department of Orthopaedic Surgery, Orthopaedic Hospital Research Center, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, CA, United States
| | - Howard Y Park
- Department of Orthopaedic Surgery, Orthopaedic Hospital Research Center, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, CA, United States
| | - Christopher M Hart
- Department of Orthopaedic Surgery, Orthopaedic Hospital Research Center, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, CA, United States
| | - Takeru Kondo
- Weintraub Center for Reconstructive Biotechnology, Division of Advanced Prosthodontics, University of California Los Angeles School of Dentistry, Los Angeles, CA, United States
| | - Christopher D Hamad
- Department of Orthopaedic Surgery, Orthopaedic Hospital Research Center, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, CA, United States
| | - Yan Hu
- Department of Orthopaedic Surgery, Orthopaedic Hospital Research Center, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, CA, United States
| | - Amanda H Loftin
- Department of Orthopaedic Surgery, Orthopaedic Hospital Research Center, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, CA, United States
| | - Daniel O Johansen
- Department of Orthopaedic Surgery, Orthopaedic Hospital Research Center, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, CA, United States
| | - Zachary Burke
- Department of Orthopaedic Surgery, Orthopaedic Hospital Research Center, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, CA, United States
| | - Samuel Clarkson
- Department of Orthopaedic Surgery, Orthopaedic Hospital Research Center, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, CA, United States
| | - Chad Ishmael
- Department of Orthopaedic Surgery, Orthopaedic Hospital Research Center, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, CA, United States
| | - Kellyn Hori
- Department of Orthopaedic Surgery, Orthopaedic Hospital Research Center, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, CA, United States
| | - Zeinab Mamouei
- Department of Orthopaedic Surgery, Orthopaedic Hospital Research Center, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, CA, United States
| | - Hiroko Okawa
- Weintraub Center for Reconstructive Biotechnology, Division of Advanced Prosthodontics, University of California Los Angeles School of Dentistry, Los Angeles, CA, United States
| | - Ichiro Nishimura
- Weintraub Center for Reconstructive Biotechnology, Division of Advanced Prosthodontics, University of California Los Angeles School of Dentistry, Los Angeles, CA, United States
| | - Nicholas M Bernthal
- Department of Orthopaedic Surgery, Orthopaedic Hospital Research Center, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, CA, United States.
| | - Tatiana Segura
- Department of Chemical and Biomolecular Engineering, University of California Los Angeles, Los Angeles, CA, United States.
- Department of Biomedical Engineering, Neurology, Dermatology, Duke University, Durham, NC, United States.
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18
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Khalifa AA, Farouk OA. Total hip arthroplasty periprosthetic infection management, the dilemma remains. JOURNAL OF MUSCULOSKELETAL SURGERY AND RESEARCH 2021; 5:139-141. [DOI: 10.25259/jmsr_85_2021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
Affiliation(s)
- Ahmed A. Khalifa
- Department of Orthopedics, Qena Faculty of Medicine and University Hospital, South Valley University, Qena,
| | - Osama A. Farouk
- Department of Orthopedics and Traumatology, Assiut University Hospitals, Assiut, Egypt,
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19
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Fehring TK, Fehring KA, Hewlett A, Higuera CA, Otero JE, Tande AJ. What's New in Musculoskeletal Infection. J Bone Joint Surg Am 2021; 103:1251-1258. [PMID: 34048412 DOI: 10.2106/jbjs.21.00311] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- Thomas K Fehring
- OrthoCarolina Hip & Knee Center, Charlotte, North Carolina.,Atrium Musculoskeletal Institute, Charlotte, North Carolina
| | | | | | | | - Jesse E Otero
- OrthoCarolina Hip & Knee Center, Charlotte, North Carolina.,Atrium Musculoskeletal Institute, Charlotte, North Carolina
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20
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Citak M, Luck S, Linke P, Gehrke T, Kühn KD. [Manual addition of antibiotics to industrial bone cement mixes : Investigations of the dry mix in the cement cartridge during manual admixture to polymer-active substance mixtures]. DER ORTHOPADE 2021; 51:44-51. [PMID: 34032883 DOI: 10.1007/s00132-021-04115-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 04/21/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Periprosthetic infection (PPI) is a rare but serious complication. An elementary component of the therapy of PPI is the use of bone cement with the addition of antibiotics. For targeted therapy, manual mixing of antibiotics with industrially produced bone cement mixtures is often necessary. Possible problems resulting from manual mixing have not been described sufficiently so far. OBJECTIVES Therefore, the aim of the present study was to describe the influence of the additional homogenisation by dry mixing of a polymer-active substance mixture on the quality of manually added cement. MATERIAL AND METHODS In the laboratory-based study, four cement samples were prepared using different methods for manual addition and homogenisation of antibiotics (vancomycin). The reference control was Copal® G + V (Heraeus Medical GmbH, Wehrheim, Germany), to which the vancomycin (V) had already been industrially added. The samples were then examined for mechanical, microbiological and microscopic parameters. RESULTS In the mechanical and microbiological results, no statistically significant differences were found between the manually added mixtures and the reference. After dry mixing of the polymer powder, the inner surface of the mixing cartridges used showed signs of scratching in the microscopic examination and showed indications of abrasion during mixing. CONCLUSION The manual addition of antibiotics to industrially produced bone cement should be reserved for selected indications if the bone cement mixtures produced by industry are not sufficient.
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Affiliation(s)
- Mustafa Citak
- Abteilung für Orthopädische Chirurgie, Helios ENDO-Klinik, Holstenstr. 2, 22767, Hamburg, Deutschland
| | - Stefan Luck
- Abteilung für Orthopädische Chirurgie, Helios ENDO-Klinik, Holstenstr. 2, 22767, Hamburg, Deutschland
| | - Philip Linke
- Abteilung für Orthopädische Chirurgie, Helios ENDO-Klinik, Holstenstr. 2, 22767, Hamburg, Deutschland.
| | - Thorsten Gehrke
- Abteilung für Orthopädische Chirurgie, Helios ENDO-Klinik, Holstenstr. 2, 22767, Hamburg, Deutschland
| | - Klaus-Dieter Kühn
- Universitätsklinik für Orthopädie und Traumatologie, Medizinische Universität Graz, Graz, Österreich
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Berberich CE, Josse J, Laurent F, Ferry T. Dual antibiotic loaded bone cement in patients at high infection risks in arthroplasty: Rationale of use for prophylaxis and scientific evidence. World J Orthop 2021; 12:119-128. [PMID: 33816139 PMCID: PMC7995342 DOI: 10.5312/wjo.v12.i3.119] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Revised: 01/20/2021] [Accepted: 03/08/2021] [Indexed: 02/06/2023] Open
Abstract
In view of the demographic changes and projected increase of arthroplasty procedures worldwide, the number of prosthetic joint infection cases will naturally grow. Therefore, in order to counteract this trend more rigid rules and a stricter implementation of effective preventive strategies is of highest importance. In the absence of a “miracle weapon” priorities should lie in evidence-based measures including preoperative optimization of patients at higher infection risks, the fulfilment of strict hygiene rules in the operating theatre and an effective antibiotic prophylaxis regimen. Instead of a “one size fits all” philosophy, it has been proposed to adjust the antibiotic prophylaxis protocol to major infection risks taking into account important patient- and procedure-related risk factors. A stronger focus on the local application mode via use of high dose dual antibiotic-loaded bone cement in such risk situations may have its advantages and is easy to apply in the theatre. The more potent antimicrobial growth inhibition in vitro and the strong reduction of the prosthetic joint infection rate in risk for infection patients with aid of dual antibiotic-loaded bone cement in clinical studies align with this hypothesis.
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Affiliation(s)
| | - Jérôme Josse
- Institut des Sciences Pharmaceutiques et Biologiques de Lyon (ISPB), International Center for Research in Infectiology, Inserm U1111, CNRS UMR5308, ENS de Lyon, UCBL1, Lyon 69008, France
- Interregional Reference Center for the Management of Complex Osteo-Articular Infections, Hospices Civils de Lyon, Lyon 69008, France
| | - Frédéric Laurent
- Institut des Sciences Pharmaceutiques et Biologiques de Lyon (ISPB), International Center for Research in Infectiology, Inserm U1111, CNRS UMR5308, ENS de Lyon, UCBL1, Lyon 69008, France
- Interregional Reference Center for the Management of Complex Osteo-Articular Infections, Hospices Civils de Lyon, Lyon 69008, France
- Bacteriology Laboratory, Institute of Infectious Agents, Croix-Rousse Hospital, Hospices Civils de Lyon, Lyon 69008, France
| | - Tristan Ferry
- Institut des Sciences Pharmaceutiques et Biologiques de Lyon (ISPB), International Center for Research in Infectiology, Inserm U1111, CNRS UMR5308, ENS de Lyon, UCBL1, Lyon 69008, France
- Interregional Reference Center for the Management of Complex Osteo-Articular Infections, Hospices Civils de Lyon, Lyon 69008, France
- Infectious and Tropical Diseases Department, Croix-Rousse Hospital, Hospices Civils de Lyon, Lyon 69008, France
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Mendame Ehya RE, Zhang H, Qi B, Yu A. Application and Clinical Effectiveness of Antibiotic-Loaded Bone Cement to Promote Soft Tissue Granulation in the Treatment of Neuropathic Diabetic Foot Ulcers Complicated by Osteomyelitis: A Randomized Controlled Trial. J Diabetes Res 2021; 2021:9911072. [PMID: 34337074 PMCID: PMC8294998 DOI: 10.1155/2021/9911072] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Accepted: 06/25/2021] [Indexed: 11/17/2022] Open
Abstract
This study explored the clinical effectiveness of antibiotic-loaded bone cement on primary treatment of diabetic foot infection. This is a randomized controlled study, including thirty-six patients with diabetic foot ulcer complicated by osteomyelitis who had undergone treatment between May 2018 and December 2019. Patients were randomly divided into control group (group A) and study group (group B). Patients in the intervention group received antibiotic-loaded bone cement repair as primary treatment, while patients in the control group received conventional vacuum sealing draining treatment. Clinical endpoints were assessed and compared between the two groups, including wound healing time, wound bacterial conversion, NRS pain score, number of wound dressing changes, and average hospitalization time. All patients were followed up for a period of 12 months after discharge. Results show that compared with the control group, patients in the study group had significant difference in the number of patients for baseline pathogens eradication, short NRS pain score, hospital length of stay and cost, wound surface reduction, healing time, low rate of complications, and infection recurrence. Based on the findings, we conclude that antibiotic-loaded bone cement can be used for treatment of wound in patient with diabetic foot infection. It can help to control wound infections, shorten hospital length of stay, reduce medical cost, and relieve both doctors' and patients' burden. The application of antibiotic-loaded bone cement is suitable for diabetic wound with soft tissue infection or osteomyelitis.
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Affiliation(s)
- Regis Ernest Mendame Ehya
- Department of Orthopedics Trauma and Microsurgery, Zhongnan Hospital of Wuhan University, Wuhan, 430071 Hubei, China
| | - Hao Zhang
- Department of Orthopedics Trauma and Microsurgery, Zhongnan Hospital of Wuhan University, Wuhan, 430071 Hubei, China
| | - Baiwen Qi
- Department of Orthopedics Trauma and Microsurgery, Zhongnan Hospital of Wuhan University, Wuhan, 430071 Hubei, China
| | - Aixi Yu
- Department of Orthopedics Trauma and Microsurgery, Zhongnan Hospital of Wuhan University, Wuhan, 430071 Hubei, China
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Sanz-Ruiz P, Berberich C. Infection Risk-Adjusted Antibiotic Prophylaxis Strategies in Arthroplasty: Short Review of Evidence and Experiences of a Tertiary Center in Spain. Orthop Res Rev 2020; 12:89-96. [PMID: 32821178 PMCID: PMC7418150 DOI: 10.2147/orr.s256211] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Accepted: 06/21/2020] [Indexed: 12/17/2022] Open
Abstract
There is growing body of evidence that important patient-, procedure- and pathogen-related factors are linked to higher risks for prosthetic joint infections (PJI) following arthroplasty surgeries. The prior identification and optimization of such risk factors is considered paramount to minimize the incidence of these infections. Without any doubt, antibiotic prophylaxis remains one of the cornerstones among all preventive measures. However, the ideal antibiotic prophylaxis is still in debate and discussions have emerged, whether certain situations deserve adjustments or variations of the standard protocol taking into account antibiotic resistance surveillance data and patient risk factors for infections. This review aims to provide the reader with an overview of possible antibiotic prophylaxis strategies in response to these risks and discusses the clinical experiences so far obtained. We further present preliminary evidence that the use of a reinforced local antibiotic prophylaxis regimen with high-dose dual antibiotic-loaded bone cement may be an effective and easy-to-apply option in patients at high infection risks.
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Affiliation(s)
- Pablo Sanz-Ruiz
- Department of Orthopedics & Traumatology, University Hospital Gregorio Maranon, Madrid, Spain
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