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Zanna L, Lee M, Karlidag T, Luo TD, Gehrke T, Citak M. Intramedullary Positive Tissue Culture Increases the Risk of Reinfection Following One-Stage Septic Revision Total Knee Arthroplasty. J Arthroplasty 2024; 39:2094-2099. [PMID: 38403076 DOI: 10.1016/j.arth.2024.02.053] [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: 09/09/2023] [Revised: 02/15/2024] [Accepted: 02/19/2024] [Indexed: 02/27/2024] Open
Abstract
BACKGROUND Intraoperative acquisition of representative tissue samples is essential during revision arthroplasty of the infected total knee arthroplasty (TKA). While the number of intraoperative tissue samples needed to identify the organism is well described in the literature, there is still a paucity of evidence regarding the location of positive intraoperative samples and their correlation to postoperative outcomes. METHODS There were forty-two patients who had septic failure following one-stage revision TKA for periprosthetic joint infection who were identified between January 2009 and December 2017. They were matched to a control group of patients who had successful one-stage revision TKA without septic failure. The location of positive intraoperative tissue samples was categorized as: 1) soft tissue; 2) interface between bone and prosthesis; and 3) intramedullary (IM). Chi-square, Student's t-, and Wilcoxon Mann-Whitney U-tests were used as appropriate. Univariate and multivariate logistic regression analyses were performed to evaluate predictors of septic failure. RESULTS Weight > 100 kilograms (P = .033), higher Charlson Comorbidity Index (P < .001), and positive IM cultures (P < .001) were associated with a higher risk of reinfection after one-stage revision TKA. A positive IM sample carried a nearly five-fold increase in odds of reinfection (odds ratio 4.86, 95% confidence interval 1.85 to 12.78, P = .001). CONCLUSIONS A positive IM culture sample is significantly associated with septic failure after one-stage exchange for periprosthetic joint infection of the knee. Patients who had positive IM cultures may benefit from longer postoperative antibiotic therapy for the treatment of one-stage exchange arthroplasty to minimize the risk of reinfection.
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Affiliation(s)
- Luigi Zanna
- Department of Orthopaedic Surgery, Helios ENDO-Klinik Hamburg, Hamburg, Germany; Department of Orthopaedic Surgery, Santa Maria Annunziata Hospital, Azienda USL Toscana Centro, Bagno A Ripoli (FI), Italy
| | - Minjae Lee
- Department of Orthopaedic Surgery, Helios ENDO-Klinik Hamburg, Hamburg, Germany
| | - Taner Karlidag
- Department of Orthopaedic Surgery, Helios ENDO-Klinik Hamburg, Hamburg, Germany
| | - T David Luo
- Department of Orthopaedic Surgery, Helios ENDO-Klinik Hamburg, Hamburg, Germany; Orthopaedics Northeast, Fort Wayne, Indiana
| | - Thorsten Gehrke
- Department of Orthopaedic Surgery, Helios ENDO-Klinik Hamburg, Hamburg, Germany
| | - Mustafa Citak
- Department of Orthopaedic Surgery, Helios ENDO-Klinik Hamburg, Hamburg, Germany
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Otero JE, Dombrowski ME, Brown TS, Courtney PM, Kamath AF, Nandi S, Fehring KA. What's New in Musculoskeletal Infection. J Bone Joint Surg Am 2024; 106:1249-1255. [PMID: 38781349 DOI: 10.2106/jbjs.24.00230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/25/2024]
Affiliation(s)
- Jesse E Otero
- OrthoCarolina Hip and Knee Center, Charlotte, North Carolina
- Atrium Health Musculoskeletal Institute, Charlotte, North Carolina
| | - Malcolm E Dombrowski
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Timothy S Brown
- Department of Orthopedics and Sports Medicine, Houston Methodist Hospital, Houston, Texas
| | | | - Atul F Kamath
- Orthopaedic & Rheumatologic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Sumon Nandi
- University of Maryland School of Medicine, Baltimore, Maryland
| | - Keith A Fehring
- OrthoCarolina Hip and Knee Center, Charlotte, North Carolina
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Schnetz M, Maluki R, Ewald L, Klug A, Hoffmann R, Gramlich Y. Above-knee amputation shows higher complication and mortality rates in line with lower functional outcome compared to knee arthrodesis in severe periprosthetic joint infection. Bone Joint J 2024; 106-B:669-679. [PMID: 38946307 DOI: 10.1302/0301-620x.106b7.bjj-2023-0978.r2] [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] [Indexed: 07/02/2024]
Abstract
Aims In cases of severe periprosthetic joint infection (PJI) of the knee, salvage procedures such as knee arthrodesis (KA) or above-knee amputation (AKA) must be considered. As both treatments result in limitations in quality of life (QoL), we aimed to compare outcomes and factors influencing complication rates, mortality, and mobility. Methods Patients with PJI of the knee and subsequent KA or AKA between June 2011 and May 2021 were included. Demographic data, comorbidities, and patient history were analyzed. Functional outcomes and QoL were prospectively assessed in both groups with additional treatment-specific scores after AKA. Outcomes, complications, and mortality were evaluated. Results A total of 98 patients were included, 52 treated with arthrodesis and 47 with AKA. The mean number of revision surgeries between primary arthroplasty and arthrodesis or AKA was 7.85 (SD 5.39). Mean follow-up was 77.7 months (SD 30.9), with a minimum follow-up of two years. Complications requiring further revision surgery occurred in 11.5% of patients after arthrodesis and in 37.0% of AKA patients. Positive intraoperative tissue cultures obtained during AKA was significantly associated with the risk of further surgical revision. Two-year mortality rate of arthrodesis was significantly lower compared to AKA (3.8% vs 28.3%), with age as an independent risk factor in the AKA group. Functional outcomes and QoL were better after arthrodesis compared to AKA. Neuropathic pain was reported by 19 patients after AKA, and only 45.7% of patients were fitted or were intended to be fitted with a prosthesis. One-year infection-free survival after arthrodesis was 88.5%, compared to 78.5% after AKA. Conclusion Above-knee amputation in PJI results in high complication and mortality rates and poorer functional outcome compared to arthrodesis. Mortality rates after AKA depend on patient age and mobility, with most patients not able to be fitted with a prosthesis. Therefore, arthrodesis should be preferred whenever possible if salvage procedures are indicated.
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Affiliation(s)
- Matthias Schnetz
- Department of Trauma and Orthopedic Surgery, Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, Frankfurt, Germany
| | - Roman Maluki
- Department of Trauma and Orthopedic Surgery, Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, Frankfurt, Germany
| | - Larissa Ewald
- Department of Trauma and Orthopedic Surgery, Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, Frankfurt, Germany
| | - Alexander Klug
- Department of Trauma and Orthopedic Surgery, Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, Frankfurt, Germany
| | - Reinhard Hoffmann
- Department of Trauma and Orthopedic Surgery, Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, Frankfurt, Germany
| | - Yves Gramlich
- Department of Trauma and Orthopedic Surgery, Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, Frankfurt, Germany
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Mittal A, Blackburn AZ, Katakam A, Bedair HS, Melnic CM. Dual Surgical Setup Associated with Reduced Infection Recurrence for Hip and Knee Arthroplasty After Two-Stage Exchange. J Am Acad Orthop Surg 2024; 32:68-74. [PMID: 37793169 DOI: 10.5435/jaaos-d-23-00317] [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: 04/02/2023] [Accepted: 07/20/2023] [Indexed: 10/06/2023] Open
Abstract
INTRODUCTION Two-stage exchange (TSE) is the gold standard for the treatment of chronic periprosthetic joint infection (PJI) after total joint arthroplasty of the hip and knee in the United States. Failure of treatment can have devastating consequences for the patient, including poor functional outcomes, multiple further surgeries, and increased mortality. Several factors associated with infection recurrence have previously been identified in the literature. The purpose of this study was to evaluate whether the use of a dual surgical setup was associated with reduced risk of recurrence after TSE for PJI. METHODS A retrospective study was conducted between January 2000 and December 2021 to isolate patients who underwent TSE after total joint arthroplasty of the hip and knee. Failure was defined as infection recurrence requiring surgical intervention. Demographic factors (age, sex, body mass index, smoking status, American Society of Anesthesiologists status), preoperative comorbidities (hypertension, cardiac disease, diabetes status, depression diagnosis, pulmonary disease), operating surgeon, single versus dual setup, hospital setting, use of long-term antibiotics postoperatively after TSE, aspiration data, and infecting organism were compared between cohorts using multivariate regression analysis. RESULTS A total of 134 patients were identified who underwent TSE after diagnosis of PJI. The mean follow-up was 67.84 (range, 13 to 236) months. Dual setup (odds ratio, 0.13; confidence interval, 0.02 to 0.52; P = 0.0122) was found to be an independent predictive variable associated with a lower risk of infection recurrence. CONCLUSION Utilization of a dual surgical setup is a low-cost modifiable risk factor associated with a lower risk of recurrence of after TSE of the hip and knee for PJI.
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Affiliation(s)
- Ashish Mittal
- From the Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA (Mittal, Blackburn, Katakam, Bedair, and Melnic), and the Department of Orthopaedic Surgery, Newton-Wellesley Hospital, Newton, MA (Bedair, and Melnic)
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Shaikh S, Lapin NA, Prasad B, Sturge CR, Pybus C, Pifer R, Wang Q, Evers BM, Chopra R, Greenberg DE. Intermittent alternating magnetic fields diminish metal-associated biofilm in vivo. Sci Rep 2023; 13:22456. [PMID: 38105253 PMCID: PMC10725887 DOI: 10.1038/s41598-023-49660-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Accepted: 12/11/2023] [Indexed: 12/19/2023] Open
Abstract
Prosthetic joint infection (PJI) is a complication of arthroplasty that results in significant morbidity. The presence of biofilm makes treatment difficult, and removal of the prosthesis is frequently required. We have developed a non-invasive approach for biofilm eradication from metal implants using intermittent alternating magnetic fields (iAMF) to generate targeted heating at the implant surface. The goal of this study was to determine whether iAMF demonstrated efficacy in an in vivo implant biofilm infection model. iAMF combined with antibiotics led to enhanced reduction of biofilm on metallic implants in vivo compared to antibiotics or untreated control. iAMF-antibiotic combinations resulted in a > 1 - log further reduction in biofilm burden compared to antibiotics or iAMF alone. This combination effect was seen in both S. aureus and P. aeruginosa and seen with multiple antibiotics used to treat infections with these pathogens. In addition, efficacy was temperature dependent with increasing temperatures resulting in a greater reduction of biofilm. Tissue damage was limited (< 1 mm from implant-tissue interface). This non-invasive approach to eradicating biofilm could serve as a new paradigm in treating PJI.
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Affiliation(s)
| | - Norman A Lapin
- Department of Radiology, University of Texas Southwestern Medical School, Dallas, TX, USA
- Advanced Imaging Research Center, University of Texas Southwestern Medical School, Dallas, TX, USA
| | | | - Carolyn R Sturge
- Department of Internal Medicine, Infectious Diseases and Geographic Medicine, University of Texas Southwestern Medical School, Dallas, TX, USA
| | - Christine Pybus
- Department of Internal Medicine, Infectious Diseases and Geographic Medicine, University of Texas Southwestern Medical School, Dallas, TX, USA
| | - Reed Pifer
- Department of Internal Medicine, Infectious Diseases and Geographic Medicine, University of Texas Southwestern Medical School, Dallas, TX, USA
| | - Qi Wang
- Department of Radiology, University of Texas Southwestern Medical School, Dallas, TX, USA
| | - Bret M Evers
- Department of Pathology, University of Texas Southwestern Medical School, Dallas, TX, USA
| | - Rajiv Chopra
- Department of Radiology, University of Texas Southwestern Medical School, Dallas, TX, USA
- Advanced Imaging Research Center, University of Texas Southwestern Medical School, Dallas, TX, USA
- Solenic Medical, Addison, TX, USA
| | - David E Greenberg
- Department of Internal Medicine, Infectious Diseases and Geographic Medicine, University of Texas Southwestern Medical School, Dallas, TX, USA.
- Department of Microbiology, University of Texas Southwestern Medical School, Dallas, TX, USA.
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