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Schiffman CJ, Baker W, Kwak D, Ramsey ML, Namdari S, Austin LS. High failure rate of 2-stage revision for the infected total elbow arthroplasty: a single institution's experience. J Shoulder Elbow Surg 2024; 33:S122-S129. [PMID: 38417731 DOI: 10.1016/j.jse.2024.01.023] [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: 07/09/2023] [Revised: 12/19/2023] [Accepted: 01/01/2024] [Indexed: 03/01/2024]
Abstract
BACKGROUND Despite 2-stage revision being a common treatment for elbow prosthetic joint infection (PJI), failure rates are high. The purpose of this study was to report on a single institution's experience with 2-stage revisions for elbow PJI and determine risk factors for failed eradication of infection. The secondary purpose was to determine risk factors for needing allograft bone at the second stage of revision in the setting of compromised bone stock. METHODS We retrospectively analyzed all 2-stage revision total elbow arthroplasties (TEAs) performed for infection at a single institution between 2006 and 2020. Data collected included demographics and treatment course prior to, during, and after 2-stage revision. Radiographs obtained after explantation and operative reports were reviewed to evaluate for partial component retention and incomplete cement removal. The primary outcome was failed eradication of infection, defined as the need for repeat surgery to treat infection after the second-stage revision. The secondary outcome was the use of allograft for compromised bone stock during the second-stage revision. Risk factors for both outcomes were determined. RESULTS Nineteen patients were included. Seven patients (37%) had either the humeral or ulnar component retained during the first stage, and 10 (53%) had incomplete removal of cement in either the humerus or ulna. Nine patients (47%) had allograft strut used during reimplantation and reconstruction. Nine patients (47%) failed to eradicate the infection after 2-stage revision. Demographic data were similar between the repeat-infection and nonrepeat-infection groups. Six patients (60%) with retained cement failed compared with 3 patients (33%) with full cement removal (P = .370). Two patients (29%) with a retained component failed compared to 7 patients (58%) with full component removal (P = .350). Allograft was used less frequently when a well-fixed component or cement was retained, with no patients with a retained component needing allograft compared to 9 with complete component removal (P = .003). Three patients (30%) with retained cement needed allograft, compared with 6 patients (67%) who had complete cement removal (P = .179). CONCLUSION Nearly half of the patients failed to eradicate infection after 2-stage revision. The data did not demonstrate a clear association between retained cement or implants and risk of recurrent infection. Allograft was used less frequently when a component and cement were retained, possibly serving as a proxy for decreased bone loss during the first stage of revision. Therefore, the unclear benefit of removing well-fixed components and cement need to be carefully considered as it likely leads to compromised bone stock that complicates the second stage of revision.
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Affiliation(s)
- Corey J Schiffman
- Department of Orthopaedic Surgery, The University of Washington, Seattle, WA, USA.
| | - William Baker
- Department of Orthopaedic Surgery, Rowan University School of Osteopathic Medicine, Stratford, NJ, USA
| | - Daniel Kwak
- Sidney Kimmel Medical College, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Matthew L Ramsey
- Department of Orthopaedic Surgery, The Rothman Institute, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Surena Namdari
- Department of Orthopaedic Surgery, The Rothman Institute, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Luke S Austin
- Department of Orthopaedic Surgery, The Rothman Institute, Thomas Jefferson University Hospital, Philadelphia, PA, USA
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Macken AA, Prkić A, van Oost I, Spekenbrink-Spooren A, The B, Eygendaal D. Implant survival of total elbow arthroplasty: analysis of 514 cases from the Dutch Arthroplasty Registry. Bone Jt Open 2023; 4:110-119. [PMID: 37051858 PMCID: PMC9999123 DOI: 10.1302/2633-1462.42.bjo-2022-0152.r1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/14/2023] Open
Abstract
The aim of this study is to report the implant survival and factors associated with revision of total elbow arthroplasty (TEA) using data from the Dutch national registry. All TEAs recorded in the Dutch national registry between 2014 and 2020 were included. The Kaplan-Meier method was used for survival analysis, and a logistic regression model was used to assess the factors associated with revision. A total of 514 TEAs were included, of which 35 were revised. The five-year implant survival was 91%. Male sex, a higher BMI, and previous surgery to the same elbow showed a statistically significant association with revision (p < 0.036). Of the 35 revised implants, ten (29%) underwent a second revision. This study reports a five-year implant survival of TEA of 91%. Patient factors associated with revision are defined and can be used to optimize informed consent and shared decision-making. There was a high rate of secondary revisions.
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Affiliation(s)
- Arno A Macken
- Department of Orthopaedics and Sports Medicine, Erasmus Medical Centre, Rotterdam, the Netherlands
- Department of Orthopaedic Surgery, Amphia Hospital, Breda, the Netherlands
| | - Ante Prkić
- Department of Orthopaedics and Sports Medicine, Erasmus Medical Centre, Rotterdam, the Netherlands
- Department of Orthopaedic Surgery, Amphia Hospital, Breda, the Netherlands
| | - Iris van Oost
- Foundation for Orthopaedic Research Care & Education (FORCE), Amphia Hospital, Breda, the Netherlands
| | | | - Bertram The
- Department of Orthopaedic Surgery, Amphia Hospital, Breda, the Netherlands
| | - Denise Eygendaal
- Department of Orthopaedics and Sports Medicine, Erasmus Medical Centre, Rotterdam, the Netherlands
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Martinez-Catalan N, Nguyen NTV, Morrey ME, O’Driscoll SW, Sanchez-Sotelo J. Two-stage reimplantation for deep infection after total elbow arthroplasty. Shoulder Elbow 2022; 14:668-676. [PMID: 36479006 PMCID: PMC9720873 DOI: 10.1177/17585732211043524] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Revised: 08/09/2021] [Accepted: 08/13/2021] [Indexed: 11/15/2022]
Abstract
Background Persistent infection rate after 2-stage reimplantation complicating elbow arthroplasty has been reported to be as high as 25%. The purposes of this retrospective study were to determine the infection eradication rates, complications and outcomes in a cohort of patients treated with two-stage reimplantation for deep periprosthetic joint infection (PJI) following total elbow arthroplasty (TEA) and to determine possible associated risk factors for treatment failure. Methods Between 2000 and 2017, 52 elbows underwent a two-stage reimplantation for PJI after TEA. There were 22 males and 30 females with a mean age of 61 (range, 25-82) years. The most common bacterium was Staphylococcus epidermidis (28 elbows). Mayo Elbow Performance Scores were calculated at the latest follow-up. Mean follow-up time was 6 years (range, 2-14 years). Results PJI was eradicated in 36 elbows (69%). The remaining 16 elbows were considered treatment failures secondary to recurrent infection. The risk of persistent infection was 3.3 times higher in elbows with retained cement (p 0.04), and 3.5 times higher when the infecting organism was Staphylococcus epidermidis (p 0.06). Conclusion Two-stage reimplantation for PJI after TEA was successful in eradicating deep infection in 69% of cases. The eradication of PJI after TEA still needs to be improved substantially.
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Affiliation(s)
- Natalia Martinez-Catalan
- Department of Orthopedic Surgery, Mayo Clinic, USA
- Department of Orthopedic Surgery, Hospital Fundacion Jimenez Diaz, Spain
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Kwak JM, So SP, Jeon IH. Staged revision still works for chronic and deep infection of total elbow arthroplasty? SICOT J 2022; 8:21. [PMID: 35616598 PMCID: PMC9135019 DOI: 10.1051/sicotj/2022019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Accepted: 05/01/2022] [Indexed: 11/16/2022] Open
Abstract
Purpose: Infected total elbow arthroplasty (TEA) is challenging. We evaluate the clinical and radiologic outcomes for chronic and deep infection of TEA with two-stage revision surgery. Methods: A total of 10 elbows were included in the study. The mean age was 69.1 ± 15 years (range, 34–83 years). The mean follow-up was 62 (range, 24–108) months. The clinical outcomes were assessed using a visual analog scale (VAS), range of motion (ROM) arc, and Mayo elbow performance score (MEPS). Moreover, radiographic outcomes, time to revision, pathogenic bacteria, preoperative complications, and disease period were evaluated. Results: Mean preoperative VAS score of 6.1 had improved to 3.3. Mean preoperative ROM was 68° (flexion-extension), which improved to 86.7°. Mean preoperative MEPS was 46 (range, 0–70), which improved to 75.5 (range, 35–85). The mean disease duration was 8.4 months (range, 5–20 months). The most common causative organism was methicillin-resistant Staphylococcus aureus. The second revision rate was 80% at the final follow-up. Radiographic outcome at final follow-up showed that 3 (30%) of 10 patients exhibited radiolucency evidence around the components. Three patients showed nonprogressive radiolucency around the implant interfaces without other indications of infection at the most recent follow-up. Conclusion: In patients with chronic and deep infection of TEA, two-stage revision can be an affordable option for eradication of the infection, relieving pain, and restoring joint function. However, the high second revision rate owing to bone and soft-tissue deficits remains a critical issue. Level of evidence: Level IV, Case series, Treatment study
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Affiliation(s)
- Jae-Man Kwak
- Department of Orthopedic Surgery, Uijeongbu Eulji Medical Center, College of Medicine, Eulji University, Uijeongbu 11759, South Korea
| | - Sang-Pil So
- Department of Orthopedic Surgery, Asan Medical Center, College of Medicine, Ulsan University, Seoul 05505, South Korea
| | - In-Ho Jeon
- Department of Orthopedic Surgery, Asan Medical Center, College of Medicine, Ulsan University, Seoul 05505, South Korea
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Leung B, McKee M, Peach C, Matthews T, Arnander M, Moverley R, Murphy R, Phadnis J. Elbow arthroplasty is safe for the management of simple open distal humeral fractures. J Shoulder Elbow Surg 2022; 31:1005-1014. [PMID: 35017081 DOI: 10.1016/j.jse.2021.12.005] [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: 08/18/2021] [Revised: 11/26/2021] [Accepted: 12/04/2021] [Indexed: 02/01/2023]
Abstract
BACKGROUND Elbow arthroplasty (EA) is an established technique for the treatment of select distal humeral fractures, yet little data exists regarding the safety and outcome of EA in the presence of an open distal humeral fracture where the risk of periprosthetic infection is an even greater concern. We hypothesized that EA does not carry an increased risk of infection or other postoperative complications when performed for simple open distal humeral fractures. METHODS Seventeen patients underwent total EA (n = 9) or hemiarthroplasty (n = 8) for an open distal humeral fracture. The open fracture component was classified according to the Orthopaedic Trauma Society system as "simple" or "complex." Outcome measures collected included the Mayo Elbow Performance Score (MEPS), range of motion, complications, and reoperations. Patients who underwent primary débridement and implantation were compared with those who underwent preliminary débridement procedures and subsequent staged arthroplasty. A systematic review of the existing literature was performed to analyze other reported cases and contextualize our findings. RESULTS The mean follow-up was 46 months (range, 12-138 months). All fractures were multifragmentary and intra-articular. Sixteen patients had a "simple" open fracture and 1 had a "complex" fracture. The overall mean MEPS was 83 (range, 30-100; standard deviation ± 17), with a mean flexion-extension arc of 96°. Patients who underwent primary débridement and implantation demonstrated a higher mean flexion arc (116° vs. 79°, P = .02) than those who underwent staged arthroplasty. The mean MEPS was not significantly different between the groups (90 vs. 78, P = .12). Complications included asymptomatic ulna component loosening (n = 1), joint instability (n = 1), and symptomatic heterotopic ossification (n = 3). There were no deep or superficial infections recorded. CONCLUSION EA is safe and effective when performed for simple open distal humeral fractures. Primary débridement and implantation may offer functional benefits over a staged approach.
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Affiliation(s)
- Brook Leung
- Brighton and Sussex Medical School, Brighton, UK.
| | - Michael McKee
- University of Arizona College of Medicine, Phoenix, AZ, USA
| | - Chris Peach
- Manchester University NHS Foundation Trust, Manchester, UK
| | - Tim Matthews
- Cardiff and Vale University Health Board, Cardiff, UK
| | - Magnus Arnander
- St George's University Hospitals NHS Foundation Trust, London, UK
| | | | | | - Joideep Phadnis
- Brighton and Sussex Medical School, Brighton, UK; University Hospitals Sussex, Brighton, UK
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Goh GS, Tornetta P, Parvizi J. Facilitating the Approval Process of Anti-Infective Technologies and Advancing Them to the Market: Insights from an FDA Workshop on Orthopaedic Device-Related Infections. J Bone Joint Surg Am 2021; 103:e57. [PMID: 34357892 DOI: 10.2106/jbjs.21.00007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Orthopaedic device-related infection is one of the most devastating complications in orthopaedic and trauma surgery. With increasing life expectancies as well as the lifelong risk of bacterial seeding on an implant, the prevention and treatment of device-related infection remains an important area for research and development. To facilitate information exchange and enhance collaboration among various stakeholders in the orthopaedic community, the U.S. Food and Drug Administration (FDA) Center for Devices and Radiological Health (CDRH) organized an inaugural workshop on orthopaedic device-related infections, exploring the regulatory challenges that are faced when proceeding from the bench level to marketing and clinical implementation of new infection-control devices and products. This article summarizes the perspectives of scientists, clinicians, and industry partners on the current regulatory approval process for orthopaedic anti-infective technologies as well as the proposed strategies to overcome these regulatory challenges.
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Affiliation(s)
- Graham S Goh
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Paul Tornetta
- Department of Orthopaedic Surgery, Boston University Medical Center, Boston, Massachusetts
| | - Javad Parvizi
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
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Watanabe S, Kobayashi N, Tomoyama A, Choe H, Yamazaki E, Inaba Y. Clinical characteristics and risk factors for culture-negative periprosthetic joint infections. J Orthop Surg Res 2021; 16:292. [PMID: 33941220 PMCID: PMC8091510 DOI: 10.1186/s13018-021-02450-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Accepted: 04/26/2021] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Culture-negative periprosthetic joint infections (PJIs) can complicate diagnosis and management of PJI. This study aimed to identify risk factors for culture-negative PJI and differences in clinical characteristics between culture-positive and culture-negative PJI group. METHODS This retrospective, cross-sectional study evaluated PJI cases obtained between January 2013 and October 2019 at our institution. These PJI cases were divided into culture-positive and culture-negative groups and then compared. The demographics, laboratory findings, and details of patient's clinical characteristics were investigated. Univariate and multivariate logistic regression analysis were performed to investigate risk factors for culture-negative PJI. RESULTS A total of 109 PJI cases were included in the analysis: 82 (75%) culture-positive and 27 (25%) culture-negative. The mean serum white blood cell (WBC) count, C-reactive protein level, and erythrocyte sedimentation rate in the culture-negative group were significantly lower than those in the culture-positive group (p < 0.05). There were no significant differences between the two groups regarding history of prior antibacterial administration or treatment success rates. Multivariate analysis identified a low serum WBC count as a risk factor for culture-negative PJI (odds ratio = 0.78; 95% confidence interval [CI] = 0.63-0.97; p = 0.027). CONCLUSIONS A low serum WBC count is a risk factor for culture-negative PJI, but prior antimicrobial therapy is not. The results suggest that PJI cases with lower levels of systemic inflammation are likely to be culture-negative; therefore, the possibility of a culture-negative result should be considered in suspected cases of PJI with low inflammatory markers, regardless of prior antibiotic exposure.
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Affiliation(s)
- Shintaro Watanabe
- Department of Orthopedic Surgery, Yokohama City University, 3-9 Fukuura, Kanazawa-ku, Yokohama City, Kanagawa Japan
| | - Naomi Kobayashi
- Department of Orthopedic Surgery, Yokohama City University Medical Center, 4-57 Urafune-cho, Minami-ku, Yokohama City, Kanagawa Japan
| | - Akito Tomoyama
- Department of Clinical Laboratory Center, Yokohama City University, 3-9 Fukuura, Kanazawa-ku, Yokohama City, Kanagawa Japan
| | - Hyonmin Choe
- Department of Orthopedic Surgery, Yokohama City University, 3-9 Fukuura, Kanazawa-ku, Yokohama City, Kanagawa Japan
| | - Etsuko Yamazaki
- Department of Clinical Laboratory Center, Yokohama City University, 3-9 Fukuura, Kanazawa-ku, Yokohama City, Kanagawa Japan
| | - Yutaka Inaba
- Department of Orthopedic Surgery, Yokohama City University, 3-9 Fukuura, Kanazawa-ku, Yokohama City, Kanagawa Japan
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