1
|
Potter GR, Feuchtenberger BW, Sowinski HN, Roberts AJ, Siegel ER, Dietz MJ, Stambough JB, Bedard NA, Mears SC. How Many Patients Qualify for Extended Oral Antibiotic Prophylaxis Infection Following Primary and Revision Hip and Knee Arthroplasties? J Knee Surg 2024; 37:530-537. [PMID: 38101450 DOI: 10.1055/s-0043-1777788] [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: 12/17/2023]
Abstract
Extended oral antibiotic prophylaxis (EOAP) has been suggested to reduce rates of periprosthetic joint infection (PJI) postoperatively after total joint arthroplasty (TJA). The purpose of this multicenter study is to define how many TJA patients are considered high risk for developing PJI based on published EOAP criteria and determine whether this status is associated with socioeconomic or demographic factors. All primary and aseptic revision TJAs performed in 2019 at three academic medical centers were reviewed. High-risk status was defined based on prior published EOAP criteria. Area deprivation index (ADI) was calculated as a measure of socioeconomic status. Data were reported as means with standard deviation. Both overall and institutional differences were compared. Of the 2,511 patients (2,042 primary and 469 revision) in this cohort, 73.3% met criteria for high risk (primary: 72.9% [1,490] and revision: 74.6% [350]). Patient's race or age did not have a significant impact on risk designation; however, a larger proportion of high-risk patients were women (p = 0.002) and had higher Elixhauser scores (p < 0.001). The mean ADI for high-risk patients was higher (more disadvantaged) than for standard-risk patients (64.0 [20.8] vs. 59.4 [59.4]) (p < 0.001). Over 72% of primary and revision TJA patients at three medical centers met published criteria for EOAP. These patients were more often women, had more comorbidities, and lived in more disadvantaged areas. Our findings suggest that most patients qualify for EOAP, which may call for more stringent criteria on who would benefit extended antibiotic prophylaxis.
Collapse
Affiliation(s)
- Genna R Potter
- Department of Orthopedic Surgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Bennett W Feuchtenberger
- Department of Orthopedic Surgery, Roy J. and Lucille A. Carver College of Medicine, University of Iowa, Iowa City, Iowa
| | - Halee N Sowinski
- Department of Orthopaedics, West Virginia University School of Medicine, Morgantown, West Virginia
| | - Austin J Roberts
- Department of Orthopaedics, West Virginia University School of Medicine, Morgantown, West Virginia
| | - Eric R Siegel
- Department of Biostatistics, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Matthew J Dietz
- Department of Orthopaedics, West Virginia University School of Medicine, Morgantown, West Virginia
| | - Jeffery B Stambough
- Department of Orthopedic Surgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | | | - Simon C Mears
- Department of Orthopedic Surgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| |
Collapse
|
2
|
Wagener N, Pumberger M, Hardt S. Impact of fixation method on femoral bone loss: a retrospective evaluation of stem loosening in first-time revision total hip arthroplasty among two hundred and fifty five patients. INTERNATIONAL ORTHOPAEDICS 2024:10.1007/s00264-024-06230-4. [PMID: 38822836 DOI: 10.1007/s00264-024-06230-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Accepted: 05/22/2024] [Indexed: 06/03/2024]
Abstract
PURPOSE Implant loosening represent the most common indication for stem revision in hip revision arthroplasty. This study compares femoral bone loss and the risk of initial revisions between cemented and uncemented loosened primary stems, investigating the impact of fixation method at primary implantation on femoral bone defects. METHODS This retrospective study reviewed 255 patients who underwent their first revision for stem loosening from 2010 to 2022, receiving either cemented or uncemented stem implants. Femoral bone loss was preoperatively measured using the Paprosky classification through radiographic evaluations. Kaplan-Meier analysis estimated the survival probability of the original stem, and the hazard ratio assessed the relative risk of revision for uncemented versus cemented stems in the first postoperative year and the following two to ten years. RESULTS Cemented stems showed a higher prevalence of significant bone loss (type 3b and 4 defects: 32.39% vs. 2.72%, p < .001) compared to uncemented stems, which more commonly had type 1 and 2 defects (82.07% vs. 47.89%, p < .001). In our analysis of revision cases, primary uncemented stems demonstrated a 20% lower incidence of stem loosening in the first year post-implantation compared to cemented stems (HR 0.8; 95%-CI 0.3-2.0). However, the incidence in uncemented stems increased by 20% during the subsequent years two to ten (HR 1.2; 95%-CI 0.7-1.8). Septic loosening was more common in cemented stems (28.17% vs. 10.87% in uncemented stems, p = .001). Kaplan-Meier analysis indicated a modestly longer revision-free period for cemented stems within the first ten years post-implantation (p < .022). CONCLUSION During first-time revision, cemented stems show significantly larger femoral bone defects than uncemented stems. Septic stem loosening occurred 17.30% more in cemented stems.
Collapse
Affiliation(s)
- Nele Wagener
- Center for Musculoskeletal Surgery, Department of Orthopaedic Surgery, Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Charitéplatz 1, 10117, Berlin, Germany.
| | - Matthias Pumberger
- Center for Musculoskeletal Surgery, Department of Orthopaedic Surgery, Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Sebastian Hardt
- Center for Musculoskeletal Surgery, Department of Orthopaedic Surgery, Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Charitéplatz 1, 10117, Berlin, Germany
| |
Collapse
|
3
|
Roos J, Ben Amar S, Weinhold L, Zellner AA, Touet A, Prangenberg C, Loy T, Gathen M. Optimizing Interhospital Transfers in Orthopedics and Trauma Surgery: Challenges, Insights, and Proposals for Standardized Care in Germany. Clin Pract 2024; 14:789-800. [PMID: 38804395 PMCID: PMC11130787 DOI: 10.3390/clinpract14030063] [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: 02/05/2024] [Revised: 04/09/2024] [Accepted: 04/22/2024] [Indexed: 05/29/2024] Open
Abstract
BACKGROUND Germany's high density of under-equipped hospitals and anticipated surge in orthopedic and trauma surgery-related diseases by 2030, combined with personnel shortages, are expected to increase patient transfers between hospitals, an issue that urgently needs standardized protocols. Despite some existing cooperative agreements, such as between joint-replacement centers or within the Trauma Network DGU®, these measures do not adequately address the full range of patient-transfer cases, including those due to a lack of specialization or staff shortages, resulting in delayed treatment and potential health risks. This study aims to dissect the intricacies of interhospital transfers in orthopedics and trauma surgery across Germany, focusing on understanding the underlying reasons for transfers, comparing the operational structures of small and large hospitals, and laying the groundwork for future standardized protocols to enhance patient care. MATERIAL AND METHODS A cross-sectional study was conducted in the form of an online survey via SoSci Survey, which was directed at orthopedic surgeons and trauma surgeons working in hospitals in Germany. The 22-question survey gathered information on participants' clinic roles, departmental details, transfer processes, frequent diagnoses, perceptions of transfer quality, and improvement areas. The survey was sent to orthopedic and trauma surgeons in Germany by the specialist society. The data were analyzed using descriptive and inferential statistics to ensure a comprehensive insight into interhospital transfer practices. RESULTS The study involved 152 participants from various hospital ranks and located in different hospital sizes and types across rural and urban areas. A significant difference was observed between the care structures of basic/regular care and central/maximum care hospitals, especially regarding the available facilities and specialties. These findings suggest improvements such as better patient documentation, increased digital communication, optimized patient distribution, and standardization of transfer requests, among others. CONCLUSIONS This study highlights the urgent need for improved protocols and resource allocation to eliminate inequalities in transfers between hospitals in orthopedics and trauma surgery in Germany.
Collapse
Affiliation(s)
- Jonas Roos
- Department of Orthopedics and Trauma Surgery, University Hospital of Bonn, 53127 Bonn, Germany
| | - Soufian Ben Amar
- Department of Orthopedics and Trauma Surgery, University Hospital of Bonn, 53127 Bonn, Germany
| | - Leonie Weinhold
- Institute for Medical Biometrics, Informatics and Epidemiology, University Hospital of Bonn, 53127 Bonn, Germany
| | - Alberto Alfieri Zellner
- Department of Orthopedics and Trauma Surgery, University Hospital of Bonn, 53127 Bonn, Germany
| | - Amadeo Touet
- Department of Orthopedics and Trauma Surgery, University Hospital of Bonn, 53127 Bonn, Germany
| | - Christian Prangenberg
- Department of Orthopedics and Trauma Surgery, University Hospital of Bonn, 53127 Bonn, Germany
| | - Thomas Loy
- Department of Orthopedics and Trauma Surgery, University Hospital of Bonn, 53127 Bonn, Germany
| | - Martin Gathen
- Department of Orthopedics and Trauma Surgery, University Hospital of Bonn, 53127 Bonn, Germany
| |
Collapse
|
4
|
Hoveidaei AH, Ghaseminejad-Raeini A, Hosseini-Asl SH, Shrestha A, Hoveidaei A, Taghavi SP, Nwankwo BO, Khonji MS, Conway JD. Initiating chemotherapy in joint arthroplasty patients increases the risk of periprosthetic joint infections. Arch Orthop Trauma Surg 2024:10.1007/s00402-024-05307-4. [PMID: 38693289 DOI: 10.1007/s00402-024-05307-4] [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: 01/04/2024] [Accepted: 03/24/2024] [Indexed: 05/03/2024]
Abstract
BACKGROUND Total Joint Arthroplasties (TJAs) are becoming more popular, resulting in a growing economic burden due to potential postoperative complications, with periprosthetic joint infections (PJIs) playing a significant role. The effect of immunosuppression on PJI risk, particularly in cancer patients following chemotherapy, is unknown. The hypothesis of this study investigated whether chemotherapy increases PJI rates in patients who received post-arthroplasty chemotherapy within one year of surgery. METHODS Data from the M161Ortho dataset of PearlDiver patient records database were utilized using ICD-9, ICD-10, and CPT codes. The cohort includes Total Knee Arthroplasty (TKA), Total Hip Arthroplasty (THA), and Total Shoulder Arthroplasty (TSA) patients who underwent post-arthroplasty chemotherapy within one year after surgery between 2010 and 2022. Patients in the matched control group did not receive post-arthroplasty chemotherapy. Pre-arthroplasty chemotherapy recipients, PJI, and post-op first year revisions were excluded. Analyses including the linear logistic regression were performed via R statistical software. RESULTS Totally, 17,026 patients (8,558 TKAs, 6,707 THAs, and 1,761 TSAs) were included. At two (OR = 1.59, p = 0.034), three (OR = 1.57, p = 0.009), and four (OR = 1.40, p = 0.032) years for TKA, and two (OR = 2.27, p = 0.008), three (OR = 2.32, p < 0.001), and four (OR = 2.25, p0.001) years for THA, PJI rates were significantly higher in the chemotherapy group. TSA patients had a significant rise in PJI after four years (OR = 2.20, p = 0.031). CONCLUSIONS This study reveals a possible relationship between postoperative chemotherapy and an increased incidence of PJI in patients with arthroplasty. Chemotherapy suppresses the immune system, rendering patients more vulnerable to infections. Additional research is required to confirm these findings.
Collapse
Affiliation(s)
- Amir Human Hoveidaei
- International Center for Limb Lengthening, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Schoeneman Building, 2nd Floor, Baltimore, 2401, MD, USA
| | | | | | - Ashesh Shrestha
- International Center for Limb Lengthening, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Schoeneman Building, 2nd Floor, Baltimore, 2401, MD, USA
| | - Armin Hoveidaei
- Students' Scientific Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Seyed Pouya Taghavi
- School of Medicine, Student Research Committee, Kashan University of Medical Sciences, Kashan, Iran
| | - Basilia Onyinyechukwu Nwankwo
- International Center for Limb Lengthening, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Schoeneman Building, 2nd Floor, Baltimore, 2401, MD, USA
- Department of Orthopaedic Surgery and Rehabilitation, Howard University Hospital, Washington, DC, USA
| | - Mohammad Saeid Khonji
- Bone and Joint Reconstruction Research Center, Iran University of Medical Sciences (IUMS), Tehran, Iran
| | - Janet D Conway
- International Center for Limb Lengthening, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Schoeneman Building, 2nd Floor, Baltimore, 2401, MD, USA.
| |
Collapse
|
5
|
Vitiello R, Smimmo A, Matteini E, Micheli G, Fantoni M, Ziranu A, Maccauro G, Taccari F. Systemic Inflammation Response Index (SIRI) and Monocyte-to-Lymphocyte Ratio (MLR) Are Predictors of Good Outcomes in Surgical Treatment of Periprosthetic Joint Infections of Lower Limbs: A Single-Center Retrospective Analysis. Healthcare (Basel) 2024; 12:867. [PMID: 38727424 PMCID: PMC11083165 DOI: 10.3390/healthcare12090867] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2024] [Revised: 04/11/2024] [Accepted: 04/21/2024] [Indexed: 05/13/2024] Open
Abstract
BACKGROUND Periprosthetic joint infection (PJI) is a devastating complication that develops after total joint arthroplasty (TJA), whose incidence is expected to increase over the years. Traditionally, surgical treatment of PJI has been based on algorithms, where early infections are preferably treated with debridement, antibiotics, and implant retention (DAIR) and late infections with two-stage revision surgery. Two-stage revision is considered the "gold standard" for treatment of chronic prosthetic joint infection (PJI) as it enables local delivery of antibiotics, maintenance of limb-length and mobility, and easier reimplantation. Many studies have attempted to identify potential predicting factors for early diagnosis of PJI, but its management remains challenging. In this observational retrospective study, we investigated the potential role of inflammatory blood markers (neutrophil-to-lymphocyte ratio (NLR), monocyte-to-lymphocyte ratio (MLR), platelet-to-lymphocyte ratio (PLR), systemic inflammatory index (SII), systemic inflammatory response index (SIRI), and aggregate index of systemic inflammation (AISI)) as prognostic factors in two-stage exchange arthroplasty for PJI. METHODS A single-center retrospective analysis was conducted, collecting clinical data and laboratory parameters from patients submitted to prosthetic explantation (EP) for chronic PJI. Laboratory parameters (PCR, NLR, MLR, PLR, SIRI, SII, and AISI) were evaluated at the explantation time; at 4, 6, and 8 weeks after surgery; and at reimplantation time. The correlation between laboratory parameters and surgery success was evaluated and defined as infection absence/resolution at the last follow-up. RESULTS A total of 57 patients with PJI were evaluated (62% males; average age 70 years, SD 12.14). Fifty-three patients with chronic PJI were included. Nine patients underwent DAIR revision surgery and chronic suppressive therapy; two patients died. Nineteen patients completed the two-stage revision process (prosthetic removal, spacer placement, and subsequent replanting). Among them, none showed signs of reinfection or persistence of infection at the last available follow-up. The other twenty-three patients did not replant due to persistent infection: among them, some (the most) underwent spacer retention; others (fewer in number) were submitted to resection arthroplasty and arthrodesis (Girdlestone technique) or chronic suppressive antibiotic therapy; the remaining were, over time, lost to follow-up. Of the patients who concluded the two-stage revision, the ones with high SIRI values (mean 3.08 SD 1.7 and p-value 0.04) and MLR values (mean 0.4 SD 0.2 and p-value 0.02) at the explantation time were associated with a higher probability of infection resolution. Moreover, higher variation in the SIRI and PCR, also defined, respectively, as delta-SIRI (mean -2.3 SD 1.8 and p-value 0.03) and delta-PCR (mean -46 SD 35.7 and p-value 0.03), were associated with favorable outcomes. CONCLUSIONS The results of our study suggest that, in patients with PJI undergoing EP, the SIRI and MLR values and delta-SIRI and delta-PCR values could be predictive of a favorable outcome. The evaluation of these laboratory indices, especially their determination at 4 weeks after removal, could therefore help to determine which patients could be successfully replanted and to identify the best time to replant. More studies analyzing a wider cohort of patients with chronic PJI are needed to validate the promising results of this study.
Collapse
Affiliation(s)
- Raffaele Vitiello
- Dipartimento di Ortopedia, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy; (R.V.); (A.Z.); (G.M.)
| | - Alessandro Smimmo
- Department of Orthopedic and Traumatology, Villa Stuart Sport Clinic-FIFA Medical Centre of Excellence, 00135 Rome, Italy;
| | - Elena Matteini
- Dipartimento di Sicurezza e Bioetica—Sezione di Malattie Infettive, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Giulia Micheli
- Dipartimento di Sicurezza e Bioetica—Sezione di Malattie Infettive, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Massimo Fantoni
- Dipartimento di Sicurezza e Bioetica—Sezione di Malattie Infettive, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
- Dipartimento di Scienze di Laboratorio ed Infettivologiche, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy;
| | - Antonio Ziranu
- Dipartimento di Ortopedia, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy; (R.V.); (A.Z.); (G.M.)
| | - Giulio Maccauro
- Dipartimento di Ortopedia, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy; (R.V.); (A.Z.); (G.M.)
| | - Francesco Taccari
- Dipartimento di Scienze di Laboratorio ed Infettivologiche, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy;
| |
Collapse
|
6
|
Liukkonen R, Honkanen M, Skyttä E, Eskelinen A, Karppelin M, Reito A. Trends in Revision Knee Arthroplasty for Prosthetic Joint Infection: A Single-Center Study of 384 Knees at a High-Volume Center Between 2008 and 2021. J Arthroplasty 2023; 38:2447-2454. [PMID: 37236284 DOI: 10.1016/j.arth.2023.05.033] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Revised: 05/15/2023] [Accepted: 05/17/2023] [Indexed: 05/28/2023] Open
Abstract
BACKGROUND Prosthetic joint infection (PJI) is one of the most devastating complications after total knee arthroplasty (TKA), and comorbidities increase the risk. We examined whether a temporal change has occurred in the demographics, especially regarding comorbidities, of patients who have PJI and were treated at our institution over a 13-year study period. In addition, we assessed the surgical methods used and the microbiology of the PJIs. METHODS Revisions (n = 384, 377 patients) due to PJI of the knee performed at our institution between 2008 and September 2021 were identified. All included PJIs fulfilled the 2013 International Consensus Meeting diagnostic criteria. The surgeries were categorized into one of the following categories: debridement, antibiotics, and retention (DAIR), 1-stage revision, and 2-stage revision. Infections were classified as early, acute hematogenous, and chronic. RESULTS No changes in the median age of the patients nor comorbidity burden were observed during the study period. However, the proportion of 2-stage revisions decreased remarkably from 57.6% in 2008 to 2009 to 6.3% in 2020 to 2021. A DAIR was the most used treatment strategy, but the proportion of 1-stage revisions increased the most. In 2008 to 2009, 12.1% of the revisions were 1-stage, but in 2020 to 2021, the proportion was 43.8%. The most common pathogen was Staphylococcus aureus (27.8%). CONCLUSION The comorbidity burden remained at the same level with no trends. A DAIR was the most used strategy, but the proportion of 1-stage revisions rose to almost the same level. The incidence of PJI varied between the years, but remained relatively low.
Collapse
Affiliation(s)
- Rasmus Liukkonen
- Coxa Hospital for Joint Replacement, and Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Meeri Honkanen
- Department of Internal Medicine, Tampere University Hospital, Tampere, Finland
| | - Eerik Skyttä
- Coxa Hospital for Joint Replacement, and Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Antti Eskelinen
- Coxa Hospital for Joint Replacement, and Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Matti Karppelin
- Department of Internal Medicine, Tampere University Hospital, Tampere, Finland
| | - Aleksi Reito
- Coxa Hospital for Joint Replacement, and Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| |
Collapse
|
7
|
Karczewski D, Scholz J, Hipfl C, Akgün D, Gonzalez MR, Hardt S. Gram negative periprosthetic hip infection: nearly 25% same pathogen infection persistence at a mean of 2 years. Arch Orthop Trauma Surg 2023:10.1007/s00402-023-05104-5. [PMID: 37910220 DOI: 10.1007/s00402-023-05104-5] [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: 05/26/2023] [Accepted: 10/09/2023] [Indexed: 11/03/2023]
Abstract
PURPOSE While gram negative (GN) periprosthetic joint infections (PJI) have previously been described as difficult to treat pathogens with high rates of reinfection, limited investigations have addressed midterm outcomes and risk of infection persistence by the same pathogen. This study analyzed (1) baseline demographics, treatment strategy, and midterm outcomes of GN PJIs, as well as (2) differences in reinfection and relapse rates compared to gram positive (GP) PJIs. METHODS We identified 29 patients that were revised for 30 GN PJIs of total hip arthroplasties (THAs) between 2010 and 2020 using a university-based hip registry. Mean age was 77 years, 63% were females (19), and mean BMI was 27 kg/m2. Major causative pathogens included Escherichia coli (12), Klebsiella pneumoniae (5), Pseudomonas aeruginosa (5), and Enterobacter cloacae complex (5). Mean follow-up was 3.5 years. Study outcomes included (1) Kaplan-Meier survivorship analyses of all 30 GN PJIs, and (2) comparison of 18 two-stage exchanges for GN PJIs and 104 two-stage exchanges for GP PJIs, performed during the time from 2013 to 2017. RESULTS (1) The 5-year survivorship free of recurrent PJI was 69%, and there were 7 recurrent PJIs at a mean of 2 years. There were 2 further suprafascial wound infections, resulting in a 61% survivorship free of any infection at 5-years. At a mean of 2 years, there were 7 patients with reinfection by the same GN pathogen (6 PJIs, one wound infection) as at index revision (23%). (2) Following two-stage exchange, the 5-year survivorship free of recurrent PJI (GN: 74%; GP: 91%; p = 0.072), any infection (GN: 61%; GP: 91%; p = 0.001), and reinfection by the same pathogen was significantly lower among GN PJIs (GN: 73%; GP: 98%; p < 0.001). CONCLUSIONS Patients revised for GN PJIs are at increased risk of reinfection as opposed to GP infections. Affected patients must be counseled on the exceptionally high risk of infection persistence with one in four developing relapses. LEVEL OF EVIDENCE Therapeutic Level III.
Collapse
Affiliation(s)
- Daniel Karczewski
- Department of Orthopaedic Surgery and Traumatology, Charité Berlin, University Hospital, Chariteplatz 1, 10117, Berlin, Germany
| | - Johann Scholz
- Department of Orthopaedic Surgery and Traumatology, Charité Berlin, University Hospital, Chariteplatz 1, 10117, Berlin, Germany.
| | - Christian Hipfl
- Department of Orthopaedic Surgery and Traumatology, Charité Berlin, University Hospital, Chariteplatz 1, 10117, Berlin, Germany
| | - Doruk Akgün
- Department of Orthopaedic Surgery and Traumatology, Charité Berlin, University Hospital, Chariteplatz 1, 10117, Berlin, Germany
| | - Marcos R Gonzalez
- Department of Orthopaedic Surgery, Musculoskeletal Oncology Service, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA, 02114, USA
| | - Sebastian Hardt
- Department of Orthopaedic Surgery and Traumatology, Charité Berlin, University Hospital, Chariteplatz 1, 10117, Berlin, Germany
| |
Collapse
|
8
|
Trends in Revision Hip Arthroplasty for Prosthetic Joint Infection: A Single-Center Study of 423 Hips at a High-Volume Center Between 2008 and 2021. J Arthroplasty 2023; 38:1151-1159. [PMID: 36863575 DOI: 10.1016/j.arth.2023.02.061] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Revised: 02/16/2023] [Accepted: 02/21/2023] [Indexed: 03/04/2023] Open
Abstract
BACKGROUND Prosthetic joint infection (PJI) is one of the most devastating complications after total hip arthroplasty (THA), and comorbidities increase the risk. We examined whether there was a temporal change in the demographics, especially regarding comorbidities, of patients who have PJIs and were treated over a 13-year study period at a high-volume academic joint arthroplasty center. In addition, the surgical methods used and the microbiology of the PJIs were assessed. METHODS Revisions (n = 423, 418 patients) due to PJI of the hip performed at our institution between 2008 and September 2021 were identified. All included PJIs fulfilled the 2013 International Consensus Meeting diagnostic criteria. The surgeries were categorized into one of the following categories: debridement, antibiotics, and implant retention, 1-stage revision, and 2-stage revision. Infections were classified as early, acute hematogenous, and chronic infections. RESULTS There was no change in the median age of the patients, but the proportion of ASA-class 4 patients increased from 10.5% to 20%. The incidence of early infections increased from 0.11 per 100 primary THAs in 2008 to 1.09 in 2021. The incidence of 1-stage revisions increased the most, rising from 0.10 per 100 primary THAs in 2010 to 0.91 per 100 primary THAs in 2021. Furthermore, the proportion of infections caused by Staphylococcus aureus increased from 26.3% in 2008 to 2009 to 40% in 2020 to 2021. CONCLUSION The comorbidity burden of PJI patients increased during the study period. This increase may present a treatment challenge, as comorbidities are known to have a negative effect on PJI treatment outcomes.
Collapse
|
9
|
Gandotra R, Chen TW, Kuo FC, Lee MS, Lee GB. An aptamer-based sandwich assay for detection of alpha-defensin human neutrophil protein 1 on a microfluidic platform. Biosens Bioelectron 2023; 229:115120. [PMID: 36963324 DOI: 10.1016/j.bios.2023.115120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Revised: 01/26/2023] [Accepted: 02/01/2023] [Indexed: 02/05/2023]
Abstract
The diagnosis of periprosthetic joint infection (PJI) remains a labor-intensive and challenging issue, with life-threatening complications associated with misdiagnoses. Superior diagnostic approaches are therefore urgently needed, and synovial biomarkers are gaining substantial attention in this capacity. A new aptamer-based sandwich assay was developed where the aptamer probes specific to one such biomarker, alpha-defensin human neutrophil protein 1 (HNP 1), was integrated herein into a new microfluidic platform. The magnetic beads coated with the primary aptamer probe were able to bind the target protein with high affinity and high specificity in synovial fluid and a fluorescent-labelled secondary aptamer were further used to quantify HNP 1 in a sandwich approach. Up to four clinical samples with low volume (∼50 μL each) in a much faster assay including detection within <60 min with 100% accuracy (with totally 13 clinical samples without the need of sample pretreatment) through the use of the aptamer-based sandwich assay were automatically detected on a single chip. The wide dynamic range of this compact device, 0.5-100 mg/L, highlights its utility for future PJI diagnostics in the clinic.
Collapse
Affiliation(s)
- Rishabh Gandotra
- Institute of NanoEngineering and Microsystems, National Tsing Hua University, Hsinchu, Taiwan
| | - To-Wen Chen
- Department of Power Mechanical Engineering, National Tsing Hua University, Hsinchu, Taiwan
| | - Feng-Chih Kuo
- Department of Orthopedic Surgery, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Mel S Lee
- Department of Orthopedic Surgery, Paochien Hospital, Pintung, Taiwan.
| | - Gwo-Bin Lee
- Institute of NanoEngineering and Microsystems, National Tsing Hua University, Hsinchu, Taiwan; Department of Power Mechanical Engineering, National Tsing Hua University, Hsinchu, Taiwan.
| |
Collapse
|
10
|
Cao H, Qiao S, Qin H, Jandt KD. Antibacterial Designs for Implantable Medical Devices: Evolutions and Challenges. J Funct Biomater 2022; 13:jfb13030086. [PMID: 35893454 PMCID: PMC9326756 DOI: 10.3390/jfb13030086] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2022] [Revised: 06/12/2022] [Accepted: 06/17/2022] [Indexed: 11/25/2022] Open
Abstract
The uses of implantable medical devices are safer and more common since sterilization methods and techniques were established a century ago; however, device-associated infections (DAIs) are still frequent and becoming a leading complication as the number of medical device implantations keeps increasing. This urges the world to develop instructive prevention and treatment strategies for DAIs, boosting the studies on the design of antibacterial surfaces. Every year, studies associated with DAIs yield thousands of publications, which here are categorized into four groups, i.e., antibacterial surfaces with long-term efficacy, cell-selective capability, tailored responsiveness, and immune-instructive actions. These innovations are promising in advancing the solution to DAIs; whereas most of these are normally quite preliminary “proof of concept” studies lacking exact clinical scopes. To help identify the flaws of our current antibacterial designs, clinical features of DAIs are highlighted. These include unpredictable onset, site-specific incidence, and possibly involving multiple and resistant pathogenic strains. The key point we delivered is antibacterial designs should meet the specific requirements of the primary functions defined by the “intended use” of an implantable medical device. This review intends to help comprehend the complex relationship between the device, pathogens, and the host, and figure out future directions for improving the quality of antibacterial designs and promoting clinical translations.
Collapse
Affiliation(s)
- Huiliang Cao
- Interfacial Electrochemistry and Biomaterials, School of Materials Science and Engineering, East China University of Science and Technology, Shanghai 200237, China
- Lab of Low-Dimensional Materials Chemistry, Key Laboratory for Ultrafine Materials of Ministry of Education, East China University of Science & Technology, Shanghai 200237, China
- Chair of Materials Science, Otto Schott Institute of Materials Research (OSIM), Friedrich Schiller University Jena, 07743 Jena, Germany
- Correspondence: (H.C.); (S.Q.); (H.Q.); (K.D.J.)
| | - Shichong Qiao
- Department of Implant Dentistry, Shanghai Ninth People’s Hospital, College of Stomatology, Shanghai Jiao Tong University School of Medicine, Shanghai 200011, China
- National Clinical Research Center for Oral Diseases, Shanghai 200011, China
- Shanghai Key Laboratory of Stomatology & Shanghai Research Institute of Stomatology, Shanghai 200011, China
- Correspondence: (H.C.); (S.Q.); (H.Q.); (K.D.J.)
| | - Hui Qin
- Department of Orthopaedics, Shanghai Jiaotong University Affiliated Sixth People’s Hospital, Shanghai 200233, China
- Correspondence: (H.C.); (S.Q.); (H.Q.); (K.D.J.)
| | - Klaus D. Jandt
- Chair of Materials Science, Otto Schott Institute of Materials Research (OSIM), Friedrich Schiller University Jena, 07743 Jena, Germany
- Jena Center for Soft Matter (JCSM), Friedrich Schiller University Jena, 07743 Jena, Germany
- Jena School for Microbial Communication (JSMC), Neugasse 23, 07743 Jena, Germany
- Correspondence: (H.C.); (S.Q.); (H.Q.); (K.D.J.)
| |
Collapse
|
11
|
Šuster K, Cör A. Fast and specific detection of staphylococcal PJI with bacteriophage-based methods within 104 sonicate fluid samples. J Orthop Res 2022; 40:1358-1364. [PMID: 34432330 DOI: 10.1002/jor.25167] [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: 03/25/2021] [Revised: 07/19/2021] [Accepted: 07/30/2021] [Indexed: 02/04/2023]
Abstract
The number of prosthetic joint infection (PJI) cases is increasing along with total joint arthroplasties. There is currently no diagnostic test available with 100% sensitivity to identify PJI. The aim of the study was to assess and compare two different bacteriophage K-based methods with standard microbiological culturing methods to detect staphylococci. Samples were retrieved from 104 patients undergoing revision surgery due to suspected PJI. Implants were subjected to sonication and sonicate fluid (SF) was assessed with the methods of qPCR detection of bacteriophage K DNA and adenosine triphosphate (ATP) detection after bacteriophage K lysis. The results were compared with the results of standard microbiological culturing methods. PJI was confirmed in 33 cases according to the PJI definition. Using the methods of ATP and bacteriophage K DNA detection 100% specificity and predictive value were achieved. The sensitivity of qPCR detection was higher (81.25%) than the sensitivity of ATP detection (62.50%) when analyzing SF directly. The sensitivity of the methods significantly improved (to 94.12%) with SF pre-cultivation. Importantly, both methods provided results in 3-4 h when analyzing SF directly, while results from pre-cultivated SF were obtained 19-20 h after sample collection. Our results suggest that bacteriophage-based methods are specific and sensitive and importantly, faster than standard culturing methods. The addition of new bacteriophages to expand the bacterial detection spectrum could lead to the development of a faster, more sensitive, specific, and also economical, and handy method for PJI diagnosis.
Collapse
Affiliation(s)
- Katja Šuster
- Department of Research, Valdoltra Orthopaedic Hospital, Ankaran, Slovenia
| | - Andrej Cör
- Department of Research, Valdoltra Orthopaedic Hospital, Ankaran, Slovenia.,Faculty of Education, University of Primorska, Koper, Slovenia
| |
Collapse
|
12
|
Jaubert M, Le Baron M, Jacquet C, Couvreur A, Fabre-Aubrespy M, Flecher X, Ollivier M, Argenson JN. Failure analysis of articulating polymethyl methacrylate spacers in two-stage revision total hip arthroplasty. Bone Jt Open 2022; 3:485-494. [PMID: 35695030 PMCID: PMC9233427 DOI: 10.1302/2633-1462.36.bjo-2022-0024.r1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Aims Two-stage exchange revision total hip arthroplasty (THA) performed in case of periprosthetic joint infection (PJI) has been considered for many years as being the gold standard for the treatment of chronic infection. However, over the past decade, there have been concerns about its safety and its effectiveness. The purposes of our study were to investigate our practice, collecting the overall spacer complications, and then to analyze their risk factors. Methods We retrospectively included 125 patients with chronic hip PJI who underwent a staged THA revision performed between January 2013 and December 2019. All spacer complications were systematically collected, and risk factors were analyzed. Statistical evaluations were performed using the Student's t-test, Mann-Whitney U test, and Fisher's exact test. Results Our staged exchange practice shows poor results, which means a 42% mechanical spacer failure rate, and a 20% recurrent infection rate over the two years average follow-up period. Moreover, we found a high rate of spacer dislocation (23%) and a low rate of spacer fracture (8%) compared to the previous literature. Our findings stress that the majority of spacer complications and failures is reflecting a population with high comorbid burden, highlighted by the American Society of Anesthesiology grade, Charlson Comorbidity Index, and Lee score associations, as well as the cardiac, pulmonary, kidney, or hepatic chronic conditions. Conclusion Our experience of a two-stage hip exchange revision noted important complication rates associated with high failure rates of polymethylmethacrylate spacers. These findings must be interpreted in the light of the patient’s comorbidity profiles, as the elective population for staged exchange has an increasing comorbid burden leading to poor results. In order to provide better results for this specific population, our conclusion suggests that comparative strategy studies are required to improve our therapeutic indication. Cite this article: Bone Jt Open 2022;3(6):485–494.
Collapse
Affiliation(s)
- Maxime Jaubert
- Institute for Locomotion, Department of Orthopedics and Traumatology, Northern Hospital, Marseille, France
| | - Marie Le Baron
- Institute for Locomotion, Department of Orthopedics and Traumatology, Northern Hospital, Marseille, France
| | - Christophe Jacquet
- Institute for Locomotion, Department of Orthopedics and Traumatology ISM, CNRS, Aix-Marseille University, St. Marguerite Hospital, Marseille, France
| | - Antoine Couvreur
- Institute for Locomotion, Department of Orthopedics and Traumatology ISM, CNRS, Aix-Marseille University, St. Marguerite Hospital, Marseille, France
| | - Maxime Fabre-Aubrespy
- Institute for Locomotion, Department of Orthopedics and Traumatology ISM, CNRS, Aix-Marseille University, St. Marguerite Hospital, Marseille, France
| | - Xavier Flecher
- Institute for Locomotion, Department of Orthopedics and Traumatology, Northern Hospital, Marseille, France
- Institute for Locomotion, Department of Orthopedics and Traumatology ISM, CNRS, Aix-Marseille University, St. Marguerite Hospital, Marseille, France
| | - Matthieu Ollivier
- Institute for Locomotion, Department of Orthopedics and Traumatology ISM, CNRS, Aix-Marseille University, St. Marguerite Hospital, Marseille, France
| | - Jean-Noel Argenson
- Institute for Locomotion, Department of Orthopedics and Traumatology ISM, CNRS, Aix-Marseille University, St. Marguerite Hospital, Marseille, France
| |
Collapse
|
13
|
The use of antibiotic-loaded bone cement does not increase antibiotic resistance after primary total joint arthroplasty. Knee Surg Sports Traumatol Arthrosc 2022; 30:3208-3214. [PMID: 34244827 PMCID: PMC9418265 DOI: 10.1007/s00167-021-06649-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Accepted: 06/21/2021] [Indexed: 11/11/2022]
Abstract
PURPOSE One of the preventive strategies for periprosthetic joint infection (PJI) is the use of antibiotic-loaded bone cement (ALBC) in primary total joint arthroplasty (TJA). Even though it is widely used, there are concerns about the development of antibacterial resistance. The aim of the study was to investigate whether using ALBC in primary TJA increases the antibiotic-resistant PJI. The hypothesis was that the regular use of ALBC does not increase the rate of resistant PJI. METHODS Patients with confirmed PJI who had revision surgery from year 2010 to 2019 were included in this international multicenter study. The ALBC group was compared to the non-ALBC TJA group from the same time period. Medical records were used to collect clinical (age, gender, body mass index, comorbidities), TJA-related (type of operation, implant type and survival) and PJI-related (cultured microorganism, antibiogram) data. Resistance to gentamicin, clindamycin and vancomycin were recorded from the antibiograms. Multiple logistic regression model was used to identify risk factors and account for the potential confounders. RESULTS 218 patients with PJI were included in the study: 142 with gentamicin-loaded bone cement and 76 in the non-ALBC group. The average age in the ALBC group was 71 ± 10 years and 62 ± 12 years in the comparison group (p < 0.001). Coagulase negative Staphylococci (CONS) were the most common (49%) isolated pathogens. The use of ALBC did not increase the rate of any resistant bacteria significantly (OR = 0.79 (0.42-1.48), p = 0.469). The presence of CONS was associated with higher risk of antibiotic resistance. CONCLUSIONS The current study demonstrates no increase in antibiotic resistance due to ALBC after primary TJA. Thus, the use of ALBC during primary TJA should not be feared in the context of antimicrobial resistance. LEVEL OF EVIDENCE III.
Collapse
|
14
|
The reasons for and mortality of patients unable to receive reimplantation after resection arthroplasty for chronic hip periprosthetic infection. INTERNATIONAL ORTHOPAEDICS 2021; 46:465-472. [PMID: 34746981 DOI: 10.1007/s00264-021-05254-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Accepted: 10/22/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Two-stage exchange arthroplasty is a feasible treatment for chronic PJI (periprosthetic joint infection) of total hip arthroplasty (THA). However, there are large numbers of patients who are unable to ultimately receive reimplantation after resection arthroplasty owing to uncontrolled infection and multiple comorbidities. The purpose of the current study was to identify patient-related risk factors and reasons for being unable to undergo revision THA. METHODS Individuals undergoing resection arthroplasty for chronic PJI treatment from 2013 to 2020 at our institution were retrospectively reviewed. A variety of patient comorbidities, laboratory data, isolated pathogens, and follow-up status were collected for analysis. RESULTS A total of 84 patients (46 men and 38 women) with a 2.7 ± 2.1-year follow-up were analyzed. Thirty-eight (45.2%) patients eventually underwent revision THA, while the other 46 (54.8%) did not receive reimplantation during follow-up. The patients without receiving reimplantation had higher Charlson comorbidity index (CCI) score (3.1 ± 2.9 versus 1.2 ± 1.5; p = 0.001). Lower cumulative incidence of receiving reimplantation was observed in patients with chronic kidney disease (log-rank test, p = 0.019), anemia (p = 0.011), presence of initial fever (p = 0.030), and oxacillin-resistant strain infection (p = 0.030). The most common reasons for not receiving reimplantation were uncontrolled infection, unstable medical conditions, and death. The patients without reimplantation had a relatively higher mortality rate (log-rank test, p = 0.002). CONCLUSION Chronic hip PJI with poor medical conditions or oxacillin-resistant strain infection decreased the chance of undergoing revision surgery. These patients had unfavourable outcomes and a higher mortality rate after resection arthroplasty.
Collapse
|
15
|
Meier MP, Bauer IJ, Maheshwari AK, Husen M, Jäckle K, Hubert J, Hawellek T, Lehmann W, Saul D. Predicting the Exception-CRP and Primary Hip Arthroplasty. J Clin Med 2021; 10:4985. [PMID: 34768504 PMCID: PMC8584609 DOI: 10.3390/jcm10214985] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Revised: 10/22/2021] [Accepted: 10/26/2021] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND While primary hip arthroplasty is the most common operative procedure in orthopedic surgery, a periprosthetic joint infection is its most severe complication. Early detection and prediction are crucial. In this study, we aimed to determine the value of postoperative C-reactive protein (CRP) and develop a formula to predict this rare, but devastating complication. METHODS We retrospectively evaluated 708 patients with primary hip arthroplasty. CRP, white blood cell count (WBC), and several patient characteristics were assessed for 20 days following the operative procedure. RESULTS Eight patients suffered an early acute periprosthetic infection. The maximum CRP predicted an infection with a sensitivity and specificity of 75% and 56.9%, respectively, while a binary logistic regression reached values of 75% and 80%. A multinominal logistic regression, however, was able to predict an early infection with a sensitivity and specificity of 87.5% and 78.9%. With a one-phase decay, 71.6% of the postoperative CRP-variance could be predicted. CONCLUSION To predict early acute periprosthetic joint infection after primary hip arthroplasty, a multinominal logistic regression is the most promising approach. Including five parameters, an early infection can be predicted on day 5 after the operative procedure with 87.5% sensitivity, while it can be excluded with 78.9% specificity.
Collapse
Affiliation(s)
- Marc-Pascal Meier
- Department of Trauma, Orthopedics and Reconstructive Surgery, Georg-August-University of Goettingen, 37075 Göttingen, Germany; (M.-P.M.); (I.J.B.); (K.J.); (T.H.); (W.L.)
| | - Ina Juliana Bauer
- Department of Trauma, Orthopedics and Reconstructive Surgery, Georg-August-University of Goettingen, 37075 Göttingen, Germany; (M.-P.M.); (I.J.B.); (K.J.); (T.H.); (W.L.)
| | - Arvind K. Maheshwari
- Kogod Center on Aging and Division of Endocrinology, Mayo Clinic, Rochester, MN 55905, USA;
| | - Martin Husen
- Department of Orthopedic Surgery, Rochester, MN 55905, USA;
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Essen, 45147 Essen, Germany
| | - Katharina Jäckle
- Department of Trauma, Orthopedics and Reconstructive Surgery, Georg-August-University of Goettingen, 37075 Göttingen, Germany; (M.-P.M.); (I.J.B.); (K.J.); (T.H.); (W.L.)
| | - Jan Hubert
- Division of Orthopaedics, Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, 20521 Hamburg, Germany;
| | - Thelonius Hawellek
- Department of Trauma, Orthopedics and Reconstructive Surgery, Georg-August-University of Goettingen, 37075 Göttingen, Germany; (M.-P.M.); (I.J.B.); (K.J.); (T.H.); (W.L.)
| | - Wolfgang Lehmann
- Department of Trauma, Orthopedics and Reconstructive Surgery, Georg-August-University of Goettingen, 37075 Göttingen, Germany; (M.-P.M.); (I.J.B.); (K.J.); (T.H.); (W.L.)
| | - Dominik Saul
- Department of Trauma, Orthopedics and Reconstructive Surgery, Georg-August-University of Goettingen, 37075 Göttingen, Germany; (M.-P.M.); (I.J.B.); (K.J.); (T.H.); (W.L.)
- Kogod Center on Aging and Division of Endocrinology, Mayo Clinic, Rochester, MN 55905, USA;
| |
Collapse
|
16
|
Monárrez R, Maltenfort MG, Figoni A, Szapary HJ, Chen AF, Hansen EN, Kheir MM. External Validation Demonstrates Limited Clinical Utility of a Preoperative Prognostic Calculator for Periprosthetic Joint Infection. J Arthroplasty 2021; 36:2541-2545. [PMID: 33745800 DOI: 10.1016/j.arth.2021.02.067] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Revised: 02/20/2021] [Accepted: 02/24/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Preoperative calculation of treatment failure risk in patients undergoing surgery for periprosthetic joint infection (PJI) is imperative to allow for medical optimization and targeted prevention. A preoperative prognostic model for PJI treatment failure was previously developed, and this study sought to externally validate the model. METHODS A retrospective review was performed of 380 PJIs treated at two institutions. The model was used to calculate the risk of treatment failure, and receiver operating characteristic curves were generated to calculate the area under the curve (AUC) for each institution. RESULTS When applying this model to institution 1, an AUC of 0.795 (95% confidence interval [CI]: 0.693-0.897) was found, whereas institution 2 had an AUC of 0.592 (95% CI: 0.502-0.683). Comparing all institutions in which the model had been applied to, we found institution 2 represented a significantly sicker population and different infection profile. CONCLUSION In this cohort study, we externally validated the prior published model for institution 1. However, institution 2 had a decreased AUC using the prior model and represented a sicker and less homogenous cohort compared with institution 1. When matching for chronicity of the infection, the AUC of the model was not affected. This study highlights the impact of comorbidities and their distributions on PJI prognosis and brings to question the clinical utility of the algorithm which requires further external validation.
Collapse
Affiliation(s)
- Rubén Monárrez
- Department of Orthopaedic Surgery, Rubin Institute for Advanced Orthopaedics, Baltimore, MD
| | - Mitchell G Maltenfort
- Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Andrew Figoni
- Department of Orthopaedic Surgery, University of California, San Francisco, CA
| | - Hannah J Szapary
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, MA
| | - Antonia F Chen
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, MA
| | - Erik N Hansen
- Department of Orthopaedic Surgery, University of California, San Francisco, CA
| | - Michael M Kheir
- Department of Orthopaedic Surgery, Indiana University School of Medicine, Indianapolis, IN
| |
Collapse
|
17
|
A New Antifungal-Loaded Sol-Gel Can Prevent Candida albicans Prosthetic Joint Infection. Antibiotics (Basel) 2021; 10:antibiotics10060711. [PMID: 34204833 PMCID: PMC8231561 DOI: 10.3390/antibiotics10060711] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Revised: 06/08/2021] [Accepted: 06/09/2021] [Indexed: 12/12/2022] Open
Abstract
Fungal PJI is one of the most feared complications after arthroplasty. Although a rare finding, its high associated morbidity and mortality makes it an important object of study. The most frequent species causing fungal PJI is C. albicans. New technology to treat this type of PJI involves organic-inorganic sol-gels loaded with antifungals, as proposed in this study, in which anidulafungin is associated with organophosphates. This study aimed to evaluate the efficacy of an anidulafungin-loaded organic-inorganic sol-gel in preventing prosthetic joint infection (PJI), caused by Candida albicans using an in vivo murine model that evaluates many different variables. Fifty percent (3/6) of mice in the C. albicans-infected, non-coated, chemical-polished (CP)-implant group had positive culture and 100% of the animals in the C. albicans-infected, anidulafungin-loaded, sol-gel coated (CP + A)-implant group had a negative culture (0/6) (p = 0.023). Taking the microbiology and pathology results into account, 54.5% (6/11) of C. albicans-infected CP-implant mice were diagnosed with a PJI, whilst only 9.1% (1/11) of C. albicans-infected CP + A-implant mice were PJI-positive (p = 0.011). No differences were observed between the bone mineral content and bone mineral density of noninfected CP and noninfected CP + A (p = 0.835, and p = 0.181, respectively). No histological or histochemical differences were found in the tissue area occupied by the implant among CP and CP + A. Only 2 of the 6 behavioural variables evaluated exhibited changes during the study: limping and piloerection. In conclusion, the anidulafungin-loaded sol-gel coating showed an excellent antifungal response in vivo and can prevent PJI due to C. albicans in this experimental model.
Collapse
|