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Ascione T, Balato G, Festa E, Pandolfo G, Siciliano R, Pagliano P. Ideal Timing of Reimplantation in Patients with Periprosthetic Knee Infection Undergoing 2-Stage Exchange: A Diagnostic Scoring System. J Bone Joint Surg Am 2024; 106:984-991. [PMID: 38478627 DOI: 10.2106/jbjs.23.00424] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/06/2024]
Abstract
BACKGROUND This study evaluated appropriate thresholds for serum biomarkers, synovial fluid white blood cell (SF-WBC) count, and synovial fluid neutrophil (polymorphonuclear leukocyte [PMN]) percentage to predict infection in a patient group who underwent definitive reimplantation after receiving a continuous course of antibiotic therapy for chronic knee periprosthetic joint infection (PJI). These thresholds were then used to generate a scoring system to predict recurrence (or persistence) of infection. METHODS The study included 153 patients with a median age of 73 years (range, 46 to 91 years) who underwent 2-stage revision for chronic knee PJI. Staphylococci were identified at baseline in 107 (70%) of the patients. After the 96-week follow-up period, 12% (19) of the 153 patients had recurrence of the PJI. A receiver operating characteristic (ROC) curve analysis was used to assess the predictive value of common serum biomarkers and SF aspiration before reimplantation, and the area under the curve (AUC) was evaluated. Variables that were significantly different between patients with and without infection recurrence were evaluated using a multivariable logistic regression model. A half-integer-point scoring system was created based on the final beta coefficients. RESULTS Regarding the prediction of recurrent infection, a D-dimer level of >1110 ng/mL yielded a sensitivity of 74%, specificity of 61%, and AUC of 0.69; an SF-WBC count of >934 cells/µL showed a sensitivity of 68%, specificity of 90%, and AUC of 0.79; and an SF-PMN percentage of >52% showed a sensitivity of 73%, specificity of 90%, and AUC of 0.82. The beta coefficients were approximated to 1.5 for the D-dimer level and to 2 for the SF-WBC count and SF-PMN percentage. A total score of >2 was used to classify patients with a high risk of infection recurrence. The ability to discriminate infection recurrence was demonstrated by an AUC of 0.90 (95% confidence interval: 0.82 to 0.99). CONCLUSIONS Patients with a score of >2 on our proposed scoring system based on serum biomarkers, SF-WBC count, and SF-PMN percentage should not undergo reimplantation, as they are at a high risk for recurrent PJI. Patients with a score of ≤2 can undergo definitive reimplantation with the lowest risk of recurrence. LEVEL OF EVIDENCE Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Tiziana Ascione
- Service of Infectious Diseases, Cardarelli Hospital, Naples, Italy
| | - Giovanni Balato
- Section of Orthopedic Surgery, Department of Public Health, University of Naples Federico II, Naples, Italy
| | - Enrico Festa
- Section of Orthopedic Surgery, Department of Public Health, University of Naples Federico II, Naples, Italy
| | - Giuseppe Pandolfo
- Department of Industrial Engineering, University of Naples Federico II, Naples, Italy
| | - Roberta Siciliano
- Department of Electrical Engineering and Information Technologies, University of Naples Federico II, Naples, Italy
| | - Pasquale Pagliano
- Unit of Infectious Diseases, Department of Medicine and Surgery, University of Salerno, Baronissi, Italy
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Ascione T, Balato G, Pagliano P. Upcoming evidence in clinical practice of two-stage revision arthroplasty for prosthetic joint infection. J Orthop Traumatol 2024; 25:26. [PMID: 38761247 PMCID: PMC11102413 DOI: 10.1186/s10195-024-00767-1] [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: 03/15/2024] [Accepted: 04/23/2024] [Indexed: 05/20/2024] Open
Abstract
Total joint arthroplasty is the recommended treatment for patients with end-stage osteoarthritis, as it reduces disability and pain and restores joint function. However, prosthetic joint infection is a serious complication of this procedure, with the two-stage exchange being the most common treatment method. While there is consensus on diagnosing prosthetic joint infection, there is a lack of agreement on the parameters that can guide the surgeon in performing definitive reimplantation in a two-stage procedure. One approach that has been suggested to improve the accuracy of microbiologic investigations before definitive reimplantation is to observe a holiday period from antibiotic therapy to improve the accuracy of cultures from periprosthetic tissues, but these cultures report some degree of aspecificity. Therefore, several pieces of evidence highlight that performing reimplantation using continuous antibiotic therapy should be considered a safe and effective approach, leading to higher cure rates and a shorter period of disability. Dosage of C-reactive protein (CRP), erythrocyte sedimentation rate (ERS) and D-dimer are helpful in diagnosing prosthetic joint infection, but only D-dimer has shown sufficient accuracy in predicting the risk of infection recurrence after a two-stage procedure. Synovial fluid analysis before reimplantation has been shown to be the most accurate in predicting recurrence, and new cutoff values for leukocyte count and neutrophil percentage have shown a useful predictive rule to identify patients at risk of unfavourable outcome. A new scoring system based on a numerical score calculated from the beta coefficient derived through multivariate analysis of D-dimer levels, synovial fluid leukocytes and relative neutrophils percentage has demonstrated high accuracy when it comes to guiding the second step of two-stage procedure. In conclusion, reimplantation may be a suitable option for patients who are on continuous therapy without local symptoms, and with CRP and ERS within the normal range, with low synovial fluid leukocytes (< 952/mL) and a low relative neutrophil percentage (< 52%) and D-dimer below 1100 µg/mL. A numerical score derived from analysing these three parameters can serve as a valuable tool in determining the feasibility of reimplantation in these patients.
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Affiliation(s)
- Tiziana Ascione
- Service of Infectious Diseases, Cardarelli Hospital, Via A. Cardarelli 9, 80131, Naples, Italy.
| | - Giovanni Balato
- Department of Public Health, Orthopedic Unit, "Federico II" University, Naples, Italy
| | - Pasquale Pagliano
- Unit of Infectious Diseases, Department of Medicine, Surgery and Dentistry, "Scuola Medica Salernitana", University of Salerno, Baronissi, Italy
- Clinica Malattie Infettive, AOU San Giovanni di Dio e Ruggi d'Aragona, Salerno, Italy
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Caldwell M, Hughes M, Wei F, Ngo C, Pascua R, Pugazhendhi AS, Coathup MJ. Promising applications of D-amino acids in periprosthetic joint infection. Bone Res 2023; 11:14. [PMID: 36894568 PMCID: PMC9998894 DOI: 10.1038/s41413-023-00254-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2022] [Revised: 02/02/2023] [Accepted: 02/10/2023] [Indexed: 03/11/2023] Open
Abstract
Due to the rise in our aging population, a disproportionate demand for total joint arthroplasty (TJA) in the elderly is forecast. Periprosthetic joint infection (PJI) represents one of the most challenging complications that can occur following TJA, and as the number of primary and revision TJAs continues to rise, an increasing PJI burden is projected. Despite advances in operating room sterility, antiseptic protocols, and surgical techniques, approaches to prevent and treat PJI remain difficult, primarily due to the formation of microbial biofilms. This difficulty motivates researchers to continue searching for an effective antimicrobial strategy. The dextrorotatory-isoforms of amino acids (D-AAs) are essential components of peptidoglycan within the bacterial cell wall, providing strength and structural integrity in a diverse range of species. Among many tasks, D-AAs regulate cell morphology, spore germination, and bacterial survival, evasion, subversion, and adhesion in the host immune system. When administered exogenously, accumulating data have demonstrated that D-AAs play a pivotal role against bacterial adhesion to abiotic surfaces and subsequent biofilm formation; furthermore, D-AAs have substantial efficacy in promoting biofilm disassembly. This presents D-AAs as promising and novel targets for future therapeutic approaches. Despite their emerging antibacterial efficacy, their role in disrupting PJI biofilm formation, the disassembly of established TJA biofilm, and the host bone tissue response remains largely unexplored. This review aims to examine the role of D-AAs in the context of TJAs. Data to date suggest that D-AA bioengineering may serve as a promising future strategy in the prevention and treatment of PJI.
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Affiliation(s)
- Matthew Caldwell
- Biionix Cluster & College of Medicine, University of Central Florida, 6900 Lake Nona Blvd, Orlando, FL, 32827, USA
| | - Megan Hughes
- School of Biosciences, Cardiff University, CF10 3AT, Wales, UK
| | - Fei Wei
- Biionix Cluster & College of Medicine, University of Central Florida, 6900 Lake Nona Blvd, Orlando, FL, 32827, USA
| | - Christopher Ngo
- Biionix Cluster & College of Medicine, University of Central Florida, 6900 Lake Nona Blvd, Orlando, FL, 32827, USA
| | - Raven Pascua
- Burnett School of Biomedical Sciences, College of Medicine, University of Central Florida, 6900 Lake Nona Blvd, Orlando, FL, 32827, USA
| | - Abinaya Sindu Pugazhendhi
- Biionix Cluster & College of Medicine, University of Central Florida, 6900 Lake Nona Blvd, Orlando, FL, 32827, USA
| | - Melanie J Coathup
- Biionix Cluster & College of Medicine, University of Central Florida, 6900 Lake Nona Blvd, Orlando, FL, 32827, USA.
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Khan IA, Boyd BO, Chen AF, Cortés-Penfield N, Myers TG, Brown TS, Suh GA, McGwin G, Ghanem ES, Fillingham YA. Utility of Diagnostic Tests Before Reimplantation in Patients Undergoing 2-Stage Revision Total Joint Arthroplasty: A Systematic Review and Meta-analysis. JBJS Rev 2023; 11:01874474-202303000-00007. [PMID: 36947634 DOI: 10.2106/jbjs.rvw.22.00201] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/24/2023]
Abstract
INTRODUCTION Periprosthetic joint infection (PJI) is a devastating complication after total joint arthroplasty (TJA), with treatment failure occurring in 12% to 28% after 2-stage revision. It is vital to identify diagnostic tools indicative of persistent infection or treatment failure after 2-stage revision for PJI. METHODS The Cochrane Library, PubMed (MEDLINE), and EMBASE were searched for randomized controlled trials and comparative observational studies published before October 3, 2021, which evaluated the utility of serum/plasma biomarkers (erythrocyte sedimentation rate [ESR], C-reactive protein [CRP], interleukin-6 [IL-6], fibrinogen, D-dimer), synovial biomarkers (white blood cell [WBC] count, neutrophil percentage [PMN %], alpha-defensin [AD], leukocyte esterase [LE]), tissue frozen section, tissue culture, synovial fluid culture, or sonicated spacer fluid culture indicative of persistent infection before the second stage of 2-stage revision for PJI or treatment failure after 2-stage revision for PJI. RESULTS A total of 47 studies including 6,605 diagnostic tests among 3,781 2-stage revisions for PJI were analyzed. Among those cases, 723 (19.1%) experienced persistent infection or treatment failure. Synovial LE (sensitivity 0.25 [0.10-0.47], specificity 0.99 [0.93-1.00], positive likelihood ratio 14.0 [1.45-135.58]) and serum IL-6 (sensitivity 0.52 [0.33-0.70], specificity 0.92 [0.85-0.96], positive likelihood ratio 7.90 [0.86-72.61]) had the highest diagnostic accuracy. However, no biomarker was associated with a clinically useful negative likelihood ratio. In subgroup analysis, synovial PMN %, synovial fluid culture, serum ESR, and serum CRP had limited utility for detecting persistent infection before reimplantation (positive likelihood ratios ranging 2.33-3.74; negative likelihood ratios ranging 0.31-0.9) and no utility for predicting failure after the second stage of 2-stage revision. CONCLUSIONS Synovial WBC count, synovial PMN %, synovial fluid culture, serum ESR, and serum CRP have modest sensitivity and specificity for predicting persistent infection during the second stage of 2-stage revision, suggesting some combination of these diagnostic tests might be useful before reimplantation. No biomarker or culture accurately predicted treatment failure after reimplantation. LEVEL OF EVIDENCE Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Irfan A Khan
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Brandon O Boyd
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Antonia F Chen
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | | | - Thomas G Myers
- Department of Orthopaedics and Physical Performance, University of Rochester Medical Center, Rochester, New York
| | - Timothy S Brown
- Department of Orthopaedic Surgery, Houston Methodist Orthopaedics & Sports Medicine, Houston, Texas
| | - Gina A Suh
- Division of Infectious Diseases, Mayo Clinic, Rochester, Minnesota
| | - Gerald McGwin
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Elie S Ghanem
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Yale A Fillingham
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
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Benda S, Mederake M, Schuster P, Fink B. Diagnostic Value of C-Reactive Protein and Serum White Blood Cell Count during Septic Two-Stage Revision of Total Knee Arthroplasties. Antibiotics (Basel) 2022; 12:antibiotics12010014. [PMID: 36671215 PMCID: PMC9854734 DOI: 10.3390/antibiotics12010014] [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: 11/08/2022] [Revised: 12/13/2022] [Accepted: 12/19/2022] [Indexed: 12/24/2022] Open
Abstract
AIMS AND METHODS In septic two-stage revision arthroplasty, the timing of reimplantation is crucial for therapeutic success. Recent studies have shown that singular values of C-reactive protein (CRP) and white blood cell count (WBC count) display weak diagnostic value in indicating whether periprosthetic joint infection (PJI) is controlled or not during two-stage revision surgery of knee arthroplasty. Therefore, in addition to the values of CRP and WBC, the course of CRP and WBC counts were compared between groups with and without later reinfection in 95 patients with two-stage revision (TSR) of infected total knee arthroplasties (TKA). Of these patients, 16 had a reinfection (16.84%). RESULTS CRP values decreased significantly after the first stage of TSR in both the reinfection and no-reinfection groups. WBC count values decreased significantly in the no-reinfection group. Decrease in WBC count was not significant in the reinfection group. No significant difference could be found in either the CRP values or the WBC counts at the first stage of TSR, the second stage of TSR, or their difference between stages when comparing groups with and without reinfection. Area under the curve (AUC) values ranging between 0.631 and 0.435 showed poor diagnostic value for the calculated parameters. The courses of CRP over 14 days after the first stage of both groups were similar with near identical AUC. CONCLUSIONS CRP and WBC count as well as their course over 14 days postoperatively are not suitable for defining whether a PJI of the knee is under control or not.
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Affiliation(s)
- Sebastian Benda
- Department of Arthroplasty and Revision Arthroplasty, Orthopaedic Clinic Markgröningen GmbH, Kurt-Lindemann-Weg 10, 71706 Markgröningen, Germany
| | - Moritz Mederake
- Department of Orthopaedic Surgery, University Hospital Tübingen, Hoppe Seyler–Str. 3, 72076 Tübingen, Germany
| | - Philipp Schuster
- Department of Arthroplasty and Revision Arthroplasty, Orthopaedic Clinic Markgröningen GmbH, Kurt-Lindemann-Weg 10, 71706 Markgröningen, Germany
- Department of Orthopaedics and Traumatology, Paracelsus Medical Private University, Clinic Nuremberg, Prof. Ernst Nathan Straße 1, 90419 Nürnberg, Germany
| | - Bernd Fink
- Department of Arthroplasty and Revision Arthroplasty, Orthopaedic Clinic Markgröningen GmbH, Kurt-Lindemann-Weg 10, 71706 Markgröningen, Germany
- Orthopaedic Department, University-Hospital Hamburg-Eppendorf, Martinistrasse 52, 20251 Hamburg, Germany
- Correspondence: ; Tel.: +49-(0)7145-9153201
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Owens JM, Dennis DA, Abila PM, Johnson RM, Jennings JM. Alpha-Defensin Offers Limited Utility in Work-Up Prior to Reimplantation in Chronic Periprosthetic Joint Infection in Total Joint Arthroplasty Patients. J Arthroplasty 2022; 37:2431-2436. [PMID: 35803520 DOI: 10.1016/j.arth.2022.06.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 06/27/2022] [Accepted: 06/29/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Alpha-defensin (AD) is a synovial biomarker included in the 2018 consensus criteria for diagnosing periprosthetic joint infection (PJI). Its value in assessing eradication of infection prior to second stage reimplantation is unclear. The purpose of this study was to evaluate the impact of AD on eligibility for reimplantation following resection for chronic PJI. METHODS This study included patients who previously underwent resection arthroplasty for PJI. Synovial fluid aspirated from 87 patients was retrospectively reviewed. All patients completed a 6-week course of intravenous antibiotics and an appropriate drug holiday. Synovial white blood cell count, percentage neutrophils, and culture from the AD immunoassay laboratory were reviewed with serum erythrocyte sedimentation rate and C-reactive protein values from our institution. A modified version of the 2018 consensus criteria was used, including white blood cell count, percentage neutrophils, erythrocyte sedimentation rate, and C-reactive protein. AD was then added to determine if it changed diagnosis or clinical management. RESULTS Four patients were categorized as "infected" (score >6), none exhibited a positive AD or positive culture. Sixty eight patients were diagnosed as "possibly infected" (score 2 to 5), none had a positive AD, and one had a positive culture (Cutibacterium acnes). AD did not change the diagnosis from "possibly infected" to "infected" in any case or alter treatment plans. Fifteen patients had a score of <2 (not infected) and none had a positive AD. CONCLUSION The routine use of AD in the work-up prior to a second-stage arthroplasty procedure for PJI may not be warranted.
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Affiliation(s)
| | - Douglas A Dennis
- Colorado Joint Replacement, Denver, Colorado; Department of Mechanical and Materials Engineering, University of Denver, Denver, Colorado; Department of Orthopaedics, University of Colorado School of Medicine, Denver, Colorado; Department of Biomedical Engineering, University of Tennessee, Knoxville, Tennessee
| | | | | | - Jason M Jennings
- Colorado Joint Replacement, Denver, Colorado; Department of Mechanical and Materials Engineering, University of Denver, Denver, Colorado
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Tang H, Xu J, Yuan W, Wang Y, Yue B, Qu X. Reliable Diagnostic Tests and Thresholds for Preoperative Diagnosis of Non-Inflammatory Arthritis Periprosthetic Joint Infection: A Meta-analysis and Systematic Review. Orthop Surg 2022; 14:2822-2836. [PMID: 36181336 PMCID: PMC9627080 DOI: 10.1111/os.13500] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Revised: 08/19/2022] [Accepted: 08/23/2022] [Indexed: 02/06/2023] Open
Abstract
Objective The current diagnostic criteria for periprosthetic joint infection (PJI) are diverse and controversial, leading to delayed diagnosis. This study aimed to evaluate and unify their diagnostic accuracy and the threshold selection of serum and synovial routine tests for PJI at an early stage. Methods We searched the MEDLINE and Embase databases for retrospective or prospective studies which reported preoperative‐available assays (serum, synovial, or culture tests) for the diagnosis of chronic PJI among inflammatory arthritis (IA) or non‐IA populations from January 1, 2000 to June 30, 2022. Threshold effective analysis was performed on synovial polymorphonuclear neutrophils (PMN%), synovial white blood cell (WBC), serum C‐reactive protein (CRP), and erythrocyte sedimentation rate (ESR) to find the relevant cut‐offs. Results Two hundred and sixteen studies and information from 45,316 individuals were included in the final analysis. Synovial laboratory‐based α‐defensin and calprotectin had the best comprehensive sensitivity (0.91 [0.86–0.94], 0.95 [0.88–0.98]) and specificity (0.96 [0.94‐0.97], 0.95 [0.89–0.98]) values. According to the threshold effect analysis, the recommended cut‐offs are 70% (sensitivity 0.89 [0.85–0.92], specificity 0.90 [0.87–0.93]), 4100/μL (sensitivity 0.90 [0.87–0.93], specificity 0.97 [0.93–0.98]), 13.5 mg/L (sensitivity 0.84 [0.78–0.89], specificity 0.83 [0.73–0.89]), and 30 mm/h (sensitivity 0.79 [0.74–0.83], specificity 0.78 [0.72–0.83]) for synovial PMN%, synovial WBC, serum CRP, and ESR, respectively, and tests seem to be more reliable among non‐IA patients. Conclusions The laboratory‐based synovial α‐defensin and synovial calprotectin are the two best independent preoperative diagnostic tests for PJI. A cut off of 70% for synovial PMN% and tighter cut‐offs for synovial WBC and serum CRP could have a better diagnostic accuracy for non‐IA patients with chronic PJI.
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Affiliation(s)
- Haozheng Tang
- Department of Bone and Joint Surgery, Department of Orthopedics, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jialian Xu
- Department of Bone and Joint Surgery, Department of Orthopedics, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Wei'en Yuan
- Ministry of Education Engineering Research Center of Cell & Therapeutic Antibody, School of Pharmacy, Shanghai Jiao Tong University, Shanghai, China
| | - You Wang
- Department of Bone and Joint Surgery, Department of Orthopedics, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Bing Yue
- Department of Bone and Joint Surgery, Department of Orthopedics, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xinhua Qu
- Department of Bone and Joint Surgery, Department of Orthopedics, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
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Khury F, Oltmanns M, Fuchs M, Leiprecht J, Reichel H, Faschingbauer M. Against the Norm: Do Not Rely on Serum C-Reactive Protein and White Blood Cell Count Only When Assessing Eradication of Periprosthetic Joint Infection. Antibiotics (Basel) 2022; 11:antibiotics11091174. [PMID: 36139954 PMCID: PMC9495056 DOI: 10.3390/antibiotics11091174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Revised: 08/20/2022] [Accepted: 08/27/2022] [Indexed: 11/16/2022] Open
Abstract
Introduction: Periprosthetic joint infections (PJI) following primary arthroplasty continue to be a serious complication, despite advances in diagnostics and treatment. Two-stage revision arthroplasty has been commonly used as the gold standard for the treatment of PJI. However, much discussion persists regarding the interim of the two-stage procedure and the optimal timing of reimplantation. Serology markers have been proposed as defining parameters for a successful reimplantation. The objective of this matched-pair analysis was to assess the role of serum C-reactive protein (CRP) and white blood cell count (WBC) in determining infection eradication and proper timing of reimplantation. We investigated the delta (∆) change in CRP and WBC values prior to both stages of two-stage revision arthroplasty as a useful marker of infection eradication. Methods: We analyzed 39 patients and 39 controls, matched by propensity score matching (BMI, age, ASA-classification), with a minimum follow-up of 24 months and treated with a two-stage revision THA or TKA in our institution. Data of serum CRP and WBC values were gathered at two selected time points: prior to the explantation of the implant (preexplantation) and following the completion of antibiotic treatment regimen, both systemic and with a drug-eluting cement spacer (prereimplantation). Patient records were reviewed electronically for preexisting comorbidities, overall health status, synovial fluid cultures, inflammatory serologies, revision surgeries, and recurrent or persistent infection based on the modified Musculoskeletal Infection Society criteria. Patient demographics, ∆CRP, ∆WBC, and time interval to reimplantation were statistically analyzed using receiver operator curves (ROC), Pearson’s correlation coefficient, Levene’s test, and Student’s t-test. Results: Infection-free patients exhibited higher mean CRP and WBC than did patients who were reinfected at both time points. When comparing preexplantation with prereimplantation values, the median ∆CRP was 9.48 mg/L (interquartile range (IQR) 2.3−36.6 mg/L) for patients who did not develop a reinfection versus 2.74 mg/L (IQR 1.4−14.2 mg/L) for patients who developed reinfection (p = 0.069). The median ∆WBC was 1.5 × 109/L (IQR 0.6−4.0 × 109/L) for patients who remained infection-free versus 1.2 × 109/L (IQR 0.8−2.2 109/L) for patients who developed reinfection (p = 0.072). Analysis of areas under the curve (AUC) using ROC demonstrated poor prediction of persistent infection by ∆CRP (AUC = 0.654) and ∆WBC (AUC = 0.573). Although a highly significant correlation was found between the interim interval and infection persistence (r = 0.655, p < 0.01), analysis using ROC failed to result in a specific threshold time to reimplantation above which patients are at significantly higher risk for reinfection (AUC = 0.507). Conclusion: No association could be determined between the delta change in serum CRP and WBC before and after two-stage revision arthroplasty for PJI and reinfection risk. Even though inflammatory serologies demonstrate a downtrending pattern prior to reimplantation, the role of CRP and WBC in determining the optimal timing of reimplantation seems to be dispensable. Planning a second-stage reimplantation requires assessing multiple variables rather than relying on specific numeric changes in these inflammatory marker values.
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Affiliation(s)
- Farouk Khury
- Department of Orthopedic Surgery, University of Ulm, Oberer Eselsberg 45, 89081 Ulm, Germany
- Division of Orthopedic Surgery, Rambam Medical Center, The Ruth and Bruce Rappaport Faculty of Medicine, HaAliya HaShniya St 8, Haifa 3109601, Israel
| | - Moritz Oltmanns
- Department of Orthopedic Surgery, University of Ulm, Oberer Eselsberg 45, 89081 Ulm, Germany
| | - Michael Fuchs
- Department of Orthopedic Surgery, University of Ulm, Oberer Eselsberg 45, 89081 Ulm, Germany
| | - Janina Leiprecht
- Department of Orthopedic Surgery, University of Ulm, Oberer Eselsberg 45, 89081 Ulm, Germany
| | - Heiko Reichel
- Department of Orthopedic Surgery, University of Ulm, Oberer Eselsberg 45, 89081 Ulm, Germany
| | - Martin Faschingbauer
- Department of Orthopedic Surgery, University of Ulm, Oberer Eselsberg 45, 89081 Ulm, Germany
- Correspondence: or
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Pannu TS, Villa JM, Corces A, Riesgo AM, Higuera CA. Synovial White Blood Cell Count and Differential to Predict Successful Infection Management in a Two-Stage Revision. J Arthroplasty 2022; 37:1159-1164. [PMID: 35181449 DOI: 10.1016/j.arth.2022.02.030] [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: 12/08/2021] [Accepted: 02/09/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND An array of synovial white blood cell (WBC) count and polymorphonuclear differential (PMN%) thresholds have been reported using 2013 Musculoskeletal Infection Society (MSIS) definition which has a poor accuracy to confirm infection control before reimplantation. The workgroup of MSIS recently developed a comprehensive definition of successful infection management. Our objectives were to determine optimal thresholds for WBC count and PMN% associated with reimplantation success based on this new MSIS definition and assess if values above these thresholds indicate decreased survival time. METHODS A retrospective review was conducted on a consecutive series of 133 two-stage hip/knee arthroplasties performed by 15 surgeons (2014-2020) at 2 institutions. All surgeries had a minimum follow-up of 1 year. The inclusion criteria included reporting of preoperative synovial fluid aspiration results. Thus, 88 were finally included. Surgical success was defined by MSIS outcome reporting tool (Tiers 1-4). Receiver operating characteristic curve analyses were performed to estimate optimal thresholds of WBC count and PMN%. A Kaplan-Meier survival analyses with log-rank test were performed. RESULTS With area under the curve of 0.65, synovial PMN% showed superior accuracy than WBC count (area under the curve = 0.52) in determining outcome of reimplantation. The optimal PMN% threshold (62%) demonstrated sensitivity of 57% and specificity of 77%. The calculated WBC count threshold (2,733/μL) showed poor sensitivity (21%) but high specificity (95%). There was a significant difference in failure-free survival (24 months) between the cases with WBC count higher vs lower than 2,733/μL (P = .002). This was also true for PMN% at 5 months postoperatively (P = .009). CONCLUSION WBC count (2,733/μL) shows very high specificity to confirm successful reimplantation. Both WBC count and PMN% (62%) thresholds can significantly determine reimplantation survival.
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Affiliation(s)
- Tejbir S Pannu
- Levitetz Department of Orthopaedic Surgery, Cleveland Clinic Florida, Weston, FL
| | - Jesus M Villa
- Levitetz Department of Orthopaedic Surgery, Cleveland Clinic Florida, Weston, FL
| | - Arturo Corces
- Department of Orthopaedic Surgery, Larkin Community Hospital, South Miami, FL
| | - Aldo M Riesgo
- Levitetz Department of Orthopaedic Surgery, Cleveland Clinic Florida, Weston, FL
| | - Carlos A Higuera
- Levitetz Department of Orthopaedic Surgery, Cleveland Clinic Florida, Weston, FL
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Ascione T, Balato G, Mariconda M, Smeraglia F, Baldini A, De Franco C, Pandolfo G, Siciliano R, Pagliano P. Synovial Cell Count Before Reimplantation Can Predict the Outcome of Patients with Periprosthetic Knee Infections Undergoing Two-stage Exchange. Clin Orthop Relat Res 2021; 479:2061-2068. [PMID: 33944811 PMCID: PMC8373579 DOI: 10.1097/corr.0000000000001788] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Accepted: 03/31/2021] [Indexed: 01/31/2023]
Abstract
BACKGROUND Although synovial fluid can be used to diagnose periprosthetic joint infections (PJI) effectively, only the cutoff values adopted at the time of PJI diagnosis have been standardized, and few data are currently available about effectiveness of synovial fluid examination before definitive reimplantation. QUESTIONS/PURPOSES We asked: (1) What are the most appropriate thresholds for synovial fluid leukocyte counts (WBC) and neutrophil percentage (PMN percentage) in a patient group undergoing definitive reimplantation after an uninterrupted course of antibiotic therapy for chronic PJI? (2) What is the predictive value of our synovial WBC and PMN percentage threshold compared with previously proposed thresholds? METHODS In all, 101 patients with PJI were evaluated for inclusion from January 2016 to December 2018. Nineteen percent (19 of 101) of patients were excluded because of the presence of a chronic inflammatory disease, acute/late hematogenous infection, low amount of synovial fluid for laboratory investigations or infection persistence after spacer placement, and adequate antibiotic therapy. Finally, 81% (82 of 101) of patients with a median (range) age of 74 years (48 to 92) undergoing two-stage revision for chronic TKA infection, who were followed up at our institution for a period 96 weeks or more, were included in this study. The patients did not discontinue antibiotic treatment before reimplantation and were treated for 15 days after reimplantation if intraoperative cultures were negative. No patient remained on suppressive treatment after reimplantation. Synovial fluid was aspirated aseptically with a knee spacer in place to evaluate the cell counts before reimplantation. Thirteen percent (11 of 82) of patients had persistent or recurrent infection, defined as continually elevated erythrocyte sedimentation rate or C-reactive protein levels coupled with local signs and symptoms or positive cultures. The synovial fluid WBC counts and PMN percentage from the 11 patients with persistent or recurrent PJI were compared with the 71 patients who were believed to be free of PJI. Receiver operating characteristic (ROC) curve analyses assessed the predictive value of the parameters, and the areas under the curves (AUCs) were evaluated. The sensitivities, specificities, and positive and negative predictive values were determined for the WBC count and PMN percentage. Patients with persistent or recurrent infection had higher median WBC counts (471 cells/µL versus 1344 cells/µL; p < 0.001) and PMN percentage (36% versus 61%; p < 0.001) than did patients believed to be free of PJI. RESULTS ROC curve analysis identified the best threshold values to be a WBC count of 934 cells/µL or more (sensitivity 0.82 [95% CI 0.71 to 0.89], specificity 0.82 [95% CI 0.71 to 0.89]) as well as a PMN percentage of at least 52% (sensitivity 0.82 [95% CI 0.71 to 0.89] and specificity 0.78 [95% CI 0.67 to 0.86]. We found no difference between the AUCs for the WBC count and the PMN percentage (0.87 [95% CI 0.79 to 0.96] versus 0.84 [95% CI 0.73 to 0.95]. Comparing the sensitivities and specificities of the synovial fluid WBC count and PMN percentage proposed by other authors, we find that a PMN percentage more than 52% showed better predictive value than previously reported. CONCLUSION Based on our findings, we believe that patients with WBC counts of at least 934 and PMN percentage of 52% or more should not undergo reimplantation but rather a repeat debridement, as their risk of persistent or recurrent PJI appears prohibitively high. The accuracy of the proposed cutoffs is better than previously reported. LEVEL OF EVIDENCE Level III, diagnostic study.
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Affiliation(s)
- Tiziana Ascione
- Service of Infectious Diseases, Cardarelli Hospital, Naples, Italy
- Department of Infectious Diseases, D. Cotugno Hospital, AORN dei Colli - Naples
| | - Giovanni Balato
- Department of Public Health, Orthopedic Unit, “Federico II” University, Naples, Italy
| | - Massimo Mariconda
- Department of Public Health, Orthopedic Unit, “Federico II” University, Naples, Italy
| | - Francesco Smeraglia
- Department of Public Health, Orthopedic Unit, “Federico II” University, Naples, Italy
| | - Andrea Baldini
- Orthopedic Unit, Istituto Fiorentino di Cura e Assistenza (IFCA), Florence, Italy
| | - Cristiano De Franco
- Department of Public Health, Orthopedic Unit, “Federico II” University, Naples, Italy
| | - Giuseppe Pandolfo
- Department of Industrial Engineering, “Federico II” University, Naples, Italy
| | - Roberta Siciliano
- Department of Industrial Engineering, “Federico II” University, Naples, Italy
| | - Pasquale Pagliano
- Department of Infectious Diseases, D. Cotugno Hospital, AORN dei Colli - Naples
- Unit of Infectious Diseases, Department of Medicine and Surgery, University of Salerno, Baronissi, Italy
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11
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Yuan T, Wang Y, Sun S. Thromboelastography parameters in diagnosing periprosthetic joint infection and predicting reimplantation timing. BMC Musculoskelet Disord 2021; 22:689. [PMID: 34388995 PMCID: PMC8364122 DOI: 10.1186/s12891-021-04578-x] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Accepted: 08/02/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Coagulation-related biomarkers are drawing new attention in the diagnosis of periprosthetic joint infection (PJI). The thromboelastography (TEG) assay provides a comprehensive assessment of blood coagulation; therefore, it could be a promising test for PJI. This study aims to assess the value of TEG in diagnosing PJI and to determine the clinical significance of TEG in analysing reimplantation timing for second-stage revision. METHODS From October 2017 to September 2020, 62 patients who underwent revision arthroplasty were prospectively included. PJI was defined by the 2011 Musculoskeletal Infection Society criteria, in which 23 patients were diagnosed with PJI (Group A), and the remaining 39 patients were included as having aseptic loosening (Group B). In group A, 17 patients completed a two-stage revision in our centre. C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), D-dimer, and TEG parameters (clotting time, α-angle, MA [maximum amplitude], amplitude at 30 min, and thrombodynamic potential index) were measured preoperatively in all included patients. In addition, receiver operating characteristic curves were used to evaluate the diagnostic value of these biomarkers. RESULTS ESR (area under curve [AUC], 0.953; sensitivity, 81.82; specificity, 94.87) performed best for PJI diagnosis, followed by MA (AUC, 0.895; sensitivity, 82.61; specificity, 97.44) and CRP (AUC, 0.893; sensitivity, 82.61; specificity, 94.74). When these biomarkers were combined in pairs, the diagnostic value improved compared with any individual biomarker. The overall success rate of the two-stage revision was 100%. Furthermore, ESR and MA were valuable in determining the time of reimplantation, and their values all decreased below the cut-off values before reimplantation. CONCLUSION TEG could be a promising test in assisting PJI diagnosis, and a useful tool in judging the proper timing of reimplantation.
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Affiliation(s)
- Tao Yuan
- Department of Joint Surgery, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, 250012, Shandong, China
| | - Yi Wang
- Department of Joint Surgery, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, 250012, Shandong, China
| | - Shui Sun
- Department of Joint Surgery, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, 250012, Shandong, China. .,Department of Joint Surgery, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China.
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12
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Pannu TS, Villa JM, Engh C, Patel A, Levine BR, Piuzzi NS, Higuera CA, Riesgo AM. Plasma D-dimer Does Not Anticipate the Fate of Reimplantation in Two-stage Exchange Arthroplasty for Periprosthetic Joint Infection: A Preliminary Investigation. Clin Orthop Relat Res 2021; 479:1458-1468. [PMID: 33830953 PMCID: PMC8208420 DOI: 10.1097/corr.0000000000001738] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Accepted: 02/26/2021] [Indexed: 01/31/2023]
Abstract
BACKGROUND Inflammatory markers such as the erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) levels have always been a part of the diagnostic criteria for periprosthetic joint infection (PJI), but they perform poorly anticipating the outcome of reimplantation. D-dimer has been reported in a small series as a potential marker to measure infection control after single-stage revisions to treat PJI. Nonetheless, its use to confirm infection control and decide the proper timing of reimplantation remains uncertain. QUESTIONS/PURPOSES (1) What is the best diagnostic threshold and accuracy values for plasma D-dimer levels compared with other inflammatory markers (ESR and CRP) or what varying combinations of these tests are associated with persistent infection after reimplantation? (2) Do D-dimer values above this threshold, ESR, CRP, and varying test combinations at the time of reimplantation indicate an increased risk of subsequent persistent infection after reimplantation? METHODS We retrospectively studied the electronic medical records of all 53 patients who had two-stage revisions for PJI and who underwent plasma D-dimer testing before reimplantation at one of two academic institutions from November 22, 2017 to December 5, 2020. During that period, all patients undergoing two-stage revisions also had a D-dimer test drawn. The minimum follow-up duration was 1 year. We are reporting at this early interval (rather than the more typical 2-year time point) because of the poorer-than-expected performance of this diagnostic test. Of these 53 patients, 17% (9) were lost to follow-up before 1 year and could not be analyzed; the remaining 44 patients (17 hips and 27 knees) were studied here. The mean follow-up was 503 ± 135 days. Absence or persistence of infection after reimplantation were defined according to the Delphi criteria. The conditions included in these criteria were: (1) control of infection, as characterized by a healed wound without fistula, drainage, or pain; (2) no subsequent surgical intervention owing to infection after reimplantation; and (3) no occurrence of PJI-related mortality. The absence of any of the aforementioned conditions until the final follow-up examination was deemed a persistent infection after reimplantation. Baseline patient characteristics were not different between patients with persistent infection (n = 10) and those with absence of it after reimplantation (n = 34) as per the Delphi criteria. Baseline patient characteristics evaluated were age, gender, self-reported race (white/Black/other) or ethnicity (nonHispanic/Hispanic), BMI, American Society of Anesthesiologists (ASA) status, smoking status(smoker/nonsmoker), and joint type (hip/knee). The optimal D-dimer threshold to differentiate between persistence of infection or not after reimplantation was calculated using the Youden index. A receiver operating characteristic curve analysis was performed to test the accuracy of D-dimer, ESR, CRP, and their combinations to establish associations, if any, with persistent infection after reimplantation. A Kaplan-Meier survival analysis (free of infection after reimplantation) with a log-rank test was performed to investigate if D-dimer, ESR, and CRP were associated with absence of infection after reimplantation. Survival or being free of infection after reimplantation was determined as per Delphi criteria. Alpha was set at p < 0.05. RESULTS In the receiver operating characteristic curve analysis, with an area under the curve of 0.62, D-dimer showed low accuracy and did not anticipate persistent infection after reimplantation. The optimal D-dimer threshold differentiating between persistence of infection or not after reimplantation was 3070 ng/mL. When using this threshold, D-dimer demonstrated a sensitivity of 90% (95% CI 55.5% to 99.7%) and negative predictive value of 94% (95% CI 70.7% to 99.1%), but low specificity (47% [95% CI 29.8% to 64.9%]) and positive predictive value (33% [95% CI 25.5% to 42.2%]). Although D-dimer showed the highest sensitivity, the combination of D-dimer with ESR and CRP showed the highest specificity (91% [95% CI 75.6% to 98%]) defining the persistence of infection after reimplantation. Based on plasma D-dimer levels, with the numbers available, there was no difference in survival free from infection after reimplantation (Kaplan-Meier survivorship free from infection at minimum 1 year in patients with D-dimer below 3070 ng/mL versus survivorship free from infection with D-dimer above 3070 ng/mL: 749 days [95% CI 665 to 833 days] versus 615 days [95% CI 471 to 759 days]; p = 0.052). Likewise, there were no associations between high ESR and CRP levels and persistent infection after reimplantation, but the number of events was very small, and insufficient power is a concern with this analysis. CONCLUSION In this preliminary series, with the numbers available, D-dimer alone had poor accuracy and was not associated with survival free from infection after reimplantation in patients who underwent two-stage exchange arthroplasty. D-dimer alone might be used to establish that PJI is unlikely, and the combination of D-dimer, ESR, and CRP should be considered to confirm PJI diagnosis in the setting of reimplantation.Level of Evidence Level IV, diagnostic study.
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Affiliation(s)
- Tejbir S. Pannu
- Levitetz Department of Orthopaedic Surgery, Cleveland Clinic Florida, Weston, FL, USA
| | - Jesus M. Villa
- Levitetz Department of Orthopaedic Surgery, Cleveland Clinic Florida, Weston, FL, USA
| | - Charles Engh
- Midwest Orthopaedics at Rush University Medical Center, Chicago, IL, USA
| | - Arpan Patel
- Midwest Orthopaedics at Rush University Medical Center, Chicago, IL, USA
| | - Brett R. Levine
- Midwest Orthopaedics at Rush University Medical Center, Chicago, IL, USA
| | - Nicolas S. Piuzzi
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Carlos A. Higuera
- Levitetz Department of Orthopaedic Surgery, Cleveland Clinic Florida, Weston, FL, USA
| | - Aldo M. Riesgo
- Levitetz Department of Orthopaedic Surgery, Cleveland Clinic Florida, Weston, FL, USA
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Sahin E, Karaismailoglu B, Ozsahin MK, Guven MF, Kaynak G. Low value of platelet count to mean platelet volume ratio to diagnose chronic PJI: A case control study. Orthop Traumatol Surg Res 2021; 107:102899. [PMID: 33774191 DOI: 10.1016/j.otsr.2021.102899] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Revised: 10/13/2020] [Accepted: 10/19/2020] [Indexed: 02/03/2023]
Abstract
INTRODUCTION Numerous tests are being evaluated in order to aid the diagnosis of periprosthetic infections since it is a complicated and sometimes inconclusive process. The purpose of this study was to assess the diagnostic performance of platelet count to mean platelet volume ratio as a tool to aid the diagnosis of periprosthetic joint infections. The investigated questions were: "Is platelet count/mean platelet volume ratio more sensitive or specific than C-reactive protein (CRP) or erythrocyte sedimentation rate (ESR) in the diagnosis of periprosthetic joint infections?" and "Does platelet count/mean platelet volume ratio increase the accuracy of periprosthetic joint infection diagnosis?". HYPOTHESIS Platelet count/mean platelet volume ratio increases the accuracy of periprosthetic joint infection diagnosis. MATERIALS AND METHODS This study was performed retrospectively on patients who underwent revision hip or knee arthroplasty between 2016 and 2019. 62 patients with 33 aseptic (AR) and 29 septic revision (SR) who met our inclusion criteria were included. The sensitivity, specificity and diagnostic performance of CRP, ESR and platelet count/mean platelet volume values were analyzed and compared. RESULTS The demographic characteristics were similar between groups. Staphylococcus aureus and Staphylococcus epidermidis were the most commonly encountered microorganisms, while seven patients had negative cultures in SR group. ESR, CRP and platelet count/mean platelet volume values were significantly higher in SR group compared to AR group (p<0.01). ROC analysis for platelet count/mean platelet volume ratio revealed a cut-off value at 35.3 which provided 75.9% sensitivity and 78.8% specificity for periprosthetic joint infections. Platelet count/mean platelet volume ratio yielded lower sensitivity and similar specificity compared to ESR and CRP values. Platelet count/mean platelet volume had a lower area under curve value, indicating a poorer diagnostic performance compared to ESR and CRP. DISCUSSION The diagnostic performance of platelet count/mean platelet volume ratio is low and current findings do not support its usage to increase the accuracy of periprosthetic joint infections diagnosis. LEVEL OF EVIDENCE III; diagnostic case-control study.
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Affiliation(s)
| | - Bedri Karaismailoglu
- Istanbul University-Cerrahpasa, Cerrahpasa Medical Faculty, Department of orthopaedics, Istanbul, Turkey
| | - Mahmut Kursat Ozsahin
- Istanbul University-Cerrahpasa, Cerrahpasa Medical Faculty, Department of orthopaedics, Istanbul, Turkey
| | - Mehmet Fatih Guven
- Istanbul University-Cerrahpasa, Cerrahpasa Medical Faculty, Department of orthopaedics, Istanbul, Turkey
| | - Gokhan Kaynak
- Istanbul University-Cerrahpasa, Cerrahpasa Medical Faculty, Department of orthopaedics, Istanbul, Turkey.
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14
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Management of Large Segmental Bone Defects at the Knee With Intramedullary Stabilized Antibiotic Spacers During Two-Stage Treatment of Endoprosthetic Joint Infection. J Arthroplasty 2021; 36:2165-2170. [PMID: 33546952 DOI: 10.1016/j.arth.2021.01.026] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 12/20/2020] [Accepted: 01/11/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Following debridement of infected prostheses that require reconstruction with an endoprosthetic replacement (EPR), instability related to segmental residual bone defects present a challenge in management with 2-stage reimplantation. METHODS We retrospectively reviewed all patients treated for revision total joint or endoprosthetic infection at the knee from 1998 to 2018. At our institution, patients with skeletal defects >6 cm following explant of prosthesis and debridement (stage 1) were managed with intramedullary nail-stabilized antibiotic spacers. Following stage 1, antimicrobial therapy included 6 weeks of intravenous antibiotics and a minimum of 6 weeks of oral antibiotics. Following resolution of inflammatory markers and negative tissue cultures, reimplantation (stage 2) of an EPR was performed. RESULTS Twenty-one patients at a mean age of 54 ± 21 years were treated for prosthetic joint infection at the knee. Polymicrobial growth was detected in 38% of cases, followed by coagulase-negative staphylococci (24%) and Staphylococcus aureus (19%). Mean residual skeletal defect after stage 1 treatment was 20 cm. Prosthetic joint infection eradication was achieved in 18 (86%) patients, with a mean Musculoskeletal Tumor Society score of 77% and mean knee range of motion of 100°. Patients with polymicrobial infections had a greater number of surgeries prior to infection (P = .024), and were more likely to require additional debridement prior to EPR (odds ratio 12.0, P = .048). CONCLUSION Management of large segmental skeletal defects at the knee following explant using intramedullary stabilized antibiotic spacers maintain stability and result in high rates of limb salvage with conversion to an endoprosthesis.
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15
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Jeyanathan A, Ramalhete R, Blunn G, Gibbs H, Pumilia CA, Meckmongkol T, Lovejoy J, Coathup MJ. Lactobacillus cell-free supernatant as a novel bioagent and biosurfactant against Pseudomonas aeruginosa in the prevention and treatment of orthopedic implant infection. J Biomed Mater Res B Appl Biomater 2021; 109:1634-1643. [PMID: 33634961 DOI: 10.1002/jbm.b.34821] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Revised: 01/13/2021] [Accepted: 02/14/2021] [Indexed: 01/09/2023]
Abstract
The hypothesis was that probiotic Lactobacillus species (spp.) or their cell-free supernatant (CFS) are effective in inhibiting (a) planktonic growth of Pseudomonas aeruginosa (PA), (b) its adhesion to a Ti6Al4V-alloy surface, and (c) in dispersing biofilm once formed. (a) A planktonic co-culture containing PA(104 colony-forming unit [CFU]/ml) was combined with either Lactobacillus acidophilus, Lactobacillus plantarum (LP), or Lactobacillus fermentum (LF) at a suspension of 104 (1:1) or 108 CFU/ml (1:2). Lactobacillus and PA CFUs were then quantified. (b) Ti-6Al-4V discs were inoculated with PA followed by supplementation with CFS and adherent PA quantified. (c) Biofilm covered discs were supplemented with Lactobacillus CFS and remaining PA activity quantified. Results showed that whole-cell cultures were ineffective in preventing PA growth; however, the addition of CFS resulted in a 99.99 ± 0.003% reduction in adherent PA in all Lactobacillus groups (p < .05 in all groups) with no viable PA growth measured in the LF and LP groups. Following PA biofilm formation, CFS resulted in a significant reduction in PA activity in all Lactobacillus groups (p ≤ .05 in all groups) with a 29.75 ± 15.98% increase measured in control samples. Supplementation with CFS demonstrated antiadhesive, antibiofilm, and toxic properties to PA.
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Affiliation(s)
- Augustina Jeyanathan
- Institute of Orthopaedics and Musculoskeletal Science, Division of Surgery and Interventional Science, Royal National Orthopaedic Hospital, University College London, Stanmore, UK
| | - Rita Ramalhete
- Institute of Orthopaedics and Musculoskeletal Science, Division of Surgery and Interventional Science, Royal National Orthopaedic Hospital, University College London, Stanmore, UK
| | - Gordon Blunn
- Institute of Orthopaedics and Musculoskeletal Science, Division of Surgery and Interventional Science, Royal National Orthopaedic Hospital, University College London, Stanmore, UK.,School of Pharmacy and Biomedical Sciences, University of Portsmouth, Portsmouth, UK
| | - Hannah Gibbs
- Biionix (Bionic Materials, Implants & Interfaces) Cluster, Department of Internal Medicine, College of Medicine, University of Central Florida, Orlando, Florida, USA
| | - Cyrus Anthony Pumilia
- Biionix (Bionic Materials, Implants & Interfaces) Cluster, Department of Internal Medicine, College of Medicine, University of Central Florida, Orlando, Florida, USA
| | - Teerin Meckmongkol
- Biionix (Bionic Materials, Implants & Interfaces) Cluster, Department of Internal Medicine, College of Medicine, University of Central Florida, Orlando, Florida, USA.,Department of General Surgery, Nemours Children's Hospital, Orlando, Florida, USA
| | - John Lovejoy
- Biionix (Bionic Materials, Implants & Interfaces) Cluster, Department of Internal Medicine, College of Medicine, University of Central Florida, Orlando, Florida, USA.,Department of Orthopaedics, Sports Medicine and Physical Medicine and Rehabilitation, Nemours Children's Hospital, Orlando, Florida, USA
| | - Melanie J Coathup
- Institute of Orthopaedics and Musculoskeletal Science, Division of Surgery and Interventional Science, Royal National Orthopaedic Hospital, University College London, Stanmore, UK.,Biionix (Bionic Materials, Implants & Interfaces) Cluster, Department of Internal Medicine, College of Medicine, University of Central Florida, Orlando, Florida, USA
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16
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Li C, Ojeda-Thies C, Xu C, Trampuz A. Meta-analysis in periprosthetic joint infection: a global bibliometric analysis. J Orthop Surg Res 2020; 15:251. [PMID: 32650802 PMCID: PMC7350679 DOI: 10.1186/s13018-020-01757-9] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Accepted: 06/16/2020] [Indexed: 02/07/2023] Open
Abstract
Background Periprosthetic joint infection (PJI) is the most serious complication of joint replacement surgery. Further comorbidities include bedsore, deep vein thrombosis, reinfection, or even death. An increasing number of researchers are focusing on this challenging complication. The aim of the present study was to estimate global PJI research based on bibliometrics from meta-analysis studies. Methods A database search was performed in PubMed, Scopus, and Web of Science. Relevant studies were assessed using the bibliometric analysis. Results A total of 117 articles were included. The most relevant literature on PJI was found on Scopus. China made the highest contributions to global research, followed by the USA and the UK. The institution with the most contributions was the University of Bristol. The journal with the highest number of publications was The Journal of Arthroplasty, whereas the Journal of Clinical Medicine had the shortest acceptance time. Furthermore, the top three frequently used databases were Embase, MEDLINE, and Cochrane. The most frequent number of authors in meta-analysis studies was four. Most studies focused on the periprosthetic hip and knee. The alpha-defensin diagnostic test, preventive measures on antibiotics use, and risk factors of intra-articular steroid injections were the most popular topic in recent years. Conclusion Based on the results of the present study, we found that there was no single database that covered all relevant articles; the optimal method for bibliometric analysis is a combination of databases. The most popular research topics on PJI focused on alpha-defensin, antibiotic use, risk factors of intra-articular steroid injections, and the location of prosthetic hip and knee infection.
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Affiliation(s)
- Cheng Li
- Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Center for Musculoskeletal Surgery (CMSC), Charitéplatz 1, D-10117, Berlin, Germany
| | | | - Chi Xu
- Department of Orthopaedic Surgery, General Hospital of People's Liberation Army, Beijing, People's Republic of China
| | - Andrej Trampuz
- Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Center for Musculoskeletal Surgery (CMSC), Charitéplatz 1, D-10117, Berlin, Germany.
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17
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Jenny JY. Specificities of total hip and knee arthroplasty revision for infection. Orthop Traumatol Surg Res 2020; 106:S27-S34. [PMID: 31813779 DOI: 10.1016/j.otsr.2019.05.020] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2018] [Revised: 05/06/2019] [Accepted: 05/24/2019] [Indexed: 02/02/2023]
Abstract
Hip or knee revision for infection requires careful planning of the debridement phase. Bacteriological sample management needs to be planned. Multidisciplinary decisions have to be taken as to 1- or 2-stage strategy, reconstruction technique and soft-tissue management. Surgical resection should be complete while economical. There must be no shortcomings in the technical procedure. Implant removal and surgical debridement are the keys to curing the infection, and planning is essential to optimize this phase. Bacteriological techniques are well codified. Wide-spectrum curative antibiotic therapy should be initiated immediately after intraoperative sampling and secondarily adapted to culture findings. A high-level microbiology laboratory is indispensable to good quality treatment. Prophylactic antibiotic therapy is controversial, but probably contributive. Two-stage exchange has not demonstrated superiority in curing infection. A 1-stage procedure may be preferred if all prerequisites are met. In the knee, any need for flap coverage should be planned for rather than encountered intraoperatively. The principles of reconstruction are unchanged by infection, but extended resection may require a larger revision implant. The temptation to oversimplify has to be resisted, and non-escalation or indeed "de-escalation" in implant size should be sought. Bone defect management is unaffected by infection. Fixation technique is at the surgeon's discretion. Pain relief and functional results are probably less good than after exchange without infectious context. The creation of regional complex bone and joint infection centers in France (CRIOACs) constitutes a considerable advance in periprosthetic infection management, and an opinion should be systematically requested; transfer is to be considered on a case-by-case basis.
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Affiliation(s)
- Jean-Yves Jenny
- Pôle Locomax, hôpitaux universitaires de Strasbourg, 1, avenue Molière, 67200 Strasbourg, France.
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18
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Apostolakis S. Use of Focused Ultrasound (Sonication) for the Diagnosis of Infections in Neurosurgical Operations: A Systematic Review and Meta-Analysis. World Neurosurg 2020; 136:364-373.e2. [PMID: 31899387 DOI: 10.1016/j.wneu.2019.12.143] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Revised: 12/22/2019] [Accepted: 12/23/2019] [Indexed: 10/25/2022]
Abstract
OBJECTIVE Postoperative infections are one of the most devastating complications in neurosurgery, and their results are even more disastrous when biocompatible implants are involved. As the application of these implants increases, the need for a sensitive and efficient method to detect pathogens becomes imperative. The application of sonication appears to be a viable option. METHODS A systematic review and meta-analysis of the available literature was conducted, looking for studies reporting findings from the application of sonication following neurosurgical operations. To be included, an article needed to contain information about the material that was subjected to sonication, indication of other culture methods that were applied, and information about the isolated pathogens. RESULTS Six studies comprising 437 patients were included in the meta-analysis. Potential superiority of sonication over conventional microbiologic methods was found in the detection of gram-positive bacteria and in particular of coagulase-negative Staphylococcus species. A sensitivity of 0.87 and a specificity of 0.57 were calculated. CONCLUSIONS Regardless of the potential of sonication, it is still not a panacea. Additional studies are expected to provide significant insight into the indications and limitations of this technique.
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CORR Insights®: Positive Alpha-defensin at Reimplantation of a Two-stage Revision Arthroplasty Is Not Associated with Infection at 1 Year. Clin Orthop Relat Res 2019; 477:1622-1623. [PMID: 30801289 PMCID: PMC6999992 DOI: 10.1097/corr.0000000000000648] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
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Xu C, Chai W, Chen JY. Can we rely on the combination of serological tests and frozen sections at the time of reimplantation for two-stage exchange hip arthroplasty in patients with a "dry tap"? J Orthop Surg Res 2019; 14:184. [PMID: 31221181 PMCID: PMC6585103 DOI: 10.1186/s13018-019-1223-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Accepted: 06/04/2019] [Indexed: 12/13/2022] Open
Abstract
Purpose The optimal timing of reimplantation of two-stage exchange arthroplasty for periprosthetic joint infection remains unknown. The purpose of the study was to (1) evaluate performance of combination of serum erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), and frozen section in predicting persistent infection at the time of second-stage hip reimplantation and (2) compare accuracies of 5 and 10 polymorphonuclear neutrophils (PMNs) per high power field (HPF) as the threshold of frozen section. Methods We retrospectively reviewed 97 two-stage exchange hip arthroplasties from 2012–2016. Persistent infection at time of reimplantation was diagnosed using the Musculoskeletal Infection Society (MSIS) criteria. Two diagnostic models were developed. Model 1 utilized ESR, CRP, and > 5 PMNs/HPF on frozen section. Model 2 utilized ESR, CRP, and > 10 PMNs/HPF. Receiver operating characteristic (ROC) curves of the two models were generated, and areas under the curves (AUCs) were compared. A set of sensitivity analysis, using the Delphi-based consensus criteria for treatment success, was conducted to verify the accuracy of our models. Results The overall rate of infection at reimplantation was 14.4%. AUCs for models 1 and 2 were 0.709 (95% confidence interval [CI], 0.557–0.852) and 0.697 (95% CI, 0.529–0.847), respectively. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were 57.1%, 88.0%, 44.4%, and 92.4%, respectively, in model 1 and 42.9%, 96.4%, 66.7%, and 90.9%, respectively, in model 2. Models 1 and 2 had no significant difference in predictive values (p = 0.821). Results remained robust in the sensitivity analysis. Conclusions This study reveals that the combination of serum ESR, CRP, and frozen section has limited diagnostic value in predicting persistent infection at reimplantation. Additionally, no significant difference in accuracies between 5 and 10 PMNs/HPF as the threshold of frozen section were found. There is a need for timely biomarkers with higher accuracy in diagnosing infection before reimplantation.
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Affiliation(s)
- Chi Xu
- Department of Orthopaedic Surgery, General Hospital of People's Liberation Army, No.28 Fuxing Road, Haidian District, Beijing, China
| | - Wei Chai
- Department of Orthopaedic Surgery, General Hospital of People's Liberation Army, No.28 Fuxing Road, Haidian District, Beijing, China
| | - Ji-Ying Chen
- Department of Orthopaedic Surgery, General Hospital of People's Liberation Army, No.28 Fuxing Road, Haidian District, Beijing, China.
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