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Oetojo W, Feffer M, Wesolowski M, Hopkinson WJ, Brown NM. Incidence and Risk Factors for Acid-fast Bacillus/Fungal Culture Positivity in Primary, Conversion, and Revision Hip and Knee Arthroplasty. J Am Acad Orthop Surg 2024; 32:e576-e584. [PMID: 38569465 PMCID: PMC11147707 DOI: 10.5435/jaaos-d-23-00980] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Accepted: 01/27/2024] [Indexed: 04/05/2024] Open
Abstract
INTRODUCTION Previous literature has reported minimal incidences of positive fungal/AFB cultures, questioning the routine use of these tests. With growing concern for excessive use, predictive factors for patients at higher risk for intraoperative AFB/fungal infections would help surgeons limit unnecessary testing. This study evaluates the positivity rate and predictive factors of positive fungal and/or acid-fast bacillus (AFB) cultures after primary, conversion, or revision hip and knee arthroplasty. METHOD Two hundred thirty-eight knee and hip procedures were done between January 2007 and 2022 where intraoperative AFB/fungal cultures were obtained. Procedures included primary total knee arthroplasty, primary total hip arthroplasty, conversion, first of two-stage, second of two-stage, irrigation and débridement polyexchange, and aseptic revision. Positivity rates of intraoperative AFB/fungal cultures were calculated as binomial exact proportions with 95% confidence intervals and are displayed as percentages. Univariable generalized linear mixed models estimated the unadjusted effects of demographics, individual comorbid conditions, and procedural characteristics on the logit of positive AFB/fungal cultures. RESULTS Two hundred thirty-eight knee and hip procedures recorded an overall positivity rate of 5.8% for intraoperative AFB/fungal cultures. Aseptic revisions showed the lowest rates of positivity at 3.6%, while conversions showed the highest rates of positivity at 14.3%. The positivity rates are highest among patients who are male (9.0%), of Hispanic origin (12.0%), with body mass index <30 (6.4%), and a Charlson Comorbidity Index <5 (6.1%). History of a prior infection in the same surgical joint showed statistically significant influence of odds of culture positivity with an odds ratio of 3.47 ( P -value: 0.039). Other demographic factors that we investigated including age, sex, race, ethnicity, body mass index, and Charlson Comorbidity Index did not show any notable influence on AFB/fungal positivity rates. CONCLUSION These results suggest utility in obtaining routine intraoperative AFB/fungal cultures, given the relatively high positivity and poor predictive factors.
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Affiliation(s)
- William Oetojo
- From the Stritch School of Medicine, Loyola University, Maywood, IL (Oetojo), the LUMC Center for Translational Research and Education, Maywood, IL (Feffer, and Wesolowski), and Department of Orthopaedic Surgery and Rehabilitation, the Loyola University Health System, Maywood, IL (Hopkinson, and Brown)
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Lee C, Mayer E, Bernthal N, Wenke J, O'Toole RV. Orthopaedic infections: what have we learned? OTA Int 2023; 6:e250. [PMID: 37168032 PMCID: PMC10166335 DOI: 10.1097/oi9.0000000000000250] [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: 09/20/2022] [Accepted: 12/22/2022] [Indexed: 05/13/2023]
Abstract
Orthopaedic infections remain challenging complications to treat, with profound economic impact in addition to patient morbidity. The overall estimates of infection after orthopaedic surgery with internal devices has been estimated at 5%, with hospital costs eight times that of those without fracture-related infections and with significantly poorer functional and pain interference PROMIS scores. Orthopaedic infection interventions have been focused on prevention and treatment options. The creation of new modalities for orthopaedic infection treatment can benefit from the understanding of the temporal relationship between bacterial colonization and host-cell integration, a concept referred to as "the race for the surface." Regarding prevention, host modulation and antibiotic powder use have been explored as viable options to lower infection rates. Orthopaedic infection treatment has additionally continued to evolve, with PO antibiotics demonstrating equivalent efficacy to IV antibiotics for the treatment of orthopaedic infections in recent studies. In conclusion, orthopaedic infections remain difficult clinical dilemmas, although evolving prevention and treatment modalities continue to emerge.
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Affiliation(s)
- Christopher Lee
- Department of Orthopaedic Surgery, University of California Los Angeles, Los Angeles, CA
- Corresponding author. Address: Christopher Lee, MD, University of California Los Angeles Department of Orthopaedic Surgery, 10833 Le Conte Ave, Los Angeles, CA 90095. E-mail:
| | - Erik Mayer
- Department of Orthopaedic Surgery, University of California Los Angeles, Los Angeles, CA
| | - Nicholas Bernthal
- Department of Orthopaedic Surgery, University of California Los Angeles, Los Angeles, CA
| | - Joseph Wenke
- Department of Orthopaedic Surgery and Rehabilitation, University of Texas Medical Branch at Galveston, Galveston, TX; and
| | - Robert V. O'Toole
- Department of Orthopaedic Surgery, University of Maryland, Baltimore, MD
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Zhang Y, Gao Z, Zhang T, Dong Y, Sheng Z, Zhang F, Zhou Y, Guo L. A comparsion study between debridement, antibiotics, and implant retention and two-stage revision total knee arthroplasty for the management of periprosthetic joint infection occurring within 12 weeks from index total knee arthroplasty. J Orthop Surg Res 2022; 17:330. [PMID: 35761314 PMCID: PMC9235174 DOI: 10.1186/s13018-022-03218-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Accepted: 06/13/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Managing periprosthetic joint infections are variable in practices. Debridement, antibiotics, and implant retention (DAIR) is one of the favorable interventions. Given that the success rate of the two-stage revision total knee arthroplasty (rTKA) might be overestimated. The purpose of this study is to compare the success rate between DAIR and standard two-stage rTKA with a comparable intervention time. METHODS We retrospectively reviewed the consecutive knee periprosthetic joint infection cases which underwent DAIR or two-stage rTKA (all procedures were performed by the senior author) within 12 weeks since their primary TKA between July 2009 and October 2019. Average follow-up was 72.20 ± 40.70 months (range 29-148 months) in the DAIR group compared to 89.14 ± 43.06 months after spacer insertion (range 29-163 months) in the two-stage revision group (P = 0.156). According to different interventions, demographic data; timing of surgical intervention; hospital for special surgery knee score; and success rate were collected and compared between the DAIR group and two-stage revision group. Failure of treatment was based on the Delphi consensus and the fate of spacers. The pathogen types and failure cases were also recorded and analyzed. RESULTS Average follow-up was 72.20 ± 40.70 months (range 29-148 months) in the DAIR group compared to 89.14 ± 43.06 months after spacer insertion (range 29-163 months) in the two-stage revision group. Time from index surgery was 3.90 ± 2.92 weeks (range 0-12 weeks) in the DAIR group, and 5.11 ± 2.86 weeks (range 0-12 weeks) in the 2-stage exchange group, respectively. The success rate was 70.0% and 75.0% in the DAIR group and two-stage revision group, respectively. But no significant differences were observed between the two groups. CONCLUSION DAIR demonstrated comparable effectiveness with two-stage rTKA. We recommended DAIR as a choice for patients with current infection within 12 weeks after primary TKA. For methicillin-resistant staphylococcal infections and fungal infections, two-stage rTKA might be preferred.
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Affiliation(s)
- Yanchao Zhang
- Medical School of Chinese PLA, Beijing, 100853, China.,Department of Orthopedics, The First Medical Center, Chinese People's Liberation Army General Hospital, Fuxing Road, Haidian District, Beijing, 100048, China.,Senior Department of Orthopedics, The Fourth Medical Center of PLA General Hospital, Beijing, 100048, China
| | - Zhisen Gao
- Department of Orthopedics, The First Medical Center, Chinese People's Liberation Army General Hospital, Fuxing Road, Haidian District, Beijing, 100048, China.,Senior Department of Orthopedics, The Fourth Medical Center of PLA General Hospital, Beijing, 100048, China
| | - Ti Zhang
- Department of Orthopedics, The First Medical Center, Chinese People's Liberation Army General Hospital, Fuxing Road, Haidian District, Beijing, 100048, China.,Senior Department of Orthopedics, The Fourth Medical Center of PLA General Hospital, Beijing, 100048, China.,Medical School of Nankai University, Tianjin, 300071, China
| | - Yu Dong
- Department of Orthopedics, The First Medical Center, Chinese People's Liberation Army General Hospital, Fuxing Road, Haidian District, Beijing, 100048, China.,Senior Department of Orthopedics, The Fourth Medical Center of PLA General Hospital, Beijing, 100048, China.,Medical School of Nankai University, Tianjin, 300071, China
| | - Zhuoqi Sheng
- Medical School of Chinese PLA, Beijing, 100853, China.,Department of Orthopedics, The First Medical Center, Chinese People's Liberation Army General Hospital, Fuxing Road, Haidian District, Beijing, 100048, China.,Senior Department of Orthopedics, The Fourth Medical Center of PLA General Hospital, Beijing, 100048, China
| | - Fei Zhang
- Medical School of Chinese PLA, Beijing, 100853, China.,Department of Orthopedics, The First Medical Center, Chinese People's Liberation Army General Hospital, Fuxing Road, Haidian District, Beijing, 100048, China.,Senior Department of Orthopedics, The Fourth Medical Center of PLA General Hospital, Beijing, 100048, China
| | - Yonggang Zhou
- Department of Orthopedics, The First Medical Center, Chinese People's Liberation Army General Hospital, Fuxing Road, Haidian District, Beijing, 100048, China. .,Senior Department of Orthopedics, The Fourth Medical Center of PLA General Hospital, Beijing, 100048, China.
| | - Lingfei Guo
- Department of Orthopedics, The First Medical Center, Chinese People's Liberation Army General Hospital, Fuxing Road, Haidian District, Beijing, 100048, China. .,Department of Orthopedics, the Eighth Medical Centre, Chinese People's Liberation Army General Hospital, Heishanhu Road, Haidian District, Beijing, 100091, China.
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Pinsornsak P, Niruktisarn T, Surabotsopon P, Boontanapibul K. Novel molded antibiotic cement spacer: is it better than handmade cement spacer for treatment of chronically infected total hip arthroplasty? INTERNATIONAL ORTHOPAEDICS 2022; 46:1693-1700. [PMID: 35678842 DOI: 10.1007/s00264-022-05456-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/06/2022] [Accepted: 05/23/2022] [Indexed: 10/18/2022]
Abstract
PURPOSE A handmade antibiotic cement spacer is the easiest method for producing a spacer for treating chronic periprosthetic joint infection after total hip arthroplasty (THA). However, a molded spacer offers more head and stem sizes to match the patient's anatomy. The purpose of this study was to evaluate the functional outcomes and complications between handmade and molded spacers. METHODS This retrospective case note study compared the functional results, re-infection rate, and spacer related complications after the first stage and second stage exchange arthroplasty between a handmade spacer and a novel molded cement spacer with three sizes of femoral head (45, 50, and 55 mm) and two stem sizes (small, large). RESULTS Fifteen chronically infected THA patients were identified: nine handmade and 6 molded spacers. The modified Harris Hip Score showed no inter-group differences pre-operatively and after first stage and second stage exchange arthroplasty. The erythrocyte sedimentary rates and C-reactive protein concentrations were similar at all time points, and there were no re-infections. The molded spacer group showed lower post-operative complications with no spacer fractures, spacer dislocations, and periprosthetic fractures, but two had spacer subsidence. The handmade spacer had two spacer fractures, one spacer dislocation with a periprosthetic femoral fracture, and four cases of spacer subsidence. CONCLUSION Our small study showed no differences in functional outcomes and no re-infections in either group, but higher spacer-related complications occurred in the handmade spacer group. These data suggest molded spacers are better than handmade spacers.
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Affiliation(s)
- Piya Pinsornsak
- Department of Orthopedics, Faculty of Medicine, Thammasat University, Khlong Luang, Pathum Thani, Thailand
| | - Ta Niruktisarn
- Department of Orthopedics, Faculty of Medicine, Thammasat University, Khlong Luang, Pathum Thani, Thailand
| | - Potsawat Surabotsopon
- Department of Orthopedics, Faculty of Medicine, Thammasat University, Khlong Luang, Pathum Thani, Thailand
| | - Krit Boontanapibul
- Department of Orthopedics, Chulabhorn International College of Medicine, Thammasat University, Klong Luang, Pathum Thani, Thailand.
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Gabrielli A, Wilson A, Wawrose R, Dombrowski M, O'Malley M, Klatt B. The presence of a draining sinus is associated with failure of re-implantation during two-stage exchange arthroplasty. J Bone Jt Infect 2022; 7:55-60. [PMID: 35402147 PMCID: PMC8985591 DOI: 10.5194/jbji-7-55-2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Accepted: 03/14/2022] [Indexed: 11/11/2022] Open
Abstract
Background: Reinfection rates after two-stage
exchange arthroplasty for prosthetic joint infection (PJI) have been
reported as high as 33 % in the literature. Understanding risk factors for
treatment failure will help to preoperatively counsel patients on the
likelihood of successful treatment and possibly influence the surgeon's
treatment algorithm. This study aimed to delineate whether the presence of a
draining sinus tract is associated with risk of failure of two-stage
exchange arthroplasty. Methods: We performed a single
institution, multi-center retrospective chart review of outcomes of patients
treated for PJI with two-stage exchange arthroplasty between June 2006 and
May 2016. For patients treated prior to 2011, PJI was defined based on the
preoperative work-up and intraoperative findings as determined by the
attending surgeon. After 2011, PJI was defined using MSIS consensus
criteria. All patients had a minimum of follow-up of 2 years or treatment
failure prior to 2 years. Treatment failure was defined as reinfection or
failure to complete two-stage exchange secondary to persistent infection or
other host factors. Operative reports and clinical notes were reviewed to
assess for presence of a draining sinus tract. Results: 240
patients were treated for PJI with intended two-stage exchange arthroplasty.
The overall rate of treatment failure was 29.6 % (71/240), while the
overall rate of reinfection was 13.3 % (32/240). A total of 39 patients did not
complete second stage revision; final treatment for these patients was
amputation, fusion, or chronic antibiotic suppression. A total of 52 of 240 patients
(21.7 %) had a draining sinus tract at presentation. Patients with a sinus
tract were significantly less likely to be replanted compared to those without a
sinus tract at presentation (13.3 % vs. 26.9 %, p=0.02). However, when
accounting for all mechanisms of treatment failure, including reinfection
following replantation, there was no statistically significant difference
detected between the sinus and no-sinus groups (27.7 % vs. 36.5 %, p=0.22). Discussion: A draining sinus tract represents a chronic,
deep infectious process with ultimate compromise of overlying soft tissues.
Thus we hypothesized it would be associated with failure in a two-stage
exchange arthroplasty. These data demonstrate that patients with a draining
sinus are significantly less likely to undergo re-implantation. This
provides evidence to the paucity of data surrounding draining sinuses and
two-stage PJI treatment.
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Greig D, Trikha R, Sekimura T, Cevallos N, Kelley BV, Mamouei Z, Yeaman MR, Bernthal NM. Platelet Deficiency Represents a Modifiable Risk Factor for Periprosthetic Joint Infection in a Preclinical Mouse Model. J Bone Joint Surg Am 2021; 103:1016-1025. [PMID: 33877055 PMCID: PMC10364842 DOI: 10.2106/jbjs.20.01428] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Well known for their hemostatic function, platelets are increasingly becoming recognized as important immunomodulators. The purpose of the present study was to assess the impact of platelet depletion on antimicrobial host defense in a mouse model of periprosthetic joint infection (PJI). METHODS Thrombocytopenia (TCP) was induced in C57BL/6 mice with use of a selective antibody against platelet CD41 (anti-CD41). Whole blood from pre-treated mice was incubated with Staphylococcus aureus to assess antimicrobial efficacy with use of bioluminescent imaging, quantitative histological staining, and colony forming unit (CFU) quantification. In parallel, untreated heterologous platelets were added to TCP blood to assess potential rescue of antimicrobial efficacy. In vivo, TCP and control mice underwent placement of a titanium implant in the femur inoculated with bioluminescent Xen36 S. aureus. Longitudinal bioluminescent imaging was performed postoperatively to quantify the evolution of bacterial burden, which was confirmed via assessment of S. aureus CFUs on the implant and in peri-implant tissue on postoperative day (POD) 28. RESULTS Anti-CD41 treatment resulted in significant dose-dependent reductions in platelet count. Ex vivo, platelet-depleted whole blood demonstrated significantly less bacterial reduction than control blood. These outcomes were reversed with the addition of untreated rescue platelets. In vivo, infection burden was significantly higher in TCP mice and was inversely correlated with preoperative platelet count (r2 = 0.63, p = 0.037). Likewise, CFU quantification on POD28 was associated with increased bacterial proliferation and severity of periprosthetic infection in TCP mice compared with controls. CONCLUSIONS Thrombocytopenia resulted in an increased bacterial burden both ex vivo and in vivo in a mouse model of PJI. CLINICAL RELEVANCE In orthopaedic patients, deficiencies in platelet quantity or function represent an easily modifiable risk factor for PJI.
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Affiliation(s)
- Danielle Greig
- Department of Orthopaedic Surgery, University of California Los Angeles, Santa Monica, California
| | - Rishi Trikha
- Department of Orthopaedic Surgery, University of California Los Angeles, Santa Monica, California
| | - Troy Sekimura
- Department of Orthopaedic Surgery, University of California Los Angeles, Santa Monica, California
| | - Nicolas Cevallos
- Department of Orthopaedic Surgery, University of California Los Angeles, Santa Monica, California
| | - Benjamin V Kelley
- Department of Orthopaedic Surgery, University of California Los Angeles, Santa Monica, California
| | - Zeinab Mamouei
- Department of Orthopaedic Surgery, University of California Los Angeles, Santa Monica, California
| | - Michael R Yeaman
- Divisions of Molecular Medicine and Infectious Diseases, Department of Medicine, and The Lundquist Institute for Biomedical Innovation, Harbor-UCLA Medical Center, Torrance, California
| | - Nicholas M Bernthal
- Department of Orthopaedic Surgery, University of California Los Angeles, Santa Monica, California
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7
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Xu Y, Wang L, Xu W. Risk factors affect success rate of debridement, antibiotics and implant retention (DAIR) in periprosthetic joint infection. ARTHROPLASTY 2020; 2:37. [PMID: 35236454 PMCID: PMC8796582 DOI: 10.1186/s42836-020-00056-2] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Accepted: 10/27/2020] [Indexed: 12/23/2022] Open
Abstract
Background Periprosthetic joint infection (PJI) is the most devastating complication of joint replacement that seriously affects the quality of life and causes a heavy burden to the families and society. Due to shorter hospital stays, lower costs, improved joint function and less morbidity, a process of debridement, antibiotics and implant retention (DAIR) is recommended as the preferred treatment for acute periprosthetic joint infection. However, the factors that impact the success rate of DAIR remain controversial. This article evaluates the influential factors of DAIR and provides insights for orthopaedics surgeons to make optimal decisions to improve the success rate of DAIR. Conclusion The poor general condition of patients, high preoperative C-reactive protein (CRP) level, repeated joint surgeries, and Methicillin-resistant Staphylococcus aureus (MRSA) infections may be associated with lower DAIR success rate. To the contrary, early surgery, radical debridement, exchange of removable components, washing with iodine and vacuum sealing drainage (VSD) may improve the success rate of DAIR. A sinus tract may not be absolutely contraindicated, but surgeons should treat it with caution. As there is no consensus on many issues, more high-quality research is required.
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8
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Difficult to treat: are there organism-dependent differences and overall risk factors in success rates for two-stage knee revision? Arch Orthop Trauma Surg 2020; 140:1595-1602. [PMID: 31960169 DOI: 10.1007/s00402-020-03335-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Indexed: 01/04/2023]
Abstract
OBJECTIVES Failure after two-stage procedure for periprosthetic joint infection (PJI) is a rare, but devastating complication. Some authors assume a correlation of underlying organisms and recurrence rate. Methicillin-resistant Staphylococci (MRS) and other organisms (quinolone-resistant Gram-negative bacteria, rifampicin-resistant Staphylococcus, Enterococcus, and Candida) are meant to be "difficult to treat" (DTT) with an inferior outcome for two-stage revision. In addition to the type of bacteria, some more risk factors seem to be present. The aim of this study was (1) to detect a difference of reinfection rates between reinfection-causing groups of bacteria ["difficult to treat" (DTT), "easy to treat" (ETT) and methicillin-resistant staphylococci (MRS)] after a two-stage procedure, and (2) find overall risk factors for reinfection in a standardized long (spacer insertion for at least 6 weeks) two-stage procedure for periprosthetic knee infection. METHODS One hundred and thirty-seven two-stage revisions for periprosthetic knee infection were performed at one tertiary referral center. Finally, 96 patients could be included for analyses. Possible risk factors (comorbidities, prior surgery, etc.) and the types of organisms were documented. Quinolone-resistant Gram-negative bacteria, rifampicin-resistant Staphylococcus, Enterococcus, and Candida were classified as "difficult to treat" (DTT). Methicillin-resistant Staphylococci were summarized as "MRS", all other organism are summarized as "easy to treat" (ETT). Statistical analyses included univariate analysis (t test, Fisher's exact test, Chi square test) and logistic regression analysis. RESULTS There were no statistical significant differences in recurrent infection rates between organism groups (DTT vs. ETT, p = 0.674; DTT vs. MRS, p = 0.705; ETT vs. MRS, p = 0.537). Risk factors seem to be "need of revision after first stage" (p = 0.019, OR 5.62) or completed second stage (p = 0.000, OR 29.07), numbers of surgeries (p = 0.028) and alcohol abuse (p = 0.019, OR 5.62). CONCLUSIONS Revision needed during or after a two-stage exchange, numbers of surgeries and alcohol abuse are risk factors for recurrence, a different recurrence rates between organism-groups cannot be shown. The absence of significant differences in recurrence rates points to the importance of the individuality of each periprosthetic infection case: a reduction of necessary surgeries (with a thorough debridement, appropriate antibiotic addition to spacers) and the control of comorbidities (alcohol abuse) appear to be essential components of a two-stage exchange.
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Fu J, Xiang Y, Ni M, Chen J, Li X, Yu B, Liu K, Zhou Y, Hao L. The use of augmented antibiotic-loaded cement spacer in periprosthetic joint infection patients with acetabular bone defect. J Orthop Surg Res 2020; 15:448. [PMID: 32998728 PMCID: PMC7528588 DOI: 10.1186/s13018-020-01831-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Accepted: 07/29/2020] [Indexed: 02/08/2023] Open
Abstract
Background Spacer complications may affect final clinical outcome of the two-stage approach in periprosthetic joint infection (PJI) patients. This study aimed to investigate clinical outcomes and complications of augmented antibiotic-loaded cement spacer in PJI patients with acetabular bone defect. Methods Data on PJI patients with acetabular bone defect receiving two-stage revision from January 2009 to December 2016, in our hospital were retrospectively reviewed. Screw-cement-shell was used to improve the stability of the hip with acetabular wall defect. Handmade acetabular spacer could prevent femoral spacer entering into pelvis in patients with acetabular internal wall defect. A total of 26 patients (11 males and 15 females) were included in the current study. Their mean age was 46.7 ± 15.4 years old. Clinical outcomes and complications were measured. Results Twenty-one of total 26 hips (21/26, 80.8%) showed positive cultures and 15/26 (57.7%) samples were cultured with staphylococcus. Of enrolled patients, 5/26 (19.2%) developed mixed infection. There was one patient (3.8%) with spacer dislocation and two (7.7%) with spacer fracture. One patient developed acute PJI 5 years after the second-stage revision, so overall success rate among these patients was 96.2%. Differences in Paprosky classifications before the first and second stage did not reach significant level (p > 0.05). Hip Harris score was raised from 40.9 ± 14.0 to 81.2 ± 11.2 (p < 0.05). Conclusions Augmented antibiotic-loaded cement spacer could achieve satisfactory clinical outcomes in PJI patients with acetabular bone defect. It provided joint mobility, increased additional joint stability, and decreased iatrogenic bone defect caused by acetabular wear.
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Affiliation(s)
- Jun Fu
- Department of Orthopaedics, Chinese People's Liberation Army General Hospital (301 Hospital), Beijing, China
| | - Yi Xiang
- Department of Orthopaedics, The 985 Hospital of PLA, Taiyuan, Shanxi, China
| | - Ming Ni
- Department of Orthopaedics, Chinese People's Liberation Army General Hospital (301 Hospital), Beijing, China
| | - Jiying Chen
- Department of Orthopaedics, Chinese People's Liberation Army General Hospital (301 Hospital), Beijing, China.
| | - Xiang Li
- Department of Orthopaedics, Chinese People's Liberation Army General Hospital (301 Hospital), Beijing, China
| | - Baozhan Yu
- Department of Orthopaedics, Chinese People's Liberation Army General Hospital (301 Hospital), Beijing, China
| | - Kan Liu
- Department of Orthopaedics, Chinese People's Liberation Army General Hospital (301 Hospital), Beijing, China
| | - Yonggang Zhou
- Department of Orthopaedics, Chinese People's Liberation Army General Hospital (301 Hospital), Beijing, China
| | - Libo Hao
- Department of Orthopaedics, Chinese People's Liberation Army General Hospital (301 Hospital), Beijing, China.
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Conservative two-stage revision with primary components of infected total hip arthroplasty: An analysis of survival, clinical and radiographic outcomes. PLoS One 2020; 15:e0239981. [PMID: 33002069 PMCID: PMC7529346 DOI: 10.1371/journal.pone.0239981] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Accepted: 09/01/2020] [Indexed: 12/11/2022] Open
Abstract
Few studies provide an analysis of conservative two-stage revision of hip
periprosthetic joint infection (PJI) and its impact on final outcome. A
conservative revision is defined when soft tissues and bone quality enable the
use of primary prosthetic components. Data of patients treated for chronic hip
PJI who underwent two-stage revision between 2009 and 2016 and had a minimum of
2 years of follow-up were collected. Oxford Hip Score (OHS), Harris Hip Score
(HHS) and radiological and microbiological data were retrieved and analysed.
Clinical and functional outcome, survival, mortality, eradication, reinfection
and re-revision rates within subgroups of patients with primary components and
revision components are reported herein. A total of 148 patients underwent
two-stage hip exchange with a mean follow-up of 55.6 ± 23.1 months and a mean
age at surgery of 64.3 ± 12.7 years. Forty-four percent of patients underwent
conservative revision. The mean HHS significantly improved from 40.6 ± 9.4
points to the final value of 87.8 ± 10.5 points (p = .002), and the mean OHS
went from 20.3 ± 3.8 points to 40.3 ± 5. points (p< .001). Patients who were
treated with primary components or isolated revision stems in the second stage
had a significant reduction in surgical times (p< .001). The mortality rate
for all causes of death was 6.8%, the eradication rate was 89.9%, the
reinfection rate was 4.7% and the reoperation rate was 7.4% without differences
between conservative and non-conservative revisions. Two-stage exchange
arthroplasty for total hip arthroplasty (THA) PJI is a good strategy that
provides satisfactory results, high eradication rates and no further need for
revision. The conservative two-stage revision in patients with adequate bone
stock represents a feasible option with good results and survival rates.
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11
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Lueck E, Schlaepfer TE, Schildberg FA, Randau TM, Hischebeth GT, Jaenisch M, Ossendorff R, Wirtz DC, Wimmer MD. The psychological burden of a two-stage exchange of infected total hip and knee arthroplasties. J Health Psychol 2020; 27:470-480. [PMID: 32840382 DOI: 10.1177/1359105320948583] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Infection is one of the most challenging complications after total joint arthroplasties affecting up to 30,000 patients in the US per year. This study investigates the psycho-social burden induced by the two-stage intervention in infected hip or knee replacements. All patients were treated with a two-stage exchange and were assessed at three different timepoints regarding their psychological conditions. Our findings suggest that psychological sequelae after treatment of periprosthetic joint infection are clearly underestimated in the literature and psychological correlates and side effects should be further highlighted during the training process of young surgeons.
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Affiliation(s)
- Eva Lueck
- Department of Orthopedics and Trauma Surgery, University Hospital Bonn, Bonn, Germany
| | - Thomas E Schlaepfer
- University Hospital Freiburg, Center for Psychiatric Diseases, Freiburg, Freiburg i.Br., Germany.,The Johns Hopkins University, Baltimore, MD, USA
| | - Frank A Schildberg
- Department of Orthopedics and Trauma Surgery, University Hospital Bonn, Bonn, Germany
| | - Thomas M Randau
- Department of Orthopedics and Trauma Surgery, University Hospital Bonn, Bonn, Germany
| | - Gunnar Tr Hischebeth
- Institute of Medical Microbiology, Immunology and Parasitology, University Hospital Bonn, Bonn, Germany
| | - Max Jaenisch
- Department of Orthopedics and Trauma Surgery, University Hospital Bonn, Bonn, Germany
| | - Robert Ossendorff
- Department of Orthopedics and Trauma Surgery, University Hospital Bonn, Bonn, Germany
| | - Dieter C Wirtz
- Department of Orthopedics and Trauma Surgery, University Hospital Bonn, Bonn, Germany
| | - Matthias D Wimmer
- Department of Orthopedics and Trauma Surgery, University Hospital Bonn, Bonn, Germany
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12
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Escudero-Sanchez R, Senneville E, Digumber M, Soriano A, Del Toro MD, Bahamonde A, Del Pozo JL, Guio L, Murillo O, Rico A, García-País MJ, Rodríguez-Pardo D, Iribarren JA, Fernández M, Benito N, Fresco G, Muriel A, Ariza J, Cobo J. Suppressive antibiotic therapy in prosthetic joint infections: a multicentre cohort study. Clin Microbiol Infect 2020; 26:499-505. [PMID: 31539638 DOI: 10.1016/j.cmi.2019.09.007] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Revised: 09/01/2019] [Accepted: 09/07/2019] [Indexed: 02/08/2023]
Abstract
OBJECTIVES The aim was to describe the effectiveness of suppressive antibiotic treatment (SAT) in routine clinical practice when used in situations in which removal of a prosthetic implant is considered essential for the eradication of an infection, and it cannot be performed. METHODS This was a descriptive retrospective and multicentre cohort study of prosthetic joint infection (PJI) cases managed with SAT. SAT was considered to have failed if a fistula appeared or persisted, if debridement was necessary, if the prosthesis was removed due to persistence of the infection or if uncontrolled symptoms were present. RESULTS In total, 302 patients were analysed. Two hundred and three of these patients (67.2%) received monotherapy. The most commonly used drugs were tetracyclines (39.7% of patients) (120/302) and cotrimoxazole (35.4% of patients) (107/302). SAT was considered successful in 58.6% (177/302) of the patients (median time administered, 36.5 months; IQR 20.75-59.25). Infection was controlled in 50% of patients at 5 years according to Kaplan-Meier analysis. Resistance development was documented in 15 of 65 (23.1%) of the microbiologically documented cases. SAT failure was associated with age <70 years (sub-hazard ratio (SHR) 1.61, 95% CI 1.1-2.33), aetiology other than Gram-positive cocci (SHR 1.56, 95% CI 1.09-2.27) and location of the prosthesis in the upper limb (SHR 2.4, 95% CI 1.5-3.84). SAT suspension was necessary due to adverse effects in 17 of 302 patients (5.6%). CONCLUSIONS SAT offers acceptable results for patients with PJI when surgical treatment is not performed or when it fails to eradicate the infection.
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Affiliation(s)
| | - E Senneville
- Centre Hospitalier Gustave Dron, Tourcoing, France
| | - M Digumber
- Centre Hospitalier Gustave Dron, Tourcoing, France
| | | | | | | | | | - L Guio
- Hospital Cruces, Vizcaya, Spain
| | - O Murillo
- Hospital Bellvitge, Barcelona, Spain
| | - A Rico
- Hospital Universitario La Paz, Madrid, Spain
| | | | | | | | | | - N Benito
- Hospital Santa Creu I Sant Pau, Barcelona, Spain
| | - G Fresco
- Hospital Ramón y Cajal, IRYCIS, Madrid, Spain
| | - A Muriel
- Hospital Ramón y Cajal, IRYCIS, CIBER, Madrid, Spain
| | - J Ariza
- Hospital Bellvitge, Barcelona, Spain
| | - J Cobo
- Hospital Ramón y Cajal, IRYCIS, Madrid, Spain
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13
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Johnson JP, Cohen EM, Antoci V. Treatment of a periprosthetic femur fracture around an antibiotic spacer with revision and an antibiotic plate. Arthroplast Today 2019; 5:401-406. [PMID: 31886379 PMCID: PMC6920730 DOI: 10.1016/j.artd.2019.09.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Revised: 08/23/2019] [Accepted: 09/20/2019] [Indexed: 11/22/2022] Open
Abstract
Infection following total hip arthroplasty can be a devastating complication, often necessitating a 2-stage surgery with the temporary placement of an antibiotic spacer. Fracture around this spacer is an uncommon complication that presents serious treatment challenges. Our manuscript details the successful surgical treatment of a previously unreported fracture around an antibiotic spacer, treated with revision to a hemiarthroplasty and placement of an antibiotic plate.
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Affiliation(s)
- Joey P Johnson
- Department of Orthopaedic Surgery, Loma Linda University, Loma Linda, CA, USA
| | - Eric M Cohen
- Division of Adult Reconstruction, Department of Orthopaedic Surgery, Warren Alpert Medical School, Brown University, Providence, RI, USA
| | - Valentin Antoci
- Division of Adult Reconstruction, Department of Orthopaedic Surgery, Warren Alpert Medical School, Brown University, Providence, RI, USA
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14
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Enhancing biology and providing structural support for acetabular reconstruction in single-stage revision for infection. J Orthop Traumatol 2019; 20:23. [PMID: 31236707 PMCID: PMC6591340 DOI: 10.1186/s10195-019-0530-6] [Citation(s) in RCA: 5] [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: 01/05/2017] [Accepted: 08/29/2018] [Indexed: 11/26/2022] Open
Abstract
Background Reconstruction of combined segmental and cavitary defects of the acetabulum is a challenge to the hip surgeon. One question regards the efficacy of reconstruction of acetabular defects using a combination of tantalum metal augments (TMAs) and impaction graft in single-stage revision for periprosthetic infection. Materials and methods In the period between July 2009 and August 2014, 24 patients with combined segmental and cavitary acetabular defects and Paprosky classification grade IIB, IIC, and IIIA had hips reconstructed using the combination of TMAs and antibiotic-loaded impaction grafting. A similar group of 30 patients who received single-stage revision without metal augments were identified and taken as control. All patients received a polyethylene cemented cup and long cementless (Wagner SL) stem. Patients were prospectively evaluated using the modified Harris Hip Score (HHS) in addition to radiological evaluation at 3, 6, and 12 months then annually thereafter. Results At an average follow-up period of 4 years (range 2–7 years), all but one patient in the study group were free of infection, indicating a 96% success rate. This rate of eradicating infection was comparable to the 97% success rate in the control group. All metal augments were stable, and good incorporation of the impacted bone graft was observed. The HHS improved significantly from 27 preoperatively to 83 postoperatively (P < 0.001). Conclusion Metal augments can convert massive acetabular defects to a more contained defect suitable for grafting. The combination of tantalum augments that provide strong structural support and antibiotic-loaded allograft is successful in the mid-term in single-stage revisions for infection. Level of evidence Level IV (prospective case series).
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15
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Ryan SP, Vovos TJ, Hong CS, Bergen MA, Formby PM, Bolognesi MP, Seyler TM. Treatment of Prosthetic Joint Infection: Established Patient Relationships May Impact Medical Decision-Making. J Arthroplasty 2019; 34:352-358. [PMID: 30482664 DOI: 10.1016/j.arth.2018.09.091] [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: 08/09/2018] [Revised: 09/15/2018] [Accepted: 09/29/2018] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Choosing the intervention for prosthetic joint infections, whether debridement, antibiotics, and implant retention (DAIR), or explant and antibiotic spacer placement, is multifactorial. One characteristic that may influence this decision is a previously established relationship with the patient. We hypothesized that patients receiving their arthroplasty at an outside institution and presenting with infection would be more likely to undergo removal of their implant without an attempt at DAIR compared to patients who underwent primary arthroplasty at the investigating institution. METHODS The institutional database was queried for primary total hip and knee arthroplasty infections. Manual review of medical records was performed, excluding patients who did not meet the Musculoskeletal Infection Society definition of infection. Patient demographics, medical comorbidities, presenting infection characteristics, and surgical intervention were collected. Multivariable analysis was performed to determine the independent predictors of treatment. RESULTS A total of 270 patients were included for analysis. McPherson score (P < .001) and duration of symptoms (P < .001) were associated with subsequent treatment. Additionally, when controlling for age, gender, symptom duration category, procedure, McPherson score, and American Society of Anesthesiologists category, patients with index procedures at outside hospitals were more likely to undergo implant removal (odds ratio, 36.30; 95% confidence interval, 8.16-161.51; P < .001). CONCLUSION Patients receiving their primary arthroplasty at an outside hospital and presenting with infection are more likely to undergo removal of hardware as their initial treatment. To avoid treatment bias, institutional protocols should be implemented to guide the shared decision-making process.
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Affiliation(s)
- Sean P Ryan
- Department of Orthopaedic Surgery, Duke University Hospital, Durham, NC
| | - Tyler J Vovos
- Department of Orthopaedic Surgery, Duke University Hospital, Durham, NC
| | - Cierra S Hong
- Department of Orthopaedic Surgery, Duke University Hospital, Durham, NC
| | - Michael A Bergen
- Department of Orthopaedic Surgery, Duke University Hospital, Durham, NC
| | - Peter M Formby
- Department of Orthopaedic Surgery, Duke University Hospital, Durham, NC
| | | | - Thorsten M Seyler
- Department of Orthopaedic Surgery, Duke University Hospital, Durham, NC
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16
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Aalirezaie A, Bauer TW, Fayaz H, Griffin W, Higuera CA, Krenn V, Krenn V, Molano M, Moojen DJ, Restrepo C, Shahi A, Shubnyakov I, Sporer S, Tanavalee A, Teloken M, Velázquez Moreno JD. Hip and Knee Section, Diagnosis, Reimplantation: Proceedings of International Consensus on Orthopedic Infections. J Arthroplasty 2019; 34:S369-S379. [PMID: 30343965 DOI: 10.1016/j.arth.2018.09.021] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
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17
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Defining Treatment Success After 2-Stage Exchange Arthroplasty for Periprosthetic Joint Infection. J Arthroplasty 2018; 33:3541-3546. [PMID: 30100137 DOI: 10.1016/j.arth.2018.06.015] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2018] [Revised: 06/05/2018] [Accepted: 06/09/2018] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Two-stage exchange arthroplasty remains the preferred surgical treatment method for patients with chronic periprosthetic joint infection (PJI). The success of this procedure is not known exactly as various definitions of success have been used. This study aimed at analyzing the difference in outcome following 2-stage exchange arthroplasty using different definitions for success. METHODS A retrospective study of 703 patients with PJI who underwent resection arthroplasty and spacer insertion between January 1999 and June 2015 was performed. Chart review identified intraoperative cultures at the time of spacer, reimplantation, and any subsequent reinfections or surgeries following spacer insertion. After applying the exclusion criteria, a total of 570 patients were included in the analysis. Five definitions of treatment success were assessed: (1) Delphi consensus success, (2) modified Delphi consensus success, (3) microbiological success, (4) implant success, and (5) surgical success. RESULTS Of the 570 patients with PJIs, 458 were reimplanted at a mean of 4.1 months. Mortality was 13.9% with 6.7% occurring before reimplantation. Treatment success was highly variable depending on the definition used (54.2%-88.9%). In 19.6% of PJI cases, the Delphi consensus definition could not be assessed as reimplantation never occurred. Furthermore, 67.0% of these patients underwent reoperations, which may not be accounted for in the Delphi consensus definition. CONCLUSION Treatment success rates vary dramatically depending on the definition used at our institution. We hope these definitions can help bring forth awareness for standardized reporting of outcomes, but further validation and agreement of these definitions among surgeons and infectious disease physicians is crucial.
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18
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Hischebeth GT, Randau TM, Ploeger MM, Friedrich MJ, Kaup E, Jacobs C, Molitor E, Hoerauf A, Gravius S, Wimmer MD. Staphylococcus aureus versus Staphylococcus epidermidis in periprosthetic joint infection-Outcome analysis of methicillin-resistant versus methicillin-susceptible strains. Diagn Microbiol Infect Dis 2018; 93:125-130. [PMID: 30266398 DOI: 10.1016/j.diagmicrobio.2018.08.012] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Revised: 08/16/2018] [Accepted: 08/26/2018] [Indexed: 01/25/2023]
Abstract
Periprosthetic joint infections (PJIs) are a major complication in total joint arthroplasty. Staphylococcus aureus and coagulase-negative staphylococci are known to cause the majority of all PJIs. This study aimed to analyze the eradication rates of S. aureus and S. epidermidis with methicillin susceptibility and methicillin resistance in a 2-stage therapy algorithm. Seventy-four patients with PJI caused by methicillin-resistant S. aureus (MRSA), methicillin-resistant coagulase-negative staphylococci (MRSE), methicillin-susceptible S. aureus (MSSA), and methicillin-susceptible coagulase-negative staphylococci (MSSE) were included, and the outcome was analyzed retrospectively. After a minimal follow-up of 2 years, n = 56 patients (75.7%) were definitively free of infection. The analysis revealed significant differences between the groups, with eradication rates as follows: MSSA (92.6%), MSSE (95.2%), MRSA (80%), and MRSE (54.2%). MRSE showed a significantly lower rate of patients graded as "definitively free of infection" as compared to patients with infections caused by MSSA, MSSE, and MRSA.
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Affiliation(s)
- G T Hischebeth
- Institute of Medical Microbiology, Immunology and Parasitology, University Hospital Bonn, Germany.
| | - T M Randau
- Department of Orthopedics and Trauma Surgery, University Hospital Bonn, Germany
| | - M M Ploeger
- Department of Orthopedics and Trauma Surgery, University Hospital Bonn, Germany
| | - M J Friedrich
- Department of Orthopedics and Trauma Surgery, University Hospital Bonn, Germany
| | - E Kaup
- Department of Orthopedics and Trauma Surgery, University Hospital Bonn, Germany
| | - C Jacobs
- Department of Orthopedics and Trauma Surgery, University Hospital Bonn, Germany
| | - E Molitor
- Institute of Medical Microbiology, Immunology and Parasitology, University Hospital Bonn, Germany
| | - A Hoerauf
- Institute of Medical Microbiology, Immunology and Parasitology, University Hospital Bonn, Germany
| | - S Gravius
- Department of Orthopedics and Trauma Surgery, University Hospital Bonn, Germany
| | - M D Wimmer
- Department of Orthopedics and Trauma Surgery, University Hospital Bonn, Germany
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19
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Ford AN, Holzmeister AM, Rees HW, Belich PD. Characterization of Outcomes of 2-Stage Exchange Arthroplasty in the Treatment of Prosthetic Joint Infections. J Arthroplasty 2018; 33:S224-S227. [PMID: 29576486 DOI: 10.1016/j.arth.2018.02.043] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2017] [Revised: 02/05/2018] [Accepted: 02/08/2018] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Two-stage revision is the preferred treatment for prosthetic hip and knee infections in the United States. Recent studies have questioned the true success rate of this treatment. The purpose of this study is to investigate outcomes of prosthetic hip and knee infections undergoing resection arthroplasty and spacer insertion at a single institution. METHODS We identified 103 patients who underwent prosthesis resection and spacer placement for infection over a 10-year period. Twenty-three cases were excluded based on preset exclusion criteria leaving 80 cases (56 knees, 24 hips). A retrospective review was performed to examine the outcomes of these patients. RESULTS Following spacer placement but before reimplantation, 9 (11.25%) of the 80 joints underwent repeat debridement and spacer exchange for persistent infection. Twenty-four (30.00%) patients had a serious complication during their treatment course. Fourteen (17.50%) patients never underwent reimplantation. Of these, 10 continued with spacer retention, 2 had resection arthroplasty, and 1 each had an amputation and an arthrodesis. Of the 66 patients with successful reimplantation, 48 (72.70%) remained infection free at most recent follow-up. CONCLUSIONS Two-stage revision does not result in the high rates of cure reported previously, when taking into account the substantial number of patients who never undergo the subsequent reimplantation surgery. Of those who underwent reimplantation in our study, many required additional spacer exchange or had complications. Surgeons and patients should consider these outcomes when discussing the treatment of prosthetic hip and knee infections.
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Affiliation(s)
- Amy N Ford
- Department of Orthopaedic Surgery and Rehabilitation, Loyola University Chicago, Maguire Center, Maywood, IL
| | - Adam M Holzmeister
- Department of Orthopaedic Surgery and Rehabilitation, Loyola University Chicago, Maguire Center, Maywood, IL
| | - Harold W Rees
- Department of Orthopaedic Surgery and Rehabilitation, Loyola University Chicago, Maguire Center, Maywood, IL
| | - Paul D Belich
- Department of Orthopaedic Surgery and Rehabilitation, Loyola University Chicago, Maguire Center, Maywood, IL
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20
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Saitoh Y, Setoguchi T, Yoshioka T, Nishi J, Tanimoto A, Komiya S. Intraoperative evaluation of polymorphonuclear leukocyte during second-stage revision surgery promote overdiagnosis of persistent periprosthetic joint infection. ACTA ORTHOPAEDICA ET TRAUMATOLOGICA TURCICA 2018; 52:191-195. [PMID: 29503078 PMCID: PMC6136319 DOI: 10.1016/j.aott.2018.02.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/12/2017] [Revised: 11/13/2017] [Accepted: 02/04/2018] [Indexed: 11/28/2022]
Abstract
Objective The aim of this study was to evaluate whether intraoperative histopathological examination could predict the risk of relapse of infection in periprosthetic joint infections (PJI). Methods The study included 25 patients (14 women and 11 men, with a mean age of 67.0 years (range, 37–83 years)), who had two-staged revision surgery for a PJI. Following prosthetic removal in the first stage, all patient underwent an intraoperative histopathological examination during the second stage. The patients were divided into PMNs-positive group (≥five PMNs per high-powered field) or -negative group (<five PMNs). A relapse was defined as the occurrence of PJI. Median follow-up was 51 months (range, 32–80 months) following second-stage revision surgery. Results Intraoperative histopathological revealed that 8.0% of cases were PMNs-positive. Postoperative histopathological examination revealed that 28.0% of cases were PMNs-positive. 28.0% of cases showed discrepancy between the PMNs-positivity. Intraclass correlation coefficient indicates poor reproducibility. Infection relapse after revision surgery occurred in two cases (8.0%); both relapse cases were from the PMNs-negative group. There was no statistical relationship between the presence of PMNs in periprosthetic tissue by intraoperative or postoperative histopathological examination and relapse of infection. Conclusions Our findings showed that intraoperative histopathological examination could not predict the relapse of infection. Intraoperative histopathological examination promotes overdiagnosis of the requirement for re-implantation of antibiotic-impregnated cement and prolonged treatment periods. Level of evidence Level III, diagnostic study
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21
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Joint implants: An elution solution. Nat Biomed Eng 2017. [DOI: 10.1038/s41551-017-0087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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22
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Acetabular spacers in 2-stage hip revision: is it worth it? A single-centre retrospective study. Hip Int 2017; 27:187-192. [PMID: 27886355 DOI: 10.5301/hipint.5000446] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/16/2016] [Indexed: 02/04/2023]
Abstract
PURPOSE The aim of this work is to evaluate an acetabular antibiotic loaded bone cement spacer in 2-stage revision surgery as a potential approach able to reduce complications during the inter-stage period (i.e. dislocation, acetabular wear), as well as simplify 2-stage hip revision surgery and improve hip biomechanics. METHODS We performed a retrospective comparative study and evaluated clinical, radiological and surgical data of 71 patients affected by periprosthetic hip infection who were treated with 2-stage exchange. 31 patients were treated using an acetabular spacer in addition to the femoral (group A) while 40 underwent a standard revision surgery (femoral spacer only, group B). RESULTS Mean time of surgery for the first stage was 148 ± 59 minutes and 142 ± 45 minutes for group A and B respectively; we noted a statistically significant reduction (26 min, p = 0.015) in the same parameter for the second stage (83 ± 35 minutes for group A and 109 ± 36 minutes for group B). We observed the following interstage complications: 5 femoral spacer dislocations (1 for group A and 4 for group B); 1 spacer fracture (group B), 1 spacer fracture (group A), 2 periprosthetic fractures (group B) and 2 patients with acetabular spacer instability (group B). Additionally, we observed a significant improvement in leg length restoration for group A (p = 0.03). CONCLUSIONS Our data show that the acetabular spacer technique is able to reduce the interstage complication rate and allow improved hip biomechanics restoration.
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23
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Volpin A, Sukeik M, Alazzawi S, Haddad FS. Aggressive Early Debridement in Treatment of Acute Periprosthetic Joint Infections After Hip and Knee Replacements. Open Orthop J 2016; 10:669-678. [PMID: 28144377 PMCID: PMC5220182 DOI: 10.2174/1874325001610010669] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2016] [Revised: 06/24/2016] [Accepted: 07/15/2016] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Periprosthetic Joint Infection Remains a Dreaded Complication After Hip and Knee Replacement Surgery. Treatment Options for Acute Postoperative and Acute Hematogenous Infections Include Arthroscopic or Open Debridement With Retention or Exchange of the Prostheses. This Review Article Aims to Summarize the Evidence for Management of Acute Postoperative And Acute Hematogenous Infections. METHODS A Systematic Literature Search Was Performed Using a Computer-based Search Engine Covering Medline (OvidSP), PubMed Database (U.S. National Library of Medicine, National Institutes of Health), Embase, Web of Science, Cochrane and Google Scholar for Relevant Articles. RESULTS Common Themes Around Treatment of Acute Postoperative and Acute Hematogenous Infections Discussed in this Review Include the Timing of Intervention, Description of the Optimal Procedure and How we Perform it at our Institution, the Role of Arthroscopic Debridement, Most Commonly Isolated Micro-organisms and Prognostic Factors for Infection Control. CONCLUSION Success in Treating Acute Postoperative and Acute Hematogenous Infections Depends on Early Diagnosis and Aggressive Surgical Debridement Combined With Effective Antibiotic Therapy.
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Affiliation(s)
- Andrea Volpin
- Department of Trauma and Orthopaedics, University College London Hospital, 235 Euston Road, NW1 2BU, London, United Kingdom
| | - Mohamed Sukeik
- Department of Trauma and Orthopaedics, The Royal London Hospital, Whitechapel, E1 1BB, London, United Kingdom
| | - Sulaiman Alazzawi
- Department of Trauma and Orthopaedics, The Royal London Hospital, Whitechapel, E1 1BB, London, United Kingdom
| | - Fares Sami Haddad
- Department of Trauma and Orthopaedics, University College London Hospital, 235 Euston Road, NW1 2BU, London, United Kingdom
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Abstract
Despite the battery of available tests, the diagnosis of periprosthetic joint infection (PJI) remains a challenge. A comprehensive medical history and physical examination with appropriate radiographs followed by erythrocyte sedimentation rate and serum C-reactive protein are the first-line screening test for patients with suspected hip PJI. The second line of investigation of patients with abnormal serology or a strong suspicion for PJI, is joint aspiration. Aspirates should be sent for assessment of white blood cell count, polymorphonuclear percentage, leukocyte esterase strip test, and microbiology. If the first attempt fails, the joint should be re-aspirated at a different time. The International Consensus recommends against infiltration of saline or other fluids into a "dry" joint. In patients not planned for surgery but need further evaluation for PJI, a nuclear imaging study may help. In others with a planned revision surgery, intraoperative samples for frozen section and culture study are the best measures available. Treatment strategies for PJI are well established in the literature. Poor surgical candidates receive oral suppressive antibiotic therapy alone. Acute PJI, presenting within 4 weeks of the index surgery, or as a result of bacteraemia, may be treated with irrigation and debridement and implant retention. Chronic PJI, occurring more than 4 weeks after initial surgery, is treated with 1-stage or 2-stage revision arthroplasty. In some persistent infections or patients who refuse to undergo revision surgery, salvage procedures may be needed.
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Kaufman MG, Meaike JD, Izaddoost SA. Orthopedic Prosthetic Infections: Diagnosis and Orthopedic Salvage. Semin Plast Surg 2016; 30:66-72. [PMID: 27152098 PMCID: PMC4856527 DOI: 10.1055/s-0036-1580730] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Orthopedic hardware infections are much feared and costly complications that can occur when these devices are implemented both in traumatic cases as well as in joint replacement surgery. Because these infections can lead to great morbidity, it is important to understand their pathophysiology as well as the principles behind their diagnosis and initial treatment. Plastic surgeons are frequently consulted as part of a multidisciplinary team to provide stable soft tissue coverage of the associated defects that result from these infections. A review of the existing literature was performed to identify the potential causes of these infections, to provide established diagnostic criteria guidelines, and to explain how these prosthetic infections are managed from an orthopedic surgery perspective prior to consulting the plastic surgery team.
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Affiliation(s)
- Matthew G. Kaufman
- Division of Plastic and Reconstructive Surgery, Baylor College of Medicine, Houston, Texas
| | - Jesse D. Meaike
- Division of Plastic and Reconstructive Surgery, Baylor College of Medicine, Houston, Texas
| | - Shayan A. Izaddoost
- Division of Plastic and Reconstructive Surgery, Baylor College of Medicine, Houston, Texas
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26
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Banke IJ, Stade N, Prodinger PM, Mühlhofer HM, Thomas P, Thomas B, Summer B, van Griensven M, von Eisenhart-Rothe R, Gollwitzer H. [Synovial biomarkers for differential diagnosis of painful arthroplasty]. DER ORTHOPADE 2015; 44:93, 936-8, 940-1. [PMID: 26542406 DOI: 10.1007/s00132-015-3188-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND The diagnosis and treatment of periprosthetic joint infection (PJI) remain true clinical challenges. PJI diminishes therapeutic success, causes dissatisfaction for the patient and medical staff, and often requires extensive surgical revision(s). At the present time, an extensive multimodal algorithmic approach is used to avoid time- and cost-consuming diagnostic aberrations. However, especially in the case of the frequent and clinically most relevant "low-grade" PJI, the current diagnostic "gold standard" has reached its limits. EVALUATION Synovial biomarkers are thought to close this diagnostic gap, hopefully enabling the safe differentiation among aseptic, (chronic) septic, implant allergy-related and the arthrofibrotic genesis of symptomatic arthroplasty. Therefore, joint aspiration for obtaining synovial fluid is preferred over surgical synovial tissue biopsy because of the faster results, greater practicability, greater patient safety, and lower costs. In addition to the parameters synovial IL-6, CRP, and leukocyte esterase, novel biomarkers such as antimicrobial peptides and other proinflammatory cytokines are currently highlighted because of their very high to excellent diagnostic accuracy. CONCLUSION Independent multicenter validation studies are required to show whether a set of different innovative synovial fluid biomarkers rather than a few single parameters is favorable for a safe "one-stop shop" differential diagnosis of PJI.
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Affiliation(s)
- I J Banke
- Klinik und Poliklinik für Orthopädie und Sportorthopädie, Klinikum rechts der Isar der TU München, Ismaninger Str. 22, 81675, München, Deutschland.
| | - N Stade
- Klinik und Poliklinik für Orthopädie und Sportorthopädie, Klinikum rechts der Isar der TU München, Ismaninger Str. 22, 81675, München, Deutschland
| | - P M Prodinger
- Klinik und Poliklinik für Orthopädie und Sportorthopädie, Klinikum rechts der Isar der TU München, Ismaninger Str. 22, 81675, München, Deutschland
| | - H M Mühlhofer
- Klinik und Poliklinik für Orthopädie und Sportorthopädie, Klinikum rechts der Isar der TU München, Ismaninger Str. 22, 81675, München, Deutschland
| | - P Thomas
- Klinik und Poliklinik für Dermatologie und Allergologie der LMU München, Frauenlobstraße 9-11, 80337, München, Deutschland
| | - B Thomas
- Klinik und Poliklinik für Dermatologie und Allergologie der LMU München, Frauenlobstraße 9-11, 80337, München, Deutschland
| | - B Summer
- Klinik und Poliklinik für Dermatologie und Allergologie der LMU München, Frauenlobstraße 9-11, 80337, München, Deutschland
| | - M van Griensven
- Experimentelle Unfallchirurgie, Klinik und Poliklinik für Unfallchirurgie, Klinikum rechts der Isar der TU München, Ismaninger Str. 22, 81675, München, Deutschland
| | - R von Eisenhart-Rothe
- Klinik und Poliklinik für Orthopädie und Sportorthopädie, Klinikum rechts der Isar der TU München, Ismaninger Str. 22, 81675, München, Deutschland
| | - H Gollwitzer
- Klinik und Poliklinik für Orthopädie und Sportorthopädie, Klinikum rechts der Isar der TU München, Ismaninger Str. 22, 81675, München, Deutschland.,ATOS Klinik München, Effnerstr. 38, 81925, München, Deutschland
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