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Fraval A, Zhou Y, Parvizi J. Antibiotic-loaded cement in total joint arthroplasty: a comprehensive review. Arch Orthop Trauma Surg 2024:10.1007/s00402-024-05328-z. [PMID: 38687383 DOI: 10.1007/s00402-024-05328-z] [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: 02/26/2024] [Accepted: 04/14/2024] [Indexed: 05/02/2024]
Abstract
This review evaluates the decision-making framework for using antibiotic-loaded cement (ALC) in the management of prosthetic joint infection (PJI). Drawing on available literature, we offer orthopaedic surgeons a guided discussion on several critical considerations. First, we explore the impact of antibiotic-loading on the mechanical properties of polymethylmethacrylate (PMMA) cement, assessing both strength and durability. We then explore the optimal antibiotic dosage to load into cement, aiming to achieve effective local concentrations for infection control without compromising mechanical stability. Furthermore, we explore how cement and antibiotic properties affect the overall antibiotic elution characteristics of ALC. Finally, we discuss risks of systemic toxicity, particularly acute kidney injury, when using ALC. The principal goal in this review is to provide a balanced approach based on best available evidence that optimises antibiotic elution from ALC whilst minimising potential harms associated with its use.
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Affiliation(s)
- Andrew Fraval
- Department of Orthopaedic Surgery, St. Vincent's Hospital Melbourne, 41 Victoria Parade, Fitzroy, VIC, 3065, Australia.
- Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, PA, USA.
| | - Yushy Zhou
- Department of Orthopaedic Surgery, St. Vincent's Hospital Melbourne, 41 Victoria Parade, Fitzroy, VIC, 3065, Australia
| | - Javad Parvizi
- Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, PA, USA
- International Joint Center, Acibadem University Hospital, Istanbul, Turkey
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2
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Lekkala S, Inverardi N, Grindy SC, Hugard S, Muratoglu OK, Oral E. Irradiation Behavior of Analgesic and Nonsteroidal Anti-Inflammatory Drug-Loaded UHMWPE for Joint Replacement. Biomacromolecules 2024; 25:2312-2322. [PMID: 38456765 DOI: 10.1021/acs.biomac.3c01179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/09/2024]
Abstract
Local delivery of pain medication can be a beneficial strategy to address pain management after joint replacement, as it can decrease systemic opioid usage, leading to less side and long-term effects. In this study, we used ultrahigh molecular weight polyethylene (UHMWPE), commonly employed as a bearing material for joint implants, to deliver a wide set of analgesics and the nonsteroidal anti-inflammatory drug tolfenamic acid. We blended the drugs with UHMWPE and processed the blend by compression molding and sterilization by low-dose gamma irradiation. We studied the chemical stability of the eluted drugs, drug elution, tensile properties, and wear resistance of the polymer blends before and after sterilization. The incorporation of bupivacaine hydrochloride and tolfenamic acid in UHMWPE resulted in either single- or dual-drug loaded materials that can be sterilized by gamma irradiation. These compositions were found to be promising for the development of clinically relevant drug-eluting implants for joint replacement.
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Affiliation(s)
- Sashank Lekkala
- Harris Orthopaedic Laboratory, Massachusetts General Hospital, Boston, Massachusetts 02114, United States
| | - Nicoletta Inverardi
- Harris Orthopaedic Laboratory, Massachusetts General Hospital, Boston, Massachusetts 02114, United States
- Department of Orthopaedic Surgery, Harvard Medical School, Boston, Massachusetts 02114, United States
| | - Scott C Grindy
- Harris Orthopaedic Laboratory, Massachusetts General Hospital, Boston, Massachusetts 02114, United States
- Department of Orthopaedic Surgery, Harvard Medical School, Boston, Massachusetts 02114, United States
| | - Shannon Hugard
- Harris Orthopaedic Laboratory, Massachusetts General Hospital, Boston, Massachusetts 02114, United States
| | - Orhun K Muratoglu
- Harris Orthopaedic Laboratory, Massachusetts General Hospital, Boston, Massachusetts 02114, United States
- Department of Orthopaedic Surgery, Harvard Medical School, Boston, Massachusetts 02114, United States
| | - Ebru Oral
- Harris Orthopaedic Laboratory, Massachusetts General Hospital, Boston, Massachusetts 02114, United States
- Department of Orthopaedic Surgery, Harvard Medical School, Boston, Massachusetts 02114, United States
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3
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Eikani C, Hoyt A, Cho E, Levack AE. The State of Local Antibiotic Use in Orthopedic Trauma. Orthop Clin North Am 2024; 55:207-216. [PMID: 38403367 DOI: 10.1016/j.ocl.2023.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/27/2024]
Abstract
Fracture-related infections are a challenging complication in orthopedic trauma that often necessitates multiple surgeries. Early administration of systemic antibiotics and surgical intervention remains the gold standard of care, but despite these measures, treatment failures can be as high as 35%. For these reasons, the introduction of local antibiotics at the site of at-risk fractures has increased over the past decade. This review looks at the various measures being used clinically including local antibiotic powder, polymethylmethacrylate, biodegradable substances, antibiotic-coated implants, and novel methods such as hydrogels and nanoparticles that have the potential for use in the future.
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Affiliation(s)
- Carlo Eikani
- Loyola University Stritch School of Medicine; Department of Orthopaedic Surgery & Rehabilitation, Loyola University Medical Center, 2160 South 1st Avenue, Maguire Suite 1700, Maywood, IL, USA.
| | - Aaron Hoyt
- Department of Orthopaedic Surgery & Rehabilitation, Loyola University Medical Center, 2160 South 1st Avenue, Maguire Suite 1700, Maywood, IL, USA
| | - Elizabeth Cho
- Department of Orthopaedic Surgery & Rehabilitation, Loyola University Medical Center, 2160 South 1st Avenue, Maguire Suite 1700, Maywood, IL, USA
| | - Ashley E Levack
- Loyola University Stritch School of Medicine; Department of Orthopaedic Surgery & Rehabilitation, Loyola University Medical Center, 2160 South 1st Avenue, Maguire Suite 1700, Maywood, IL, USA
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4
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Hlad LM, Rizkalla JN, So E, Herzenberg JE. Treatment of External Fixator Pin Tract Deep Infections With an Antibiotic "Sparkler". Foot Ankle Spec 2024:19386400241235389. [PMID: 38450616 DOI: 10.1177/19386400241235389] [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] [Indexed: 03/08/2024]
Abstract
Pin tract infections are virtually universal complications with the use of external fixation. While most are superficial and respond to oral antibiotics and local care, septic loosening may occur at the bone-pin interface, which may lead to instability of the fixator, catastrophic failure, fracture, and long-term osteomyelitis. Classification systems and prevention protocols have been developed to address this ubiquitous complication. Treatment of severe pin tract infections often requires debridement, parenteral antibiotics, and removal of the offending pin or the entire external fixator. In cases of osteomyelitic pin tracks, a sizable cavity is often present. We describe a simple technique for treatment of deep bone pin tract infection through the use of debridement, irrigation, and an antibiotic "sparkler," which is a specially prepared percutaneous implant of antibiotic laden bone cement.Levels of Evidence: Level 5.
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Affiliation(s)
- Lee M Hlad
- Ankle & Foot Associates LLC, Waycross, Georgia
| | | | - Eric So
- Capital Foot and Ankle, Lincoln, Nebraska
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5
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Warwick HS, Tan TL, Rangwalla K, Shau DN, Barry JJ, Hansen EN. Effect of Antibiotic Spacer Dosing on Treatment Success in Two-Stage Exchange for Periprosthetic Joint Infection. J Am Acad Orthop Surg Glob Res Rev 2024; 8:01979360-202402000-00014. [PMID: 38385716 PMCID: PMC10883627 DOI: 10.5435/jaaosglobal-d-23-00103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Accepted: 01/10/2024] [Indexed: 02/23/2024]
Abstract
INTRODUCTION In two-stage exchange for periprosthetic joint infection (PJI), adding antibiotics to cement spacers is the standard of care; however, little is known about optimal dosage. There is emphasis on using >3.6 g of total antibiotic, including ≥2.0 g of vancomycin, per 40 g of cement, but these recommendations lack clinical evidence. We examined whether recommended antibiotic spacer doses affect treatment success. METHODS This was a retrospective review of 202 patients who underwent two-stage exchange for PJI from 2004 to 2020 with at least 1-year follow-up. Patients were separated into high (>3.6 g of total antibiotic per 40 g of cement) and low-dose spacer groups. Primary outcomes were overall and infectious failure. RESULTS High-dose spacers were used in 80% (162/202) of patients. High-dose spacers had a reduced risk of overall (OR, 0.37; P = 0.024) and infectious (OR, 0.35; P = 0.020) failure for infected primary arthroplasties, but not revisions. In multivariate analysis, vancomycin dose ≥2.0 g decreased the risk of infectious failure (OR, 0.31; P = 0.016), although not overall failure (OR, 0.51; P = 0.147). CONCLUSION During two-stage exchange for PJI, spacers with greater than 3.6 g of total antibiotic may reduce overall and infectious failure for infected primary arthroplasties. Furthermore, using at least 2.0 g of vancomycin could independently decrease the risk of infectious failure.
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Affiliation(s)
- Hunter S Warwick
- From the Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco, CA
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6
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Lunz A, Schonhoff M, Omlor GW, Knappe K, Bangert Y, Lehner B, Renkawitz T, Jaeger S. Enhanced antibiotic release from bone cement spacers utilizing dual antibiotic loading with elevated vancomycin concentrations in two-stage revision for periprosthetic joint infection. INTERNATIONAL ORTHOPAEDICS 2023; 47:2655-2661. [PMID: 37566227 PMCID: PMC10602962 DOI: 10.1007/s00264-023-05922-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Accepted: 08/01/2023] [Indexed: 08/12/2023]
Abstract
PURPOSE Antibiotic loaded bone cement spacers provide high local antibiotic concentrations, preserve bone stock, and reduce soft tissue contractions. The objective of this in-vitro study was to compare antibiotic release from spacers, aiming to discover the most optimal preparation and identify modifiable factors that can further enhance antibiotic release. METHODS Six distinct spacer preparation were created using three different bone cements and manual incorporation of antibiotics. During a six-week period, the release of antibiotics from each spacer was measured individually at ten predetermined time points using a chemiluminescent immunoassay. RESULTS Manually adding 4 g of vancomycin to every 40 g of "Palacos R + G" yielded the most favorable release profile. Throughout all preparations, antibiotic release consistently and significantly decreased over the six-week period. When incorporating a higher concentration of vancomycin, a significantly higher cumulative release of vancomycin was observed, with varying effects on the release of gentamicin. The choice of bone cement had a significant impact on antibiotic release. CONCLUSION To enhance antibiotic release from spacers, surgeons should manually incorporate high antibiotic concentrations into the most appropriate bone cement and keep the interim period as short as possible. Specifically, we suggest manual incorporation of 4 g of vancomycin to every 40 g of gentamicin premixed "Palacos R + G" to create bone cement spacers.
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Affiliation(s)
- Andre Lunz
- Department of Orthopaedics, Heidelberg University Hospital, Schlierbacher Landstr. 200a, 69118, Heidelberg, Germany.
| | - Mareike Schonhoff
- Laboratory of Biomechanics and Implant Research, Department of Orthopaedics, Heidelberg University Hospital, Schlierbacher Landstr. 200a, 69118, Heidelberg, Germany
| | - Georg W Omlor
- Center for Orthopedics and Joint Replacement, Marienhaus Hospital St. Wendel-Ottweiler, Am Hirschberg 1, 66606, St. Wendel, Germany
| | - Kevin Knappe
- Department of Orthopaedics, Heidelberg University Hospital, Schlierbacher Landstr. 200a, 69118, Heidelberg, Germany
| | - Yannic Bangert
- Department of Orthopaedics, Heidelberg University Hospital, Schlierbacher Landstr. 200a, 69118, Heidelberg, Germany
| | - Burkhard Lehner
- Department of Orthopaedics, Heidelberg University Hospital, Schlierbacher Landstr. 200a, 69118, Heidelberg, Germany
| | - Tobias Renkawitz
- Department of Orthopaedics, Heidelberg University Hospital, Schlierbacher Landstr. 200a, 69118, Heidelberg, Germany
| | - Sebastian Jaeger
- Laboratory of Biomechanics and Implant Research, Department of Orthopaedics, Heidelberg University Hospital, Schlierbacher Landstr. 200a, 69118, Heidelberg, Germany
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7
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Blersch BP, Barthels M, Schuster P, Fink B. A Low Rate of Periprosthetic Infections after Aseptic Knee Prosthesis Revision Using Dual-Antibiotic-Impregnated Bone Cement. Antibiotics (Basel) 2023; 12:1368. [PMID: 37760665 PMCID: PMC10525338 DOI: 10.3390/antibiotics12091368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Revised: 08/22/2023] [Accepted: 08/24/2023] [Indexed: 09/29/2023] Open
Abstract
AIM The incidence of periprosthetic joint infections (PJI) following aseptic knee revision arthroplasty lies between 3% and 7.5%. The aim of this study was to verify the hypothesis that the use of dual-antibiotic-impregnated cement in knee revision arthroplasty leads to a lower rate of periprosthetic joint infections. METHODS We retrospectively reviewed 403 aseptic revision knee arthroplasties performed between January 2013 and March 2021 (148 revisions of a unicompartmental prosthesis, 188 revisions of a bicondylar total knee arthroplasty (TKA), 41 revisions of an axis-guided prosthesis, and 26 revisions of only one component of a surface replacement prosthesis). The bone cement Copal G+C (Heraeus Medical, Wertheim, Germany) with two antibiotics-gentamycin and clindamycin-was used for the fixation of the new implant. The follow-up period was 53.4 ± 27.9 (4.0-115.0) months. RESULTS Five patients suffered from PJI within follow-up (1.2%). The revision rate for any reason was 8.7%. Survival for any reason was significantly different between the types of revision (p = 0.026, Log-Rank-test), with lower survival rates after more complex surgical procedures. The 5-year survival rate with regard to revision for any reason was 91.3% [88.2-94.4%] and with regard to revision for PJI 98.2% [98.7-99.9%], respectively. CONCLUSION The use of the dual-antibiotic-impregnated bone cement Copal G+C results in a lower rate of periprosthetic infections after aseptic knee prosthesis replacement than that reported in published prosthesis revisions using only one antibiotic in the bone cement.
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Affiliation(s)
- Benedikt Paul Blersch
- Department of Joint Replacement, General and Rheumatic Orthopaedics, Orthopaedic Clinic Markgröningen gGmbH, Kurt-Lindemann-Weg 10, 71706 Markgröningen, Germany; (B.P.B.); (M.B.); (P.S.)
| | - Michael Barthels
- Department of Joint Replacement, General and Rheumatic Orthopaedics, Orthopaedic Clinic Markgröningen gGmbH, Kurt-Lindemann-Weg 10, 71706 Markgröningen, Germany; (B.P.B.); (M.B.); (P.S.)
| | - Philipp Schuster
- Department of Joint Replacement, General and Rheumatic Orthopaedics, Orthopaedic Clinic Markgröningen gGmbH, Kurt-Lindemann-Weg 10, 71706 Markgröningen, Germany; (B.P.B.); (M.B.); (P.S.)
- Department of Orthopaedics and Traumatology, Paracelsus Medical University, Prof. Ernst Nathan Straße 1, 90419 Nuremberg, Germany
| | - Bernd Fink
- Department of Joint Replacement, General and Rheumatic Orthopaedics, Orthopaedic Clinic Markgröningen gGmbH, Kurt-Lindemann-Weg 10, 71706 Markgröningen, Germany; (B.P.B.); (M.B.); (P.S.)
- Orthopaedic Department, University Hospital Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany
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8
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Hollyer I, Ivanov D, Kappagoda S, Lowenberg DW, Goodman SB, Amanatullah DF. Selecting a high-dose antibiotic-laden cement knee spacer. J Orthop Res 2023; 41:1383-1396. [PMID: 37127938 DOI: 10.1002/jor.25570] [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: 03/14/2023] [Accepted: 04/17/2023] [Indexed: 05/03/2023]
Abstract
Prosthetic joint infection [PJI] after total knee arthroplasty (TKA) remains a common and challenging problem for joint replacement surgeons and patients. Once the diagnosis of PJI has been made, patient goals and characteristics as well as the infection timeline dictate treatment. Most commonly, this involves a two-stage procedure with the removal of all implants, debridement, and placement of a static or dynamic antibiotic spacer. Static spacers are commonly indicated for older, less healthy patients that would benefit from soft tissue rest after initial debridement. Mobile spacers are typically used in younger, healthier patients to improve quality of life and reduce soft-tissue contractures during antibiotic spacer treatment. Spacers are highly customizable with regard to antibiotic choice, cement variety, and spacer design, each with reported advantages, drawbacks, and indications that will be covered in this article. While no spacer is superior to any other, the modern arthroplasty surgeon must be familiar with the available modalities to optimize treatment for each patient. Here we propose a treatment algorithm to assist surgeons in deciding on treatment for PJI after TKA.
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Affiliation(s)
- Ian Hollyer
- Department of Orthopaedic Surgery, Stanford University, Redwood City, California, USA
| | - David Ivanov
- Department of Orthopaedic Surgery, Stanford University, Redwood City, California, USA
| | - Shanthi Kappagoda
- Division of Infectious Diseases and Geographic Medicine, Stanford Univeristy, Stanford, California, USA
| | - David W Lowenberg
- Department of Orthopaedic Surgery, Stanford University, Redwood City, California, USA
| | - Stuart B Goodman
- Department of Orthopaedic Surgery, Stanford University, Redwood City, California, USA
| | - Derek F Amanatullah
- Department of Orthopaedic Surgery, Stanford University, Redwood City, California, USA
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9
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Gil D, Hugard S, Borodinov N, Ovchinnikova OS, Muratoglu OK, Bedair H, Oral E. Dual-analgesic loaded UHMWPE exhibits synergistic antibacterial effects against Staphylococci. J Biomed Mater Res B Appl Biomater 2023; 111:912-922. [PMID: 36462210 DOI: 10.1002/jbm.b.35201] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 09/15/2022] [Accepted: 11/06/2022] [Indexed: 12/07/2022]
Abstract
Total joint arthroplasty is one of the most common surgeries in the United States, with almost a million procedures performed annually. Periprosthetic joint infections (PJI) remain the most devastating complications associated with total joint replacement. Effective antibacterial prophylaxis after primary arthroplasty could substantially reduce incidence rate of PJI. In the present study we propose to provide post-arthroplasty prophylaxis via dual-analgesic loaded ultra-high molecular weight polyethylene (UHMWPE). Our approach is based on previous studies that showed pronounced antibacterial activity of analgesic- and NSAID-loaded UHMWPE against Staphylococci. Here, we prepared bupivacaine/tolfenamic acid-loaded UHMWPE and assessed its antibacterial activity against Staphylococcus aureus and Staphylococcus epidermidis. Dual-drug loaded UHMWPE yielded an additional 1-2 log reduction of bacteria, when compared with single-drug loaded UHMWPE. Analysis of the drug elution kinetics suggested that the observed increase in antibacterial activity is due to the increased tolfenamic acid elution from dual-drug loaded UHMWPE. We showed that the increased fractal dimension of the drug domains in UHMWPE could be associated with increased drug elution, leading to higher antibacterial activity. Dual-analgesic loaded UHMWPE proposed here can be used as part of multi-modal antibacterial prophylaxis and promises substantial reduction in post-arthroplasty mortality and morbidity.
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Affiliation(s)
- Dmitry Gil
- Harris Orthopaedic Laboratory, Massachusetts General Hospital, Boston, Massachusetts, USA.,Department of Orthopaedic Surgery, Harvard Medical School, Harvard University, Boston, Massachusetts, USA
| | - Shannon Hugard
- Harris Orthopaedic Laboratory, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Nikolay Borodinov
- Center for Nanophase Materials Sciences, Oak Ridge National Laboratory, Oak Ridge, Tennessee, USA
| | - Olga S Ovchinnikova
- Center for Nanophase Materials Sciences, Oak Ridge National Laboratory, Oak Ridge, Tennessee, USA
| | - Orhun K Muratoglu
- Harris Orthopaedic Laboratory, Massachusetts General Hospital, Boston, Massachusetts, USA.,Department of Orthopaedic Surgery, Harvard Medical School, Harvard University, Boston, Massachusetts, USA
| | - Hany Bedair
- Harris Orthopaedic Laboratory, Massachusetts General Hospital, Boston, Massachusetts, USA.,Department of Orthopaedic Surgery, Harvard Medical School, Harvard University, Boston, Massachusetts, USA
| | - Ebru Oral
- Harris Orthopaedic Laboratory, Massachusetts General Hospital, Boston, Massachusetts, USA.,Department of Orthopaedic Surgery, Harvard Medical School, Harvard University, Boston, Massachusetts, USA
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10
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Zhao Z, Zhang Y, Cheng Y, Li J, Wang W, Huang S, Ma X, Zhang X. Thermosensitive Nanotherapeutics for Localized Photothermal Ablation of MRSA-Infected Osteomyelitis Combined with Chemotherapy. ACS APPLIED MATERIALS & INTERFACES 2023; 15:12842-12854. [PMID: 36862542 DOI: 10.1021/acsami.2c23312] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/18/2023]
Abstract
Chronic osteomyelitis is an inflammatory skeletal disease caused by a bacterial infection that affects the periosteum, bone, and bone marrow. Methicillin-resistant Staphylococcus aureus (MRSA) is the most common causative agent. The bacterial biofilm formed on the necrotic bone is a considerable challenge to treating MRSA-infected osteomyelitis. Here, we developed an all-in-one cationic thermosensitive nanotherapeutic (TLCA) for treating MRSA-infected osteomyelitis. The prepared TLCA particles were positively charged and <230 nm in size, which allowed them to diffuse effectively into the biofilm. The positive charges of the nanotherapeutic accurately targeted the biofilm, and it subsequently regulated the drug release under near-infrared (NIR) light irradiation, thereby efficiently exerting the synergistic effect of NIR light-driven photothermal sterilization and chemotherapy. More than 80% of the antibiotics were abruptly released at 50 °C, which dispersed the biofilm by up to 90%. When applied to MRSA-infected osteomyelitis, with a localized temperature of 50 °C induced by 808 nm laser irradiation, it not only eliminated the bacteria and controlled infection but also inhibited the bone tissue inflammatory response, significantly reducing TNF-α, IL-1β, and IL-6 levels. In conclusion, we constructed an all-in-one antimicrobial treatment modality that provides a new and effective strategy for the topical treatment of chronic osteomyelitis.
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Affiliation(s)
- Zhe Zhao
- Department of Orthopaedics, Tianjin Hospital, No. 406 Jiefangnan Road, Hexi District, Tianjin 300211, China
| | - Yufei Zhang
- Key Laboratory of Functional Polymer Materials of Ministry Education, Institute of Polymer Chemistry, College of Chemistry, Nankai University, Tianjin 300071, China
| | - Yijie Cheng
- Key Laboratory of Functional Polymer Materials of Ministry Education, Institute of Polymer Chemistry, College of Chemistry, Nankai University, Tianjin 300071, China
| | - Jie Li
- Key Laboratory of Functional Polymer Materials of Ministry Education, Institute of Polymer Chemistry, College of Chemistry, Nankai University, Tianjin 300071, China
| | - Wenbo Wang
- Key Laboratory of Functional Polymer Materials of Ministry Education, Institute of Polymer Chemistry, College of Chemistry, Nankai University, Tianjin 300071, China
| | - Siyuan Huang
- Key Laboratory of Functional Polymer Materials of Ministry Education, Institute of Polymer Chemistry, College of Chemistry, Nankai University, Tianjin 300071, China
| | - Xinlong Ma
- Department of Orthopaedics, Tianjin Hospital, No. 406 Jiefangnan Road, Hexi District, Tianjin 300211, China
| | - Xinge Zhang
- Key Laboratory of Functional Polymer Materials of Ministry Education, Institute of Polymer Chemistry, College of Chemistry, Nankai University, Tianjin 300071, China
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11
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Ziroglu N, Koluman A, Kaleci B, Tanriverdi B, Tanriverdi G, Kural A, Bilgili MG. The antibiotics supplemented bone cement improved the masquelet's induced membrane in a rat femur critical size defect model. Injury 2023; 54:329-338. [PMID: 36334950 DOI: 10.1016/j.injury.2022.10.027] [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: 07/19/2022] [Revised: 10/10/2022] [Accepted: 10/24/2022] [Indexed: 11/05/2022]
Abstract
BACKGROUND Masquelet technique is a two-stage surgical procedure used in the treatment of critical-size bone defects (CSD). Adding antibiotics to polymethylmethacrylate (PMMA) is still questionable to create higher quality induced membrane (IM). The aim of the study was to evaluate the effects of three antibiotic-supplemented cement, fusidic acid, teicoplanin, and gentamicin, on osteogenesis and IM progression applied to rat femur CSD model by comparing histopathological, biochemical, and immunohistochemical findings. METHODS Twenty-eight male rats were divided into four groups control, gentamicin (G), teicoplanin (T), and fusidic acid (FA). A 10 mm CSD was created in rat femurs. In the postoperative 4th week, intracardiac blood samples were collected for biochemical analysis of bone alkaline phosphatase (BALP), osteocalcin (OC), and tumor necrosis factor-alpha (TNF-α) levels. IMs obtained in secondary operation were fixed and prepared for histopathological scoring of membrane progression and immunohistochemical evaluation of rat-specific Transforming Growth Factor-Beta (TGF-β), Runt-related Transcription Factor 2 (Runx2), and Vascular Endothelial Growth Factor (VEGF) expressions. RESULTS Levels of BALP and OC in serum didn't change among groups significantly while serum TNF-α levels significantly decreased in all antibiotic groups compared to the control group (P = 0.017). Histological scores of groups FA and T were significantly higher than those of groups Control and G (P = 0.0007). IMs of groups T and FA showed good progression while those of groups Control and G were also moderately progressed. A significant increase in TGF-β expression was observed in group G and FA (P = 0.001) while a significant increase in the expression of VEGF was observed in groups G and T compared to the control group (P = 0.036). CONCLUSIONS The bone cement impregnated with thermostable and safe antibiotics, gentamicin, fusidic acid, and teicoplanin can increase osteogenesis and support IM progression by increasing the expressions of TGF-β and VEGF. Anabolic effects of induced membranes used in the treatment of critical-size bone defects can be enhanced by antibiotic-supplemented PMMAs applied by altering the original technique.
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Affiliation(s)
- Nezih Ziroglu
- Department of Orthopedics and Traumatology, Acibadem Mehmet Ali Aydinlar University School of Medicine, Acibadem Atakent Hospital, Kucukcekmece/Istanbul, Turkey.
| | - Alican Koluman
- Department of Orthopedics and Traumatology, Istanbul Bakirkoy Dr. Sadi Konuk Education and Research Hospital, University of Health Sciences, Istanbul, Turkey
| | - Belisa Kaleci
- Department of Histology and Embryology, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Bulent Tanriverdi
- Department of Orthopedics and Traumatology, Istanbul Bakirkoy Dr. Sadi Konuk Education and Research Hospital, University of Health Sciences, Istanbul, Turkey
| | - Gamze Tanriverdi
- Department of Histology and Embryology, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Alev Kural
- Department of Biochemistry, Istanbul Bakirkoy Dr. Sadi Konuk Training and Research Hospital, University of Health Sciences, Istanbul, Turkey
| | - Mustafa Gokhan Bilgili
- Department of Orthopedics and Traumatology, Istanbul Bakirkoy Dr. Sadi Konuk Education and Research Hospital, University of Health Sciences, Istanbul, Turkey
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12
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Antibiotic Spacers for Shoulder Periprosthetic Joint Infection: A Review. J Am Acad Orthop Surg 2022; 30:917-924. [PMID: 35452429 DOI: 10.5435/jaaos-d-21-00984] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Accepted: 03/20/2022] [Indexed: 02/01/2023] Open
Abstract
Periprosthetic joint infection is a rare but potentially devastating complication of shoulder arthroplasty. The most conservative treatment approach is a two-stage revision involving interval placement of an antibiotic cement spacer. The purpose of this study was to contextualize the use of antibiotic spacers in the current treatment paradigm of shoulder periprosthetic joint infection and to review the history of shoulder spacers, the different types (eg, stemmed versus stemless and prefabricated versus handmade), the antibiotic composition and dosage, and their efficacy and complications.
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Elhessy AH, Rivera JC, Shu HT, Andrews TJ, Herzenberg JE, Conway JD. Intramedullary Canal Injection of Vancomycin- and Tobramycin-loaded Calcium Sulfate: A Novel Technique for the Treatment of Chronic Intramedullary Osteomyelitis. Strategies Trauma Limb Reconstr 2022; 17:123-130. [PMID: 35990181 PMCID: PMC9357795 DOI: 10.5005/jp-journals-10080-1554] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Aim In this study, we present a detailed surgical technique for treating chronic osteomyelitis (COM) of the intramedullary canal with injectable tobramycin and vancomycin-loaded calcium sulfate (CS). Background Chronic osteomyelitis of the long bones has been treated using antibiotic-impregnated polymethyl methacrylate (PMMA), which typically requires a second procedure for removal. Technique Removal of the infected intramedullary nail (if any), copious irrigation, canal reaming, and intramedullary canal injection of vancomycin- and tobramycin-loaded calcium sulfate as a single-stage procedure for the treatment of COM of long bones. Conclusion Intramedullary injection of vancomycin- and tobramycin-loaded CS can be used as a single-stage procedure for the treatment of long bone intramedullary COM. Further studies are necessary to compare the long-term outcomes of antibiotic-coated CS vs other antibiotic carriers for infection eradication. Clinical significance The authors have endeavored to explain the best surgical technique to eradicate long bones COM with injectable tobramycin and vancomycin-loaded CS. How to cite this article Elhessy AH, Rivera JC, Shu HT, et al. Intramedullary Canal Injection of Vancomycin- and Tobramycin-loaded Calcium Sulfate: A Novel Technique for the Treatment of Chronic Intramedullary Osteomyelitis. Strategies Trauma Limb Reconstr 2022;17(2):123–130.
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Affiliation(s)
- Ahmed H Elhessy
- International Center for Limb Lengthening, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland, United States of America
| | - Jessica C Rivera
- International Center for Limb Lengthening, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland, United States of America; Louisiana State University Health Science Center, New Orleans, Louisiana, United States of America
| | - Henry T Shu
- Johns Hopkins University, School of Medicine, Baltimore, Maryland, United States of America
| | - Taj-Jamal Andrews
- Center for Joint Preservation and Replacement, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland, United States of America
| | - John E Herzenberg
- International Center for Limb Lengthening, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland, United States of America
| | - Janet D Conway
- International Center for Limb Lengthening, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland, United States of America
- Janet D Conway, International Center for Limb Lengthening, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland, United States of America, Phone: +410 6019562, e-mail:
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Antibiotic Cement Utilization for the Prophylaxis and Treatment of Infections in Spine Surgery: Basic Science Principles and Rationale for Clinical Use. J Clin Med 2022; 11:jcm11123481. [PMID: 35743551 PMCID: PMC9224689 DOI: 10.3390/jcm11123481] [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] [Subscribe] [Scholar Register] [Received: 05/22/2022] [Revised: 06/11/2022] [Accepted: 06/14/2022] [Indexed: 01/27/2023] Open
Abstract
Antibiotic bone cement (ABC) is an effective tool for the prophylaxis and treatment of osteomyelitis due to the controlled, sustained release of local antibiotics. ABC has been proven to be effective in the orthopedic fields of arthroplasty and extremity trauma, but the adoption of ABC in spine surgery is limited. The characteristics of ABC make it an optimal solution for treating vertebral osteomyelitis (VO), a serious complication following spine surgery, typically caused by bacterial and sometimes fungal and parasitic pathogens. VO can be devastating, as infection can result in pathogenic biofilms on instrumentation that is dangerous to remove. New techniques, such as kyphoplasty and novel vertebroplasty methods, could amplify the potential of ABC in spine surgery. However, caution should be exercised when using ABC as there is some evidence of toxicity to patients and surgeons, antibiotic allergies, bone cement structural impairment, and possible development of antibiotic resistance. The purpose of this article is to describe the basic science of antibiotic cement utilization and review its usage in spine surgery.
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15
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Stafford J, Hunter M, Judd H, Corces A. Utilizing a Prefabricated Antibiotic-Impregnated Articular Spacer Combined With an Intramedullary Device for Significant Femoral Bone Loss in Periprosthetic Hip Infection. Arthroplast Today 2022; 15:174-179. [PMID: 35620353 PMCID: PMC9126833 DOI: 10.1016/j.artd.2022.03.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Revised: 03/08/2022] [Accepted: 03/10/2022] [Indexed: 11/30/2022] Open
Abstract
Periprosthetic joint infection can be a devastating complication following total hip arthroplasty, which often requires a lengthy treatment course that is fraught with complications. There are various types of antibiotic-impregnated spacers that can be used to treat periprosthetic hip infections, with articulating spacers being utilized frequently with the goal of preserving patient range of motion and functionality. Many of these articulating spacers have pre-set sizes and stem options, which accommodate the majority of patients. However, when significant femoral bone loss is evident at the time of revision surgery, many articulating spacer options are not sufficient to provide stability, and custom modifications of available spacer constructs may be needed to fill the bony void. The goal of this article is to report a surgical technique that can be used in the salvage of failed antibiotic-impregnated spacers where severe femoral bone loss is present.
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Affiliation(s)
- Justin Stafford
- Corresponding author. Larkin Community Hospital, Department of Orthopaedic Surgery, South Miami, FL, USA. Tel.: +1 305 284 7500.
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16
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Mistry S, Roy R, Jha AK, Pandit N, Das S, Burman S, Joy M. Treatment of long bone infection by a biodegradable bone cement releasing antibiotics in human. J Control Release 2022; 346:180-192. [PMID: 35447299 DOI: 10.1016/j.jconrel.2022.04.018] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Revised: 03/30/2022] [Accepted: 04/11/2022] [Indexed: 11/15/2022]
Abstract
Repair of methicillin-resistant Staphylococcal (MRSA) chronic osteomyelitis and resulting bone defect is one of the major challenges in orthopaedics. Previous study has shown the effectiveness of antibiotic loaded biodegradable composite bone cement with in vitro tests and in the treatment of experimental osteomyelitis. The cement is composed of poly(lactide-co-glycolide) encapsulated antibiotic-biphasic calcium phosphate granule complex and additive antibiotic powder in gypsum binder. In this study, the cement was studied further to evaluate its in vitro biological properties (cytocompatibility, platelet activation), anti-infective, and bone regenerative potential in comparison to poly(methyl methacrylate) (PMMA) cement and parenteral therapy in 43 patients (age 5-57 years) with chronic MRSA osteomyelitis by analyzing the results of histopathology, radiographs, magnetic resonance imaging, scanning electron microscopy, and serum drug concentrations for 1 year. The composite cement showed superior cytocompatibility and coagulant activity compared to PMMA cement. Moreover, the results of different postoperative clinical and radiological examinations also proved the supremacy of composite cement over the other treatment modalities in terms of success rate, faster sepsis control and bone regeneration. Low serum antibiotic concentrations and normal serum calcium levels indicate that the calcium-rich composite cement is safe for application in human. Therefore, we conclude that the composite bone cement is a promising candidate for the treatment of chronic osteomyelitis.
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Affiliation(s)
- Surajit Mistry
- Department of Periodontics, Burdwan Dental College & Hospital, Powerhouse Para, West Bengal 713101, India.
| | - Rajiv Roy
- Department of Orthopaedics, Calcutta National Medical College & Hospital, Kolkata, West Bengal 700014, India
| | - Amit Kumar Jha
- Department of Orthopaedics, Apex Hospital, Varanasi, Uttar Pradesh 221004, India
| | - Narayan Pandit
- Department of Radiodiagnosis, North Bengal Medical College & Hospital, Siliguri, West Bengal 734012, India
| | - Sabyasachi Das
- Department of Anaesthesiology, Medical College Kolkata, 88-College Street, Kolkata, West Bengal 700073, India
| | - Subhasish Burman
- Department of Oral & Maxillofacial Surgery, Burdwan Dental College & Hospital, Powerhouse Para, West Bengal 713101, India
| | - Mathew Joy
- Department of Chemistry, T.I.M.E., Erode, Tamil Nadu 638003, India
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17
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A comparison of low-dose teicoplanin-loaded spacer application vs. high-dose vancomycin-and-gentamicin-loaded spacer application in the treatment of periprosthetic knee infection. JOURNAL OF ORTHOPAEDICS, TRAUMA AND REHABILITATION 2022. [DOI: 10.1177/22104917221082312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background/purpose In the current study, our aim was to compare the efficacy and biocompatibility of teicoplanin-loaded and vancomycin-and-gentamicin-loaded articulating spacers used in two-stage revision arthroplasty for eradication of periprosthetic knee joint infection. Methods In the current retrospective cohort study, there were 24 patients who were given 2 g or less antibiotics per 40 g of cement in the low-dose teicoplanin group, and 20 patients who were given a total of 3.6 g or more antibiotics per 40 g of cement in the high-dose vancomycin and gentamicin group. Two groups were compared statistically. Results There was no statistically significant difference in the treatment failure between the two groups (p = 0.488). No statistically significant differences were found in spacer fracture rates between the two groups (p = 0.802). Conclusion The current study has demonstrated that low-dose teicoplanin protocol is as effective and safe as high-dose vancomycin and gentamycin protocol.
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18
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Pargas CD, Elhessy AH, Abouei M, Gesheff MG, Conway JD. Tobramycin Blood Levels after Local Antibiotic Treatment of Bone and Soft Tissue Infection. Antibiotics (Basel) 2022; 11:antibiotics11030336. [PMID: 35326799 PMCID: PMC8944707 DOI: 10.3390/antibiotics11030336] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 02/24/2022] [Accepted: 02/28/2022] [Indexed: 02/04/2023] Open
Abstract
Local antibiotic delivery using different carriers plays an important role in both infection prophylaxis and treatment. Besides dead space management, these carriers have the advantage of providing a high concentration of local antibiotics with a lower risk of systemic toxicity. Few studies have reported on systemic toxicity associated with antibiotic-impregnated carriers. The present study investigates the systemic tobramycin concentration at 24, 48 and 72 h postoperatively after using tobramycin-loaded polymethyl methacrylate (PMMA) and calcium sulfate (CS) as local antibiotic carriers. Additionally, this work assesses the renal function postoperatively for indications of acute kidney injury (AKI). Fifty-two patients were treated in 58 procedures with tobramycin and vancomycin-loaded PMMA, CS, or both. All systemic tobramycin levels were <2 mcg/mL at 72 h, and the resulting rate of AKI was 12% (7/58). In conclusion, local tobramycin antibiotic delivery using PMMA, CS, or both remains a safe and effective modality in the treatment of osteomyelitis as long as the surgeon is aware of its possible nephrotoxic effect.
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19
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Borick JJ, Balan S, Lichtenberger P, Bjork L. Timely explantation of tobramycin-impregnated beads and bone cement to avoid haemodialysis in a patient with worsening renal failure. BMJ Case Rep 2022; 15:e242760. [PMID: 35131767 PMCID: PMC8823038 DOI: 10.1136/bcr-2021-242760] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/31/2021] [Indexed: 11/03/2022] Open
Abstract
A male patient with right total knee arthroplasty complicated by prosthetic joint infection on intravenous antimicrobials developed an acute kidney injury (AKI) with creatinine up to 7.3 mg/dL ('normal' range (0.5-1.2 mg/dL)) after hardware removal and tobramycin loaded polymethylmethacrylate beads and spacer placement. The AKI was initially attributed to intravenous vancomycin. Despite discontinuing vancomycin, the AKI worsened. A tobramycin level was collected and resulted at 5.5 µg/mL. Due to high suspicion for aminoglycoside-induced renal toxicity and to prevent haemodialysis, the antibiotic cement spacer with tobramycin-impregnated beads was removed. After the removal, tobramycin level rapidly decreased and renal functions improved. AKI is an increasingly recognised complication related to antibiotic-loaded bone cement (ALBC) due to the systemic absorption of antibiotics. With this case we highlight the early recognition of ALBC-induced renal toxicity necessitating explantation of ALBC and beads in order to prevent haemodialysis and emphasise monitoring aminoglycoside levels in the early postoperative period.
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Affiliation(s)
- Joseph Jeffry Borick
- Infectious Disease, University of Miami Miller School of Medicine, Miami, Florida, USA
- Infectious Disease, Jackson Memorial Hospital, Miami, Florida, USA
- Infectious Disease, VA Medical Center, Miami, Florida, USA
| | - Shuba Balan
- Infectious Disease, University of Miami Miller School of Medicine, Miami, Florida, USA
- Infectious Disease, Jackson Memorial Hospital, Miami, Florida, USA
- Infectious Disease, VA Medical Center, Miami, Florida, USA
| | - Paola Lichtenberger
- Infectious Disease, University of Miami Miller School of Medicine, Miami, Florida, USA
- Infectious Disease, VA Medical Center, Miami, Florida, USA
| | - Lauren Bjork
- Clinical Pharmacy, VA Medical Center Miami, Miami, Florida, USA
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20
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Nishino T, Oshima T, Teramura S, Taniguchi Y, Kanamori A, Mishima H, Yamazaki M. Development of a Self-made Cement Bead Maker and Its Clinical Application for the Treatment of Periprosthetic Joint Infection. Arthroplast Today 2022; 13:188-193. [PMID: 35118182 PMCID: PMC8792394 DOI: 10.1016/j.artd.2021.10.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Revised: 10/16/2021] [Accepted: 10/31/2021] [Indexed: 11/29/2022] Open
Abstract
Antibiotic-loaded acrylic cement beads have a large surface area and excellent sustained-release properties. However, there are some difficulty manufacturing reasonably sized beads and their careful handling. We developed a self-made cement bead maker using a mold of a sphere with a diameter of 8 and 10 mm with a 2-mm-diameter connecting hole. With this instrument, approximately 32 beads can be made from 40 g of bone cement. We clinically applied this technique to 11 cases of periprosthetic joint infection. There was no recurrence of infection noted. The advantages of this device were that it was possible to adjust the combination of antimicrobial agents and that the shape was uniform and easy to handle during surgery.
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Affiliation(s)
- Tomofumi Nishino
- Department of Orthopaedic Surgery, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
- Corresponding author. 1-1-1 Tennodai, Tsukuba, Ibaraki, 305-8575, Japan. Tel.: +81-29-853-3219.
| | | | - Shin Teramura
- Department of Orthopaedic Surgery, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Yu Taniguchi
- Department of Orthopaedic Surgery, Ichihara Hospital, Tsukuba, Ibaraki, Japan
| | - Akihiro Kanamori
- Department of Orthopaedic Surgery, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Hajime Mishima
- Department of Orthopaedic Surgery, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Masashi Yamazaki
- Department of Orthopaedic Surgery, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
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21
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Samelis PV, Papagrigorakis E, Sameli E, Mavrogenis A, Savvidou O, Koulouvaris P. Current Concepts on the Application, Pharmacokinetics and Complications of Antibiotic-Loaded Cement Spacers in the Treatment of Prosthetic Joint Infections. Cureus 2022; 14:e20968. [PMID: 35154947 PMCID: PMC8815820 DOI: 10.7759/cureus.20968] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/04/2022] [Indexed: 01/15/2023] Open
Abstract
Prosthetic joint infection (PJI) is a devastating complication of total joint replacement surgery. It affects about 2% of primary total joint replacements. Treatment aims at infection eradication and restoration of patient's mobility. Two-stage revision arthroplasty with an interim application of an antibiotic-loaded cement spacer (ALCS) is the widely accepted treatment for PJI. Spacers are powerful local carriers of antibiotics at the site of infection, effective against biofilm-protected microbes. On the other hand, spacers permit some mobility of the patient and facilitate final prosthesis implantation. ALCS's are either commercially available or prepared intraoperatively on prefabricated or improvised molds. Antibiotic elution from the spacer depends on the amount of the antibiotic used for cement impregnation, at the expense of mechanical stiffness of the spacer. The antibiotic should not exceed 4g per 40g of bone cement to preserve the mechanical properties of the cement. Spacers are frequently accompanied by local or systemic complications. The spacer may break, dislocate and compress vessels or nerves of the limb. Systemic complications are the result of excess elution of antibiotic and include nephrotoxicity, hepatotoxicity, ototoxicity, allergic reactions or neutropenia. Elderly patients with comorbidities are at risk to present such complications. Microbial resistance is a potential risk of long-lasting spacer retention. Persisting infection may require multiple spacer replacements.
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22
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Ismat A, Walter N, Baertl S, Mika J, Lang S, Kerschbaum M, Alt V, Rupp M. Antibiotic cement coating in orthopedic surgery: a systematic review of reported clinical techniques. J Orthop Traumatol 2021; 22:56. [PMID: 34940945 PMCID: PMC8702599 DOI: 10.1186/s10195-021-00614-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Accepted: 11/17/2021] [Indexed: 11/30/2022] Open
Abstract
Background Antibiotic-containing cement and bone graft substitute-coated orthopedic implants provide the advantages of simultaneous local antibiotic delivery and internal stable fixation, aiding in both infection eradication and osseous healing. Standardized protocols pertaining to implant coating techniques in various clinical and particularly intraoperative settings are scarce, and available literature is limited. This systematic review aims to provide a summary of the available current literature reporting on custom-made coating techniques of orthopedic implants, indications, outcomes, and associated complications in clinical use. Methods A systematic search of the literature in PubMed, Medline, Embase, and Cochrane Library databases was performed in accordance with PRISMA guidelines. Articles reporting specifically on custom-made coating techniques of orthopedic implants in a clinical setting were eligible. Results A total of 41 articles with a cumulative total number of 607 cases were included. Indications for treatment mostly involved intramedullary infections after previous plate osteosynthesis or nailing. A variety of implants ranging from intramedullary nails, plates, wires, and rods served as metal cores for coating. Polymethylmethacrylate (PMMA) bone cement was most commonly used, with vancomycin as the most frequently added antibiotic additive. Chest tubes and silicone tubes were most often used to mold. Common complications are cement debonding and breakage of the metallic implant. Conclusion Adequate coating techniques can reduce the burden of treatment and be associated with favorable outcomes. Lack of general consensus and heterogeneity in the reported literature indicate that the perfect all-in-one implant coating method is yet to be found. Further efforts to improve implant coating techniques are warranted. Level of evidence III.
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Affiliation(s)
- Abdullah Ismat
- Department of Trauma Surgery, University Medical Center Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Germany
| | - Nike Walter
- Department of Trauma Surgery, University Medical Center Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Germany
| | - Susanne Baertl
- Department of Trauma Surgery, University Medical Center Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Germany
| | - Joerg Mika
- Experimental Rheumatology Unit, Department of Orthopedics, Jena University Hospital, Waldkliniken Eisenberg GmbH, Klosterlausnitzer Strasse 81, 07607, Eisenberg, Germany
| | - Siegmund Lang
- Department of Trauma Surgery, University Medical Center Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Germany
| | - Maximilian Kerschbaum
- Department of Trauma Surgery, University Medical Center Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Germany
| | - Volker Alt
- Department of Trauma Surgery, University Medical Center Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Germany
| | - Markus Rupp
- Department of Trauma Surgery, University Medical Center Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Germany.
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23
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Hoshino T, Watanabe T, Nakagawa Y, Katagiri H, Ozeki N, Ohara T, Shioda M, Kono Y, Sekiya I, Koga H. Clinical outcomes of two-stage revision total knee arthroplasty in infected cases with antibiotic-loaded cement spacers produced using a handmade silicone mold. Knee Surg Relat Res 2021; 33:27. [PMID: 34454632 PMCID: PMC8400397 DOI: 10.1186/s43019-021-00113-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Accepted: 08/05/2021] [Indexed: 01/04/2023] Open
Abstract
Purpose This study assessed the clinical outcomes of periprosthetic joint infection patients who underwent two-stage revision total knee arthroplasty with antibiotic-loaded cement spacers fabricated using a handmade silicone mold. Materials and methods This study included seven patients (average age 77 years, average follow-up time 54 months) who underwent surgery at our hospital between 2009 and 2013. Clinical outcomes including knee scores, function scores, knee range of motion, and walking ability at the final observation, period from the primary total knee arthroplasty to implant removal, period from implant removal to revision total knee arthroplasty, and follow-up period after revision total knee arthroplasty were investigated. Results At the final follow-up, the average knee range of motion was 99°, with no significant differences at each stage; average knee and function scores were 84 and 77, respectively. With cement spacers, five patients were able to walk with a t-cane. No recurrence of infection was observed. Conclusions The clinical outcomes of the current case series demonstrated good knee function with preserved walking ability, without any recurrence of periprosthetic joint infection. This study suggests that using a handmade silicone mold could be an effective option for periprosthetic joint infection after a total knee arthroplasty.
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Affiliation(s)
- Takashi Hoshino
- Department of Orthopaedic Surgery, Tokyo Medical and Dental University Hospital of Medicine, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan.,Department of Joint Surgery and Sports Medicine, Graduate School, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan
| | - Toshifumi Watanabe
- Department of Joint Surgery and Sports Medicine, Graduate School, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan. .,Second Department of Orthopaedic Surgery, Dokkyo Medical University Saitama Medical Center, 2-1-50 Minami-Koshigaya, Koshigaya-shi, Saitama, 343-8555, Japan.
| | - Yusuke Nakagawa
- Department of Orthopaedic Surgery, Tokyo Medical and Dental University Hospital of Medicine, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan.,Department of Joint Surgery and Sports Medicine, Graduate School, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan
| | - Hiroki Katagiri
- Department of Joint Surgery and Sports Medicine, Graduate School, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan.,Second Department of Orthopaedic Surgery, Dokkyo Medical University Saitama Medical Center, 2-1-50 Minami-Koshigaya, Koshigaya-shi, Saitama, 343-8555, Japan
| | - Nobutake Ozeki
- Department of Orthopaedic Surgery, Tokyo Medical and Dental University Hospital of Medicine, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan
| | - Toshiyuki Ohara
- Department of Orthopaedic Surgery, Tokyo Medical and Dental University Hospital of Medicine, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan
| | - Mikio Shioda
- Department of Orthopaedic Surgery, Tokyo Medical and Dental University Hospital of Medicine, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan
| | - Yuji Kono
- Department of Orthopaedic Surgery, Tokyo Medical and Dental University Hospital of Medicine, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan
| | - Ichiro Sekiya
- Department of Orthopaedic Surgery, Tokyo Medical and Dental University Hospital of Medicine, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan
| | - Hideyuki Koga
- Department of Orthopaedic Surgery, Tokyo Medical and Dental University Hospital of Medicine, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan.,Department of Joint Surgery and Sports Medicine, Graduate School, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan
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24
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Amerstorfer F, Schober M, Valentin T, Klim S, Leithner A, Fischerauer S, Glehr M. Risk of reinfection after two- or multiple-stage knee revision surgery using superficial vancomycin coating and conventional spacers. J Orthop Res 2021; 39:1700-1709. [PMID: 33118642 PMCID: PMC8451795 DOI: 10.1002/jor.24892] [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: 03/23/2020] [Revised: 10/06/2020] [Accepted: 10/21/2020] [Indexed: 02/04/2023]
Abstract
This study investigates the effect of superficial vancomycin coating (SVC) in two- or more-stage exchange procedures of prosthetic knee joint infections. We hypothesized that spacer treatment with SVC result in lower reinfection rates than conventional spacers after prosthetic reimplantation. Our secondary aim was to determine the demographic and treatment factors associated with reinfection rates. This retrospective cohort study compromised 96 cases with prosthetic knee infections. Twenty-four cases were treated with a temporary SVC spacer and 72 cases with conventional spacers. Prosthetic reinfection occurred after a median observation period of 1.7 ± 4.0 years in 24 cases (25%). The prevalence of having a reinfection was not significantly different between the two treatment groups (13% [3 cases] in the SVC group vs. 29% [21 cases] in the conventional spacer group [p = .104]). In seven cases (7.3%), two in the SVC group (8.3%) and five (6.9%) in the conventional spacer group (p ≥ .999), histological, respectively microbiological evaluations from the intraoperative specimens revealed persistent infection at the second stage. Nevertheless, in all seven cases no significant higher risk of periprosthetic reinfection was observed during follow-up (p = .750). Our secondary investigation of cofactors revealed that spacers additionally stabilized by nails were significantly associated with a 3.9-fold higher hazard ratio of sustaining a reinfection of revision prosthesis (p = .005).
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Affiliation(s)
| | - Martina Schober
- Department of Orthopedics and TraumaHospital St. Josef BraunauBraunau am InnAustria
| | - Thomas Valentin
- Section of Infectious Diseases and Tropical Medicine, Department of Internal MedicineMedical University of GrazGrazAustria
| | - Sebastian Klim
- Department of Orthopedics and TraumaMedical University of GrazGrazAustria
| | - Andreas Leithner
- Department of Orthopedics and TraumaMedical University of GrazGrazAustria
| | - Stefan Fischerauer
- Department of Orthopedics and TraumaMedical University of GrazGrazAustria
| | - Mathias Glehr
- Department of Orthopedics and TraumaMedical University of GrazGrazAustria
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Labmayr V, Lerchbaumer MH, Kuehn KD, Kittinger C, Amerstorfer F, Leithner A, Glehr M. Comparison of elution characteristics and mechanical properties of acrylic bone cements with and without superficial vancomycin coating (SVC) in the late phase of polymerization. Orthop Traumatol Surg Res 2021; 107:102908. [PMID: 33789200 DOI: 10.1016/j.otsr.2021.102908] [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: 04/23/2020] [Revised: 01/11/2021] [Accepted: 01/13/2021] [Indexed: 02/03/2023]
Abstract
INTRODUCTION Antibiotic-loaded bone cements (ALBCs) are used as spacers in two-stage revision arthroplasty for periprosthetic joint infection. We previously described a new technique applying vancomycin powder coating to custom-made cements. To our best knowledge, this method of superficial vancomycin coating (SVC) has not been assessed before. We therefore performed an in-vitro study to determine: (1) whether manually applied SVC strengthened the cements' antibiotic effect; and (2) whether the mechanical requirements for the cements were fulfilled. HYPOTHESIS SVC increases the antibiotic effect of cement within the first 24hours. METHODS Cuboid blocks were produced from two commercially available acrylic ALBCs (Palacos R+G and Copal G+V) with and without SVC. Each block was eluted in phosphate-buffered saline at 37°C. Eluates obtained at 1, 2, 3, 4, 5, 10, 15, 30 and 60minutes and 3, 6 and 24hours were evaluated against Staphylococcus aureus (Palacos, Copal) and methicillin-resistant Staphylococcus aureus (MRSA) (Copal) using zone of inhibition tests. Mechanical test results (bending modulus, bending strength) were compared to ISO requirements (≥1800MPa, ≥50MPa). RESULTS Palacos with SVC produced significantly greater zones of inhibition against Staphylococcus aureus than Palacos without SVC (p=0.002). Copal with SVC showed greater zones of inhibition against both Staphylococcus aureus and MRSA (p=0.002). The antibiotic effect was enhanced by SVC in both cements at every time point within 24hours. The bending modulus and bending strength of Palacos with SVC (2089±166MPa, 60.8±2.6 MPA) and Copal with SVC (2283±195MPa, 56.9±2.4MPa) were significantly above ISO requirements. CONCLUSION SVC boosts the antibiotic effect of ALBCs in the first 24hours, while maintaining sufficient stability. These findings endorse SVC as a promising additive in septic revision surgery. LEVEL OF EVIDENCE III; case control study.
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Affiliation(s)
- Viktor Labmayr
- Department of Orthopaedics and Trauma, Medical University of Graz, Auenbruggerplatz 5, 8036 Graz, Austria.
| | - Markus H Lerchbaumer
- Department of Radiology, Charité-Universitaetsmedizin Berlin, 10117 Berlin, Germany
| | - Klaus-Dieter Kuehn
- Department of Orthopaedics and Trauma, Medical University of Graz, Auenbruggerplatz 5, 8036 Graz, Austria
| | - Clemens Kittinger
- Institute of Hygiene, Microbiology and Environmental Medicine, Medical University of Graz, Neue Stiftingtalstrasse 2, 8010 Graz, Austria
| | - Florian Amerstorfer
- Department of Orthopaedics and Trauma, Medical University of Graz, Auenbruggerplatz 5, 8036 Graz, Austria
| | - Andreas Leithner
- Department of Orthopaedics and Trauma, Medical University of Graz, Auenbruggerplatz 5, 8036 Graz, Austria
| | - Mathias Glehr
- Department of Orthopaedics and Trauma, Medical University of Graz, Auenbruggerplatz 5, 8036 Graz, Austria
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Kulkarni GS, Kulkarni S, Babhulkar S. Cement beads and cement spacers: indications, techniques, and clinical results. OTA Int 2021; 4:e118(1-6). [PMID: 37609476 PMCID: PMC10441671 DOI: 10.1097/oi9.0000000000000118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Accepted: 12/22/2020] [Indexed: 08/24/2023]
Abstract
Objectives To report our experience on the use of antibiotic coated nails (ACN) and cement beads for the management of bone infections. Materials and methods Infected nonunion (INU) cases were classified as: Type I (mild infection with no gap), Type II (moderate with good alignment, severe infection, gap <3 cm, no deformity), Type III (severe infection with gap ≥3 cm, deformity and limb shortening). Treatment involved either the insertion of ACN and cast (Type I), insertion of ACN, beads and external fixator (Type II), or Ilizarov methodology (Type III). A subset of 28 open fractures were admitted with severe contamination or delayed presentation with established infection and treated with debridement, ACN insertion, and antibiotic beads placed in soft tissue dead space areas. Results Results of 133 cases were classified excellent, good, and poor. Type I INU reported 40 excellent and 22 good results. Type II INU reported 28 (39%) excellent, 30 (43%) good, and 13 (18%) poor results. Poor results were due to uncontrolled infection and knee stiffness. Three patients required knee fusion and 1 required amputation. Fracture union was reported in 68 cases. Four of the 28 Gustilo grade III open fractures treated with ACN developed infected nonunion and had poor function caused by stiff knees. Conclusions An antibiotic impregnated cement nail (ACN) fills the dead space and elutes high concentrations of antibiotics providing some mechanical stability. We recommend the adjunct use of an ACN for the management of INU cases and for use in select cases of Gustilo grade III open fractures.
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Affiliation(s)
| | - Sunil Kulkarni
- GSKs Fracture and Orthopedic Hospital, PG Institute of Swasthiyog Pratishthan, Miraj
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Liu JZ, Crist BD. Coated nails: is their use supported by the literature? OTA Int 2021; 4:e110(1-4). [PMID: 37609482 PMCID: PMC10441681 DOI: 10.1097/oi9.0000000000000110] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Revised: 11/05/2020] [Accepted: 12/11/2020] [Indexed: 08/24/2023]
Abstract
Antibiotic-coated intramedullary nails have been popularized in recent decades for treating long-bone infections. They are especially useful in treating diaphyseal infections requiring stability, such as those involving fractures and nonunions. The nails are made by injecting antibiotic-impregnated polymethylmethacrylate or "cement" around a metal core using a silicone tube as a mold. There are a variety of techniques that can be used to customize the nail to the affected site. Antibiotic cement has long been demonstrated as an effective local antibiotic delivery system. It is able to elute high concentrations of antibiotics while having little systemic toxicity. Several case series have reported good outcomes using this technique, defined by bone union and infection control. Further research is needed to determine the amount of weight that can safely be transferred through the nail and to optimize antibiotic elution.
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Affiliation(s)
- Jane Z Liu
- Department of Orthopaedic Surgery, University of Missouri, Columbia, MO
| | - Brett D Crist
- Department of Orthopaedic Surgery, University of Missouri, Columbia, MO
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Nagy M, Jakaraddi C, Neal T, Jackson R, Navin A, Davidson JS, Santini AJA. In vitro elution characteristics of gentamicin- and teicoplanin-loaded CMW1 and Palacos R bone cement. J Orthop 2021; 25:75-81. [PMID: 33935435 DOI: 10.1016/j.jor.2021.03.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Accepted: 03/28/2021] [Indexed: 10/21/2022] Open
Abstract
Purpose To compare the in vitro elution characteristics of CMW1 and Palacos R bone cement loaded with gentamicin, teicoplanin, or in combination. Methods Four bone cement discs were prepared for each cement type. Disc 1 contained no antibiotics; disc 2 contained 0.5 g gentamicin; disc 3 contained 2 g teicoplanin; disc 4 contained 0.5 g gentamicin and 2 g teicoplanin. Elution studies were conducted using a fluorescence polarisation immunoassay technique and performed at intervals of 6 weeks. Results For CMW1, gentamicin and teicoplanin elution levels in combination discs were higher than those in the single antibiotic discs (p < 0.001 & p < 0.06). For Palacos R, gentamicin elution levels in combination discs were higher than those in the single antibiotic discs (p < 0.001), but teicoplanin elution levels in combination discs were lesser than that from the single antibiotic discs (p < 0.02). In single and combination discs, gentamicin elution levels in Palacos R were higher than those in CMW1 (p < 0.001 & p < 0.001). Palacos R eluted more teicoplanin than CMW1, except in combined disc with gentamicin, when less teicoplanin was eluted. Conclusion Antibiotic elution is higher in Palacos R than CMW1. Antibiotic combination in both cement types has the synergistic effect of increasing antibiotic elution, except for teicoplanin from Palacos R. When high elution of gentamicin is required, Palacos R is preferable. When high elution of teicoplanin is required, Palacos R with only teicoplanin is superior to CMW1.
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Affiliation(s)
- M Nagy
- Lower Limb Arthroplasty Unit, Department of Trauma and Orthopaedic Surgery, Liverpool University Hospitals, Liverpool, UK
| | - C Jakaraddi
- Lower Limb Arthroplasty Unit, Department of Trauma and Orthopaedic Surgery, Liverpool University Hospitals, Liverpool, UK
| | - T Neal
- Department of Microbiology, Liverpool University Hospitals, Liverpool, UK
| | - R Jackson
- Liverpool Cancer Trial Centre, Statistical Department, University of Liverpool, UK
| | - A Navin
- Lower Limb Arthroplasty Unit, Department of Trauma and Orthopaedic Surgery, Liverpool University Hospitals, Liverpool, UK
| | - J S Davidson
- Lower Limb Arthroplasty Unit, Department of Trauma and Orthopaedic Surgery, Liverpool University Hospitals, Liverpool, UK
| | - A J A Santini
- Lower Limb Arthroplasty Unit, Department of Trauma and Orthopaedic Surgery, Liverpool University Hospitals, Liverpool, UK.,Faculty of Health and Life Sciences, University of Liverpool, UK
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Ren EJ, Guardia A, Shi T, Begeman P, Ren W, Vaidya R. A distinctive release profile of vancomycin and tobramycin from a new and injectable polymeric dicalcium phosphate dehydrate cement (P-DCPD). Biomed Mater 2021; 16:025019. [PMID: 33361554 DOI: 10.1088/1748-605x/abd689] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
A novel injectable polymeric dicalcium phosphate dehydrate (P-DCPD) cement was developed with superior mechanical strength and excellent cohesion. The purpose of this study was to assess the in vitro performance of P-DCPD loaded with vancomycin (VAN-P), tobramycin (TOB-P) and combination of both (VAN/TOB-P) (10%, w/w). There is a distinctive release profile between VAN and TOB. VAN-P showed decreased initial burst (<30% within 3 d) and sustained VAN release (76% in 28 d). In the presence of TOB (VAN/TOB-P), >90% of VAN was released within 3 d (p < 0.05). Slow and limited TOB release was observed both in TOB-P (<5%) and in TOB/VAN-P (<1%) over 28 d. Zone of inhibition (ZOI) of Staphylococcus aureus growth showed that eluents collected from VAN-P had stronger and longer ZOI (28 d) than that from TOB-P (14 d, p < 0.05). Direct contact of VAN-P, TOB-P and VAN/TOB-P cements displayed persistent and strong ZOI for >3 weeks. Interestingly, the cement residues (28 d after drug release) still maintained strong ZOI ability. P-DCPD with or without antibiotics loading were nontoxic and had no inferior impacts on the growth of osteoblastic MC3T3 cells. VAN-P and TOB-P were injectable. No significant influence on setting time was observed in both VAN-P (11.7 ± 1.9 min) and VAN/TOB-P (10.8 ± 1.5 min) as compared to control (12.2 ± 2.6 min). We propose that a distinctive release profile of VAN and TOB observed is mainly due to different distribution pattern of VAN and TOB within P-DCPD matrix. A limited release of TOB might be due to the incorporation of TOB inside the crystalline lattice of P-DCPD crystals. Our data supported that the bactericidal efficacy of antibiotics-loaded P-DCPD is not only depend on the amount and velocity of antibiotics released, but also probably more on the direct contact of attached bacteria on the degrading cement surface.
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Affiliation(s)
- E J Ren
- Department of Orthopaedic Surgery, Detroit Medical Center, Detroit, MI 48201, United States of America
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Wall V, Nguyen TH, Nguyen N, Tran PA. Controlling Antibiotic Release from Polymethylmethacrylate Bone Cement. Biomedicines 2021; 9:26. [PMID: 33401484 PMCID: PMC7824110 DOI: 10.3390/biomedicines9010026] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Revised: 12/26/2020] [Accepted: 12/29/2020] [Indexed: 12/20/2022] Open
Abstract
Bone cement is used as a mortar for securing bone implants, as bone void fillers or as spacers in orthopaedic surgery. Antibiotic-loaded bone cements (ALBCs) have been used to prevent and treat prosthetic joint infections by providing a high antibiotic concentration around the implanted prosthesis. High antibiotic concentrations are, on the other hand, often associated with tissue toxicity. Controlling antibiotic release from ALBCS is key to achieving effective infection control and promoting prosthesis integration with the surrounding bone tissue. However, current ALBCs still need significant improvement in regulating antibiotic release. In this review, we first provide a brief introduction to prosthetic joint infections, and the background concepts of therapeutic efficacy and toxicity in antibiotics. We then review the current state of ALBCs and their release characteristics before focusing on the research and development in controlling the antibiotic release and osteo-conductivity/inductivity. We then conclude by a discussion on the need for better in vitro experiment designs such that the release results can be extrapolated to predict better the local antibiotic concentrations in vivo.
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Affiliation(s)
- Victoria Wall
- Faculty of Medicine (Princess Alexandra Hospital), St Lucia Campus, The University of Queensland, Brisbane, QLD 4072, Australia;
- Interface Science and Materials Engineering Group, School of Mechanical, Medical and Process Engineering, Queensland University of Technology (QUT), 2 George Street, Brisbane, QLD 4000, Australia
| | - Thi-Hiep Nguyen
- Tissue Engineering and Regenerative Medicine Department, School of Biomedical Engineering, International University, Ho Chi Minh City 70000, Vietnam; (T.-H.N.); (N.N.)
- Vietnam National University, Ho Chi Minh City 70000, Vietnam
| | - Nghi Nguyen
- Tissue Engineering and Regenerative Medicine Department, School of Biomedical Engineering, International University, Ho Chi Minh City 70000, Vietnam; (T.-H.N.); (N.N.)
- Vietnam National University, Ho Chi Minh City 70000, Vietnam
| | - Phong A. Tran
- Interface Science and Materials Engineering Group, School of Mechanical, Medical and Process Engineering, Queensland University of Technology (QUT), 2 George Street, Brisbane, QLD 4000, Australia
- Centre for Biomedical Technologies, Queensland University of Technology (QUT), 2 George Street, Brisbane, QLD 4000, Australia
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Systems for local, sustained release of zoledronic acid as a potential treatment for metastatic bone disease. MATERIALS SCIENCE & ENGINEERING. C, MATERIALS FOR BIOLOGICAL APPLICATIONS 2021; 118:111395. [DOI: 10.1016/j.msec.2020.111395] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Revised: 07/22/2020] [Accepted: 08/17/2020] [Indexed: 01/31/2023]
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Affiliation(s)
- René A Monzón
- Adult Reconstruction, Department of Orthopaedics, University of California-Davis Medical Center, Sacramento, California
| | - John G Coury
- Department of Orthopaedic Surgery, Doctors Medical Center, Valley Consortium for Medical Education, Modesto, California
| | - Gregory D Disse
- Adult Reconstruction, Department of Orthopaedics, University of California-Davis Medical Center, Sacramento, California
| | - Zachary C Lum
- Adult Reconstruction, Department of Orthopaedics, University of California-Davis Medical Center, Sacramento, California
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Sandiford NA. Complication rates are low with the use of Stimulan calcium sulphate based antibiotic delivery system in the management of patients with hip-related PJI: early results of a consecutive case series. Hip Int 2020; 30:3-6. [PMID: 32907427 DOI: 10.1177/1120700020925093] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Effective management of prosthetic joint infection (PJI) requires prolonged, sustained delivery of antibiotics to the effective joint space. Calcium sulphate antibiotic delivery systems have been used in this setting, however, potentially serious complications including symptomatic hypercalcaemia have been described. There is relatively little prospective data on the results with the use of these compounds. METHODS A prospective study was performed between October 2016 and June 2018. 29 patients who underwent revision total hip arthroplasty (THA) for confirmed PJI were treated with Stimulan calcium sulphate antibiotic delivery system. Laboratory blood tests including serum calcium levels, C-reactive protein (CRP) and white cell count (WBC) were monitored for 6 weeks post-surgery. Wounds were assessed for discharge and radiographs for dissolution and for signs of heterotopic ossification. RESULTS The mean age was 67 years and mean ASA score III. There was no significant increase between the preoperative serum calcium and those at 2 and 6 weeks. The CRP and white cell count were significantly reduced at 6 weeks. Full dissolution occurred by 6 weeks post-op. 1 patient (3.4%) had a prolonged wound discharge. CONCLUSIONS Stimulan is a valid option for management of patients with PJI following total hip arthroplasty. Complication rates are low following its use.
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Affiliation(s)
- N Amir Sandiford
- Joint Reconstruction Unit, Southland Hospital, Invercargill, New Zealand.,Work carried out at St. George's Hospital, London, UK
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Lawrie CM, Jo S, Barrack T, Roper S, Wright RW, Nunley RM, Barrack RL. Local delivery of tobramycin and vancomycin in primary total knee arthroplasty achieves minimum inhibitory concentrations for common bacteria causing acute prosthetic joint infection. Bone Joint J 2020; 102-B:163-169. [PMID: 32475280 DOI: 10.1302/0301-620x.102b6.bjj-2019-1639.r1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
AIMS The aim of this study was to determine if the local delivery of vancomycin and tobramycin in primary total knee arthroplasty (TKA) can achieve intra-articular concentrations exceeding the minimum inhibitory concentration thresholds for bacteria causing acute prosthetic joint infection (PJI). METHODS Using a retrospective single-institution database of all primary TKAs performed between January 1 2014 and May 7 2019, we identified patients with acute PJI that were managed surgically within 90 days of the initial procedure. The organisms from positive cultures obtained at the time of revision were tested for susceptibility to gentamicin, tobramycin, and vancomycin. A prospective study was then performed to determine the intra-articular antibiotic concentration on postoperative day one after primary TKA using one of five local antibiotic delivery strategies with tobramycin and/or vancomycin mixed into the polymethylmethacrylate (PMMA) or vancomycin powder. RESULTS A total of 19 patients with acute PJI after TKA were identified and 29 unique bacterial isolates were recovered. The mean time to revision was 37 days (6 to 84). Nine isolates (31%) were resistant to gentamicin, ten (34%) were resistant to tobramycin, and seven (24%) were resistant to vancomycin. Excluding one Fusobacterium nucleatum, which was resistant to all three antibiotics, all isolates resistant to tobramycin or gentamicin were susceptible to vancomycin and vice versa. Overall, 2.4 g of tobramycin hand-mixed into 80 g of PMMA and 1 g of intra-articular vancomycin powder consistently achieved concentrations above the minimum inhibitory concentrations of susceptible organisms. CONCLUSION One-third of bacteria causing acute PJI after primary TKA were resistant to the aminoglycosides commonly mixed into PMMA, and one-quarter were resistant to vancomycin. With one exception, all bacteria resistant to tobramycin were susceptible to vancomycin and vice versa. Based on these results, the optimal cover for organisms causing most cases of acute PJI after TKA can be achieved with a combination of tobramycin mixed in antibiotic cement, and vancomycin powder. Cite this article: Bone Joint J 2020;102-B(6 Supple A):163-169.
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Affiliation(s)
- Charles M Lawrie
- Department of Orthopedic Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Sally Jo
- Department of Orthopedic Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Toby Barrack
- Department of Orthopedic Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Stephen Roper
- Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Rick W Wright
- Department of Orthopaedics and Rehabilitation, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Ryan M Nunley
- Department of Orthopedic Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Robert L Barrack
- Department of Orthopedic Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
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Ramey WL, von Glinski A, Jack A, Blecher R, Oskouian RJ, Chapman JR. Antibiotic-impregnated polymethylmethacrylate strut graft as a treatment of spinal osteomyelitis: case series and description of novel technique. J Neurosurg Spine 2020; 33:415-420. [PMID: 32384277 DOI: 10.3171/2020.3.spine191313] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Accepted: 03/06/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The surgical treatment of osteomyelitis and discitis of the spine often represents a challenging clinical entity for a multitude of reasons, including progression of infection despite debridement, development of spinal deformity and instability, bony destruction, and seeding of hardware. Despite advancement in spinal hardware and implantation techniques, these aforementioned challenges not uncommonly result in treatment failure, especially in instances of heavy disease burden with enough bony endplate destruction as to not allow support of a modern titanium cage implant. While antibiotic-infused polymethylmethacrylate (aPMMA) has been used in orthopedic surgery in joints of the extremities, its use has not been extensively described in the spine literature. Herein, the authors describe for the first time a series of patients treated with a novel surgical technique for the treatment of spinal osteomyelitis and discitis using aPMMA strut grafts with posterior segmental fusion. METHODS Over the course of 3 years, all patients with spinal osteomyelitis and discitis at a single institution were identified and included in the retrospective cohort if they were surgically treated with spinal fusion and implantation of an aPMMA strut graft at the nidus of infection. Basic demographics, surgical techniques, levels treated, complications, and return to the operating room for removal of the aPMMA strut graft and placement of a traditional cage were examined. The surgical technique consisted of performing a discectomy and/or corpectomy at the level of osteomyelitis and discitis followed by placement of aPMMA impregnated with vancomycin and/or tobramycin into the cavity. Depending on the patient's condition during follow-up and other deciding clinical and radiographic factors, the patient may return to the operating room nonurgently for removal of the PMMA spacer and implantation of a permanent cage with allograft to ultimately promote fusion. RESULTS Fifteen patients were identified who were treated with an aPMMA strut graft for spinal osteomyelitis and discitis. Of these, 9 patients returned to the operating room for aPMMA strut graft removal and insertion of a cage with allograft at an average of 19 weeks following the index procedure. The most common infections were methicillin-sensitive Staphylococcus aureus (n = 6) and methicillin-resistant S. aureus (n = 5). There were 13 lumbosacral infections and 1 each of cervical and thoracic infection. Eleven patients were cured of their infection, while 2 had recurrence of their infection; 2 patients were lost to follow-up. Three patients required unplanned return trips to the operating room, two of which were for wound complications, with the third being for recurrent infection. CONCLUSIONS In cases of severe infection with considerable bony destruction, insertion of an aPMMA strut graft is a novel technique that should be considered in order to provide strong anterior-column support while directly delivering antibiotics to the infection bed. While the active infection is being treated medically, this structural aPMMA support bridges the time it takes for the patient to be converted from a catabolic to an anabolic state, when it is ultimately safe to perform a definitive, curative fusion surgery.
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Affiliation(s)
- Wyatt L Ramey
- 1Swedish Neuroscience Institute, Swedish Medical Center, Seattle
| | - Alexander von Glinski
- 1Swedish Neuroscience Institute, Swedish Medical Center, Seattle
- 2Seattle Science Foundation, Seattle, Washington
- 3Department of Trauma Surgery, BG University Hospital Bergmannsheil, Ruhr University Bochum, Germany; and
- 4Hansjoerg Wyss Hip and Pelvic Center, Swedish Hospital, Seattle, Washington
| | - Andrew Jack
- 1Swedish Neuroscience Institute, Swedish Medical Center, Seattle
| | - Ronen Blecher
- 1Swedish Neuroscience Institute, Swedish Medical Center, Seattle
| | - Rod J Oskouian
- 1Swedish Neuroscience Institute, Swedish Medical Center, Seattle
- 2Seattle Science Foundation, Seattle, Washington
| | - Jens R Chapman
- 1Swedish Neuroscience Institute, Swedish Medical Center, Seattle
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Kilinç S, Pazarci Ö, Keklikcioğlu Çakmak N, Taş A. Does the Addition of Poly(glycolide-co-lactide) to Teicoplanin-Containing Poly(methyl methacrylate) Beads Change the Elution Characteristics? Indian J Orthop 2020; 54:71-75. [PMID: 32952912 PMCID: PMC7474036 DOI: 10.1007/s43465-020-00116-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Accepted: 04/10/2020] [Indexed: 02/04/2023]
Abstract
BACKGROUND The objective of our study was to measure and compare the elution characteristics of teicoplanin from poly(methyl methacrylate) PMMA beads with those of poly(glycolide-co-lactide) PGLA-added beads. METHODS The study included two groups of PMMA + teicoplanin beads. PMMA was added to teicoplanin in Group 1 and PMMA + PGLA was added to teicoplanin in Group 2. A total of 16 beads of 1 cm3 were created for each group. Samples were added individually to tubes containing 3 ml of phosphate-buffered saline (PBS). Antibiotic elution was measured by measuring absorbance values of 1-ml samples taken at regular intervals using a UV-Vis spectrophotometer and cumulative percentages of drug release were calculated. In addition, the spectra of teicoplanin were identified using a FTIR spectrophotometer in a wavelength range of 400-4000 cm-1. RESULTS Drug elution in the PBS medium was measured and compared for Groups 1 and 2. The cumulative percentage of drug release from the PGLA-added beads (Group 2) was significantly higher (p = 0.01). The molecular structure of teicoplanin was also confirmed using FTIR. CONCLUSION The in vitro results showed that the addition of biodegradable PGLA into bone cement functions as a water-soluble porogen which allows for significant increases in the elution of teicoplanin from cement. This increase in elution suggests that the PGLA would allow for further fluid contact and exchange with the previously entrapped drug. These results may have important clinical applications.
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Affiliation(s)
- Seyran Kilinç
- Department of Orthopedics and Traumatology, Faculty of Medicine, Sivas Cumhuriyet University, 58140 Sivas, Turkey
| | - Özhan Pazarci
- Department of Orthopedics and Traumatology, Faculty of Medicine, Sivas Cumhuriyet University, 58140 Sivas, Turkey
| | - Neşe Keklikcioğlu Çakmak
- Department of Chemical Engineering, Faculty of Engineering, Sivas Cumhuriyet University, 58140 Sivas, Turkey
| | - Ayça Taş
- Department of Nutrition and Dietetics, Faculty of Health Sciences, Sivas Cumhuriyet University, Sivas, Turkey
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Zamani N, Sharath SE, Barshes NR, Braun JD, Kougias P. Long-term outcomes of lower extremity graft preservation using antibiotic beads in patients with early deep wound infections after major arterial reconstructions. J Vasc Surg 2020; 71:1315-1321. [DOI: 10.1016/j.jvs.2019.06.192] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2018] [Accepted: 06/02/2019] [Indexed: 11/26/2022]
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Effects of Sterilization Techniques on Bioactivity of Polymethyl Methacrylate Antibiotic Beads Containing Vancomycin and Tobramycin. J Orthop Trauma 2020; 34:e109-e113. [PMID: 32195891 DOI: 10.1097/bot.0000000000001729] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES Prefabrication and storage of antibiotic beads may decrease surgical time and allow for use in other settings. This study investigated the effects of sterilization technique and storage time on the bioactivity of antibiotic polymethyl methacrylate (PMMA) beads. METHODS Uniform beads of PMMA containing 1 g each of tobramycin and vancomycin were sterilized using autoclave, ethylene oxide (ETO), or ultraviolet (UV) light. Beads were made in a sterile fashion as a control. Disks containing eluted antibiotics from each of the 4 groups were placed onto agar plates inoculated with Staphylococcus aureus. Zones of inhibition, a measure of bioactivity for antibiotic eluted, were determined for the experimental groups and control. Repeat testing was performed for beads stored for 1 week, 1, 3, and 6 months. RESULTS Beads sterilized using autoclave, ETO, and UV light showed similar ZOIs after 24 hours of and 1 week of elution compared with the control group. Beads stored for up to 6 months demonstrated similar bioactivity to beads made sterile and tested immediately. CONCLUSION PMMA beads containing vancomycin and tobramycin made in a sterile fashion and stored for up to 6 months have the same efficacy as the current standard of beads made sterile and used immediately. The elution and bioactivity of vancomycin-tobramycin antibiotic beads are not negatively impacted by the sterilization methods of autoclaving, ETO gas, or UV light. Furthermore, nonsterile beads can be sterilized and stored up to 6 months with an expected efficacy comparable with beads made in a standard sterile fashion.
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Mohamed NS, Wilkie WA, Remily EA, Nace J, Delanois RE, Browne JA. Antibiotic Choice: The Synergistic Effect of Single vs Dual Antibiotics. J Arthroplasty 2020; 35:S19-S23. [PMID: 32046825 DOI: 10.1016/j.arth.2019.11.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Revised: 11/01/2019] [Accepted: 11/03/2019] [Indexed: 02/01/2023] Open
Abstract
INTRODUCTION This review summarizes single vs dual antibiotic cement literature, evaluating for synergistic activity with dual antibiotics. METHODS A systematic review was performed for literature regarding dual antibiotics in cement, identifying 13 studies to include for review. RESULTS Many in vitro studies reported higher elution from cement and/or improved bacteria inhibition with dual antibiotics, typically at higher dosages with a manual mixing technique. Limited clinical data from hip hemiarthroplasties and spacers demonstrated that dual antibiotics were associated with improved infection prevention and higher intra-articular antibiotic concentrations. CONCLUSION In addition to broader pathogen coverage, several studies document synergy of elution and increased antibacterial activity when dual antibiotics are added to cement. Limited clinical evidence suggests that dual antibiotic cement may be associated with reduced infection rates.
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Affiliation(s)
- Nequesha S Mohamed
- Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital, Baltimore, MD
| | - Wayne A Wilkie
- Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital, Baltimore, MD
| | - Ethan A Remily
- Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital, Baltimore, MD
| | - James Nace
- Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital, Baltimore, MD
| | - Ronald E Delanois
- Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital, Baltimore, MD
| | - James A Browne
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, VA
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Kildow BJ, Della-Valle CJ, Springer BD. Single vs 2-Stage Revision for the Treatment of Periprosthetic Joint Infection. J Arthroplasty 2020; 35:S24-S30. [PMID: 32046827 DOI: 10.1016/j.arth.2019.10.051] [Citation(s) in RCA: 52] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Revised: 10/27/2019] [Accepted: 10/27/2019] [Indexed: 02/01/2023] Open
Abstract
Periprosthetic joint infection (PJI) is one of the most devastating complications following total joint arthroplasty, accounting for a projected 10,000 revision surgeries per year by 2030. Chronic PJI is complicated by the presence of bacterial biofilm, requiring removal of components, thorough debridement, and administration of antibiotics for effective eradication. Chronic PJI is currently managed with single-stage or 2-stage revision surgery. To date, there are no randomized, prospective studies available evaluating eradication rates and functional outcomes between the 2 techniques. In this review, both treatment options are described with the most current literature to guide effective surgical decision-making that is cost-effective while decreasing patient morbidity.
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Affiliation(s)
- Beau J Kildow
- OrthoCarolina Hip and Knee Center, Charlotte, North Carolina
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Zhang B, Braun BM, Skelly JD, Ayers DC, Song J. Significant Suppression of Staphylococcus aureus Colonization on Intramedullary Ti6Al4V Implants Surface-Grafted with Vancomycin-Bearing Polymer Brushes. ACS APPLIED MATERIALS & INTERFACES 2019; 11:28641-28647. [PMID: 31313901 PMCID: PMC8086729 DOI: 10.1021/acsami.9b07648] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
Orthopedic implant-associated bacterial infection presents a major health threat due to tendency for periprosthetic bacterial colonization/biofilm formation that protects bacteria from host immune response and conventional antibiotic treatment. Using surface-initiated atom transfer radical polymerization and copper-catalyzed azide-alkyne cycloaddition (CuAAC), alkynylated vancomycin is conjugated to azido-functionalized side chains of polymethacrylates grafted from Ti6Al4V. High-efficiency CuAAC across the substrate is confirmed by complete surface conversion of azides by X-ray photoelectron spectroscopy (XPS) and elemental mapping of changing characteristic elements. The vancomycin-modified surface (Ti-pVAN) significantly reduces in vitro adhesion and colonization of Staphylococcus aureus (S. aureus), a main bacterial pathogen responsible for periprosthetic infection and osteomyelitis, compared to untreated Ti6Al4V, supporting retained antibacterial properties of the covalently conjugated antibiotics. When the surface-modified intramedullary Ti-pVAN pins are inserted into mouse femoral canals infected by bioluminescent Xen29 S. aureus, significantly reduced local bioluminescence along with mitigated blood markers for infection are detected compared to untreated Ti6Al4V pins over 21 days. Ti-pVAN pins retrieved after 21 days are confirmed with ∼20-fold reduction in adherent bacteria counts compared to untreated control, supporting the ability of surface-conjugated vancomycin in inhibiting periprosthetic S. aureus adhesion and colonization.
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Li T, Fu L, Wang J, Shi Z. High dose of vancomycin plus gentamicin incorporated acrylic bone cement decreased the elution of vancomycin. Infect Drug Resist 2019; 12:2191-2199. [PMID: 31410038 PMCID: PMC6645360 DOI: 10.2147/idr.s203740] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Accepted: 07/03/2019] [Indexed: 12/23/2022] Open
Abstract
Purpose Low doses of vancomycin and gentamicin were commonly incorporated into acrylic bone cement (antibiotic-impregnated bone cement, AIBC) during revision arthroplasty. Previous studies showed that only a very small amount of antibiotics could be eluted from AIBC. Given the fact that a high dose of antibiotic would elute high concentration of antibiotic, this study investigated the influence of a high dose of dual-antibiotic loading on the properties of cement. Methods A total of 8 groups of AIBC containing either gentamicin or vancomycin or both with different amounts of antibiotics (1 g, 2 g and 4 g) were tested on material properties, elution profiles, antibacterial activity and cytological toxicity. Results A high dose of gentamicin and vancomycin AIBC (with 2 g gentamicin and 2 g vancomycin loaded) regiment showed acceptable compressive strength of 74.25±0.72 MPa. No cytotoxicity or antibacterial activity reduction was observed in any group tested in this study. The elution profiles indicated that incorporating 2 g vancomycin resulted in 4.77% (1049.57±3.74 μg) released after 28 days. However, after 2 g gentamicin was added, the vancomycin released was significantly reduced to 2.42% (532.24±1.77 μg) (p<0.001), approximately 50% reduction. No significant influence of vancomycin on gentamicin was observed. Conclusion These findings suggest that the addition of 2 g vancomycin and 2 g gentamicin into acrylic bone cement was preferred while considering this dual-antibiotic AIBC regiment with acceptably material properties and effective antibacterial activity. However, special attention should be drawn to the reduction of vancomycin elution when incorporated with gentamicin.
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Affiliation(s)
- Tao Li
- Department of Orthopedics, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, People's Republic of China
| | - Lilan Fu
- Nanfang PET Center, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, People's Republic of China
| | - Jian Wang
- Department of Orthopedics, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, People's Republic of China
| | - Zhanjun Shi
- Department of Orthopedics, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, People's Republic of China
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Abstract
Infection after fracture fixation is a feared complication in orthopaedic surgery leading to poor bone healing and loss of function.Early detection is essential and interdisciplinary care is mandatory.Eradication of infection is only possible through combined surgical and antibiotic treatment.Intraoperative tissue samples must be taken and are effective for guidance of the antibiotic regimen.Infection after fracture fixation is different from prosthetic joint infection (PJI) and needs a specific strategy.In this review, we define infection after fracture fixation, and outline the clinical, radiological and laboratory signs of these infections, as well as a treatment algorithm for optimal patient care. Cite this article: EFORT Open Rev 2019;4:468-475. DOI: 10.1302/2058-5241.4.180093.
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Affiliation(s)
- Sylvain Steinmetz
- Service of Orthopaedics and Traumatology, Lausanne University Hospital, Lausanne, Switzerland
| | - Diane Wernly
- Service of Orthopaedics and Traumatology, Lausanne University Hospital, Lausanne, Switzerland
| | - Kevin Moerenhout
- Service of Orthopaedics and Traumatology, Lausanne University Hospital, Lausanne, Switzerland
| | - Andrej Trampuz
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Center for Musculoskeletal Surgery (CMSC), Berlin, Germany
| | - Olivier Borens
- Service of Orthopaedics and Traumatology, Lausanne University Hospital, Lausanne, Switzerland
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Shakked R, Da Rin de Lorenzo F. What Determines the Type and Dose of Antibiotic That Is Needed to Be Added to the Cement Spacer in Patients With Infected Total Ankle Arthroplasty (TAA)? Foot Ankle Int 2019; 40:48S-52S. [PMID: 31322933 DOI: 10.1177/1071100719861098] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
RECOMMENDATION We recommend tailoring the antibiotic in cement spacers to the infecting organism if it has been identified, as is typically done in total knee and hip arthroplasty. Otherwise, broad-spectrum antibiotics may be utilized. Medical comorbidities should always be considered, especially with regard to renal function and allergy profile. A thermostable antibiotic should be added to cement. LEVEL OF EVIDENCE Consensus. DELEGATE VOTE Agree: 100%, Disagree: 0%, Abstain: 0% (Unanimous, Strongest Consensus).
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Implant Fixation and Risk of Prosthetic Joint Infection Following Primary Total Hip Replacement: Meta-Analysis of Observational Cohort and Randomised Intervention Studies. J Clin Med 2019; 8:jcm8050722. [PMID: 31117318 PMCID: PMC6571822 DOI: 10.3390/jcm8050722] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Revised: 05/11/2019] [Accepted: 05/16/2019] [Indexed: 12/31/2022] Open
Abstract
Prosthetic joint infection (PJI), although uncommon, is a dreaded and devastating complication of total hip replacement (THR). Whether implant-related factors, such as the fixation method, influences the risk of PJI following THR is contentious. We conducted a systematic review and meta-analysis to evaluate the body of evidence linking fixation methods (cemented, uncemented, hybrid, or reverse hybrid) with the risk of PJI following primary THR. Observational studies and randomised controlled trials (RCTs) comparing fixation methods, and reporting PJI incidence following THR, were identified through MEDLINE, Embase, Web of Science, Cochrane Library, and reference lists of relevant studies up to 24 April 2019. Summary measures were relative risks (RRs) (95% confidence intervals, CIs). We identified 22 eligible articles (based on 11 distinct observational cohort studies comprising 2,260,428 THRs and 4 RCTs comprising 945 THRs). In pooled analyses of observational studies, all cemented fixations (plain and antibiotic combined), plain cemented fixations, hybrid fixations, and reverse hybrid fixations were each associated with an increased overall PJI risk when compared with uncemented fixations: 1.10 (95% CI: 1.04–1.17), 1.50 (95% CI: 1.27–1.77), 1.49 (95% CI: 1.36–1.64), and 1.49 (95% CI: 1.14–1.95), respectively. However, in the first six months, uncemented fixations were associated with increased PJI risk when compared to all cemented fixations. Compared to antibiotic-loaded cemented fixations, plain cemented fixations were associated with an increased PJI risk (1.52; 95% CI: 1.36–1.70). One RCT showed an increased PJI risk comparing plain cemented fixations with antibiotic-loaded cemented fixations. Uncemented and antibiotic-loaded cemented fixations remain options for the prevention of PJI in primary THR.
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Haseeb A, Ajit Singh V, Teh CSJ, Loke MF. Addition of ceftaroline fosamil or vancomycin to PMMA: An in vitro comparison of biomechanical properties and anti-MRSA efficacy. J Orthop Surg (Hong Kong) 2019; 27:2309499019850324. [PMID: 31138005 DOI: 10.1177/2309499019850324] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Ceftaroline is a cephalosporin that is effective against methicillin-resistant Staphylococcus aureus (MRSA) infections. The objective of this study was to determine the feasibility of using ceftaroline-loaded Polymethyl methacrylate (PMMA) as antibiotic cement against MRSA versus vancomycin-loaded PMMA in an in vitro setting. METHODS PMMA pellets were prepared with three separate concentrations of each of the two antibiotics tested. They were tested to determine the effect of increasing concentration of antibiotics on the biomechanical properties of PMMA and antibiotic activity by measuring the zone of inhibition and broth elution assay. RESULTS Ceftaroline PMMA at 3 wt%, three-point bending was 37.17 ± 0.51 N ( p < 0.001) and axial loading was 41.95 N ± 0.51 ( p < 0.001). At 5-wt% vancomycin-PMMA, three-point bending was 41.65 ± 0.79 N ( p = 0.02) and axial loading was 49.49 ± 2.21 N ( p = 0.01). Stiffness of ceftroline-loaded PMMA in low and medium concentration was significantly higher than the vancomycin. The zone of inhibition for ceftaroline was higher than vancomycin. Ceftaroline at 3 wt% eluted up to 6 weeks (0.3 ± 0.1 μg/ml) above the minimum inhibitory concentration (MIC) and vancomycin at 2.5 wt% eluted up to 3 weeks, same as MIC, that is, 0.5 ± 0.0 μg/ml. CONCLUSIONS Ceftaroline, loaded at similar concentrations as vancomycin into PMMA, is a more potent alternative based on its more favourable bioactivity and elution properties, while having a lesser effect on the mechanical properties of the cement. The use of 3-wt% ceftaroline as antibiotic laden PMMA against MRSA is recommended. It should be noted that this was an in vitro study and to determine the clinical efficacy would need prospective, controlled and randomized studies.
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Affiliation(s)
- Amber Haseeb
- 1 Department of Orthopaedic Surgery, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Vivek Ajit Singh
- 1 Department of Orthopaedic Surgery, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Cindy Shuan Ju Teh
- 2 Department of Medical Microbiology, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Mun Fai Loke
- 2 Department of Medical Microbiology, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
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Barger J, Fragomen AT, Rozbruch SR. Antibiotic-Coated Interlocking Intramedullary Nail for the Treatment of Long-Bone Osteomyelitis. JBJS Rev 2019; 5:e5. [PMID: 28719401 DOI: 10.2106/jbjs.rvw.16.00095] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Affiliation(s)
- James Barger
- Limb Lengthening and Complex Reconstruction Service, Hospital for Special Surgery, New York, NY
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Trombetta RP, Ninomiya MJ, El-Atawneh IM, Knapp EK, de Mesy Bentley KL, Dunman PM, Schwarz EM, Kates SL, Awad HA. Calcium Phosphate Spacers for the Local Delivery of Sitafloxacin and Rifampin to Treat Orthopedic Infections: Efficacy and Proof of Concept in a Mouse Model of Single-Stage Revision of Device-Associated Osteomyelitis. Pharmaceutics 2019; 11:E94. [PMID: 30813284 PMCID: PMC6410209 DOI: 10.3390/pharmaceutics11020094] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Revised: 02/12/2019] [Accepted: 02/17/2019] [Indexed: 12/15/2022] Open
Abstract
Osteomyelitis is a chronic bone infection that is often treated with adjuvant antibiotic-impregnated poly(methyl methacrylate) (PMMA) cement spacers in multi-staged revisions. However, failure rates remain substantial due to recurrence of infection, which is attributed to the poor performance of the PMMA cement as a drug release device. Hence, the objective of this study was to design and evaluate a bioresorbable calcium phosphate scaffold (CaPS) for sustained antimicrobial drug release and investigate its efficacy in a murine model of femoral implant-associated osteomyelitis. Incorporating rifampin and sitafloxacin, which are effective against bacterial phenotypes responsible for bacterial persistence, into 3D-printed CaPS coated with poly(lactic co-glycolic) acid, achieved controlled release for up to two weeks. Implantation into the murine infection model resulted in decreased bacterial colonization rates at 3- and 10-weeks post-revision for the 3D printed CaPS in comparison to gentamicin-laden PMMA. Furthermore, a significant increase in bone formation was observed for 3D printed CaPS incorporated with rifampin at 3 and 10 weeks. The results of this study demonstrate that osteoconductive 3D printed CaPS incorporated with antimicrobials demonstrate more efficacious bacterial colonization outcomes and bone growth in a single-stage revision in comparison to gentamicin-laden PMMA requiring a two-stage revision.
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Affiliation(s)
- Ryan P Trombetta
- Department of Biomedical Engineering, University of Rochester, Rochester, NY 14642, USA.
- Center for Musculoskeletal Research, University of Rochester, Rochester, NY 14642, USA.
| | - Mark J Ninomiya
- Center for Musculoskeletal Research, University of Rochester, Rochester, NY 14642, USA.
- Department of Microbiology and Immunology, University of Rochester, Rochester, NY 14642, USA.
| | - Ihab M El-Atawneh
- Department of Biomedical Engineering, University of Rochester, Rochester, NY 14642, USA.
- Center for Musculoskeletal Research, University of Rochester, Rochester, NY 14642, USA.
| | - Emma K Knapp
- Center for Musculoskeletal Research, University of Rochester, Rochester, NY 14642, USA.
- Department of Orthopedics, University of Rochester Medical Center, Rochester, NY 14642, USA.
| | - Karen L de Mesy Bentley
- Center for Musculoskeletal Research, University of Rochester, Rochester, NY 14642, USA.
- Department of Pathology & Laboratory Medicine, University of Rochester, Rochester, NY 14642, USA.
- Department of Orthopedics, University of Rochester Medical Center, Rochester, NY 14642, USA.
| | - Paul M Dunman
- Department of Microbiology and Immunology, University of Rochester, Rochester, NY 14642, USA.
| | - Edward M Schwarz
- Department of Biomedical Engineering, University of Rochester, Rochester, NY 14642, USA.
- Center for Musculoskeletal Research, University of Rochester, Rochester, NY 14642, USA.
- Department of Pathology & Laboratory Medicine, University of Rochester, Rochester, NY 14642, USA.
- Department of Orthopedics, University of Rochester Medical Center, Rochester, NY 14642, USA.
| | - Stephen L Kates
- Center for Musculoskeletal Research, University of Rochester, Rochester, NY 14642, USA.
- Department of Orthopaedic Surgery, Virginia Commonwealth University School of Medicine, Richmond, VA 0153, USA.
| | - Hani A Awad
- Department of Biomedical Engineering, University of Rochester, Rochester, NY 14642, USA.
- Center for Musculoskeletal Research, University of Rochester, Rochester, NY 14642, USA.
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Sautet P, Mékidèche T, Guilhaumou R, Abdel MP, Argenson JN, Parratte S, Ollivier M. Vancomycin elution kinetics from porous tantalum metal. J Orthop Res 2019; 37:308-312. [PMID: 30325073 DOI: 10.1002/jor.24160] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2018] [Accepted: 10/03/2018] [Indexed: 02/04/2023]
Abstract
Revisions TKAs are being completed with uncemented constructs more frequently. We hypothesized that tantalum cones could be an efficient carrier of antibiotics in uncemented procedures. We aimed to compare the release of vancomycin between (i) tantalum and smooth stainless cylinders; (ii) different concentrations of vancomycin; and (iii) different durations of bathing. Specifically designed tantalum cylinders were bathed in a vancomycin solution with various durations of baths. We investigated rinses between each interval as well as the dose of vancomycin. Vancomycin concentrations were determined in each group by fluorescence polarization immunoassay at different intervals (1 h, days 1, 2, 3, 5). At 1 h, the mean vancomycin concentration for the 1-hour soaking group was 3,172 μg/ml, whereas mean concentration for the smooth stainless steel group was 39.37 μg/ml (p < 0.001). The rinsing group showed a significantly lower concentration at 1 h and 1 day (p < 0.05). The 2-gram vancomycin group showed no difference at days 1, 2, and 3 compared to the 1-hour group. The 5, 15, and 30-minute bathing groups showed significantly lower vancomycin concentrations at all-time points. All vancomycin concentrations at day 3 were superior to the minimal inhibitory concentration of Staphyloccocus aureus. The mean concentration of vancomycin depends on the material, duration of bathing, the rinsing effect, and the drug dose. Our in-vitro study is the first to show that porous tantalum cylinders allow antibiotic carriage and progressive release. If appearing in vivo, in a similar extent, this intrinsic property might be useful to prevent and/or treat peri-prosthetic joint infection. © 2018 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 37:308-312, 2019.
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Affiliation(s)
- Pierre Sautet
- Institute of Movement and Locomotion, Saint-Marguerite Hospital, Boulevard Sainte-Marguerite, 13009 Marseille, France.,Aix-Marseille University, CNRS, ISM, Institute Movement Science, Marseille, France
| | - Thibaut Mékidèche
- Department of Clinical Pharmacology, Timone Hospital, Aix-Marseille University, Marseille, France
| | - Romain Guilhaumou
- Department of Clinical Pharmacology, Timone Hospital, Aix-Marseille University, Marseille, France
| | - Matthew P Abdel
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Jean-Noël Argenson
- Institute of Movement and Locomotion, Saint-Marguerite Hospital, Boulevard Sainte-Marguerite, 13009 Marseille, France.,Aix-Marseille University, CNRS, ISM, Institute Movement Science, Marseille, France
| | - Sébastien Parratte
- Institute of Movement and Locomotion, Saint-Marguerite Hospital, Boulevard Sainte-Marguerite, 13009 Marseille, France.,Aix-Marseille University, CNRS, ISM, Institute Movement Science, Marseille, France
| | - Matthieu Ollivier
- Institute of Movement and Locomotion, Saint-Marguerite Hospital, Boulevard Sainte-Marguerite, 13009 Marseille, France.,Aix-Marseille University, CNRS, ISM, Institute Movement Science, Marseille, France
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50
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Petis SM, Abdel MP, Perry KI, Mabry TM, Hanssen AD, Berry DJ. Long-Term Results of a 2-Stage Exchange Protocol for Periprosthetic Joint Infection Following Total Hip Arthroplasty in 164 Hips. J Bone Joint Surg Am 2019; 101:74-84. [PMID: 30601418 DOI: 10.2106/jbjs.17.01103] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Limited data exist that show the long-term risks of reinfection and mechanical failure with a contemporary 2-stage exchange protocol for periprosthetic joint infection following total hip arthroplasty. The purpose of this study was to determine the long-term reinfection and mechanical failure rates of 2-stage exchange for periprosthetic joint infection after total hip arthroplasty. METHODS We identified 164 hips (162 patients) with infection after total hip arthroplasty between 1991 and 2006 treated with a 2-stage exchange protocol with no prior treatment for periprosthetic joint infection. With regard to Musculoskeletal Infection Society diagnostic criteria, at least 1 major criterion or 4 of 6 minor criteria were fulfilled in 129 hips (79%). The cumulative incidence with a competing risk of death was calculated for reinfection, aseptic revisions, and all-cause revisions. The risk factors for reinfection were evaluated using Cox proportional hazards regression. Harris hip scores were calculated. The mean age at the time of spacer insertion was 68 years, and 35% of the patients were female. Excluding the patients with <2 years of follow-up, the mean follow-up was 12 years (range, 2 to 21 years). RESULTS The cumulative incidence of recurrence of infection was 10% at 1 year, 14% at 5 years, and 15% at 10 and 15 years. Seventeen patients (11%) used chronic antibiotic suppression (>6 months), with 7 (41%) of these having recurrent infection at the time of the latest follow-up. Use of chronic antibiotic suppression was the only predictive factor for reinfection (hazard ratio, 4.5 [95% confidence interval (CI), 1.9 to 10.9]; p = 0.001). The cumulative incidence of aseptic femoral and acetabular revisions was 2.6% at 5 years and 3.3% at 10 and 15 years. The cumulative incidence of all-cause revisions was 15% at 5 years and 16% at 10 and 15 years. Dislocation was the most common complication, with 28 dislocations occurring in 20 patients (12%). The mean Harris hip score improved from 52 points prior to spacer insertion to 70 points at 15 years after reimplantation (p < 0.01). CONCLUSIONS The rate of recurrence of infection of 15% for up to 15 years after total hip arthroplasty was similar to previous shorter-term reports of 2-stage exchange for periprosthetic joint infection. Surgeons should anticipate mitigating instability after reimplantation. Implant survivorship free of aseptic loosening and clinical outcomes were preserved for the long term. The role of chronic antibiotic suppression in the long-term treatment of periprosthetic joint infection requires further investigation. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Stephen M Petis
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Matthew P Abdel
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Kevin I Perry
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Tad M Mabry
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Arlen D Hanssen
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Daniel J Berry
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
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