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Sukeik M, Haddad FS. Periprosthetic joint infections after total hip replacement: an algorithmic approach. SICOT J 2019; 5:5. [PMID: 30816089 PMCID: PMC6394232 DOI: 10.1051/sicotj/2019004] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Accepted: 01/28/2019] [Indexed: 12/25/2022] Open
Abstract
An algorithm for managing periprosthetic joint infections (PJIs) after total hip replacement (THR) surgery using a multidisciplinary approach and a clearly defined protocol may improve infection eradication rates. In this article, we present an algorithm for the management of different types of PJIs including the acutely infected cemented and cementless THRs where the components are well-fixed postoperatively and when the infection is secondary to haematogenous spread in previously well-functioning and well-fixed implants. For chronic PJIs where the components are often loose, the standard treatment includes a two-stage revision procedure. However, in a highly selected subset of patients, a single-stage approach has been utilised with high rates of eradicating infections.
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Affiliation(s)
- Mohamed Sukeik
- Foothills Medical Centre, 1403 29 St NW Calgary, AB T2N 2T9, Canada
| | - Fares Sami Haddad
- University College London Hospital, 235 Euston Road, London NW1 2BU, UK
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Wang J, Duan Q, Sun X, Mou X, Song B, Yuan H. Acute compartment syndrome of the leg due to infection following an insect bite: A case report. Medicine (Baltimore) 2018; 97:e11613. [PMID: 30045298 PMCID: PMC6078673 DOI: 10.1097/md.0000000000011613] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
RATIONALE Acute compartment syndrome is a highly aggressive condition, which needs rapid diagnosis and surgical emergency. Most cases are caused by trauma, fractures, surgeries, or vascular injury, while other causes are easily misdiagnosed. PATIENTS CONCERNS A 29-year-old female, with a medical history of an insect bite on the left calf but not recent trauma, was admitted to the hospital due to the swelling and pain around the bite area. DIAGNOSES Acute compartment syndrome of the lower leg. INTERVENTIONS After admission, she developed septic shock symptoms, given intravenous antibiotics treatments. However, the condition worsened with increasing pain, loss of sensation, tense swelling, and severe pain to any stretch of the tissues. Thus the patient received fasciotomy followed by repeat and thorough debridement. After the wounds healed completely, systematic rehabilitation was performed for three weeks. OUTCOMES After three months of follow-up, the patient is able to walk, and moves up and down the stairs, independently. LESSONS Our case highlights the possibility of acute compartment syndrome caused by insect bites when the patient presents with the signs of the condition, and the importance of earlier rehabilitation interventions to improve the functional outcome post operation.
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Affiliation(s)
| | - Qiang Duan
- Department of Rehabilitation Medicine, Xijing Hospital, Fourth Military Medical University, Xi’an, China
| | - Xiaolong Sun
- Department of Rehabilitation Medicine, Xijing Hospital, Fourth Military Medical University, Xi’an, China
| | - Xiang Mou
- Department of Rehabilitation Medicine, Xijing Hospital, Fourth Military Medical University, Xi’an, China
| | | | - Hua Yuan
- Department of Rehabilitation Medicine, Xijing Hospital, Fourth Military Medical University, Xi’an, China
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Tsang STJ, Ting J, Simpson AHRW, Gaston P. Outcomes following debridement, antibiotics and implant retention in the management of periprosthetic infections of the hip: a review of cohort studies. Bone Joint J 2017; 99-B:1458-1466. [PMID: 29092984 DOI: 10.1302/0301-620x.99b11.bjj-2017-0088.r1] [Citation(s) in RCA: 86] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2017] [Accepted: 07/05/2017] [Indexed: 02/07/2023]
Abstract
AIMS The aims of the study were to review and analyse the reported series of debridement, antibiotics and implant retention (DAIR) in the management of infected total hip arthroplasties (THAs) to establish the overall success and the influencing factors. PATIENTS AND METHODS Using a standardised recognised study protocol, meta-analysis of observational studies in epidemiology guidelines, a comprehensive review and analysis of the literature was performed. The primary outcome measure was the success of treatment. The search strategy and inclusion criteria which involved an assessment of quality yielded 39 articles for analysis, which included 1296 patients. RESULTS The proportion of success following DAIR in the management of an infected THA appeared to improve after 2004 with a pooled mean proportion of success of 72.2%. For all reported series, from 1977 onwards, there was improved success with early debridement (< 7 days; 75.7%) and exchange of modular components (77.5%). There was a statistically non-significant improvement if debridement was performed within four weeks of the initial procedure (73.0%). CONCLUSION The reported success following DAIR has improved since 2004. The only determinants of outcome which we found were the timing of debridement after the onset of symptoms of infection and the exchange of modular components. Cite this article: Bone Joint J 2017;99-B:1488-66.
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Affiliation(s)
- S-T J Tsang
- University of Edinburgh, Royal Infirmary of Edinburgh, 51 Little France Crescent, Old Dalkeith Road, Edinburgh EH16 4SA, UK
| | - J Ting
- University of Edinburgh, Royal Infirmary of Edinburgh, 51 Little France Crescent, Old Dalkeith Road, Edinburgh EH16 4SA, UK
| | - A H R W Simpson
- University of Edinburgh, 51 Little France Crescent, Old Dalkeith Road, Edinburgh, EH16 4SA, UK
| | - P Gaston
- University of Edinburgh, Royal Infirmary of Edinburgh, 51 Little France Crescent, Old Dalkeith Road, Edinburgh EH16 4SA, UK
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Fink B, Schuster P, Schwenninger C, Frommelt L, Oremek D. A Standardized Regimen for the Treatment of Acute Postoperative Infections and Acute Hematogenous Infections Associated With Hip and Knee Arthroplasties. J Arthroplasty 2017; 32:1255-1261. [PMID: 27839958 DOI: 10.1016/j.arth.2016.10.011] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2016] [Revised: 10/01/2016] [Accepted: 10/09/2016] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Papers concerning the treatment of periprosthetic infections and acute hematogenous infections often concern inhomogeneous treatment concepts or low numbers of patients; this results in inconsistent rates of treatment success. METHODS Thirty-nine patients with early periprosthetic infections and 28 patients with acute hematogenous infections were treated with a homogeneous concept and followed with a mean period of 41.8 (24-132) months in order to investigate the success rate and influencing factors. All patients were treated with open surgical debridement, a revision of all removable components and irrigation with an antiseptic solution (octinedine). All patients received a systemic vancomycin/rifampicin antibiotic therapy until the microorganism causing the infection could be identified; a specific antibiotic therapy then followed until the end of the sixth week. RESULTS This unified treatment regimen resulted in an overall success rate of 71.6%, an 82.1% success for early infections and 57.1% for acute hematogenous infections. Variables that influenced the recurrence of an infection were the timespan between revision and first appearance of symptoms (<2 days), the number of previous operations, the American Society of Anesthesiologists classification, and nicotine abuse. CONCLUSION It appears that, in cases of early postoperative infection, a reproducibly high rate of success in retaining an implant can be achieved with this specific therapy regime if surgical intervention can be carried out within 2 days of first symptoms.
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Affiliation(s)
- Bernd Fink
- Clinic of Joint Replacement, General and Rheumatic Orthopaedics, Orthopaedic Clinic Markgröningen gGmbH, Markgröningen, Germany; Department of Orthopaedics, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Philipp Schuster
- Clinic of Joint Replacement, General and Rheumatic Orthopaedics, Orthopaedic Clinic Markgröningen gGmbH, Markgröningen, Germany
| | - Christoph Schwenninger
- Clinic of Joint Replacement, General and Rheumatic Orthopaedics, Orthopaedic Clinic Markgröningen gGmbH, Markgröningen, Germany
| | - Lars Frommelt
- Service for Infectious Diseases, Clinical Microbiology and Infection Control, Hamburg, Germany
| | - Damian Oremek
- Clinic of Joint Replacement, General and Rheumatic Orthopaedics, Orthopaedic Clinic Markgröningen gGmbH, Markgröningen, Germany
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Mirza YH, Tansey R, Sukeik M, Shaath M, Haddad FS. Biofilm and the Role of Antibiotics in the Treatment of Periprosthetic Hip and Knee Joint Infections. Open Orthop J 2016; 10:636-645. [PMID: 28484579 PMCID: PMC5398090 DOI: 10.2174/1874325001610010636] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2016] [Revised: 06/17/2016] [Accepted: 07/15/2016] [Indexed: 12/20/2022] Open
Abstract
An increasing demand for lower limb arthroplasty will lead to a proportionate increase in the need for revision surgery. A notable proportion of revision surgery is secondary to periprosthetic joint infections (PJI). Diagnosing and eradicating PJI can form a very difficult challenge. An important cause of PJI is the formation of a bacterial biofilm on the implant surface. Our review article seeks to describe biofilms; their definitions and formation, common causative bacteria, prophylactic and therapeutic antibiotic therapy.
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Affiliation(s)
- Yusuf H Mirza
- Department of Trauma and Orthopaedics, University College London Hospital, 235 Euston Road, NW1 2BU, London, United Kingdom
| | - Rosamond Tansey
- Department of Trauma and Orthopaedics, University College London Hospital, 235 Euston Road, NW1 2BU, London, United Kingdom
| | - Mohamed Sukeik
- Department of Trauma and Orthopaedics, Royal London Hospital, Whitechapel, London, E1 1BB, United Kingdom
| | - Mohammed Shaath
- Department of Trauma and Orthopaedics, North Manchester General Hospital, Delaunay's Road, Crumpsall, M8 5RB, United Kingdom
| | - Fares Sami Haddad
- Department of Trauma and Orthopaedics, University College London Hospital, 235 Euston Road, NW1 2BU, London, United Kingdom
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Anagnostakos K, Schmitt C. Can periprosthetic hip joint infections be successfully managed by debridement and prosthesis retention? World J Orthop 2014; 5:218-224. [PMID: 25035823 PMCID: PMC4095013 DOI: 10.5312/wjo.v5.i3.218] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2013] [Revised: 03/02/2014] [Accepted: 04/11/2014] [Indexed: 02/06/2023] Open
Abstract
To evaluate the current literature about how successfully periprosthetic hip joint infections can be managed by debridement and prosthesis retention. A literature search was performed through PubMed until September 2013. Search terms were “DAIR (debridement, antibiotics, irrigation, and retention)” alone and in combination with “hip” as well as “hip infection + prosthesis retention”. A total of 11 studies reporting on 292 cases could be identified. Five different treatment modalities have been described with varying success rates (debridement-21% infection eradication rate; debridement + lavage-75% infection eradication rate; debridement, lavage, with change of modular prosthesis components-70.4% infection eradication rate; debridement, lavage, change of modular prosthesis components + vacuum-assisted closure-92.8% infection eradication rate; acetabular cup removal + spacer head onto retained stem-89.6% infection eradication rate). With regard to the postoperative antibiotic therapy, no general consensus could be drawn from the available data. Debridement, antibiotic therapy, irrigation, and prosthesis retention is an acceptable solution in the management of early and acute hematogenous periprosthetic hip joint infections. The current literature does not allow for generalization of conclusions with regard to the best treatment modality. A large, multi-center study is required for identification of the optimal treatment of these infections.
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Implantation of resorbable gentamicin sponges in addition to irrigation and debridement in 34 patients with infection complicating total hip arthroplasty. Hip Int 2013; 23:173-80. [PMID: 23397196 DOI: 10.5301/hip.2013.10612] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/24/2012] [Indexed: 02/04/2023]
Abstract
We evaluated a prosthesis-retaining treatment protocol for prosthetic joint infection in patients presenting at a mean of 116 days (range 10-1216 days) after primary arthroplasty. Our regime involved irrigation and debridement followed by implantation of biodegradable gentamicin loaded sponges which do not require removal after implantation. Of 34 patients with a deep infection after total hip arthroplasty, Twenty-five were treated successfully, with a mean follow-up of 35 months. There were no permanent complications. This success rate is comparable to earlier studies. Early initiation of treatment demonstrated a tendency for better results, and late chronic infections had a worse outcome. Because the sponges are degradable, a number of further surgical procedures were avoided.
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Fehring TK, Odum SM, Berend KR, Jiranek WA, Parvizi J, Bozic KJ, Della Valle CJ, Gioe TJ. Failure of irrigation and débridement for early postoperative periprosthetic infection. Clin Orthop Relat Res 2013; 471:250-7. [PMID: 22552768 PMCID: PMC3528942 DOI: 10.1007/s11999-012-2373-9] [Citation(s) in RCA: 140] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Irrigation and débridement (I&D) of periprosthetic infection (PPI) is associated with infection control ranging from 16% to 47%. Mitigating factors include organism type, host factors, and timing of intervention. While the influence of organism type and host factors has been clarified, the timing of intervention remains unclear. QUESTIONS/PURPOSES We addressed the following questions: What is the failure rate of I&Ds performed within 90 days of primary surgery? And what factors are associated with failure? METHODS We performed a multicenter retrospective analysis of I&D for PPI within 90 days of primary surgery. We included 86 patients (44 males, 42 females) with an average age of 61 years. Failure was defined as return to the operating room for an infection-related problem. We determined the failure rate of I&D within 90 days of primary surgery and whether the odds of rerevision for infection were associated with Charlson Comorbidity Index, age, sex, joint, organism type, and timing. The minimum followup was 24 months (average, 46 months; range, 24-106 months). RESULTS 54 of 86 patients (63%) failed. Eight of 10 (80%) failed within the first 10 days, 32 of 57 (56%) within 4 weeks, and 22 of 29 (76%) within 31 to 90 days postoperatively. No covariates were associated with subsequent revision surgery for infection. CONCLUSIONS I&D for PPI is frequently used in the early postoperative period to control infection. While it is assumed early intervention will lead to control of infection in most cases, our data contradict this assumption.
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Affiliation(s)
- Thomas K. Fehring
- OrthoCarolina, PA, Hip and Knee Center, 2001 Vail Avenue, Suite 200-A, Charlotte, NC 28207 USA
| | - Susan M. Odum
- OrthoCarolina Research Institute, Inc, Charlotte, NC USA
| | | | - William A. Jiranek
- Department of Orthopaedic Surgery, Virginia Commonwealth University, Richmond, VA USA
| | | | - Kevin J. Bozic
- Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco, CA USA
| | | | - Terence J. Gioe
- Department of Orthopaedic Surgery, Minneapolis Veterans Affairs Medical Center, Minneapolis, MN USA
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Aggressive early débridement for treatment of acutely infected cemented total hip arthroplasty. Clin Orthop Relat Res 2012; 470:3164-70. [PMID: 22826016 PMCID: PMC3462872 DOI: 10.1007/s11999-012-2500-7] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Up to 2% of THAs are complicated by infection, leading to dissatisfied patients with poor function and major social and economic consequences. The challenges are control of infection, restoration of full function, and prevention of recurrence. Irrigation and débridement with or without exchange of modular components remains an attractive alternative to two-stage reimplantation in acutely infected THAs but with variable results from previous studies. QUESTIONS/PURPOSES We therefore determined the rate at which aggressive early débridement with exchange of modular components controlled acutely infected cemented THAs. METHODS We retrospectively studied all 26 patients presenting with acutely infected cemented THAs (16 primaries, 10 revisions) occurring within 6 weeks of the index operation or of hematogenous spread from a confirmed source of infection elsewhere between 1999 and 2006. Microbiology confirmed bacterial colonization in all patients, with 18 early postoperative infections and eight acute hematogenous infections. Patients underwent aggressive débridement with open complete synovectomy, exchange of all mobile parts, débridement of all aspects of the joint, irrigation with antiseptic solutions, and pulsatile lavage. Minimum followup was 5 years (mean, 6.6 years; range, 5-11 years). RESULTS Eight patients had multiple washouts with control of infection in four at latest followup. Five patients underwent two-stage revisions and one patient was placed on long-term antibiotic suppression. Twenty patients returned to their expected functional level with no radiographic evidence of prosthetic failure. At minimum 5-year followup, we had a 77% infection control rate. CONCLUSIONS Our data confirm current literature and suggest there may be a role for aggressive early débridement in controlling acute postoperative and hematogenous infections after cemented THA. LEVEL OF EVIDENCE Level IV, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.
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