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Toler KO, Paranjape PR, McLaren A, Deirmengian C. Synovial Fluid Cutibacterium acnes Antigen Is Detected Among Shoulder Samples with High Inflammation and Early Culture Growth. J Bone Joint Surg Am 2024; 106:1697-1703. [PMID: 38950104 DOI: 10.2106/jbjs.23.00409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/03/2024]
Abstract
BACKGROUND An emerging paradigm suggests that positive Cutibacterium acnes shoulder cultures can result from either true infection or contamination, with true infections demonstrating a host inflammatory response and early culture growth. This clinical retrospective study examines the relationship between C. acnes antigen, C. acnes culture results, and inflammation. METHODS From January 2021 to July 2023, 1,365 periprosthetic synovial fluid samples from 347 institutions were tested for shoulder infection at a centralized clinical laboratory. A biomarker scoring system based on the 2018 International Consensus Meeting (ICM) definition was utilized to assign each sample an inflammation score. Associations between inflammation, culture results, and C. acnes antigen results were assessed utilizing cluster and correlation analyses. RESULTS Of 1,365 samples, 1,150 were culture-negative and 215 were culture-positive (94 C. acnes and 121 other organisms). Among the 94 C. acnes culture-positive samples, unsupervised clustering revealed 2 distinct sample clusters (silhouette coefficient, 0.83): a high-inflammation cluster (n = 67) and a low-inflammation cluster (n = 27). C. acnes antigen levels demonstrated moderate-strong positive correlation with inflammation (Spearman ρ, 0.60), with 166-fold higher levels of C. acnes antigen in high-inflammation samples (16.6 signal/cutoff [S/CO]) compared with low-inflammation samples (0.1 S/CO) (p < 0.0001). The days to C. acnes culture positivity demonstrated weak-inverse correlation with inflammation (Spearman ρ = -0.38), with 1.5-fold earlier growth among the 67 high-inflammation samples (6.7 compared with 10.4 days; p < 0.0001). Elevated C. acnes antigen was observed in only 4 (0.38%) of 1,050 low-inflammation culture-negative samples and in only 5 (4.9%) of 103 high-inflammation non- C. acnes -positive cultures. However, 19.0% of high-inflammation, culture-negative samples demonstrated elevated C. acnes antigen. CONCLUSIONS Synovial fluid C. acnes antigen was detected among shoulder samples with high inflammation and early culture growth, supporting the emerging paradigm that these samples represent true infection. Future research should explore antigen testing to differentiate contamination from infection and to identify culture-negative C. acnes infections. LEVEL OF EVIDENCE Diagnostic Level III . See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Krista O Toler
- Department of Diagnostics Research and Development, Zimmer Biomet, Claymont, Delaware
| | - Pearl R Paranjape
- Department of Diagnostics Research and Development, Zimmer Biomet, Claymont, Delaware
| | - Alex McLaren
- Department of Orthopaedic Surgery, University of Arizona College of Medicine-Phoenix, Phoenix, Arizona
| | - Carl Deirmengian
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, Pennsylvania
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2
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Vogel C, Reumann MK, Menger MM, Herath SC, Rollmann MFR, Lauer H, Histing T, Braun BJ. [Non-unions of the upper extremities]. CHIRURGIE (HEIDELBERG, GERMANY) 2024; 95:671-682. [PMID: 38829545 DOI: 10.1007/s00104-024-02095-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 04/17/2024] [Indexed: 06/05/2024]
Abstract
The diagnosis and treatment of non-unions still represents an interdisciplinary challenge. Therefore, prevention, early detection and specific treatment are of great importance. Non-unions of the upper extremities, although less common than that of the lower extremities, requires special attention for successful treatment due to the central role of the shoulder girdle and arm in day to day activities. Successful treatment of non-unions requires a comprehensive evaluation of the patient's medical history, a thorough clinical examination and in particular radiological imaging. In order to effectively treat the pseudarthrosis it is crucial to distinguish between pseudarthroses that are suspected to be due to infections and those that are not. This article presents a treatment algorithm for managing both pseudarthrosis due to infection and pseudarthrosis without infection in the upper extremities.
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Affiliation(s)
| | - Marie K Reumann
- Klinik für Unfall- und Wiederherstellungschirurgie, Eberhard Karls Universität Tübingen, BG Klinik Tübingen, Schnarrenbergstr. 95, 72076, Tübingen, Deutschland
| | - Maximilian M Menger
- Klinik für Unfall- und Wiederherstellungschirurgie, Eberhard Karls Universität Tübingen, BG Klinik Tübingen, Schnarrenbergstr. 95, 72076, Tübingen, Deutschland
| | - Steven C Herath
- Klinik für Unfall- und Wiederherstellungschirurgie, Eberhard Karls Universität Tübingen, BG Klinik Tübingen, Schnarrenbergstr. 95, 72076, Tübingen, Deutschland
| | - Mika F R Rollmann
- Klinik für Unfall- und Wiederherstellungschirurgie, Eberhard Karls Universität Tübingen, BG Klinik Tübingen, Schnarrenbergstr. 95, 72076, Tübingen, Deutschland
| | - Henrik Lauer
- Klinik für Hand‑, Plastische, Rekonstruktive und Verbrennungschirurgie, Eberhard Karls Universität Tübingen, BG Klinik Tübingen, Tübingen, Deutschland
| | - Tina Histing
- Klinik für Unfall- und Wiederherstellungschirurgie, Eberhard Karls Universität Tübingen, BG Klinik Tübingen, Schnarrenbergstr. 95, 72076, Tübingen, Deutschland
| | - Benedikt J Braun
- Klinik für Unfall- und Wiederherstellungschirurgie, Eberhard Karls Universität Tübingen, BG Klinik Tübingen, Schnarrenbergstr. 95, 72076, Tübingen, Deutschland.
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Poursalehian M, Lotfi M, Mortazavi SMJ. Latent infections in conversion total hip arthroplasty following internal fixation of femoral neck fractures: a systematic review and meta-analysis of diagnostic methods. Arch Orthop Trauma Surg 2024:10.1007/s00402-024-05216-6. [PMID: 38367062 DOI: 10.1007/s00402-024-05216-6] [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: 07/31/2023] [Accepted: 01/29/2024] [Indexed: 02/19/2024]
Abstract
BACKGROUND Accurate diagnosis of latent infections prior to conversion total hip arthroplasty (THA) following internal fixation of femoral neck fractures is crucial for successful surgical outcomes. This systematic review aimed to provide a comprehensive evaluation of the current literature regarding the diagnosis of latent infections before conversion THA. METHODS Systematic search of PubMed, EMBASE, and Cochrane (CENTRAL) databases was conducted, and the diagnostic accuracy of various markers and techniques was assessed. The quality of the included studies was evaluated using the QUADAS-2 instrument. RESULTS Five studies comprising 661 patients were included in the review. Pooled analysis using C-reactive protein (CRP) as a diagnostic marker resulted in a sensitivity and specificity of 72% and 76%, respectively, while using erythrocyte sedimentation rate (ESR) yielded a sensitivity and specificity of 75% and 78%, respectively. Fibrinogen and platelet count showed lower sensitivity and specificity compared to CRP and ESR. The best combined markers were CRP and serum platelet count, with a sensitivity of 76% and specificity of 86% based on one study. CONCLUSION Our review underscored the limitations and inconsistencies present in current diagnostic methods for latent infections in conversion surgery. Future research needs to focus on standardizing threshold values, exploring the potential of synovial fluid analysis, imaging techniques, and molecular methods, as well as developing tailored diagnostic algorithms. PROSPERO CRD42023394757.
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Affiliation(s)
- Mohammad Poursalehian
- Joint Reconstruction Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohadeseh Lotfi
- Joint Reconstruction Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Seyed Mohammad Javad Mortazavi
- Joint Reconstruction Research Center, Tehran University of Medical Sciences, Tehran, Iran.
- Department of Orthopedic Surgery, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran.
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Kurihara MNL, Santos INM, Eisen AKA, Caleiro GS, de Araújo J, de Sales RO, Pignatari AC, Salles MJ. Phenotypic and Genotypic Characterization of Cutibacterium acnes Isolated from Shoulder Surgery Reveals Insights into Genetic Diversity. Microorganisms 2023; 11:2594. [PMID: 37894252 PMCID: PMC10609031 DOI: 10.3390/microorganisms11102594] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Revised: 10/11/2023] [Accepted: 10/18/2023] [Indexed: 10/29/2023] Open
Abstract
Specific virulence factors that likely influence C. acnes invasion into deep tissues remain to be elucidated. Herein, we describe the frequency of C. acnes identification in deep tissue specimens of patients undergoing clean shoulder surgery and assess its phenotypic and genetic traits associated with virulence and antibiotic resistance patterns, compared with isolates from the skin of healthy volunteers. Multiple deep tissue specimens from the bone fragments, tendons, and bursa of 84 otherwise healthy patients undergoing primary clean-open and arthroscopic shoulder surgeries were aseptically collected. The overall yield of tissue sample cultures was 21.5% (55/255), with 11.8% (30/255) identified as C. acnes in 27.3% (23/84) of patients. Antibiotic resistance rates were low, with most strains expressing susceptibility to first-line antibiotics, while a few were resistant to penicillin and rifampicin. Phylotypes IB (73.3%) and II (23.3%) were predominant in deep tissue samples. Genomic analysis demonstrated differences in the pangenome of the isolates from the same clade. Even though strains displayed a range of pathogenic markers, such as biofilm formation, patients did not evolve to infection during the 1-year follow-up. This suggests that the presence of polyclonal C. acnes in multiple deep tissue samples does not necessarily indicate infection.
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Affiliation(s)
- Mariana Neri Lucas Kurihara
- Laboratório Especial de Microbiologia Clínica (LEMC), Departamento de Medicina, Escola Paulista de Medicina (EPM), Universidade Federal de Sao Paulo (UNIFESP), Sao Paulo 04025-010, Brazil; (M.N.L.K.); (I.N.M.S.); (A.C.P.)
| | - Ingrid Nayara Marcelino Santos
- Laboratório Especial de Microbiologia Clínica (LEMC), Departamento de Medicina, Escola Paulista de Medicina (EPM), Universidade Federal de Sao Paulo (UNIFESP), Sao Paulo 04025-010, Brazil; (M.N.L.K.); (I.N.M.S.); (A.C.P.)
| | - Ana Karolina Antunes Eisen
- Emerging Viruses Research Laboratory, Institute of Biomedical Sciences, University of Sao Paulo, Sao Paulo 05508-000, Brazil; (A.K.A.E.); (G.S.C.); (J.d.A.)
| | - Giovana Santos Caleiro
- Emerging Viruses Research Laboratory, Institute of Biomedical Sciences, University of Sao Paulo, Sao Paulo 05508-000, Brazil; (A.K.A.E.); (G.S.C.); (J.d.A.)
| | - Jansen de Araújo
- Emerging Viruses Research Laboratory, Institute of Biomedical Sciences, University of Sao Paulo, Sao Paulo 05508-000, Brazil; (A.K.A.E.); (G.S.C.); (J.d.A.)
| | - Romário Oliveira de Sales
- Albert Einstein Research and Education Institute, Hospital Israelita Albert Einstein, Sao Paulo 05652-900, Brazil;
| | - Antônio Carlos Pignatari
- Laboratório Especial de Microbiologia Clínica (LEMC), Departamento de Medicina, Escola Paulista de Medicina (EPM), Universidade Federal de Sao Paulo (UNIFESP), Sao Paulo 04025-010, Brazil; (M.N.L.K.); (I.N.M.S.); (A.C.P.)
| | - Mauro José Salles
- Laboratório Especial de Microbiologia Clínica (LEMC), Departamento de Medicina, Escola Paulista de Medicina (EPM), Universidade Federal de Sao Paulo (UNIFESP), Sao Paulo 04025-010, Brazil; (M.N.L.K.); (I.N.M.S.); (A.C.P.)
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Malige A, Boyd A, Manuputy I, Michelin R, Itamura JM. A High Rate of Bacteriologic Culture-Positive Findings Is Seen After Revision Rotator Cuff Surgery. Arthrosc Sports Med Rehabil 2023; 5:100792. [PMID: 37711161 PMCID: PMC10498406 DOI: 10.1016/j.asmr.2023.100792] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 08/04/2023] [Indexed: 09/16/2023] Open
Abstract
Purpose To determine the incidence of subclinical infections in patients undergoing revision arthroscopic rotator cuff repair and identify any risk factors for developing these infections. Methods Patients who underwent revision surgery by the senior author between January 2012 and December 2022 after a previous rotator cuff surgery were identified. All patients undergoing an open or arthroscopic revision of their previous rotator cuff surgery were included. Patients who had noted previous shoulder infections or had incomplete chart documentation were excluded. For each patient, demographic information, surgical information, and culture results were recorded. Results A total of 115 patients were identified. Thirty-nine were excluded due to incomplete chart documentation (35) or a history of infection (4); therefore, 22 patients (28.9%) had positive cultures (31 cultures in total). Seventeen patients had only Cutibacterium acnes identified. C acnes cultures turned positive on average 13.52 days after culture collection. There was no difference in infection incidence rates between isolated rotator cuff repair and rotator cuff repair plus additional surgeries (P = .88) or between initial arthroscopic versus open procedures (P = .83). None of the 12 identified risk factors, including age, sex, race, smoking history, previous corticosteroid injections, malnutrition, renal failure, liver failure, diabetes mellitus, immunocompromised status, intravenous drug use, and number of revisions, were correlated with the presence of a subclinical infection. Finally, 6 patients had control cultures taken. One culture (16.6%) was positive for C acnes, while this patient did not have a positive shoulder culture. Conclusions Subclinical shoulder infections can be present in more than one-quarter of patients undergoing revision after rotator cuff repair. Level of Evidence Level IV, diagnostic case series.
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Affiliation(s)
- Ajith Malige
- Cedars Sinai-Kerlan Jobe Institute, Los Angeles, California, U.S.A
| | - Alexandra Boyd
- Cedars Sinai-Kerlan Jobe Institute, Los Angeles, California, U.S.A
| | - Isaac Manuputy
- Cedars Sinai-Kerlan Jobe Institute, Los Angeles, California, U.S.A
| | - Richard Michelin
- Cedars Sinai-Kerlan Jobe Institute, Los Angeles, California, U.S.A
| | - John M. Itamura
- Cedars Sinai-Kerlan Jobe Institute, Los Angeles, California, U.S.A
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Ponraj DS, Falstie-Jensen T, Brüggemann H, Lange J. The value of sonication on orthopaedic implants in an everyday clinical setting - an exploratory study. BMC Musculoskelet Disord 2023; 24:691. [PMID: 37644417 PMCID: PMC10464118 DOI: 10.1186/s12891-023-06796-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 08/11/2023] [Indexed: 08/31/2023] Open
Abstract
BACKGROUND Sonication of removed orthopaedic implants in suspected implant-associated infections (IAI) is widely applied internationally. However, evaluation of the utility of sonication on all implants removed in everyday standard practice is scarce. This exploratory study was performed to evaluate the application of sonication fluid (SF) culture on removed orthopaedic implants, irrespective of the reason for removal. METHODS Out of 100 removed orthopaedic implants collected between August 2019 and September 2020, 77 implants with availability of concurrent tissue culture samples were included in the study. Removed implants were categorized into a confirmed or suspected IAI group and a presumed aseptic group based on pre-operative diagnosis by the responsible surgeon. Implants were sonicated and SF culture performed under both aerobic and anaerobic conditions. The significance of all bacterial isolates was evaluated based on the CFU/mL cut-offs of the EBJIS guidelines, except for C. acnes where additional investigations were performed. RESULTS The results of SF culture in the two groups were compared with their corresponding tissue cultures. Out of the 12 cases in the confirmed/suspected IAI group, SF culture was positive in 11 cases and had increased diagnostic yield in two (17%) cases compared to tissue culture. Increased diagnostic yield of SF compared to tissue culture was seen in seven (11%) of the 65 implants in the presumed aseptic group. If growth of Cutibacterium species isolates were interpreted based on EBJIS cut-off for SF culture instead of the study-specific criteria, then two isolates considered to represent infection might have been missed while three other isolates considered contaminants would have fallen under the 'infection confirmed' category in the EBJIS guidelines. CONCLUSION Sonication with SF culture has increased diagnostic yield compared to tissue cultures in all implants irrespective of reason for removal. However, positive SF cultures with Cutibacterium species should always be interpreted with extreme care.
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Affiliation(s)
| | | | | | - Jeppe Lange
- Department of Clinical Medicine, Aarhus University, Aarhus, 8000, Denmark.
- Department of Orthopaedic Surgery, Regional Hospital, Horsens, 8700, Denmark.
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Both A, Huang J, Hentschke M, Tobys D, Christner M, Klatte TO, Seifert H, Aepfelbacher M, Rohde H. Genomics of Invasive Cutibacterium acnes Isolates from Deep-Seated Infections. Microbiol Spectr 2023; 11:e0474022. [PMID: 36976006 PMCID: PMC10100948 DOI: 10.1128/spectrum.04740-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2022] [Accepted: 03/03/2023] [Indexed: 03/29/2023] Open
Abstract
Cutibacterium acnes, formerly known as Propionibacterium acnes, is a commensal of the human pilosebaceous unit but also causes deep-seated infection, especially in the context of orthopedic and neurosurgical foreign materials. Interestingly, little is known about the role of specific pathogenicity factors for infection establishment. Here, 86 infection-associated and 103 commensalism-associated isolates of C. acnes were collected from three independent microbiology laboratories. We sequenced the whole genomes of the isolates for genotyping and a genome-wide association study (GWAS). We found that C. acnes subsp. acnes IA1 was the most significant phylotype among the infection isolates (48.3% of all infection isolates; odds ratio [OR] = 1.98 for infection). Among the commensal isolates, C. acnes subsp. acnes IB was the most significant phylotype (40.8% of all commensal isolates; OR = 0.5 for infection). Interestingly, C. acnes subsp. elongatum (III) was rare overall and did not occur at all in infection. The open reading frame-based GWAS (ORF-GWAS) did not show any loci with a strong signal for infection association (no P values of ≤0.05 after adjustment for multiple testing; no logarithmic OR [logOR] of ≥|2|). We concluded that all subspecies and phylotypes of C. acnes, possibly with the exception of C. acnes subsp. elongatum, are able to cause deep-seated infection given favorable conditions, most importantly related to inserted foreign material. Genetic content appears to have a small effect on the likelihood of infection establishment, and functional studies are needed to understand the individual factors contributing to deep-seated infections caused by C. acnes. IMPORTANCE Opportunistic infections emerging from human skin microbiota are of ever-increasing importance. Cutibacterium acnes, being abundant on the human skin, may cause deep-seated infections (e.g., device-associated infections). Differentiation between invasive (i.e., clinically significant) C. acnes isolates and sole contaminants is often difficult. Identification of genetic markers associated with invasiveness not only would strengthen our knowledge related to pathogenesis but also could open ways to selectively categorize invasive and contaminating isolates in the clinical microbiology lab. We show that in contrast to other opportunistic pathogens (e.g., Staphylococcus epidermidis), invasiveness is apparently a broadly distributed ability across almost all C. acnes subspecies and phylotypes. Thus, our work strongly supports an approach in which clinical significance is judged from clinical context rather than by detecting specific genetic traits.
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Affiliation(s)
- Anna Both
- Institute for Medical Microbiology, Virology and Hygiene, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jiabin Huang
- Institute for Medical Microbiology, Virology and Hygiene, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | | | - David Tobys
- Institute for Medical Microbiology, Immunology and Hygiene, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
- German Center for Infection Research (DZIF), Partner Site Bonn-Cologne, Cologne, Germany
| | - Martin Christner
- Institute for Medical Microbiology, Virology and Hygiene, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Till Orla Klatte
- Department for Trauma Surgery and Orthopedics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Harald Seifert
- Institute for Medical Microbiology, Immunology and Hygiene, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
- German Center for Infection Research (DZIF), Partner Site Bonn-Cologne, Cologne, Germany
| | - Martin Aepfelbacher
- Institute for Medical Microbiology, Virology and Hygiene, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Holger Rohde
- Institute for Medical Microbiology, Virology and Hygiene, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Revision surgery after failed surgical treatment of midshaft clavicle fractures is often associated with positive detection of bacteria. Arch Orthop Trauma Surg 2022:10.1007/s00402-022-04669-x. [PMID: 36383227 DOI: 10.1007/s00402-022-04669-x] [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: 09/16/2022] [Accepted: 10/18/2022] [Indexed: 11/17/2022]
Abstract
BACKGROUND Midshaft clavicle fractures are common, and the proportion of patients treated surgically has increased in recent years. With this increase in surgical treatments, the complication rate, for instance of infection, non-union, or implant failure, has also risen. This study evaluates the frequency of pathogen detection during revision surgeries occurring after a prior failed osteosynthesis of midshaft clavicle fractures. METHODS All patients treated in our hospital with a prior failed surgical therapy of a clavicle midshaft fracture between January 2013 and March 2022 were screened. Epidemiological data, intraoperative tissue samples, sonication, and the type of revision surgery were assessed. A postoperative follow-up at a minimum of 6 month was defined and osseous consolidation was verified. RESULTS Twenty-one patients (twelve male and eight female) were included with a mean age of 40.4 ± 14.1 years. Eleven of the patients showed pathogen detection (Group I), and seven remained without (Group II). A significant difference in age existed between Groups I and II (36.1 ± 12.8 and 51.6 ± 11.5, p ≤ 0.05). The three most common pathogens were Cutibacterium acnes (n = 7), Staphylococcus epidermidis (n = 4), and Staphylococcus sacchorlyticus (n = 3), respectively. Thirteen patients presented for a follow-up. In nine patients (69%), bone healing was detectable. Four patients received a second revision surgery. CONCLUSION Revision surgery frequently shows pathogen detection without signs of infection. Cutibacterium acnes is the most common pathogen. Despite pathogen detection, bone healing can be achieved with revision surgery, although the rate of repeat revision surgeries is high.
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Makihara K, Takegami Y, Tokutake K, Yamauchi K, Hiramatsu Y, Matsuura Y, Imagama S. Risk factors for fracture-related infection after open reduction and internal fixation of proximal humerus fractures: A multicenter retrospective study of 496 fractures (TRON group study). Injury 2022; 53:2573-2578. [PMID: 35641333 DOI: 10.1016/j.injury.2022.05.022] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2021] [Revised: 04/04/2022] [Accepted: 05/06/2022] [Indexed: 02/02/2023]
Abstract
INTRODUCTION One of the complications of the surgical therapy for proximal humerus fractures is fracture-related infection (FRI). This multicenter study aimed to investigate the incidence of FRI and clarify the risk factors associated with FRI in patients receiving open reduction and internal fixation for proximal humerus fracture. MATERIAL AND METHODS Among 684 patients diagnosed as having proximal humerus fracture and who were treated by surgical therapy in 13 institutions (named TRON group) from 2015 through 2020, 496 patients (men, n = 134, women, n = 362; mean [SD] age, 68.5 [14.5] years; mean [SD] body mass index [BMI], 23.0 [4.4] kg/m2) were included as subjects. Excluded were 188 patients due to less than 12 month's follow-up, patients who underwent osteosynthesis using neither plate nor nail and those with open fracture. We extracted the following as risk factors of FRI: sex, BMI, smoking status, diabetes, glenohumeral fracture dislocation, fracture classification, approach, implant, waiting period, type of anesthesia, operative time and blood loss during surgery. We conducted logistic regression analysis to investigate the risk factors of FRI using these extracted items as explanatory variables and the presence or absence of FRI as the response variable. RESULT FRI occurred after surgery for proximal humerus fracture in 9 of the 496 patients (1.8%). The causative organism was methicillin-susceptible Staphylococcus aureus in 4 patients, Pseudomonas aeruginosa in one patient and Enterococcus faecalis in one patient. In the other 3 patients, causative organisms were not detected. The univariate analysis showed significant differences for present of glenohumeral fracture dislocation (p = 0.004). Logistic regression analysis showed glenohumeral fracture dislocation to be the significant explanatory factor for FRI (odds ratio 12.3, p = 0.0375). CONCLUSION This study revealed an infection rate following open reduction and internal fixation of proximal humerus fracture of 1.8% (9 patients) and that Staphylococcus was the most frequent causative organism. Glenohumeral fracture dislocation is a significant risk for postoperative FRI.
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Affiliation(s)
- Koichiro Makihara
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Yasuhiko Takegami
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan.
| | - Katsuhiro Tokutake
- Department of Hand Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Kenichi Yamauchi
- Department of Orthopaedic Surgery, Toyohashi Municipal Hospital, Toyohashi, Japan
| | - Yutaka Hiramatsu
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Yui Matsuura
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Shiro Imagama
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
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Washburn F, Tran B, Golden T. Occult clavicle osteomyelitis caused by Cutibacterium acnes (C. acnes) after coracoclavicular ligament reconstruction: A case report and review of the literature. Int J Surg Case Rep 2022; 94:107114. [PMID: 35468384 PMCID: PMC9052131 DOI: 10.1016/j.ijscr.2022.107114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 04/17/2022] [Accepted: 04/17/2022] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION Clavicle osteomyelitis is a rare, but serious complication following operative repair of acromioclavicular (AC) joint separations. Cutibacterium Acnes (C. acnes) is rarely a causative pathogen in clavicle osteomyelitis and diagnosis can be challenging due to the indolent nature of this organism. CASE PRESENTATION A 45-50 year old female with a chronic AC joint separation underwent an open coracoclavicular reconstruction using semitendinosus allograft and FiberTape (Arthrex, Naples, FL). At the six month follow up, the patient complained of mild persistent pain. Imaging demonstrated widening of the medial suture tunnel with distal clavicle osteolysis, which was concerning for osteomyelitis. This was successfully treated with implant removal revision surgery and additional intravenous antibiotics. Cultures of the graft material were positive for C. acnes. The patient continued to have osteolysis of the distal left clavicle for a period of time despite resolution of osteomyelitis. DISCUSSION C. acnes osteomyelitis of the clavicle is difficult to diagnose because of its vague associated symptoms when implicated in infections. There are no known obvious predisposing factors for C. acnes clavicle osteomyelitis. Literature suggests management should include aggressive irrigation and debridement, removal of any hardware, and extended intravenous antibiotic administration. CONCLUSION C. acnes clavicular osteomyelitis is uncommon, thus established treatment guidelines have not yet been formed. Revision surgery to remove graft material, irrigate, and debride in addition to antibiotic treatment was successful for our patient. Additional pathologic manifestations of C. acnes infections could include continued clavicular erosion post-clearance of infection, although further investigation is necessary.
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Affiliation(s)
- Frederic Washburn
- Community Memorial Health System, 147 N. Brent St., Ventura, 93003, United States of America.
| | - Britni Tran
- Community Memorial Health System, 147 N. Brent St., Ventura, 93003, United States of America.
| | - Thomas Golden
- Community Memorial Health System, 147 N. Brent St., Ventura, 93003, United States of America
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11
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Berneking L, Haas M, Frielinghaus L, Berinson B, Lütgehetmann M, Christner M, Aepfelbacher M, Gerlach U, Seide K, Both A, Rohde H. Evaluation of a syndromic panel polymerase chain reaction (spPCR) assay for the diagnosis of device-associated bone and joint infections (BJI). Int J Infect Dis 2022; 116:283-288. [PMID: 35031396 DOI: 10.1016/j.ijid.2022.01.013] [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: 08/11/2021] [Revised: 01/05/2022] [Accepted: 01/05/2022] [Indexed: 10/19/2022] Open
Abstract
OBJECTIVE Pathogen detection is crucial for diagnosis and targeted therapy in implant-associated bone and joint infections (BJI). Culture-based microbiology regularly fails to identify causative pathogens. This study evaluated the diagnostic accuracy and clinical usefulness of a syndromic panel polymerase chain reaction (spPCR) assay targeting common BJI pathogens in tissue specimens from patients with implant-associated BJI. METHODS Results obtained by spPCR assay and a 16S rDNA PCR were compared with results obtained from a standard of care (SOC) culture-based diagnostics, serving as a gold standard. In total, 126 specimens obtained from 73 patients were analyzed. RESULTS The spPCR assay correctly identified 33/40 culture-positive samples (82.5 %) and was positive in 9/86 (10.5 %) culture-negative samples, resulting in an overall sensitivity of 84.6 % (95% confidence interval [CI] 68.79-93.59%) and specificity of 89.35% (95% CI 80.6-94.81%). The spPCR was more sensitive compared with the 16S rDNA PCR (37.5%). The spPCR identified pathogens in 7/51 (13.7%) SOC-negative patients. Re-evaluation of spPCR results in clinical context suggested their clinical significance. CONCLUSION An spPCR assay targeting common pathogens causing implant-associated BJI may help to identify causative agents in culture-negative cases. As false-negative results are possible, spPCR assays appear as an add-on approach for pathogen detection in implant-associated BJI.
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Affiliation(s)
- Laura Berneking
- Institut für Medizinische Mikrobiologie, Virologie und Hygiene, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Michaela Haas
- Septische Unfallchirurgie und Orthopädie, BG Klinikum Hamburg, Hamburg, Germany
| | - Lisa Frielinghaus
- Institut für Medizinische Mikrobiologie, Virologie und Hygiene, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Benjamin Berinson
- Institut für Medizinische Mikrobiologie, Virologie und Hygiene, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Marc Lütgehetmann
- Institut für Medizinische Mikrobiologie, Virologie und Hygiene, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Martin Christner
- Institut für Medizinische Mikrobiologie, Virologie und Hygiene, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Martin Aepfelbacher
- Institut für Medizinische Mikrobiologie, Virologie und Hygiene, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Ulf Gerlach
- Septische Unfallchirurgie und Orthopädie, BG Klinikum Hamburg, Hamburg, Germany
| | - Klaus Seide
- Septische Unfallchirurgie und Orthopädie, BG Klinikum Hamburg, Hamburg, Germany
| | - Anna Both
- Institut für Medizinische Mikrobiologie, Virologie und Hygiene, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Holger Rohde
- Institut für Medizinische Mikrobiologie, Virologie und Hygiene, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany.
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Abstract
Background Plate fixation is the treatment of choice for a midshaft clavicle non-union. Those non-unions that require >1 surgical procedure to heal are termed recalcitrant non-union. Regardless of the number of previously failed procedures, our surgical strategy is aimed at achieving an optimal mechanical and biological environment to facilitate healing. Materials and methods We performed a retrospective analysis of 14 patients with a recalcitrant clavicle non-union treated with open reduction and plate fixation combined with graft augmentation when indicated. Healing rates after index surgery were analysed. All patients were observed for at least 12 months. Results All patients healed at a mean time of 193.2 days (range 90-390). Five of the 14 patients had at least one positive surprise culture, for which they received antibiotic treatment. At the latest follow-up, no patient reported pain or discomfort. Mean disability of the arm, shoulder and hand (DASH) score was 16.3 points (range 0-40), indicating only mild residual impairment. A possible link was found between the time between injury and definitive surgery and the time to healing [Pearson correlation 0.527, sig. (two-tailed) 0.000]. Conclusion This study shows 100% bone healing and good functional outcomes after surgical revision for a recalcitrant clavicle non-union. How to cite this article Grewal S, Baltes TPA, Wiegerinck E, et al. Treatment of a Recalcitrant Non-union of the Clavicle. Strategies Trauma Limb Reconstr 2022;17(1):1-6.
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Affiliation(s)
- Simran Grewal
- Department of Orthopaedic Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam Movement Sciences, Amsterdam, The Netherlands
| | - Thomas PA Baltes
- Department of Orthopaedic Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam Movement Sciences, Amsterdam, The Netherlands
| | - Esther Wiegerinck
- Department of Orthopaedic and Trauma Surgery, Tergooi Hospital, Hilversum, The Netherlands
| | - Peter Kloen
- Department of Orthopaedic Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam Movement Sciences, Amsterdam, The Netherlands
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Ponraj D, Falstie-Jensen T, Jørgensen N, Ravn C, Brüggemann H, Lange J. Diagnosis of orthopaedic-implant-associated infections caused by slow-growing Gram-positive anaerobic bacteria - a clinical perspective. J Bone Jt Infect 2021; 6:367-378. [PMID: 34660180 PMCID: PMC8515996 DOI: 10.5194/jbji-6-367-2021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Accepted: 09/13/2021] [Indexed: 12/21/2022] Open
Abstract
Slow-growing Gram-positive anaerobic bacteria (SGAB) such as Cutibacterium acnes are increasingly recognized as causative agents of implant-associated infections (IAIs) in orthopaedic surgeries. SGAB IAIs are difficult to diagnose because of their non-specific clinical and laboratory findings as well as the fastidious growth conditions required by these bacteria. A high degree of clinical suspicion and awareness of the various available diagnostic methods is therefore important. This review gives an overview of the current knowledge regarding SGAB IAI, providing details about clinical features and available diagnostic methodologies. In recent years, new methods for the diagnosis of IAI were developed, but there is limited knowledge about their usefulness in SGAB IAI. Further studies are required to determine the ideal diagnostic methodology to identify these infections so that they are not overlooked and mistakenly classified as aseptic failure.
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Affiliation(s)
| | - Thomas Falstie-Jensen
- Department of Orthopaedic Surgery, Aarhus University Hospital,
Aarhus, 8200, Denmark
| | | | - Christen Ravn
- Department of Orthopaedic Surgery, Lillebaelt Hospital, Kolding,
6000, Denmark
| | | | - Jeppe Lange
- Department of Clinical Medicine, Aarhus University, Aarhus, 8000,
Denmark
- Department of Orthopaedic Surgery, Horsens Regional Hospital,
Horsens, 8700, Denmark
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14
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Palmowski Y, Pumberger M, Perka C, Hardt S, Hipfl C. Is implant sonication useful when screening for infection in conversion of prior hip fracture fixation to total hip arthroplasty? J Int Med Res 2021; 49:3000605211028123. [PMID: 34515558 PMCID: PMC8442504 DOI: 10.1177/03000605211028123] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Objective To examine sonication results in presumed aseptic conversion total hip
arthroplasty (THA) after hip fracture fixation and to evaluate its
implications on the treatment outcome. Methods This retrospective cohort study reviewed the data from presumed aseptic
patients that underwent conversion of prior internal fixation of proximal
femoral fractures to THA between 2012 and 2018. Microbiological analysis was
performed using sonication of osteosynthesis material and tissue samples.
Treatment outcome including the occurrence of periprosthetic joint infection
(PJI) was recorded. Results A total of 32 patients were included in the study. Of these, five patients
(15.6%) had positive intraoperative cultures. The mean follow-up following
conversion THA was 43.0 months (range, 19.0–91.5 months). Sonication was
positive in three patients (9.4%), all of whom were deemed contaminated and
did not develop PJI. Tissue cultures were positive in two patients (6.3%).
One patient with Enterococcus faecalis received antibiotic
treatment and did not develop PJI. Another patient with growth of
Cutibacterium acnes that was initially classified as a
contaminant later developed acute PJI caused by the same pathogen. Overall,
PJI occurred in two patients (6.3%) after conversion THA. Conclusion Sonication of internal fixation devices did not add diagnostic value in
clinically aseptic conversion THA. Further studies are needed to better
understand the relevance of unexpected positive cultures, and to develop
diagnostic criteria for the management of these patients.
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Affiliation(s)
- Yannick Palmowski
- Centre for Musculoskeletal Surgery, Charité University Medicine Berlin, Berlin, Germany
| | - Matthias Pumberger
- Centre for Musculoskeletal Surgery, Charité University Medicine Berlin, Berlin, Germany
| | - Carsten Perka
- Centre for Musculoskeletal Surgery, Charité University Medicine Berlin, Berlin, Germany
| | - Sebastian Hardt
- Centre for Musculoskeletal Surgery, Charité University Medicine Berlin, Berlin, Germany
| | - Christian Hipfl
- Centre for Musculoskeletal Surgery, Charité University Medicine Berlin, Berlin, Germany
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15
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Falstie-Jensen T, Lange J, Daugaard H, Sørensen AKB, Ovesen J, Søballe K. Unexpected positive cultures after revision shoulder arthroplasty: does it affect outcome? J Shoulder Elbow Surg 2021; 30:1299-1308. [PMID: 33548396 DOI: 10.1016/j.jse.2020.12.014] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 12/07/2020] [Accepted: 12/17/2020] [Indexed: 02/01/2023]
Abstract
BACKGROUND Several studies have confirmed a high rate of unexpected positive cultures (UPCs) after presumably aseptic revisions of shoulder arthroplasties; however, the impact on the outcome is still unclear. The purpose of this prospective study is to compare the patient-reported outcomes of standard revisions with and without the emergence of UPCs. METHODS During a 3-year period, we included all patients who were revised for reasons other than suspicion of infection from 2 orthopedic centers. Five biopsies were obtained from every revision, and only cultures with the same bacteria in at least 3 biopsy specimens were classified as UPCs. All patients were assessed using the Oxford Shoulder Score (OSS) and range of motion preoperatively and after at least a 2-year follow-up. RESULTS In this study, 124 patients were included, with a median follow-up of 29 months (range 29-32), and UPCs emerged after 27 revisions (22%), with Cutibacterium acnes accounting for 67% (18/27). At baseline, the OSS was 22 in both the culture-negative and UPC groups (P = .46). Then, at follow-up, the OSS was 37 in the culture-negative group and 35 in the UPC group (P = .91). The forward elevation increased significantly by 44° and 41°, respectively, in the 2 groups, but no statistically significant difference between the culture-negative group and the UPC group was found (P = .66). In contrast, the external rotation was unchanged after the revision, and again, no difference in the change between the culture-negative and UPC groups (P = .54) was observed. Subgroup analyses stratified by different implant designs revealed equal patterns with no statistical differences in outcome. CONCLUSION We did not find a difference in outcome after a presumed aseptic revision regardless of the emergence of UPCs. Similarly, we could not demonstrate that patients with UPCs presented with poorer function at baseline compared with culture-negative patients. The clinical relevance of UPCs thus requires further evaluation, especially in the case of C acnes as a potential pathogenic versus a merely colonizing microbe.
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Affiliation(s)
| | - Jeppe Lange
- Orthopedic Department, Horsens Regional Hospital, Horsens, Denmark; Department of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Henrik Daugaard
- Orthopedic Department, Herlev-Gentofte Hospital, Herlev, Denmark
| | | | - Janne Ovesen
- Orthopedic Department, Aarhus University Hospital, Aarhus, Denmark
| | - Kjeld Søballe
- Orthopedic Department, Aarhus University Hospital, Aarhus, Denmark; Department of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark
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16
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Cutibacterium acnes infections in revision surgery for persistent shoulder complaints: a retrospective cohort study. Arch Orthop Trauma Surg 2021; 141:197-205. [PMID: 32232618 DOI: 10.1007/s00402-020-03415-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Indexed: 12/26/2022]
Abstract
INTRODUCTION Low-grade Cutibacterium acnes (C. acnes) infections after shoulder surgery usually result in unexplained complaints. The absence of clinical signs of infection makes the incidence unclear and underreported. This study aimed to determine the incidence of C. acnes infections in patients with artificial material and unexplained persistent shoulder complaints. We hypothesized that the incidence of C. acnes infections would be higher in patients with artificial material. Risk factors and associations between culture time and contaminations/infections were also assessed. MATERIALS AND METHODS This retrospective cohort study included patients with and without artificial material undergoing revision shoulder surgery for persistent complaints after primary surgery and the suspicion of a low-grade infection. Three-six cultures were taken in all patients. C. acnes infection incidence was determined and logistic regression analysis was performed to identify risk factors. The association between time to culture growth and infections/contaminations was evaluated using Kaplan-Meier analysis and log-rank test. RESULTS 26/61 (42.6%) patients with and 14/33 (42.2%) without material had a C. acnes infection. Age (OR 0.959; 95% CI 0.914-1.000) and BMI (OR 0.884; 95% CI 0.787-0.977) were risk factors. Time to C. acnes culture positivity was not different between infections and contaminations. CONCLUSION The incidence of C. acnes infections was 42.6% in patients with artificial material and 42.2% in patients without artificial material. Younger age and lower BMI are risk factors. Low-grade C. acnes infections should be considered in patients with unexplained persistent complaints following shoulder surgery.
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17
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Patel MS, Singh AM, Gregori P, Horneff JG, Namdari S, Lazarus MD. Cutibacterium acnes: a threat to shoulder surgery or an orthopedic red herring? J Shoulder Elbow Surg 2020; 29:1920-1927. [PMID: 32499199 DOI: 10.1016/j.jse.2020.02.020] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Revised: 02/10/2020] [Accepted: 02/20/2020] [Indexed: 02/01/2023]
Abstract
Cutibacterium acnes is a lipophilic, anaerobic, gram-positive bacillus that mainly colonizes the pilosebaceous glands of human skin. It has been implicated as the leading cause of prosthetic joint infection (PJI) after shoulder arthroplasty. However, PJI caused by C acnes rarely manifests as overt clinical, laboratory, or imaging features. In fact, more than 40% of shoulders undergoing revision arthroplasty are likely to be culture positive. However, rates of infection following a positive culture can be as low as 5%. The purpose of this review was to put forth alternative explanations for this discordance between positive cultures and infection. We describe C acnes roles as a commensal, bystander, and/or contaminant organism; the role of cultures in diagnosis and other methods that may be more accurate; its existence in a shoulder microbiome; and the variable virulence of C acnes. C acnes is an important cause of shoulder PJI in some patients. However, there is a large body of literature that suggests other functions that need to be considered. Further research is needed to define the role of C acnes that is logically explained by all of the literature and not only some.
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Affiliation(s)
- Manan S Patel
- Department of Orthopaedic Surgery, The Rothman Institute at Thomas Jefferson University, Philadelphia, PA, USA.
| | - Arjun M Singh
- Department of Orthopaedic Surgery, The Rothman Institute at Thomas Jefferson University, Philadelphia, PA, USA
| | - Pietro Gregori
- Department of Orthopaedic Surgery, The Rothman Institute at Thomas Jefferson University, Philadelphia, PA, USA
| | - John G Horneff
- Department of Orthopaedic Surgery, The Rothman Institute at Thomas Jefferson University, Philadelphia, PA, USA
| | - Surena Namdari
- Department of Orthopaedic Surgery, The Rothman Institute at Thomas Jefferson University, Philadelphia, PA, USA
| | - Mark D Lazarus
- Department of Orthopaedic Surgery, The Rothman Institute at Thomas Jefferson University, Philadelphia, PA, USA
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18
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Trotter AJ, Dean R, Whitehouse CE, Mikalsen J, Hill C, Brunton-Sim R, Kay GL, Shakokani M, Durst AZE, Wain J, McNamara I, O'Grady J. Preliminary evaluation of a rapid lateral flow calprotectin test for the diagnosis of prosthetic joint infection. Bone Joint Res 2020; 9:202-210. [PMID: 32566141 PMCID: PMC7284294 DOI: 10.1302/2046-3758.95.bjr-2019-0213.r1] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
AIMS This pilot study tested the performance of a rapid assay for diagnosing prosthetic joint infection (PJI), which measures synovial fluid calprotectin from total hip and knee revision patients. METHODS A convenience series of 69 synovial fluid samples from revision patients at the Norfolk and Norwich University Hospital were collected intraoperatively (52 hips, 17 knees) and frozen. Synovial fluid calprotectin was measured retrospectively using a new commercially available lateral flow assay for PJI diagnosis (Lyfstone AS) and compared to International Consensus Meeting (ICM) 2018 criteria and clinical case review (ICM-CR) gold standards. RESULTS According to ICM, 24 patients were defined as PJI positive and the remaining 45 were negative. The overall accuracy of the lateral flow test compared to ICM was 75.36% (52/69, 95% CI 63.51% to 84.95%), sensitivity and specificity were 75.00% (18/24, 95% CI 53.29% to 90.23%) and 75.56% (34/45, 95% CI 60.46% to 87.12%), respectively, positive predictive value (PPV) was 62.07% (18/29, 95% CI 48.23% to 74.19%) and negative predictive value (NPV) was 85.00% (34/40, 95% CI 73.54% to 92.04%), and area under the receiver operating characteristic (ROC) curve (AUC) was 0.78 (95% CI 0.66 to 0.87). Patient data from discordant cases were reviewed by the clinical team to develop the ICM-CR gold standard. The lateral flow test performance improved significantly when compared to ICM-CR, with accuracy increasing to 82.61% (57/69, 95% CI 71.59% to 90.68%), sensitivity increasing to 94.74% (18/19, 95% CI 73.97% to 99.87%), NPV increasing to 97.50% (39/40, 95% CI 85.20% to 99.62%), and AUC increasing to 0.91 (95% CI 0.81 to 0.96). Test performance was better in knees (100.00% accurate (17/17, 95% CI 80.49% to 100.00%)) compared to hips (76.92% accurate (40/52, 95% CI 63.16% to 87.47%)). CONCLUSION This study demonstrates that the calprotectin lateral flow assay could be an effective diagnostic test for PJI, however additional prospective studies testing fresh samples are required.Cite this article: Bone Joint Res. 2020;9(5):202-210.
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Affiliation(s)
- Alexander J Trotter
- University of East Anglia, Norwich, UK, Quadram Institute Bioscience, Norwich Research Park, Norwich, UK
| | - Rachael Dean
- University of East Anglia, Norwich, UK, Quadram Institute Bioscience, Norwich Research Park, Norwich, UK
| | | | | | - Claire Hill
- Quadram Institute Bioscience, Norwich Research Park, Norwich, UK, Norfolk and Norwich University Hospitals Foundation Trust, Norwich, UK
| | | | - Gemma L Kay
- Quadram Institute Bioscience, Norwich Research Park, Norwich, UK
| | | | - Alexander Z E Durst
- University of East Anglia, Norwich, UK, Norfolk and Norwich University Hospitals Foundation Trust, Norwich, UK
| | - John Wain
- University of East Anglia, Norwich, UK, Quadram Institute Bioscience, Norwich Research Park, Norwich, UK
| | - Iain McNamara
- University of East Anglia, Norwich, UK, Norfolk and Norwich University Hospitals Foundation Trust, Norwich, UK
| | - Justin O'Grady
- University of East Anglia, Norwich, UK, Quadram Institute Bioscience, Norwich Research Park, Norwich, UK
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18F FDG-PET/CT has poor diagnostic accuracy in diagnosing shoulder PJI. Eur J Nucl Med Mol Imaging 2019; 46:2013-2022. [PMID: 31292698 DOI: 10.1007/s00259-019-04381-w] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Accepted: 05/28/2019] [Indexed: 01/11/2023]
Abstract
PURPOSE Chronic low-grade periprosthetic joint infection (PJI) of a shoulder replacement can be challenging to diagnose. 18F-FDG PET/CT is suggested as a modality to diagnose lower-limb PJI, but no studies on shoulder replacements exist. The aim of this study was therefore to determine the diagnostic accuracy of 18F-FDG PET/CT in diagnosing chronic PJI of the shoulder. METHODS Patients evaluated for a failed shoulder replacement during a 3-year period were prospectively included in the study. All patients underwent pre-operative 18F-FDG PET/CT, and were evaluated for signs of infection by three independent reviewers using shoulder-specific criteria. Interrater-agreement was calculated between the reviewers. If the patient had revision surgery, biopsy specimens were obtained and cultured with bacterial growth in the cultures serving as gold standard of infection. RESULTS A total of 86 patients were included in the study. Nine patients were 18F-FDG PET/CT positive for infection, with only three true positive. Using the gold standard, infection was diagnosed after revision surgery in 22 cases. All infections were chronic and caused by low-virulent microbes. The sensitivity of 18F-FDG PET/CT was 0.14 95% CI (0.03-0.36), specificity 0.91 95% CI (0.81-0.97), positive predictive value was 0.40 95% CI (0.15-0.71) and negative predictive value 0.71 95% CI (0.67-0.75). The inter-observer agreement was 0.56 (Fleiss' kappa), indicating moderate agreement of the visual FDG-PET evaluation using the shoulder-specific criteria. CONCLUSION 18F-FDG PET/CT has poor diagnostic accuracy in diagnosing low-grade PJI of the shoulder. 18F-FDG PET/CT cannot be recommended as a part of the routine preoperative workup to diagnose low-grade infection of a shoulder replacement.
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