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Wildeman P, Rolfson O, Wretenberg P, Nåtman J, Gordon M, Söderquist B, Lindgren V. Effect of a national infection control programme in Sweden on prosthetic joint infection incidence following primary total hip arthroplasty: a cohort study. BMJ Open 2024; 14:e076576. [PMID: 38684253 PMCID: PMC11086449 DOI: 10.1136/bmjopen-2023-076576] [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: 06/15/2023] [Accepted: 03/01/2024] [Indexed: 05/02/2024] Open
Abstract
OBJECTIVES Prosthetic joint infection (PJI) is a serious complication following total hip arthroplasty (THA) entailing increased mortality, decreased quality of life and high healthcare costs.The primary aim was to investigate whether the national project: Prosthesis Related Infections Shall be Stopped (PRISS) reduced PJI incidence after primary THA; the secondary aim was to evaluate other possible benefits of PRISS, such as shorter time to diagnosis. DESIGN Cohort study. SETTING In 2009, a nationwide, multidisciplinary infection control programme was launched in Sweden, PRISS, which aimed to reduce the PJI burden by 50%. PARTICIPANTS We obtained data on patients undergoing primary THA from the Swedish Arthroplasty Registry 2012-2014, (n=45 723 patients, 49 946 THAs). Using personal identity numbers, this cohort was matched with the Swedish Prescribed Drug Registry. Medical records of patients with ≥4 weeks' antibiotic consumption were reviewed to verify PJI diagnosis (n=2240, 2569 THAs). RESULTS The cumulative incidence of PJI following the PRISS Project was 1.2% (95% CI 1.1% to 1.3%) as compared with 0.9% (95% CI 0.8% to 1.0%) before. Cox regression models for the PJI incidence post-PRISS indicates there was no statistical significance difference versus pre-PRISS (HR 1.1 (95% CI 0.9 to 1.3)). There was similar time to PJI diagnosis after the PRISS Project 24 vs 23 days (p=0.5). CONCLUSIONS Despite the comprehensive nationwide PRISS Project, Swedish PJI incidence was higher after the project and time to diagnosis remained unchanged. Factors contributing to PJI, such as increasing obesity, higher American Society of Anesthesiology class and more fractures as indications, explain the PJI increase among primary THA patients.
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Affiliation(s)
- Peter Wildeman
- Department of Orthopedics, Faculty of Medicine and Health, Orebro University, Orebro, Sweden
| | - Ola Rolfson
- Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Swedish Arthroplasty Register, Registercentrum Vastra Gotaland, Gothenburg, Sweden
| | - Per Wretenberg
- Department of Orthopedics, Faculty of Medicine and Health, Orebro University, Orebro, Sweden
| | - Jonatan Nåtman
- Swedish Arthroplasty Register, Registercentrum Vastra Gotaland, Gothenburg, Sweden
| | - Max Gordon
- Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Bo Söderquist
- School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Orebro, Sweden
- Department of Infectious Diseases, Faculty of Medicine and Health, Orebro University, Orebro, Sweden
| | - Viktor Lindgren
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
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van Veghel MHW, Belt M, Spekenbrink-Spooren A, Kuijpers MFL, van der Kooi TII, Schreurs BW, Hannink G. Validation of the Incidence of Reported Periprosthetic Joint Infections in Total Hip and Knee Arthroplasty in the Dutch Arthroplasty Register. J Arthroplasty 2024; 39:1054-1059. [PMID: 37914036 DOI: 10.1016/j.arth.2023.10.040] [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: 06/06/2023] [Revised: 10/17/2023] [Accepted: 10/21/2023] [Indexed: 11/03/2023] Open
Abstract
BACKGROUND Arthroplasty registers underreport the incidence of periprosthetic joint infections (PJIs). We validated the incidence of reported PJIs in total hip arthroplasties (THAs) and total knee arthroplasties (TKAs) in the Dutch Arthroplasty Register (LROI) using data from the Dutch National Nosocomial Surveillance Network (PREZIES). METHODS All primary THAs and TKAs from the LROI and all primary THAs and TKAs performed in consenting hospitals from PREZIES between 2012 and 2018 were matched on date of birth, date of surgery, sex, hospital, and type of procedure (THA n = 91,208; TKA n = 80,304). Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated for PJIs registered in the LROI, using PREZIES as a reference. RESULTS The incidence of registered PJIs in THAs was 1.2% in PREZIES and 0.5% in the LROI. For TKAs, this was 0.7 and 0.4%, respectively. The PJIs in THAs in the LROI had a sensitivity of 0.32 (confidence interval [CI]: 0.29 to 0.35), specificity of 1.00 (CI: 1.00 to 1.00), PPV of 0.74 (CI: 0.70 to 0.78), and NPV of 0.99 (CI: 0.99 to 0.99). In TKAs, the sensitivity, specificity, PPV, and NPV were 0.38 (CI: 0.34 to 0.42), 1.00 (CI: 1.00 to 1.00), 0.65 (CI: 0.59 to 0.70), and 1.00 (CI: 1.00 to 1.00), respectively. CONCLUSIONS The LROI captures approximately one-third of the PJIs as revision within one year for infection or resection arthroplasty. The capture rate of PJIs can be improved by including all reoperations without component exchange and nonsurgical treatments with antibiotics only.
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Affiliation(s)
- Mirthe H W van Veghel
- Department of Orthopaedics, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Maartje Belt
- Research Department, Sint Maartenskliniek, Nijmegen, The Netherlands
| | - Anneke Spekenbrink-Spooren
- Dutch Arthroplasty Register (Landelijke Registratie Orthopedische Interventies), 's-Hertogenbosch, The Netherlands
| | - Martijn F L Kuijpers
- Department of Orthopaedics, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Tjallie I I van der Kooi
- Department of Epidemiology and Surveillance, National Institute for Public Health and the Environment (RIVM), Centre for Infectious Diseases Control, Bilthoven, The Netherlands
| | - Berend Willem Schreurs
- Department of Orthopaedics, Radboud University Medical Center, Nijmegen, The Netherlands; Dutch Arthroplasty Register (Landelijke Registratie Orthopedische Interventies), 's-Hertogenbosch, The Netherlands
| | - Gerjon Hannink
- Department of Medical Imaging, Radboud University Medical Center, Nijmegen, The Netherlands
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Eriksson HK, Lazarinis S, Järhult JD, Hailer NP. Early Staphylococcal Periprosthetic Joint Infection (PJI) Treated with Debridement, Antibiotics, and Implant Retention (DAIR): Inferior Outcomes in Patients with Staphylococci Resistant to Rifampicin. Antibiotics (Basel) 2023; 12:1589. [PMID: 37998791 PMCID: PMC10668653 DOI: 10.3390/antibiotics12111589] [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: 09/25/2023] [Revised: 10/30/2023] [Accepted: 11/01/2023] [Indexed: 11/25/2023] Open
Abstract
It is unknown how rifampicin resistance in staphylococci causing a periprosthetic joint infection (PJI) affects outcomes after debridement, antibiotics, and implant retention (DAIR). We thus aimed to compare the risk of relapse in DAIR-treated early PJI caused by staphylococci with or without rifampicin resistance. In total, 81 patients affected by early PJI were included, and all patients were treated surgically with DAIR. This was repeated if needed. The endpoint of relapse-free survival was estimated using the Kaplan-Meier method, and Cox regression models were fitted to assess the risk of infection relapse for patients infected with rifampicin-resistant bacteria, adjusted for age, sex, type of joint, and type of index surgery. In patients with rifampicin-resistant staphylococci, relapse was seen in 80% after one DAIR procedure and in 70% after two DAIR procedures. In patients with rifampicin-sensitive bacteria, 51% had an infection relapse after one DAIR procedure and 33% had an infection relapse after two DAIR procedures. Patients with rifampicin-resistant staphylococcal PJI thus had an increased adjusted risk of infection relapse of 1.9 (95% CI: 1.1-3.6, p = 0.04) after one DAIR procedure compared to patients with rifampicin-sensitive bacteria and a 4.1-fold (95% CI: 1.2-14.1, p = 0.03) increase in risk of infection relapse after two DAIR procedures. Staphylococcal resistance to rifampicin is associated with inferior outcomes after DAIR. These findings suggest that DAIR may not be a useful strategy in early PJI caused by rifampicin-resistant staphylococci.
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Affiliation(s)
- Hannah K. Eriksson
- Department of Surgical Sciences, Section of Orthopaedics, Uppsala University, 751 83 Uppsala, Sweden; (S.L.); (N.P.H.)
| | - Stergios Lazarinis
- Department of Surgical Sciences, Section of Orthopaedics, Uppsala University, 751 83 Uppsala, Sweden; (S.L.); (N.P.H.)
| | - Josef D. Järhult
- Zoonosis Science Center, Department of Medical Sciences, Uppsala University, 751 83 Uppsala, Sweden;
| | - Nils P. Hailer
- Department of Surgical Sciences, Section of Orthopaedics, Uppsala University, 751 83 Uppsala, Sweden; (S.L.); (N.P.H.)
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4
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Zeng ZJ, Yao FM, He W, Wei QS, He MC. Incidence of periprosthetic joint infection after primary total hip arthroplasty is underestimated: a synthesis of meta-analysis and bibliometric analysis. J Orthop Surg Res 2023; 18:610. [PMID: 37605235 PMCID: PMC10440885 DOI: 10.1186/s13018-023-04060-5] [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: 05/21/2023] [Accepted: 07/30/2023] [Indexed: 08/23/2023] Open
Abstract
The American Musculoskeletal Society updated the diagnostic criteria for periprosthetic joint infection (PJI) in 2011 and 2018. However, the overall incidence of PJI since the introduction of these new standards has not been assessed. In order to fill this knowledge gap, a single-group meta-analysis was conducted using articles obtained from several databases, focusing on the incidence of PJI after primary total hip arthroplasty (THA). Our study revealed a significant difference in the incidence of PJI reported by different national or regional databases. Moreover, most cases of PJI were found to be underestimated. This highlights the crucial need for standardized diagnostic criteria and monitoring methods to accurately identify and track cases of PJI. Furthermore, a bibliometric analysis was conducted to provide a comprehensive overview of the current state of research on PJI after THA. This analysis explored the most productive countries, organizations, journals, and individuals in this research area. Additionally, it identified the research trends and hotspots of the last decade, highlighting the advancements and areas of focus in this field. By conducting these analyses, the study aims to contribute to the understanding of PJI after THA and provide valuable insights for clinicians, researchers, and policymakers involved in the management of this condition.
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Affiliation(s)
- Zi-Jun Zeng
- The Third School of Clinical Medicine, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Fang-Ming Yao
- The Third School of Clinical Medicine, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Wei He
- The Third School of Clinical Medicine, Guangzhou University of Chinese Medicine, Guangzhou, China.
- Guangdong Research Institute for Orthopedics and Traumatology of Chinese Medicine, Guangzhou, China.
- The Third Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China.
| | - Qiu-Shi Wei
- The Third School of Clinical Medicine, Guangzhou University of Chinese Medicine, Guangzhou, China.
- Guangdong Research Institute for Orthopedics and Traumatology of Chinese Medicine, Guangzhou, China.
- The Third Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China.
| | - Min-Cong He
- The Third School of Clinical Medicine, Guangzhou University of Chinese Medicine, Guangzhou, China.
- Guangdong Research Institute for Orthopedics and Traumatology of Chinese Medicine, Guangzhou, China.
- The Third Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China.
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5
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Moore AJ, Wylde V, Whitehouse MR, Beswick AD, Walsh NE, Jameson C, Blom AW. Development of evidence-based guidelines for the treatment and management of periprosthetic hip infection. Bone Jt Open 2023; 4:226-233. [PMID: 37051823 PMCID: PMC10065846 DOI: 10.1302/2633-1462.44.bjo-2022-0155.r1] [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: 04/03/2023] Open
Abstract
Aims Periprosthetic hip-joint infection is a multifaceted and highly detrimental outcome for patients and clinicians. The incidence of prosthetic joint infection reported within two years of primary hip arthroplasty ranges from 0.8% to 2.1%. Costs of treatment are over five-times greater in people with periprosthetic hip joint infection than in those with no infection. Currently, there are no national evidence-based guidelines for treatment and management of this condition to guide clinical practice or to inform clinical study design. The aim of this study is to develop guidelines based on evidence from the six-year INFection and ORthopaedic Management (INFORM) research programme. Methods We used a consensus process consisting of an evidence review to generate items for the guidelines and online consensus questionnaire and virtual face-to-face consensus meeting to draft the guidelines. Results The consensus panel comprised 21 clinical experts in orthopaedics, primary care, rehabilitation, and healthcare commissioning. The final output from the consensus process was a 14-item guideline. The guidelines make recommendations regarding increased vigilance and monitoring of those at increased risk of infection; diagnosis including strategies to ensure the early recognition of prosthetic infection and referral to orthopaedic teams; treatment, including early use of DAIR and revision strategies; and postoperative management including appropriate physical and psychological support and antibiotic strategies. Conclusion We believe the implementation of the INFORM guidelines will inform treatment protocols and clinical pathways to improve the treatment and management of periprosthetic hip infection. Cite this article: Bone Jt Open 2023;4(4):226–233.
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Affiliation(s)
- Andrew J. Moore
- University of Bristol, Bristol, UK
- Correspondence should be sent to Andrew J. Moore. E-mail:
| | | | | | | | - Nicola E. Walsh
- HAS - Allied Health Professions, University of the West of England, Bristol, UK
| | | | - Ashley W. Blom
- University of Sheffield Faculty of Medicine Dentistry and Health, Sheffield, UK
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Blom AW, Beswick AD, Burston A, Carroll FE, Garfield K, Gooberman-Hill R, Harris S, Kunutsor SK, Lane A, Lenguerrand E, MacGowan A, Mallon C, Moore AJ, Noble S, Palmer CK, Rolfson O, Strange S, Whitehouse MR. Infection after total joint replacement of the hip and knee: research programme including the INFORM RCT. PROGRAMME GRANTS FOR APPLIED RESEARCH 2022. [DOI: 10.3310/hdwl9760] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Background
People with severe osteoarthritis, other joint conditions or injury may have joint replacement to reduce pain and disability. In the UK in 2019, over 200,000 hip and knee replacements were performed. About 1 in 100 replacements becomes infected, and most people with infected replacements require further surgery.
Objectives
To investigate why some patients are predisposed to joint infections and how this affects patients and the NHS, and to evaluate treatments.
Design
Systematic reviews, joint registry analyses, qualitative interviews, a randomised controlled trial, health economic analyses and a discrete choice questionnaire.
Setting
Our studies are relevant to the NHS, to the Swedish health system and internationally.
Participants
People with prosthetic joint infection after hip or knee replacement and surgeons.
Interventions
Revision of hip prosthetic joint infection with a single- or two-stage procedure.
Main outcome measures
Long-term patient-reported outcomes and reinfection. Cost-effectiveness of revision strategies over 18 months from two perspectives: health-care provider and Personal Social Services, and societal.
Data sources
National Joint Registry; literature databases; published cohort studies; interviews with 67 patients and 35 surgeons; a patient discrete choice questionnaire; and the INFORM (INFection ORthopaedic Management) randomised trial.
Review methods
Systematic reviews of studies reporting risk factors, diagnosis, treatment outcomes and cost comparisons. Individual patient data meta-analysis.
Results
In registry analyses, about 0.62% and 0.75% of patients with hip and knee replacement, respectively, had joint infection requiring surgery. Rates were four times greater after aseptic revision. The costs of inpatient and day-case admissions in people with hip prosthetic joint infection were about five times higher than those in people with no infection, an additional cost of > £30,000. People described devastating effects of hip and knee prosthetic joint infection and treatment. In the treatment of hip prosthetic joint infection, a two-stage procedure with or without a cement spacer had a greater negative impact on patient well-being than a single- or two-stage procedure with a custom-made articulating spacer. Surgeons described the significant emotional impact of hip and knee prosthetic joint infection and the importance of a supportive multidisciplinary team. In systematic reviews and registry analyses, the risk factors for hip and knee prosthetic joint infection included male sex, diagnoses other than osteoarthritis, high body mass index, poor physical status, diabetes, dementia and liver disease. Evidence linking health-care setting and surgeon experience with prosthetic joint infection was inconsistent. Uncemented fixation, posterior approach and ceramic bearings were associated with lower infection risk after hip replacement. In our systematic review, synovial fluid alpha-defensin and leucocyte esterase showed high diagnostic accuracy for prosthetic joint infection. Systematic reviews and individual patient data meta-analysis showed similar reinfection outcomes in patients with hip or knee prosthetic joint infection treated with single- and two-stage revision. In registry analysis, there was a higher rate of early rerevision after single-stage revision for hip prosthetic joint infection, but, overall, 40% fewer operations are required as part of a single-stage procedure than as part of a two-stage procedure. The treatment of hip or knee prosthetic joint infection with early debridement and implant retention may be effective in > 60% of cases. In the INFORM randomised controlled trial, 140 patients with hip prosthetic joint infection were randomised to single- or two-stage revision. Eighteen months after randomisation, pain, function and stiffness were similar between the randomised groups (p = 0.98), and there were no differences in reinfection rates. Patient outcomes improved earlier in the single-stage than in the two-stage group. Participants randomised to a single-stage procedure had lower costs (mean difference –£10,055, 95% confidence interval –£19,568 to –£542) and higher quality-adjusted life-years (mean difference 0.06, 95% confidence interval –0.07 to 0.18) than those randomised to a two-stage procedure. Single-stage was the more cost-effective option, with an incremental net monetary benefit at a threshold of £20,000 per quality-adjusted life-year of £11,167 (95% confidence interval £638 to £21,696). In a discrete choice questionnaire completed by 57 patients 18 months after surgery to treat hip prosthetic joint infection, the most valued characteristics in decisions about revision were the ability to engage in valued activities and a quick return to normal activity.
Limitations
Some research was specific to people with hip prosthetic joint infection. Study populations in meta-analyses and registry analyses may have been selected for joint replacement and specific treatments. The INFORM trial was not powered to study reinfection and was limited to 18 months’ follow-up. The qualitative study subgroups were small.
Conclusions
We identified risk factors, diagnostic biomarkers, effective treatments and patient preferences for the treatment of hip and knee prosthetic joint infection. The risk factors include male sex, diagnoses other than osteoarthritis, specific comorbidities and surgical factors. Synovial fluid alpha-defensin and leucocyte esterase showed high diagnostic accuracy. Infection is devastating for patients and surgeons, both of whom describe the need for support during treatment. Debridement and implant retention is effective, particularly if performed early. For infected hip replacements, single- and two-stage revision appear equally efficacious, but single-stage has better early results, is cost-effective at 18-month follow-up and is increasingly used. Patients prefer treatments that allow full functional return within 3–9 months.
Future work
For people with infection, develop information, counselling, peer support and care pathways. Develop supportive care and information for patients and health-care professionals to enable the early recognition of infections. Compare alternative and new treatment strategies in hip and knee prosthetic joint infection. Assess diagnostic methods and establish NHS diagnostic criteria.
Study registration
The INFORM randomised controlled trial is registered as ISRCTN10956306. All systematic reviews were registered in PROSPERO (as CRD42017069526, CRD42015023485, CRD42018106503, CRD42018114592, CRD42015023704, CRD42017057513, CRD42015016559, CRD42015017327 and CRD42015016664).
Funding
This project was funded by the National Institute for Health and Care Research (NIHR) Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 10, No. 10. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Ashley W Blom
- National Institute for Health and Care Research Bristol Biomedical Research Centre, University Hospitals Bristol and Weston NHS Foundation Trust and University of Bristol, Bristol, UK
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Andrew D Beswick
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Amanda Burston
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Fran E Carroll
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Kirsty Garfield
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- Bristol Randomised Trials Collaboration, University of Bristol, Bristol, UK
| | - Rachael Gooberman-Hill
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Shaun Harris
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- Bristol Randomised Trials Collaboration, University of Bristol, Bristol, UK
| | - Setor K Kunutsor
- National Institute for Health and Care Research Bristol Biomedical Research Centre, University Hospitals Bristol and Weston NHS Foundation Trust and University of Bristol, Bristol, UK
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Athene Lane
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- Bristol Randomised Trials Collaboration, University of Bristol, Bristol, UK
| | - Erik Lenguerrand
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | | | - Charlotte Mallon
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Andrew J Moore
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Sian Noble
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Cecily K Palmer
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- National Institute for Health and Care Research Applied Research Collaboration West (NIHR ARC West), University Hospitals Bristol NHS Foundation Trust and University of Bristol, Bristol, UK
| | - Ola Rolfson
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Simon Strange
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Michael R Whitehouse
- National Institute for Health and Care Research Bristol Biomedical Research Centre, University Hospitals Bristol and Weston NHS Foundation Trust and University of Bristol, Bristol, UK
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
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7
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Blom AW, Lenguerrand E, Strange S, Noble SM, Beswick AD, Burston A, Garfield K, Gooberman-Hill R, Harris SRS, Kunutsor SK, Lane JA, MacGowan A, Mehendale S, Moore AJ, Rolfson O, Webb JCJ, Wilson M, Whitehouse MR. Clinical and cost effectiveness of single stage compared with two stage revision for hip prosthetic joint infection (INFORM): pragmatic, parallel group, open label, randomised controlled trial. BMJ 2022; 379:e071281. [PMID: 36316046 PMCID: PMC9645409 DOI: 10.1136/bmj-2022-071281] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES To determine whether patient reported outcomes improve after single stage versus two stage revision surgery for prosthetic joint infection of the hip, and to determine the cost effectiveness of these procedures. DESIGN Pragmatic, parallel group, open label, randomised controlled trial. SETTING High volume tertiary referral centres or orthopaedic units in the UK (n=12) and in Sweden (n=3), recruiting from 1 March 2015 to 19 December 2018. PARTICIPANTS 140 adults (aged ≥18 years) with a prosthetic joint infection of the hip who required revision (65 randomly assigned to single stage and 75 to two stage revision). INTERVENTIONS A computer generated 1:1 randomisation list stratified by hospital was used to allocate participants with prosthetic joint infection of the hip to a single stage or a two stage revision procedure. MAIN OUTCOME MEASURES The primary intention-to-treat outcome was pain, stiffness, and functional limitations 18 months after randomisation, measured by the Western Ontario and McMasters Universities Osteoarthritis Index (WOMAC) score. Secondary outcomes included surgical complications and joint infection. The economic evaluation (only assessed in UK participants) compared quality adjusted life years and costs between the randomised groups. RESULTS The mean age of participants was 71 years (standard deviation 9) and 51 (36%) were women. WOMAC scores did not differ between groups at 18 months (mean difference 0.13 (95% confidence interval -8.20 to 8.46), P=0.98); however, the single stage procedure was better at three months (11.53 (3.89 to 19.17), P=0.003), but not from six months onwards. Intraoperative events occurred in five (8%) participants in the single stage group and 20 (27%) in the two stage group (P=0.01). At 18 months, nine (14%) participants in the single stage group and eight (11%) in the two stage group had at least one marker of possible ongoing infection (P=0.62). From the perspective of healthcare providers and personal social services, single stage revision was cost effective with an incremental net monetary benefit of £11 167 (95% confidence interval £638 to £21 696) at a £20 000 per quality adjusted life years threshold (£1.0; $1.1; €1.4). CONCLUSIONS At 18 months, single stage revision compared with two stage revision for prosthetic joint infection of the hip showed no superiority by patient reported outcome. Single stage revision had a better outcome at three months, fewer intraoperative complications, and was cost effective. Patients prefer early restoration of function, therefore, when deciding treatment, surgeons should consider patient preferences and the cost effectiveness of single stage surgery. TRIAL REGISTRATION ISRCTN registry ISRCTN10956306.
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Affiliation(s)
- Ashley W Blom
- University of Bristol Medical School, Translational Health Sciences, Musculoskeletal Research Unit, Level 1 Learning and Research Building, Southmead Hospital, Westbury-on-Trym, Bristol, UK
- National Institute for Health and Care Research Bristol Biomedical Research Centre, University Hospitals Bristol and Weston NHS Foundation Trust and University of Bristol, Bristol, UK
| | - Erik Lenguerrand
- University of Bristol Medical School, Translational Health Sciences, Musculoskeletal Research Unit, Level 1 Learning and Research Building, Southmead Hospital, Westbury-on-Trym, Bristol, UK
| | - Simon Strange
- University of Bristol Medical School, Translational Health Sciences, Musculoskeletal Research Unit, Level 1 Learning and Research Building, Southmead Hospital, Westbury-on-Trym, Bristol, UK
| | - Sian M Noble
- University of Bristol Medical School, Population Health Sciences, Canynge Hall, Bristol, UK
| | - Andrew D Beswick
- University of Bristol Medical School, Translational Health Sciences, Musculoskeletal Research Unit, Level 1 Learning and Research Building, Southmead Hospital, Westbury-on-Trym, Bristol, UK
| | - Amanda Burston
- University of Bristol Medical School, Translational Health Sciences, Musculoskeletal Research Unit, Level 1 Learning and Research Building, Southmead Hospital, Westbury-on-Trym, Bristol, UK
| | - Kirsty Garfield
- University of Bristol Medical School, Population Health Sciences, Canynge Hall, Bristol, UK
- University of Bristol Faculty of Health Sciences, Bristol Randomised Trials Collaboration, Canynge Hall, Bristol, UK
| | - Rachael Gooberman-Hill
- University of Bristol Medical School, Translational Health Sciences, Musculoskeletal Research Unit, Level 1 Learning and Research Building, Southmead Hospital, Westbury-on-Trym, Bristol, UK
- National Institute for Health and Care Research Bristol Biomedical Research Centre, University Hospitals Bristol and Weston NHS Foundation Trust and University of Bristol, Bristol, UK
| | - Shaun R S Harris
- University of Bristol Medical School, Population Health Sciences, Canynge Hall, Bristol, UK
- University of Bristol Faculty of Health Sciences, Bristol Randomised Trials Collaboration, Canynge Hall, Bristol, UK
| | - Setor K Kunutsor
- University of Bristol Medical School, Translational Health Sciences, Musculoskeletal Research Unit, Level 1 Learning and Research Building, Southmead Hospital, Westbury-on-Trym, Bristol, UK
- National Institute for Health and Care Research Bristol Biomedical Research Centre, University Hospitals Bristol and Weston NHS Foundation Trust and University of Bristol, Bristol, UK
| | - J Athene Lane
- University of Bristol Medical School, Population Health Sciences, Canynge Hall, Bristol, UK
- University of Bristol Faculty of Health Sciences, Bristol Randomised Trials Collaboration, Canynge Hall, Bristol, UK
| | - Alasdair MacGowan
- Department of Medical Microbiology, Southmead Hospital, North Bristol NHS Trust, Bristol, Westbury-on-Trym, UK
| | - Sanchit Mehendale
- Department of Trauma and Orthopaedics, Bristol Royal Infirmary, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Andrew J Moore
- University of Bristol Medical School, Translational Health Sciences, Musculoskeletal Research Unit, Level 1 Learning and Research Building, Southmead Hospital, Westbury-on-Trym, Bristol, UK
| | - Ola Rolfson
- Department of Orthopaedics at Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Mölndal, Sweden
| | - Jason C J Webb
- University of Bristol Medical School, Translational Health Sciences, Musculoskeletal Research Unit, Level 1 Learning and Research Building, Southmead Hospital, Westbury-on-Trym, Bristol, UK
| | - Matthew Wilson
- The Exeter Hip Unit, Princess Elizabeth Orthopaedic Hospital, Royal Devon and Exeter Hospital NHS Foundation Trust, Exeter, UK
| | - Michael R Whitehouse
- University of Bristol Medical School, Translational Health Sciences, Musculoskeletal Research Unit, Level 1 Learning and Research Building, Southmead Hospital, Westbury-on-Trym, Bristol, UK
- National Institute for Health and Care Research Bristol Biomedical Research Centre, University Hospitals Bristol and Weston NHS Foundation Trust and University of Bristol, Bristol, UK
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8
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Porter M, Rolfson O, de Steiger R. International Registries: U.K. National Joint Registry, Nordic Registries, and Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR). J Bone Joint Surg Am 2022; 104:23-27. [PMID: 36260040 DOI: 10.2106/jbjs.22.00561] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
National-level joint arthroplasty registries were among the first large orthopaedic surgery databases and represent some of the longest-running and most influential big databases in our profession. Nordic registries were among the first registries and were followed by excellent registries in the United Kingdom and Australia. In this article, we describe each of these registries and highlight the data elements collected, the data points that can be obtained by linking the national arthroplasty registries to other national registries or databases, the completeness of data, and the strengths and weaknesses of each database. Each of these registries publishes an annual report that is available online, and each also can do more detailed analysis of certain aspects of its data for special studies.When evaluating and interpreting data from national joint registries, the user should be aware that, despite the power of huge numbers, there remain numerous limitations to the observational data. Strong selection biases exist with regard to which patients are chosen for which procedure. Surgeons of different skill levels may use one technique or implant differentially compared with another. The end points that registries collect differ widely: for example, some report only hip dislocations leading to revision rather than all dislocations. Registries in countries in which there are long wait times for revision surgery may report artificially low revision rates compared with countries in which revision surgery is more easily accessible. Despite these limitations, registries have the merit of reporting the actual results of huge numbers of surgical procedures performed across the spectrum of hospitals, surgeons, and patients, making the data extremely powerful for identifying trends, identifying early signs of problems related to certain implants or implant classes, and identifying associations between variables that can be further studied to determine if the effect is causal.
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Affiliation(s)
- Martyn Porter
- Centre for Hip Surgery, Wrightington Hospital, Lancashire, England
| | - Ola Rolfson
- Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Richard de Steiger
- Epworth Healthcare, University of Melbourne, Melbourne, Victoria, Australia.,Australian Orthopaedic Association National Joint Replacement Registry, Adelaide, South Australia, Australia
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9
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Probert N, Andersson ÅG, Magnuson A, Kjellberg E, Wretenberg P. Surgical-site infection after hip fracture surgery: preoperative full-body disinfection compared to local disinfection of the surgical site-a population-based observational cohort study. Eur Geriatr Med 2022; 13:1089-1097. [PMID: 35391660 PMCID: PMC9553784 DOI: 10.1007/s41999-022-00640-6] [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: 12/23/2021] [Accepted: 03/21/2022] [Indexed: 11/20/2022]
Abstract
Aim To compare preoperative full-body disinfection (FBD) prior to hip fracture surgery with local disinfection (LD) of the surgical site regarding incidence of postoperative surgical-site infection (SSI), both procedures performed with 4% chlorhexidine. Findings There were 16 (6.8%) cases of SSI in 2018 when FBD was performed and 8 (3.1%) cases in 2019 when LD was performed. FBD (2018) compared to LD (2019) presented an adjusted OR of 2.0 (95% CI 0.8–5.1) in the logistic regression analysis. Message Results suggest that LD is not inferior to FBD regarding SSI prevention, meaning patients could potentially be spared significant levels of pain caused by FBD. Purpose Swedish national guidelines recommend full-body disinfection (FBD) with 4% chlorhexidine before hip fracture surgery to prevent surgical-site infection (SSI) despite little evidence. Our objective was to compare preoperative FBD with local disinfection (LD) of the surgical site regarding SSI incidence. Methods All patients with hip fracture, operated at a hospital in Sweden, January 1, 2018 to December 31, 2019 were included. Patients in 2018 (n = 237) were prepared with FBD and patients in 2019 (n = 259) with LD. Primary outcome was SSI and secondary outcome was SSI and/or death. We adjusted for potential confounders with logistic regression. The adjusted analysis was performed in two models to enable assessment of variables that lacked either outcome; in the first model, these variables were not adjusted, and the second model was restricted to a sub-population not affected by respective variables. Results There were 16 (6.8%) cases of SSI in 2018 and 8 (3.1%) cases in 2019. FBD (2018) compared to LD (2019) presented an adjusted OR of 1.9 (95%CI 0.8–4.9, P = 0.16) respectively 2.0 (95%CI 0.8–5.1, P = 0.14) in the two models of the logistic regression. In addition, 40 (16.9%) patients in 2018 and 29 (11.2%) patients in 2019 had the combined outcome of SSI and/or death, adjusted OR 1.6 (95% CI 0.9–2.8, P = 0.08) respectively 1.7 (95% CI 0.9–2.9, P = 0.06). Conclusion We found a non-significant increased risk of SSI 2018 compared to 2019 after adjustment. Randomized control trials are needed. Nonetheless, results suggest that LD is not inferior to FBD regarding SSI prevention, meaning patients could potentially be spared substantial pain.
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Affiliation(s)
- Noelle Probert
- Faculty of Medicine and Health, Örebro University, Örebro, Sweden. .,Centre of Clinical Research, Region Värmland, Karlstad, Sweden.
| | - Åsa G Andersson
- Department of Geriatrics, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Anders Magnuson
- Clinical Epidemiology and Biostatistics, School of Medical Sciences, Örebro University, Örebro, Sweden
| | - Elin Kjellberg
- Department of Infectious Diseases, Central Hospital of Kristianstad, Kristianstad, Sweden
| | - Per Wretenberg
- Department of Orthopaedics, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
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10
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THOMPSON O, W-DAHL A, LINDGREN V, GORDON M, ROBERTSSON O, STEFÁNSDÓTTIR A. Similar periprosthetic joint infection rates after and before a national infection control program: a study of 45,438 primary total knee arthroplasties. Acta Orthop 2022; 93:3-10. [PMID: 34533104 PMCID: PMC8815852 DOI: 10.1080/17453674.2021.1977532] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Indexed: 02/08/2023] Open
Abstract
Background and purpose - Strenuous efforts to minimize postoperative infection rates have been made, including the Swedish nationwide initiative Prosthesis Related Infections Shall be Stopped (PRISS). This study calculated the incidence rate of periprosthetic joint infection (PJI) following primary total knee arthroplasty (TKA) before and after PRISS. Patients and methods - All 45,438 primary TKAs registered in the Swedish Knee Arthroplasty Register (SKAR) during 2007-2008 and 2012-2013 were included. Matched data on antibiotic prescriptions were obtained from the Swedish Prescribed Drug Register (SPDR). All patients with ≥ 28 days of continuous antibiotic treatment within 2 years of primary surgery had their medical charts reviewed to identify cases of PJI. The incidence rate was calculated by dividing the number of PJIs by the total time at risk during each time period and presented as percentages with 95% confidence interval (CI). Results - 644 PJIs were identified, equaling a 2-year incidence rate of 1.45% (CI 1.34-1.57). The incidence rate was 1.44% (CI 1.27-1.61) before PRISS and 1.46% (CI 1.31-1.61) after. Diagnosis was made within 30 days of primary TKA in 52%, and within 90 days in 73% of cases. 603 cases were reoperated on or revised. Median time from operation to diagnosis was 29 days (1-716), for both time periods. Debridement with exchange of the insert was performed in 32% and 63% of cases before and after PRISS, respectively. Interpretation - We found similar incidence rates before and after the PRISS initiative without any statistically significant difference. Time to diagnosis was similar during both time periods. The project may have contributed to increased compliance with treatment protocols.
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Affiliation(s)
- Olof THOMPSON
- Infectious Diseases, Department of Clinical Sciences Lund, Lund University, Skåne University Hospital, Lund, Sweden
| | - Annette W-DAHL
- Swedish Knee Arthroplasty Register, Lund, Sweden,Department of Clinical Sciences Lund, Lund University, Division of Orthopedics
| | - Viktor LINDGREN
- Department of Molecular Medicine and Surgery, Section of Orthopedics, Karolinska Institute, Stockholm, Sweden
| | - Max GORDON
- Department of Clinical Sciences at Danderyd Hospital, Division of Orthopedics, Karolinska Institutet, Stockholm, Sweden
| | - Otto ROBERTSSON
- Swedish Knee Arthroplasty Register, Lund, Sweden,Department of Clinical Sciences Lund, Lund University, Division of Orthopedics
| | - Anna STEFÁNSDÓTTIR
- Department of Clinical Sciences Lund, Lund University, Division of Orthopedics,Department of Orthopedics, Skåne University Hospital, Lund, Sweden
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11
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Wildeman P, Rolfson O, Söderquist B, Wretenberg P, Lindgren V. What Are the Long-term Outcomes of Mortality, Quality of Life, and Hip Function after Prosthetic Joint Infection of the Hip? A 10-year Follow-up from Sweden. Clin Orthop Relat Res 2021; 479:2203-2213. [PMID: 34061486 PMCID: PMC8445574 DOI: 10.1097/corr.0000000000001838] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Accepted: 05/03/2021] [Indexed: 01/31/2023]
Abstract
BACKGROUND Prosthetic joint infection (PJI) is a complication after arthroplasty that negatively affects patient health. However, prior reports have not addressed the long-term consequences of hip PJI in terms of patient mortality, quality of life, and hip function. QUESTIONS/PURPOSES At a minimum of 10 years after PJI in patients undergoing primary THA, in the context of several large, national databases in Sweden, we asked: (1) Is mortality increased for patients with PJI after THA compared with patients with a noninfected THA? (2) Does PJI of the hip have a negative influence on quality of life as measured by the Euro-QoL-5D-5L (EQ-5D-5L), ambulatory aids, residential status, and hip function as measured by the Oxford Hip Score (OHS)? (3) Which factors are associated with poor patient-reported outcome measures (PROMs) for patients with PJI after primary THA? METHODS This study included 442 patients with a PJI after primary THA, from a previously published national study, including all patients with a THA performed from 2005 to 2008 in Sweden (n = 45,570) recruited from the Swedish Hip Arthroplasty Registry (SHAR). Possible deep PJIs were identified in the Swedish Dispensed Drug Registry and verified by review of medical records. Mortality in patients with PJI was compared with the remaining cohort of 45,128 patients undergoing primary THA who did not have PJI. Mortality data were retrieved from the SHAR, which in turn is updated daily from the population registry. A subgroup analysis of patients who underwent primary THA in 2008 was performed to adjust for the effect of comorbidities on mortality, as American Society of Anesthesiologists (ASA) scores became available in the SHAR at that time. For the PROM analysis, we identified three controls matched by age, gender, indication for surgery, and year of operation to each living PJI patient. A questionnaire including EQ-5D-5L, ambulatory aids, residential status, and OHS was collected from patients with PJI and controls at a mean of 11 years from the primary procedure. Apart from age and gender, we analyzed reoperation data (such as number of reoperations and surgical approach) and final prosthesis in situ to explore possible factors associated with poor PROM results. RESULTS After controlling for differences in sex, age, and indication for surgery, we found the all-cause 10-year mortality higher for patients with PJI (45%) compared with patients undergoing THA without PJI (29%) (odds ratio 1.4 [95% CI 1.2 to 1.6]; p < 0.001). The questionnaire, with a minimum of 10 years of follow-up, revealed a lower EQ-5D-5L index score (0.83 versus 0.94, -0.13 [95% CI -0.18 to -0.08; p < 0.001]), greater proportion of assisted living (21% versus 12%, OR 2.0 [95% CI 1.2 to 3.3]; p = 0.01), greater need of ambulatory aids (65% versus 42%, OR 3.1 [95% 2.1 to 4.8]; p < 0.001), and a lower OHS score (36 versus 44, -5.9 [-7.7 to -4.0]; p < 0.001) for patients with PJI than for matched controls. Factors associated with lower OHS score for patients with PJI were three or more reoperations (-8.0 [95% CI -13.0 to -3.2]; p = 0.01) and a direct lateral approach used at revision surgery compared with a posterior approach (-4.3 [95% CI -7.7 to -0.9]; p = 0.01). CONCLUSION In this study, we found that PJI after THA has a negative impact on mortality, long-term health-related quality of life, and hip function. Furthermore, the subgroup analysis showed that modifiable factors such as the number of reoperations and surgical approach are associated with poorer hip function. This emphasizes the importance of prompt, proper initial treatment to reduce repeated surgery to minimize the negative long-term effects of hip PJI. LEVEL OF EVIDENCE Level III, therapeutic study.
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Affiliation(s)
- Peter Wildeman
- School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
- Department of Orthopedics, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Ola Rolfson
- Department of Orthopedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Swedish Hip Arthroplasty Register, Centre of Registers, Västra Götalandsregionen, Gothenburg, Sweden
| | - Bo Söderquist
- School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
- Department of Infectious Diseases, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Per Wretenberg
- School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
- Department of Orthopedics, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Viktor Lindgren
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
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12
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Yazdanyar A, Donato A, Wasko MC, Ward MM. Risk of 30-day Readmission after Knee or Hip Replacement in Rheumatoid Arthritis and Osteoarthritis by non-Medicare and Medicare Payer Status. J Rheumatol 2021; 49:205-212. [PMID: 34599044 DOI: 10.3899/jrheum.201370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/15/2021] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To determine the indication and risk of 30-day rehospitalization after hip or knee replacement among rheumatoid arthritis (RA) and osteoarthritis (OA) by Medicare and non-Medicare status. METHODS Using the Nationwide Readmission Database (2010-2014), we defined an Index hospitalization as an elective hospitalization with a principal procedure of total hip or knee replacement among adults aged ≥18 years. Primary payer was categorized as Medicare or non- Medicare. Survey logistic regression provided the odds of 30-day rehospitalization in RA relative to OA. We calculated the rates for principal diagnoses leading to rehospitalization. RESULTS Overall, 3.53% of 2,190,745 index hospitalization had a 30-day rehospitalization. Patients with RA had a higher adjusted risk of rehospitalization after TKR (Odds Ratio [OR], 1.11; 95% Confidence Interval [CI], 1.02 to 1.21) and THR (OR, 1.39; 95% CI, 1.19 to 1.62). Persons with RA and OA did not differ with respect to rates of infections, cardiac events, or postoperative complications leading to the rehospitalization. After TKR, RA patients with Medicare had a lower VTE risk (OR, 0.58;95% CI, 0.58 to 0.88) while post-THR those with RA had a greater VTE risk (OR, 2.41;95% CI, 1.04 to 5.57). CONCLUSION RA patients had a higher 30-day rehospitalization than OA after TKR and THR regardless of payer type. While infections, postoperative complications, cardiac did not differ, there was a significant difference in venous thromboembolism as the rehospitalization's principal diagnosis.
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Affiliation(s)
- Ali Yazdanyar
- Department of Emergency and Hospital Medicine, Lehigh Valley Hospital-Cedar Crest, Allentown, PA; Morsani College of Medicine, University of South Florida, Tampa, FL; Department of Medicine, Reading Hospital-Tower Health, Reading, PA; Department of Medicine/Rheumatology, Allegheny Health Network-West Penn Hospital, Division of Rheumatology, Pittsburgh, PA; National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, MD. Funding: Michael M Ward, MD MPH was funded by the Intramural Research Program, National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health. Conflicts of Interest: No conflict of interest to report by any of the authors of this manuscript. Corresponding Author: Ali Yazdanyar, DO PhD MS, Lehigh Valley Hospital-Cedar Crest, Department of Emergency and Hospital Medicine, 1200 South Cedar Crest Blvd, 3rd Floor, Anderson Wing, Allentown, PA 18103.
| | - Anthony Donato
- Department of Emergency and Hospital Medicine, Lehigh Valley Hospital-Cedar Crest, Allentown, PA; Morsani College of Medicine, University of South Florida, Tampa, FL; Department of Medicine, Reading Hospital-Tower Health, Reading, PA; Department of Medicine/Rheumatology, Allegheny Health Network-West Penn Hospital, Division of Rheumatology, Pittsburgh, PA; National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, MD. Funding: Michael M Ward, MD MPH was funded by the Intramural Research Program, National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health. Conflicts of Interest: No conflict of interest to report by any of the authors of this manuscript. Corresponding Author: Ali Yazdanyar, DO PhD MS, Lehigh Valley Hospital-Cedar Crest, Department of Emergency and Hospital Medicine, 1200 South Cedar Crest Blvd, 3rd Floor, Anderson Wing, Allentown, PA 18103.
| | - Mary Chester Wasko
- Department of Emergency and Hospital Medicine, Lehigh Valley Hospital-Cedar Crest, Allentown, PA; Morsani College of Medicine, University of South Florida, Tampa, FL; Department of Medicine, Reading Hospital-Tower Health, Reading, PA; Department of Medicine/Rheumatology, Allegheny Health Network-West Penn Hospital, Division of Rheumatology, Pittsburgh, PA; National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, MD. Funding: Michael M Ward, MD MPH was funded by the Intramural Research Program, National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health. Conflicts of Interest: No conflict of interest to report by any of the authors of this manuscript. Corresponding Author: Ali Yazdanyar, DO PhD MS, Lehigh Valley Hospital-Cedar Crest, Department of Emergency and Hospital Medicine, 1200 South Cedar Crest Blvd, 3rd Floor, Anderson Wing, Allentown, PA 18103.
| | - Michael M Ward
- Department of Emergency and Hospital Medicine, Lehigh Valley Hospital-Cedar Crest, Allentown, PA; Morsani College of Medicine, University of South Florida, Tampa, FL; Department of Medicine, Reading Hospital-Tower Health, Reading, PA; Department of Medicine/Rheumatology, Allegheny Health Network-West Penn Hospital, Division of Rheumatology, Pittsburgh, PA; National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, MD. Funding: Michael M Ward, MD MPH was funded by the Intramural Research Program, National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health. Conflicts of Interest: No conflict of interest to report by any of the authors of this manuscript. Corresponding Author: Ali Yazdanyar, DO PhD MS, Lehigh Valley Hospital-Cedar Crest, Department of Emergency and Hospital Medicine, 1200 South Cedar Crest Blvd, 3rd Floor, Anderson Wing, Allentown, PA 18103.
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13
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Hedlundh U, Zacharatos M, Magnusson J, Gottlander M, Karlsson J. Periprosthetic hip infections in a Swedish regional hospital between 2012 and 2018: is there a relationship between Cutibacterium acnes infections and uncemented prostheses? J Bone Jt Infect 2021; 6:219-228. [PMID: 34159046 PMCID: PMC8209581 DOI: 10.5194/jbji-6-219-2021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Accepted: 05/24/2021] [Indexed: 11/11/2022] Open
Abstract
The purpose of this study was to evaluate patients requiring in-patient care due to a periprosthetic joint infection (PJI), with respect to bacterial agents, surgical treatment, antibiotics, and outcome. We retrospectively identified all infected total hip arthroplasties (THAs) in a Swedish regional hospital during a 7-year period (2012-2018) and reviewed medical records and microbiological data. A total of 89 infected THAs in 87 patients were identified. Standardized treatment with debridement with retention of the implant and antibiotics (DAIR) was initially performed in 53 cases (60 %), one or two stage revisions in 33 cases (37 %), and an immediate Girdlestone in 3 cases (3 %). Infection eradication was seen in 77 PJIs (87 %) in addition to six patients (7 %) ending up with a permanent but uninfected Girdlestone. All six patients with manifest failures were infected with Staphylococcus aureus, two of which were also polymicrobial. Cutibacterium acnes was found in 18 of 89 patients (16 %) distributed in 15 uncemented implants but only in 3 hybrids and cemented arthroplasties, while remaining pathogens were equally distributed in uncemented THAs ( n = 31 ) and THAs with at least one cemented component ( n = 40 ; p = 0.003 ). Eradication was achieved in all 18 patients when Cutibacterium acnes was the only culture ( n = 14 ) or clearly dominant among positive cultures ( n = 4 ). DAIR was successful in selected postoperative infections up to 6 months after hip replacement. Cutibacterium acnes infections in hip arthroplasty may be underdiagnosed. Cemented components in THAs seem to protect from colonization with Cutibacterium acnes.
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Affiliation(s)
- Urban Hedlundh
- Department of Orthopedic Surgery, Uddevalla Hospital, SE 451 80, Uddevalla, Sweden
| | - Michail Zacharatos
- Department of Orthopedic Surgery, Uddevalla Hospital, SE 451 80, Uddevalla, Sweden
| | - Jonas Magnusson
- Department of Orthopedic Surgery, Uddevalla Hospital, SE 451 80, Uddevalla, Sweden
| | - Magnus Gottlander
- Department of Orthopedic Surgery, Uddevalla Hospital, SE 451 80, Uddevalla, Sweden
| | - Johanna Karlsson
- Department of Infectious Diseases, NU Hospital Group, Trollhättan/Uddevalla, Sweden.,Department of Infectious Diseases, Institute of Biomedicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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14
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Sang S, Guo G, Yu J, Zhang X. Antibacterial application of gentamicin-silk protein coating with smart release function on titanium, polyethylene, and Al 2O 3 materials. MATERIALS SCIENCE & ENGINEERING. C, MATERIALS FOR BIOLOGICAL APPLICATIONS 2021; 124:112069. [PMID: 33947562 DOI: 10.1016/j.msec.2021.112069] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Revised: 03/02/2021] [Accepted: 03/16/2021] [Indexed: 01/12/2023]
Abstract
Peri-implant infection after hip and knee arthroplasty is a common and serious complication. Titanium (Ti), polyethylene (PE), and Al2O3 materials used as joint prosthesis materials have good biocompatibility and mechanical strength but no antibacterial effect. This study aimed to provide a theoretical basis for the design and manufacture of joint prosthesis materials with antibacterial effect. We applied a coating of gentamicin-silk protein (GS-Silk) on the surface of these materials. We characterized the Ti, PE, and Al2O3 materials coated with GS-Silk (experimental group) and performed in vivo and in vitro experiments to test antibacterial activity. Scanning electron microscopy confirmed successful GS-Silk coating, and infrared spectroscopy confirmed successful loading of gentamicin onto the three materials. Nanoscratch test proved that the GS-Silk coating is relatively reliable on the surface of these three materials. The antibacterial effect of the coating in vitro and in vivo was verified by performing bacteriostatic ring test in vitro, bacterial adhesion test, and subendothelial implant infection test. We demonstrated that GS-Silk coating can effectively load gentamicin onto Ti, PE, and Al2O3 materials and change the gentamicin release rate with a change in the solution pH to achieve intelligent release. The GS-Silk coating is relatively reliable on the surface of these three materials. Ti, PE, and Al2O3 materials coated with GS-Silk have good antibacterial ability, both in vivo and in vitro.
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Affiliation(s)
- Shang Sang
- Department of Orthopaedics, Shanghai Jiao Tong University, Affiliated Sixth People's Hospital, Shanghai, China
| | - Geyong Guo
- Department of Orthopaedics, Shanghai Jiao Tong University, Affiliated Sixth People's Hospital, Shanghai, China
| | - Jinlong Yu
- Department of Orthopaedics, Shanghai Jiao Tong University, Affiliated Sixth People's Hospital, Shanghai, China
| | - Xianlong Zhang
- Department of Orthopaedics, Shanghai Jiao Tong University, Affiliated Sixth People's Hospital, Shanghai, China.
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15
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Månsson E, Tevell S, Nilsdotter-Augustinsson Å, Johannesen TB, Sundqvist M, Stegger M, Söderquist B. Methicillin-Resistant Staphylococcus epidermidis Lineages in the Nasal and Skin Microbiota of Patients Planned for Arthroplasty Surgery. Microorganisms 2021; 9:microorganisms9020265. [PMID: 33525409 PMCID: PMC7911009 DOI: 10.3390/microorganisms9020265] [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: 12/23/2020] [Revised: 01/24/2021] [Accepted: 01/26/2021] [Indexed: 12/14/2022] Open
Abstract
Staphylococcus epidermidis, ubiquitous in the human nasal and skin microbiota, is a common causative microorganism in prosthetic joint infections (PJIs). A high proportion of PJI isolates have been shown to harbor genetic traits associated with resistance to/tolerance of agents used for antimicrobial prophylaxis in joint arthroplasties. These traits were found within multidrug-resistant S. epidermidis (MDRSE) lineages of multiple genetic backgrounds. In this study, the aim was to study whether MDRSE lineages previously associated with PJIs are present in the nasal and skin microbiota of patients planned for arthroplasty surgery but before hospitalization. We cultured samples from nares, inguinal creases, and skin over the hip or knee (dependent on the planned procedure) taken two weeks (median) prior to admittance to the hospital for total joint arthroplasty from 66 patients on agar plates selecting for methicillin resistance. S. epidermidis colonies were identified and tested for the presence of mecA. Methicillin-resistant S. epidermidis (MRSE) were characterized by Illumina-based whole-genome sequencing. Using this method, we found that 30/66 (45%) of patients were colonized with MRSE at 1–3 body sites. A subset of patients, 10/66 (15%), were colonized with MDRSE lineages associated with PJIs. The qacA gene was identified in MRSE isolates from 19/30 (63%) of MRSE colonized patients, whereas genes associated with aminoglycoside resistance were less common, found in 11/30 (37%). We found that MDRSE lineages previously associated with PJIs were present in a subset of patients’ pre-admission microbiota, plausibly in low relative abundance, and may be selected for by the current prophylaxis regimen comprising whole-body cleansing with chlorhexidine-gluconate containing soap. To further lower the rate of S. epidermidis PJIs, the current prophylaxis may need to be modified, but it is important for possible perioperative MDRSE transmission events and specific risk factors for MDRSE PJIs to be investigated before reevaluating antimicrobial prophylaxis.
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Affiliation(s)
- Emeli Månsson
- School of Medical Sciencies, Faculty of Medicine and Health, Örebro University, SE-701 82 Örebro, Sweden; (S.T.); (M.S.); (B.S.)
- Centre for Clinical Research, Region Västmanland—Uppsala University, Hospital of Västmanland, Västerås, SE-721 89 Västerås, Sweden
- Correspondence:
| | - Staffan Tevell
- School of Medical Sciencies, Faculty of Medicine and Health, Örebro University, SE-701 82 Örebro, Sweden; (S.T.); (M.S.); (B.S.)
- Department of Infectious Diseases, Karlstad Hospital and Centre for Clinical Research and Education, County Council of Värmland, SE-651 82 Karlstad, Sweden
| | - Åsa Nilsdotter-Augustinsson
- Department of Infectious Diseases, and Department of Clinical and Experimental Medicine, Linköping University, SE-60182 Norrköping, Sweden;
| | - Thor Bech Johannesen
- Department of Bacteria, Parasites and Fungi, Statens Serum Institut, 2300 Copenhagen, Denmark;
| | - Martin Sundqvist
- Department of Laboratory Medicine, Clinical Microbiology, Faculty of Medicine and Health, Örebro University, SE-701 82 Örebro, Sweden;
| | - Marc Stegger
- School of Medical Sciencies, Faculty of Medicine and Health, Örebro University, SE-701 82 Örebro, Sweden; (S.T.); (M.S.); (B.S.)
- Department of Bacteria, Parasites and Fungi, Statens Serum Institut, 2300 Copenhagen, Denmark;
| | - Bo Söderquist
- School of Medical Sciencies, Faculty of Medicine and Health, Örebro University, SE-701 82 Örebro, Sweden; (S.T.); (M.S.); (B.S.)
- Department of Laboratory Medicine, Clinical Microbiology, Faculty of Medicine and Health, Örebro University, SE-701 82 Örebro, Sweden;
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16
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Tevell S, Baig S, Hellmark B, Martins Simoes P, Wirth T, Butin M, Nilsdotter-Augustinsson Å, Söderquist B, Stegger M. Presence of the neonatal Staphylococcus capitis outbreak clone (NRCS-A) in prosthetic joint infections. Sci Rep 2020; 10:22389. [PMID: 33372186 PMCID: PMC7769963 DOI: 10.1038/s41598-020-79225-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Accepted: 12/03/2020] [Indexed: 11/28/2022] Open
Abstract
Staphylococcus capitis is a coagulase-negative staphylococcus that has been described primarily as causing bloodstream infections in neonatal intensive care units (NICUs), but has also recently been described in prosthetic joint infections (PJIs). The multidrug-resistant S. capitis subsp. urealyticus clone NRCS-A, comprising three sublineages, is prevalent in NICUs across the world, but its impact on other patient groups such as those suffering from PJIs or among adults planned for arthroplasty is unknown. Genome sequencing and subsequent analysis were performed on a Swedish collection of PJI isolates (n = 21), nasal commensals from patients planned to undergo arthroplasty (n = 20), NICU blood isolates (n = 9), operating theatre air isolates (n = 4), and reference strains (n = 2), in conjunction with an international strain collection (n = 248). The NRCS-A Outbreak sublineage containing the composite type V SCCmec-SCCcad/ars/cop element was present in PJIs across three Swedish hospitals. However, it was not found among nasal carrier strains, where the less virulent S. capitis subsp. capitis was most prevalent. The presence of the NRCS-A Outbreak clone in adult patients with PJIs demonstrates that dissemination occurs beyond NICUs. As this clone has several properties which facilitate invasive infections in patients with medical implants or immunosuppression, such as biofilm forming ability and multidrug resistance including heterogeneous glycopeptide-intermediate susceptibility, further research is needed to understand the reservoirs and distribution of this hospital-associated pathogen.
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Affiliation(s)
- Staffan Tevell
- Department of Infectious Diseases, Karlstad Hospital and Centre for Clinical Research and Education, Värmland County Council, SE-65182, Karlstad, Sweden. .,School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.
| | - Sharmin Baig
- Department of Bacteria, Parasites and Fungi, Statens Serum Institut, Copenhagen, Denmark
| | - Bengt Hellmark
- Department of Laboratory Medicine, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Patricia Martins Simoes
- Department of Bacteriology, Institute for Infectious Agents, National Reference Center for Staphylococci, Hospices Civils de Lyon, Lyon, France.,Centre International de Référence en Infectiologie, INSERM U1111, CNRS UMR 5308, ENS, University of Lyon, Lyon, France
| | - Thierry Wirth
- Institut de Systématique, Evolution, Biodiversité (ISYEB), UMR-CNRS 7205, Muséum National d'Histoire Naturelle, CNRS, EPHE, Sorbonne Université, Paris, France.,École Pratique des Hautes Études, PSL Université, Paris, France
| | - Marine Butin
- Centre International de Référence en Infectiologie, INSERM U1111, CNRS UMR 5308, ENS, University of Lyon, Lyon, France.,Neonatal Intensive Care Unit, Hôpital Femme Mère Enfant, Hospices Civils de Lyon, Lyon, France
| | - Åsa Nilsdotter-Augustinsson
- Division of Inflammation and Infection, Department of Infectious Diseases, Linköping University, Norrköping, Sweden.,Division of Inflammation and Infection, Department of Biomedical and Clinical Sciences, Linköping University, Norrköping, Sweden
| | - Bo Söderquist
- School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.,Department of Laboratory Medicine, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Marc Stegger
- School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.,Department of Bacteria, Parasites and Fungi, Statens Serum Institut, Copenhagen, Denmark
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17
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Budde S, Schwarze M, Floerkemeier T, Plagge J, Wirries N, Windhagen H, Thorey F, Derksen A. Clinical and radiographic outcomes with the Nanos™ short-stem hip implant at 24 months: A prospective, single-center study. J Orthop 2020; 20:326-331. [PMID: 32641879 DOI: 10.1016/j.jor.2020.06.007] [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: 04/03/2020] [Revised: 05/04/2020] [Accepted: 06/03/2020] [Indexed: 10/24/2022] Open
Abstract
Aim Short-stem total hip arthroplasty is designed to preserve proximal bone stock in case of eventual revision, potentially benefiting younger and more active patients. This prospective, single-center study assessed the safety and performance of the partially neck-sparing Nanos™ short-stem uncemented prosthesis at 24 months using clinical outcome scores and radiographic results. Methods Between April 2011 and February 2015, 52 subjects (mean age, 54.9 years) underwent total hip arthroplasty and were followed up at 3, 6, 12 and 24 months. The primary outcome was improvement in quality of life as measured by the Short-Form 36 Mental Component Score (SF-36 MCS). Secondary clinical outcomes included the Harris Hip Score, Hip Disability and Osteoarthritis Outcome Score, Postel Merle d'Aubigné-Score, Activity Level University of California, Los Angeles score, and Pain Visual Analogue Scale. Complications and radiographic images were also recorded at each follow-up. Results Mean SF-36 MCS score significantly improved from baseline to final follow up at 24 months (61.3 vs. 79.5, respectively; p < 0.001). All secondary clinical outcomes also showed significant improvement (p < 0.001) during this time period. Neutral stem positioning was achieved in 45 subjects (86.5%). Two subjects (3.8%) underwent revisions: one for a periprosthetic fracture unrelated to the study device and another due to a prosthetic joint infection. Intraoperatively, one fissure fracture of the acetabulum occurred. Conclusion Total hip arthroplasty with the Nanos short-stem led to significant clinical improvements and a high subjective satisfaction rate at 24 months. Further follow-up will determine whether these effects are sustained in the long term.
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Affiliation(s)
- Stefan Budde
- Department of Orthopaedic Surgery at Diakovere Annastift, Hannover Medical School, Hannover, Germany
| | - Michael Schwarze
- Laboratory for Biomechanics and Biomaterials, Department of Orthopaedic Surgery at Diakovere Annastift, Hannover Medical School, Hannover, Germany
| | - Thilo Floerkemeier
- Department of Orthopaedic Surgery at Diakovere Annastift, Hannover Medical School, Hannover, Germany
| | - Jochen Plagge
- Department of Orthopaedic Surgery at Diakovere Annastift, Hannover Medical School, Hannover, Germany
| | - Nils Wirries
- Department of Orthopaedic Surgery at Diakovere Annastift, Hannover Medical School, Hannover, Germany
| | - Henning Windhagen
- Department of Orthopaedic Surgery at Diakovere Annastift, Hannover Medical School, Hannover, Germany
| | - Fritz Thorey
- Center for Hip, Knee and Foot Surgery, Sports Traumatology, ATOS Hospital, Heidelberg, Germany
| | - Alexander Derksen
- Department of Orthopaedic Surgery at Diakovere Annastift, Hannover Medical School, Hannover, Germany
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18
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Magnéli M, Unbeck M, Samuelsson B, Rogmark C, Rolfson O, Gordon M, Sköldenberg O. Only 8% of major preventable adverse events after hip arthroplasty are filed as claims: a Swedish multi-center cohort study on 1,998 patients. Acta Orthop 2020; 91:20-25. [PMID: 31615309 PMCID: PMC7006721 DOI: 10.1080/17453674.2019.1677382] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Background and purpose - Hip arthroplasty is one of the most performed surgeries in Sweden, and the rate of adverse events (AEs) is fairly high. All patients in publicly financed healthcare in Sweden are insured by the Mutual Insurance Company of Swedish County Councils (Löf). We assessed the proportion of patients that sustained a major preventable AE and filed an AE claim to Löf.Patients and methods - We performed retrospective record review using the Global Trigger Tool to identify AEs in a Swedish multi-center cohort consisting of 1,998 patients with a total or hemi hip arthroplasty. We compared the major preventable AEs with all patient-reported claims to Löf from the same cohort and calculated the proportion of filed claims.Results - We found 1,066 major preventable AEs in 744 patients. Löf received 62 claims for these AEs, resulting in a claim proportion of 8%. 58 of the 62 claims were accepted by Löf and received compensation. The claim proportion was 13% for the elective patients and 0.3% for the acute patients. The most common AE for filing a claim was periprosthetic joint infection; of the 150 infections found 37 were claimed.Interpretation - The proportion of filed claims for major preventable AEs is very low, even for obvious and serious AEs such as periprosthetic joint infection.
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Affiliation(s)
- Martin Magnéli
- Department of Clinical Sciences at Danderyd Hospital, Division of Orthopaedics, Karolinska Institutet, Stockholm
| | - Maria Unbeck
- Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Stockholm
| | - Bodil Samuelsson
- Department of Clinical Sciences at Danderyd Hospital, Division of Orthopaedics, Karolinska Institutet, Stockholm
| | - Cecilia Rogmark
- Department of Clinical Sciences Malmö, Lund University Clinical and Molecular Osteoporosis Research Unit, Malmö
| | - Ola Rolfson
- Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Mölndal, Sweden
| | - Max Gordon
- Department of Clinical Sciences at Danderyd Hospital, Division of Orthopaedics, Karolinska Institutet, Stockholm
| | - Olof Sköldenberg
- Department of Clinical Sciences at Danderyd Hospital, Division of Orthopaedics, Karolinska Institutet, Stockholm
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Peel T, Astbury S, Cheng AC, Paterson D, Buising K, Spelman T, Tran-Duy A, de Steiger RS. Multicentre randomised double-blind placebo controlled trial of combination vancomycin and cefazolin surgical antibiotic prophylaxis: the Australian surgical antibiotic prophylaxis (ASAP) trial. BMJ Open 2019; 9:e033718. [PMID: 31685516 PMCID: PMC6858103 DOI: 10.1136/bmjopen-2019-033718] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION Resistant Gram-positive organisms, such as methicillin-resistant staphylococci, account for a significant proportion of infections following joint replacement surgery. Current surgical antimicrobial prophylaxis guidelines recommend the use of first-generation or second-generation cephalosporin antibiotics, such as cefazolin. Cefazolin, however, does not prevent infections due to these resistant organisms; therefore, new prevention strategies need to be examined. One proposed strategy is to combine a glycopeptide antibiotic with cefazolin for prophylaxis. The clinical benefit and cost-effectiveness of this combination therapy compared with usual therapy, however, have not been established. METHODS AND ANALYSIS This randomised, double-blind, parallel, superiority, placebo-controlled, phase 4 trial will compare the incidence of all surgical site infections (SSIs) including superficial, deep and organ/space (prosthetic joint) infections, safety and cost-effectiveness of surgical prophylaxis with cefazolin plus vancomycin to that with cefazolin plus placebo. The study will be performed in patients undergoing joint replacement surgery. In the microbiological sub-studies, we will examine the incidence of SSIs in participants with preoperative staphylococci colonisation (Sub-Study 1) and incidence of VRE acquisition (Sub-Study 2). The trial will recruit 4450 participants over a 4-year period across 13 orthopaedic centres in Australia. The primary outcome is the incidence of SSI at 90 days post index surgery. Secondary outcomes include the incidence of SSI according to joint and microorganism and other healthcare associated infections. Safety endpoints include the incidence of acute kidney injury, hypersensitivity reactions and all-cause mortality. The primary and secondary analysis will be a modified intention-to-treat analysis consisting of all randomised participants who undergo eligible surgery. We will also perform a per-protocol analysis. ETHICS AND DISSEMINATION The study protocol was reviewed and approved by The Alfred Hospital Human Research Ethics Committee (HREC/18/Alfred/102) on 9 July 2018. Study findings will be disseminated in the printed media, and learnt forums. TRIAL REGISTRATION NUMBER ACTRN12618000642280.
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Affiliation(s)
- Trisha Peel
- Infectious Diseases, Monash University, Melbourne, Victoria, Australia
- Infectious Diseases Unit, Alfred Hospital, Melbourne, Victoria, Australia
| | - Sarah Astbury
- Infectious Diseases, Monash University, Melbourne, Victoria, Australia
| | - Allen C Cheng
- Infectious Diseases Unit, Alfred Hospital, Melbourne, Victoria, Australia
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - David Paterson
- Centre for Clinical Research, University of Queensland, Brisbane, Queensland, Australia
- Infectious Diseases, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia
| | - Kirsty Buising
- Medicine, University of Melbourne, Melbourne, Victoria, Australia
- Victorian Infectious Diseases Service, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Tim Spelman
- Department of Surgery, St Vincent's Hospital, The University of Melbourne, Melbourne, Victoria, Australia
| | - An Tran-Duy
- Centre for Health Policy, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Victoria, Australia
| | - Richard S de Steiger
- Surgery, The University of Melbourne, Melbourne, Victoria, Australia
- Orthopaedics, Epworth HealthCare, Richmond, Victoria, Australia
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20
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Aalirezaie A, Arumugam SS, Austin M, Bozinovski Z, Cichos KH, Fillingham Y, Ghanem E, Greenky M, Huang W, Jenny JY, Lazarovski P, Lee GC, Manrique J, Manzary M, Oshkukov S, Patel NK, Reyes F, Spangehl M, Vahedi H, Voloshin V. Hip and Knee Section, Prevention, Risk Mitigation: Proceedings of International Consensus on Orthopedic Infections. J Arthroplasty 2019; 34:S271-S278. [PMID: 30348568 DOI: 10.1016/j.arth.2018.09.011] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
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21
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Bargon R, Bruenke J, Carli A, Fabritius M, Goel R, Goswami K, Graf P, Groff H, Grupp T, Malchau H, Mohaddes M, Novaes de Santana C, Phillips KS, Rohde H, Rolfson O, Rondon A, Schaer T, Sculco P, Svensson K. General Assembly, Research Caveats: Proceedings of International Consensus on Orthopedic Infections. J Arthroplasty 2019; 34:S245-S253.e1. [PMID: 30348560 DOI: 10.1016/j.arth.2018.09.076] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
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22
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Ferguson RJ, Palmer AJ, Taylor A, Porter ML, Malchau H, Glyn-Jones S. Hip replacement. Lancet 2018; 392:1662-1671. [PMID: 30496081 DOI: 10.1016/s0140-6736(18)31777-x] [Citation(s) in RCA: 293] [Impact Index Per Article: 48.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2018] [Revised: 06/22/2018] [Accepted: 07/20/2018] [Indexed: 02/06/2023]
Abstract
Total hip replacement is a frequently done and highly successful surgical intervention. The procedure is undertaken to relieve pain and improve function in individuals with advanced arthritis of the hip joint. Symptomatic osteoarthritis is the most common indication for surgery. In paper 1 of this Series, we focus on how patient factors should inform the surgical decision-making process. Substantial demands are placed upon modern implants, because patients expect to remain active for longer. We discuss the advances made in implant performance and the developments in perioperative practice that have reduced complications. Assessment of surgery outcomes should include patient-reported outcome measures and implant survival rates that are based on data from joint replacement registries. The high-profile failure of some widely used metal-on-metal prostheses has shown the shortcomings of the existing regulatory framework. We consider how proposed changes to the regulatory framework could influence safety.
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Affiliation(s)
- Rory J Ferguson
- Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, Oxford, UK.
| | - Antony Jr Palmer
- Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Adrian Taylor
- Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | | | - Henrik Malchau
- Harvard Medical School, Harvard University, Boston, MA, USA
| | - Sion Glyn-Jones
- Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, Oxford, UK
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23
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Sebastian S, Malhotra R, Dhawan B. Prosthetic Joint Infection: A Major Threat to Successful Total Joint Arthroplasty. Indian J Med Microbiol 2018; 36:475-487. [DOI: 10.4103/ijmm.ijmm_19_11] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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24
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Kasina P, Enocson A, Lindgren V, Lapidus LJ. Patient claims in prosthetic hip infections: a comparison of nationwide incidence in Sweden and patient insurance data. Acta Orthop 2018; 89:394-398. [PMID: 29808747 PMCID: PMC6066767 DOI: 10.1080/17453674.2018.1477708] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Background and purpose - Patients in Sweden are insured against avoidable patient injuries. Prosthetic joint infections (PJIs) resulting from intraoperative contamination are regarded as compensable by the Swedish public insurance system. According to the Patient Injury Act, healthcare personnel must inform patients about any injury resulting from treatment and the possibility of filing a claim. To analyze any under-reporting of claims and their outcome, we investigated patients' claims of PJI in a nationwide setting Patients and methods - The national cohort of PJI after primary total hip replacement, initially operated between 2005 and 2008, was established through cross-matching of registers and review of individual medical records. We analyzed 441 PJIs and the number of filed patients' claims, with regards to incidence, outcome, and any national, sex-linked or socioeconomic differences. Results - We identified 329/441 (75%) patients with PJIs as non-claimants. 96% of the filed claims were accepted. 64 (57%) of claimants sustained permanent disability. 2 factors were found to statistically significantly reduce the odds of filing claims: patient's age above 73 years and fracture as indication for surgery. There were no significant national, sex-linked, or socioeconomic differences. Interpretation - The incidence of patients' claims of PJI is low but claims are usually accepted when filed. Healthcare personnel should increase their knowledge of the Patient Injury Act to inform patients about possibilities of eligible compensation.
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Affiliation(s)
- Piotr Kasina
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm;; ,Correspondence:
| | - Anders Enocson
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm;; ,Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Viktor Lindgren
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Lasse J Lapidus
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm;;
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Gundtoft PH, Pedersen AB, Varnum C, Overgaard S. Increased Mortality After Prosthetic Joint Infection in Primary THA. Clin Orthop Relat Res 2017; 475:2623-2631. [PMID: 28236084 PMCID: PMC5638726 DOI: 10.1007/s11999-017-5289-6] [Citation(s) in RCA: 135] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2016] [Accepted: 02/16/2017] [Indexed: 01/31/2023]
Abstract
BACKGROUND Revision for prosthetic joint infection (PJI) has a major effect on patients' health but it remains unclear if early PJI after primary THA is associated with a high mortality. QUESTIONS/PURPOSES (1) Do patients with a revision for PJI within 1 year of primary THA have increased mortality compared with patients who do not undergo revision for any reason within 1 year of primary THA? (2) Do patients who undergo a revision for PJI within 1 year of primary THA have an increased mortality risk compared with patients who undergo an aseptic revision? (3) Are there particular bacteria among patients with PJI that are associated with an increased risk of death? METHODS This population-based cohort study was based on the longitudinally maintained Danish Hip Arthroplasty Register on primary THA performed in Denmark from 2005 to 2014. Data from the Danish Hip Arthroplasty Register were linked to microbiology databases, the National Register of Patients, and the Civil Registration System to obtain data on microbiology, comorbidity, and vital status on all patients. Because reporting to the register is compulsory for all public and private hospitals in Denmark, the completeness of registration is 98% for primary THA and 92% for revisions (2016 annual report). The mortality risk for the patients who underwent revision for PJI within 1 year from implantation of primary THA was compared with (1) the mortality risk for patients who did not undergo revision for any reason within 1 year of primary THA; and (2) the mortality risk for patients who underwent an aseptic revision. A total of 68,504 primary THAs in 59,954 patients were identified, of those 445 primary THAs underwent revision for PJI, 1350 primary THAs underwent revision for other causes and the remaining 66,709 primary THAs did not undergo revision. Patients were followed from implantation of primary THA until death or 1 year of followup, or, in case of a revision, 1 year from the date of revision. RESULTS Within 1 year of primary THA, 8% (95% CI, 6%-11%) of patients who underwent revision for PJI died. The adjusted relative mortality risk for patients with revision for PJI was 2.18 (95% CI, 1.54-3.08) compared with the patients who did not undergo revision for any cause (p < 0.001). The adjusted relative mortality risk for patients with revisions for PJI compared with patients with aseptic revision was 1.87 (95% CI, 1.11-3.15; p = 0.019). Patients with enterococci-infected THA had a 3.10 (95% CI, 1.66-5.81) higher mortality risk than patients infected with other bacteria (p < 0.001). CONCLUSIONS Revision for PJI within 1 year after primary THA induces an increased mortality risk during the first year after the revision surgery. This study should incentivize further studies on prevention of PJI and on risk to patients with the perspective to reduce mortality in patients who have had THA in general and for patients with PJI specifically. LEVEL OF EVIDENCE Level III, therapeutic study.
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Affiliation(s)
- Per Hviid Gundtoft
- Department of Orthopaedics Surgery, Kolding Hospital, Kolding, Denmark ,Department of Orthopaedic Surgery and Traumatology, Odense University Hospital, Odense, Denmark ,Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Alma Becic Pedersen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | - Claus Varnum
- Department of Orthopaedic Surgery, Vejle Hospital, Vejle, Denmark
| | - Søren Overgaard
- Department of Orthopaedic Surgery and Traumatology, Odense University Hospital, Odense, Denmark ,Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
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Lübbeke A, Silman AJ, Prieto-Alhambra D, Adler AI, Barea C, Carr AJ. The role of national registries in improving patient safety for hip and knee replacements. BMC Musculoskelet Disord 2017; 18:414. [PMID: 29037237 PMCID: PMC5644143 DOI: 10.1186/s12891-017-1773-0] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2016] [Accepted: 10/04/2017] [Indexed: 12/12/2022] Open
Abstract
Background The serious adverse events associated with metal on metal hip replacements have highlighted the importance of improving methods for monitoring surgical implants. The new European Union (EU) device regulation will enforce post-marketing surveillance based on registries among other surveillance tools. Europe has a common regulatory environment, a common market for medical devices, and extensive experience with joint replacement registries. In this context, we elaborate how joint replacement registries, while building on existing structure and data, can better ensure safety and balance risks and benefits. Main text Actions to improve registry-based implant surveillance include: enriching baseline and diversifying outcomes data collection; improving methodology to limit bias; speeding-up failure detection by active real-time monitoring; implementing risk-benefit analysis; coordinating collaboration between registries; and translating knowledge gained from the data into clinical decision-making and public health policy. Conclusions The changes proposed here will improve patient safety, enforce the application of the new legal EU requirements, augment evidence, improve clinical decision-making, facilitate value-based health-care delivery, and provide up-to-date guidance for public health.
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Affiliation(s)
- Anne Lübbeke
- Division of Orthopaedic Surgery and Traumatology, Geneva University Hospitals and Geneva University, Geneva, Switzerland. .,Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK.
| | - Alan J Silman
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Daniel Prieto-Alhambra
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Amanda I Adler
- Wolfson Diabetes and Endocrine Clinic, Institute of Metabolic Science, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK.,National Institute for Health and Care Excellence, 10 Spring Gardens, London, UK
| | - Christophe Barea
- Division of Orthopaedic Surgery and Traumatology, Geneva University Hospitals and Geneva University, Geneva, Switzerland
| | - Andrew J Carr
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
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27
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One-year incidence of prosthetic joint infection in total hip arthroplasty: a cohort study with linkage of the Danish Hip Arthroplasty Register and Danish Microbiology Databases. Osteoarthritis Cartilage 2017; 25:685-693. [PMID: 27986623 DOI: 10.1016/j.joca.2016.12.010] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2016] [Revised: 11/11/2016] [Accepted: 12/06/2016] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To examine the trend of Prosthetic Joint Infections (PJI) following primary total hip arthroplasty (THA) and the antimicrobial resistance of the bacteria causing these infections. MATERIALS AND METHODS We identified a population-based cohort of patients in the Danish Hip Arthroplasty Register (DHR) who had primary THA and received their surgery in Jutland or Funen between 2005 and 2014. We followed the patients until revision, emigration, death, or up to 1-year of follow-up. Data from the DHR were combined with those from microbiology databases, the National Register of Patients, and the Civil Registration System. We estimated the cumulative 1-year incidence of PJI for two 5-year periods; 2005-2009 and 2010-2014. The hazard ratio of PJI as a measure of relative risk after adjusting for multiple risk factors was calculated. RESULTS Of 48,867 primary THAs identified, 1120 underwent revision within 1 year. Of these, 271 were due to PJI. The incidence of PJI was 0.53% (95% confidence interval (CI): 0.44; 0.63) during 2005-2009 and 0.57% (95% CI: 0.49; 0.67) during 2010-2014. The adjusted relative risk was 1.05 (95% CI: 0.82; 1.34) for the 2010-2014 period vs the 2005-2009 period. The most common micro-organisms identified in the 271 PJI were Staphylococcus aureus (36%) and coagulase-negative staphylococci (CoNS) (33%); others commonly identified included Enterobacteriaceae, enterococci, and streptococci. Antimicrobial resistance to beta-lactams and gentamicin did not change during the study period. CONCLUSION The risk of PJI within 1-year after primary THA and the antimicrobial resistance of the most prevalent bacteria remained unchanged during the 2005-2014 study period.
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In vitro activity of tedizolid and linezolid against Staphylococcus epidermidis isolated from prosthetic joint infections. Eur J Clin Microbiol Infect Dis 2017; 36:1549-1552. [PMID: 28326447 PMCID: PMC5554274 DOI: 10.1007/s10096-017-2966-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2017] [Accepted: 03/09/2017] [Indexed: 12/31/2022]
Abstract
Prosthetic joint infections (PJIs) are rare but long-lasting and are serious complications without any spontaneous resolution, requiring additional surgery and long-term treatment with antibiotics. Staphylococci are the most important aetiological agents of PJIs, and among the coagulase-negative staphylococci Staphylococcus epidermidis is the most common. However, S. epidermidis often displays multidrug resistance (MDR), demanding additional treatment options. The objective was to examine the effectiveness of tedizolid and linezolid against S. epidermidis isolated from PJIs. The standard antibiotic susceptibility pattern of S. epidermidis (n = 183) obtained from PJIs was determined by disc diffusion test, and MIC was determined by Etest for tedizolid, linezolid, and vancomycin. Tedizolid displayed MIC values ranging from 0.094 to 0.5 mg/L (MIC50: 0.19 mg/L, MIC90: 0.38 mg/L), linezolid MIC values ranging from 0.25 to 2 mg/L (MIC50: 0.75 mg/L, MIC90: 1 mg/L), and vancomycin MIC values ranging from 0.5 to 3 mg/L (MIC50 and MIC90 both 2 mg/L). According to the disc diffusion test, 153/183 (84%) isolates were resistant to ≥3 antibiotic groups, indicating MDR. In conclusion, S. epidermidis isolates from PJIs were fully susceptible, and the MIC50 and MIC90 values for tedizolid were two- to four-fold dilution steps lower compared with linezolid. Tedizolid is not approved, and there are no reports of long-term treatment, but it may display better tolerability and fewer adverse effects than linezolid; it thus could be a possible treatment option for PJIs, alone or in combination with rifampicin.
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Gallo J, Panacek A, Prucek R, Kriegova E, Hradilova S, Hobza M, Holinka M. Silver Nanocoating Technology in the Prevention of Prosthetic Joint Infection. MATERIALS (BASEL, SWITZERLAND) 2016; 9:E337. [PMID: 28773461 PMCID: PMC5503077 DOI: 10.3390/ma9050337] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/31/2016] [Revised: 04/26/2016] [Accepted: 04/27/2016] [Indexed: 02/06/2023]
Abstract
Prosthetic joint infection (PJI) is a feared complication of total joint arthroplasty associated with increased morbidity and mortality. There is a growing body of evidence that bacterial colonization and biofilm formation are critical pathogenic events in PJI. Thus, the choice of biomaterials for implanted prostheses and their surface modifications may significantly influence the development of PJI. Currently, silver nanoparticle (AgNP) technology is receiving much interest in the field of orthopaedics for its antimicrobial properties and a strong anti-biofilm potential. The great advantage of AgNP surface modification is a minimal release of active substances into the surrounding tissue and a long period of effectiveness. As a result, a controlled release of AgNPs could ensure antibacterial protection throughout the life of the implant. Moreover, the antibacterial effect of AgNPs may be strengthened in combination with conventional antibiotics and other antimicrobial agents. Here, our main attention is devoted to general guidelines for the design of antibacterial biomaterials protected by AgNPs, its benefits, side effects and future perspectives in PJI prevention.
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Affiliation(s)
- Jiri Gallo
- Department of Orthopaedics, Faculty of Medicine and Dentistry, Palacký University Olomouc, I. P. Pavlova 6, Olomouc 779 00, Czech Republic.
| | - Ales Panacek
- Regional Centre of Advanced Technologies and Materials, Palacký University Olomouc, Šlechtitelů 27, Olomouc 783 71, Czech Republic.
| | - Robert Prucek
- Regional Centre of Advanced Technologies and Materials, Palacký University Olomouc, Šlechtitelů 27, Olomouc 783 71, Czech Republic.
| | - Eva Kriegova
- Department of Immunology, Faculty of Medicine and Dentistry, Palacký University Olomouc, Hněvotínská 3, Olomouc 779 00, Czech Republic.
| | - Sarka Hradilova
- Regional Centre of Advanced Technologies and Materials, Palacký University Olomouc, Šlechtitelů 27, Olomouc 783 71, Czech Republic.
| | - Martin Hobza
- Department of Orthopaedics, Faculty of Medicine and Dentistry, Palacký University Olomouc, I. P. Pavlova 6, Olomouc 779 00, Czech Republic.
| | - Martin Holinka
- Department of Orthopaedics, Faculty of Medicine and Dentistry, Palacký University Olomouc, I. P. Pavlova 6, Olomouc 779 00, Czech Republic.
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Hamad T, Hellmark B, Nilsdotter-Augustinsson Å, Söderquist B. Antibiotic susceptibility amongStaphylococcus epidermidisisolated from prosthetic joint infections, with focus on doxycycline. APMIS 2015; 123:1055-60. [DOI: 10.1111/apm.12465] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2015] [Accepted: 09/22/2015] [Indexed: 11/27/2022]
Affiliation(s)
- Tarza Hamad
- Department of Laboratory Medicine, Clinical Microbiology; Faculty of Medicine and Health; Örebro University; Örebro Sweden
| | - Bengt Hellmark
- Department of Laboratory Medicine, Clinical Microbiology; Faculty of Medicine and Health; Örebro University; Örebro Sweden
| | - Åsa Nilsdotter-Augustinsson
- Department of Infectious Diseases; Department of Clinical and Experimental Medicine; Linköping University; Linköping Sweden
| | - Bo Söderquist
- Department of Laboratory Medicine, Clinical Microbiology; Faculty of Medicine and Health; Örebro University; Örebro Sweden
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Abstract
PURPOSE OF REVIEW This review presents an update on recent findings relating to the prevention, control and epidemiology of infections following orthopaedic surgery. RECENT FINDINGS Trends in population rates and characteristics of patients undergoing hip and knee replacement surgery, coupled with the reported excess infection risk in obese patients, emphasize the current and future impact of increasing population obesity on healthcare delivery. SUMMARY Prevention of orthopaedic infection is dependent on elimination or optimal management of documented risk factors. Guidelines and quality standards play a key role in translating this evidence base into a framework of practices for the prevention of surgical site infections. Increasing levels of orthopaedic infection due to Enterobacteriaceae, coupled with an increasingly obese surgical population may necessitate a reassessment of antimicrobial prophylaxis strategies.
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Månsson E, Hellmark B, Sundqvist M, Söderquist B. Sequence types of Staphylococcus epidermidis associated with prosthetic joint infections are not present in the laminar airflow during prosthetic joint surgery. APMIS 2015; 123:589-95. [PMID: 25951935 DOI: 10.1111/apm.12392] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2015] [Accepted: 02/24/2015] [Indexed: 11/29/2022]
Abstract
Molecular characterization of Staphylococcus epidermidis isolates from prosthetic joint infections (PJIs) has demonstrated a predominance of healthcare-associated multi-drug resistant sequence types (ST2 and ST215). How, and when, patients acquire these nosocomial STs is not known. The aim was to investigate if sequence types of S. epidermidis associated with PJIs are found in the air during prosthetic joint surgery. Air sampling was undertaken during 17 hip/knee arthroplasties performed in operating theaters equipped with mobile laminar airflow units in a 500-bed hospital in central Sweden. Species identification was performed using MALDI-TOF MS and 16S rRNA gene analysis. Isolates identified as S. epidermidis were further characterized by MLST and antibiotic susceptibility testing. Seven hundred and thirty-five isolates were available for species identification. Micrococcus spp. (n = 303) and coagulase-negative staphylococci (n = 217) constituted the majority of the isolates. Thirty-two isolates of S. epidermidis were found. S. epidermidis isolates demonstrated a high level of allelic diversity with 18 different sequence types, but neither ST2 nor ST215 was found. Commensals with low pathogenic potential dominated among the airborne microorganisms in the operating field during prosthetic joint surgery. Nosocomial sequence types of S. epidermidis associated with PJIs were not found, and other routes of inoculation are therefore of interest in future studies.
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Affiliation(s)
- Emeli Månsson
- Faculty of Medicine and Health, Örebro University, Örebro, Sweden.,Centre for Clinical Research, Uppsala University, County Hospital, Västerås, Sweden
| | - Bengt Hellmark
- Department of Laboratory Medicine, Clinical Microbiology, Örebro University Hospital, Örebro, Sweden
| | - Martin Sundqvist
- Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Bo Söderquist
- Faculty of Medicine and Health, Örebro University, Örebro, Sweden
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In vitro and in vivo evaluation of vancomycin-loaded PMMA cement in combination with ultrasound and microbubbles-mediated ultrasound. BIOMED RESEARCH INTERNATIONAL 2015; 2015:309739. [PMID: 25632389 PMCID: PMC4302969 DOI: 10.1155/2015/309739] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/08/2014] [Revised: 11/30/2014] [Accepted: 12/02/2014] [Indexed: 12/22/2022]
Abstract
Ultrasound (US) has been used to increase elution of antibiotic from an antibiotic-loaded poly(methyl methacrylate) (PMMA) bone cement (ALBC). We aimed to further investigate whether microbubbles-mediated US (US + MB) facilitate elution of vancomycin (VAN) from cylindrical specimens and enhance the activity of the eluted antibiotic against Staphylococcus aureus (S. aureus) in vitro. The study groups comprised cylindrical bone cement fabricated with VAN (VAN), ALBC using US (VAN + US), and ALBC using MB-mediated US (VAN + US + MB). We also carried out an in vivo study involving the activity of VAN from cylindrical cement implanted in tibiae of New Zealand white rabbits inoculated with S. aureus. We found that (1) in vitro, elution from VAN + US + MB cylinders was significantly higher than from either the VAN or VAN + US specimens; (2) the activity of the eluted VAN from the VAN + US + MB cylinders against planktonic S. aureus was significantly higher than from either the control or VAN or VAN + US specimens; and (3) in the rabbits, the activity of the eluted VAN from the VAN + US + MB cylinders against S. aureus was significantly higher than from either the control or VAN or VAN + US specimens. The present results suggest that VAN-loaded PMMA cement irradiated with MB-mediated US may have a role in controlling prosthetic joint infection.
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Lindgren JV, Gordon M, Wretenberg P, Kärrholm J, Garellick G. Validation of reoperations due to infection in the Swedish Hip Arthroplasty Register. BMC Musculoskelet Disord 2014; 15:384. [PMID: 25410189 PMCID: PMC4247680 DOI: 10.1186/1471-2474-15-384] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2014] [Accepted: 11/06/2014] [Indexed: 11/18/2022] Open
Abstract
Background Complete or almost complete recording of reoperations is essential to enable a correct interpretation of data in arthroplasty registers. The completeness of recordings due to infection is unknown in the Swedish Hip Arthroplasty Register (SHAR). We therefore used a combination of data from the Swedish Prescribed Drug Register (SPDR) and studies of medical records to validate the data of reoperations due to infection in the SHAR. Methods All patients registered for a primary Total Hip Replacement (THR) in the SHAR between July 1, 2005 and December 31, 2008 were selected for the study (45,531 patients with 49,219 THRs) and were matched with the SPDR. All patients with a minimum of 4 weeks of continuous outpatient antibiotic treatment within 2 years after their primary THR (1,989 patients, with 2,219 THRs) were selected for a medical records review to find the THRs reoperated due to infection. Results 599 (1.3%) of the THRs had been reoperated within 2 years after the index operation and in 47.4% of these the prosthesis had been revised or extracted. 400 of the THRs were registered for a reoperation in the SHAR resulting in a completeness of 67%. Conclusions The completeness of registration due to early infection after THR questions whether the SHAR reoperation data can be used in order to evaluate changes in postoperative infection rates. Electronic supplementary material The online version of this article (doi:10.1186/1471-2474-15-384) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- J Viktor Lindgren
- Department of Molecular Medicine and Surgery, Section of Orthopaedics, Karolinska Institutet, Stockholm, Sweden.
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