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Nourie BO, Cozzarelli NF, Krueger CA, Donnelly PC, Fillingham YA. Antibiotic Laden Bone Cement Does Not Reduce Acute Periprosthetic Joint Infection Risk in Primary Total Knee Arthroplasty. J Arthroplasty 2024:S0883-5403(24)00416-9. [PMID: 38703925 DOI: 10.1016/j.arth.2024.04.068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Revised: 04/22/2024] [Accepted: 04/23/2024] [Indexed: 05/06/2024] Open
Abstract
BACKGROUND Periprosthetic joint infection (PJI) can be a serious complication of total knee arthroplasty (TKA). A method believed to decrease the incidence of PJI is antibiotic-laden bone cement (ALBC). Current clinical practice guidelines do not recommend ALBC in primary TKA. The purpose of this study was to compare ALBC to plain cement (PC) in preventing PJI in primary TKA. METHODS This retrospective analysis included 109,242 Medicare patients in the American Joint Replacement Registry who underwent a cemented primary TKA from January 2017 to March 2021, and had at least 1 year of follow-up. Patients who received ALBC were compared to patients who received PC. Demographic and case-specific variables such as age, sex, race, body mass index, Charlson Comorbidity Index, anesthesia type, and operative time were used to create propensity scores. A logistic regression was run to predict the probability of receiving ALBC. Also, a multivariate model was run on the full unstratified population, using the same covariates as were used to create the propensity model. The primary outcome was differences in PJI rates. RESULTS Logistic regression analysis showed that a higher preoperative diagnosis of osteoarthritis, higher Charlson Comorbidity Index, higher body mass index, women, race, and anesthesia requirements increased a patient's probability of receiving ALBC. In the full unstratified multivariate model, ALBC did not show a statistically significant difference in risk of revision for infection compared to PC. CONCLUSIONS The use of ALBC in primary TKA has not been shown to be more efficacious in preventing PJI within the population of Medicare patients in the United States. However, this study is limited given it is a retrospective database study that may inherently have biases and the large dataset has a potential for overpowering the findings.
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Affiliation(s)
- Blake O Nourie
- Department of Orthopedic Surgery, Albany Medical Center, Albany, New York
| | - Nicholas F Cozzarelli
- Department of Orthopedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Chad A Krueger
- Department of Orthopedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | | | - Yale A Fillingham
- Department of Orthopedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
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Leta TH, Lie SA, Fenstad AM, Lygre SHL, Lindberg-Larsen M, Pedersen AB, W-Dahl A, Rolfson O, Bülow E, van Steenbergen LN, Nelissen RGHH, Harries D, de Steiger R, Lutro O, Mäkelä K, Venäläinen MS, Willis J, Wyatt M, Frampton C, Grimberg A, Steinbrück A, Wu Y, Armaroli C, Gentilini MA, Picus R, Bonetti M, Dragosloveanu S, Vorovenci AE, Dragomirescu D, Dale H, Brand C, Christen B, Shapiro J, Wilkinson JM, Armstrong R, Wooster K, Hallan G, Gjertsen JE, Chang RN, Prentice HA, Sedrakyan A, Paxton EW, Furnes O. Periprosthetic Joint Infection After Total Knee Arthroplasty With or Without Antibiotic Bone Cement. JAMA Netw Open 2024; 7:e2412898. [PMID: 38780939 PMCID: PMC11117087 DOI: 10.1001/jamanetworkopen.2024.12898] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Accepted: 03/20/2024] [Indexed: 05/25/2024] Open
Abstract
Importance Despite increased use of antibiotic-loaded bone cement (ALBC) in joint arthroplasty over recent decades, current evidence for prophylactic use of ALBC to reduce risk of periprosthetic joint infection (PJI) is insufficient. Objective To compare the rate of revision attributed to PJI following primary total knee arthroplasty (TKA) using ALBC vs plain bone cement. Design, Setting, and Participants This international cohort study used data from 14 national or regional joint arthroplasty registries in Australia, Denmark, Finland, Germany, Italy, New Zealand, Norway, Romania, Sweden, Switzerland, the Netherlands, the UK, and the US. The study included primary TKAs for osteoarthritis registered from January 1, 2010, to December 31, 2020, and followed-up until December 31, 2021. Data analysis was performed from April to September 2023. Exposure Primary TKA with ALBC vs plain bone cement. Main Outcomes and Measures The primary outcome was risk of 1-year revision for PJI. Using a distributed data network analysis method, data were harmonized, and a cumulative revision rate was calculated (1 - Kaplan-Meier), and Cox regression analyses were performed within the 10 registries using both cement types. A meta-analysis was then performed to combine all aggregated data and evaluate the risk of 1-year revision for PJI and all causes. Results Among 2 168 924 TKAs included, 93% were performed with ALBC. Most TKAs were performed in female patients (59.5%) and patients aged 65 to 74 years (39.9%), fully cemented (92.2%), and in the 2015 to 2020 period (62.5%). All participating registries reported a cumulative 1-year revision rate for PJI of less than 1% following primary TKA with ALBC (range, 0.21%-0.80%) and with plain bone cement (range, 0.23%-0.70%). The meta-analyses based on adjusted Cox regression for 1 917 190 TKAs showed no statistically significant difference at 1 year in risk of revision for PJI (hazard rate ratio, 1.16; 95% CI, 0.89-1.52) or for all causes (hazard rate ratio, 1.12; 95% CI, 0.89-1.40) among TKAs performed with ALBC vs plain bone cement. Conclusions and Relevance In this study, the risk of revision for PJI was similar between ALBC and plain bone cement following primary TKA. Any additional costs of ALBC and its relative value in reducing revision risk should be considered in the context of the overall health care delivery system.
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Affiliation(s)
- Tesfaye H. Leta
- The Norwegian Arthroplasty Register, Department of Orthopedic Surgery, Haukeland University Hospital, Bergen, Norway
- Faculty of Health Science, VID Specialized University, Oslo, Norway
- Department of Population Health Sciences, Weill Medical College of Cornell University, New York, New York
- Medical Device Surveillance and Assessment, Kaiser Permanente, San Diego, California
| | - Stein Atle Lie
- The Norwegian Arthroplasty Register, Department of Orthopedic Surgery, Haukeland University Hospital, Bergen, Norway
- Center for Translational Oral Research, Department of Dentistry, University of Bergen, Bergen, Norway
| | - Anne Marie Fenstad
- The Norwegian Arthroplasty Register, Department of Orthopedic Surgery, Haukeland University Hospital, Bergen, Norway
| | - Stein Håkon L. Lygre
- The Norwegian Arthroplasty Register, Department of Orthopedic Surgery, Haukeland University Hospital, Bergen, Norway
- Department of Occupational Medicine, Haukeland University Hospital, Bergen, Norway
| | - Martin Lindberg-Larsen
- The Danish Knee Arthroplasty Register, Odense, Denmark
- Department of Orthopaedic Surgery and Traumatology, Odense University Hospital, Odense, Denmark
| | - Alma B. Pedersen
- The Danish Knee Arthroplasty Register, Odense, Denmark
- Department of Clinical Epidemiology, Aarhus University Hospital and Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Annette W-Dahl
- The Swedish Arthroplasty Register, Gothenburg, Sweden
- Department of Clinical Sciences Lund, Orthopedics, Lund University, Lund, Sweden
| | - Ola Rolfson
- The Swedish Arthroplasty Register, Gothenburg, Sweden
- Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Erik Bülow
- Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Centre of Registers Västra Götaland, Gothenburg, Sweden
| | | | - Rob G. H. H. Nelissen
- The Dutch Arthroplasty Register, ‘s-Hertogenbosch, the Netherlands
- Department Orthopaedics, Leiden University Medical Center, Leiden, the Netherlands
| | - Dylan Harries
- South Australian Health and Medical Research Institute, Adelaide, Australia
| | - Richard de Steiger
- The Australian Orthopaedic Association National Joint Replacement Registry, Adelaide, Australia
| | - Olav Lutro
- Department of Medicine, Stavanger University Hospital, Stavanger, Norway
| | - Keijo Mäkelä
- The Finnish Arthroplasty Register, Helsinki, Finland
- Turku University Hospital and University of Turku, Turku, Finland
| | | | - Jinny Willis
- The New Zealand Joint Registry, Christchurch, New Zealand
| | - Michael Wyatt
- The New Zealand Joint Registry, Christchurch, New Zealand
| | - Chris Frampton
- The New Zealand Joint Registry, Christchurch, New Zealand
| | | | | | - Yinan Wu
- German Arthroplasty Registry, Berlin, Germany
| | - Cristiana Armaroli
- Arthroplasty Registry of the Autonomous Province of Trento, Clinical Epidemiology Service, Provincial Agency for Health Services of Trento, Trento, Italy
| | - Maria Adalgisa Gentilini
- Arthroplasty Registry of the Autonomous Province of Trento, Clinical Epidemiology Service, Provincial Agency for Health Services of Trento, Trento, Italy
| | - Roberto Picus
- Arthroplasty Register of Autonomous Province of Bolzano, Observatory of Health, Health Department AP of Bolzano, Bolzano, Italy
| | - Mirko Bonetti
- Arthroplasty Register of Autonomous Province of Bolzano, Observatory of Health, Health Department AP of Bolzano, Bolzano, Italy
| | - Serban Dragosloveanu
- Romanian Arthroplasty Registry, Bucharest, Romania
- University of Medicine and Pharmacy–Carol Davila, Bucharest, Romania
- Foisor Orthopaedic Hospital, Bucharest, Romania
| | - Andreea E. Vorovenci
- Romanian Arthroplasty Registry, Bucharest, Romania
- Economic Cybernetics and Statistics Doctoral School, Bucharest University of Economic Studies, Bucharest, Romania
| | - Dan Dragomirescu
- Romanian Arthroplasty Registry, Bucharest, Romania
- Economic Cybernetics and Statistics Doctoral School, Bucharest University of Economic Studies, Bucharest, Romania
| | - Håvard Dale
- The Norwegian Arthroplasty Register, Department of Orthopedic Surgery, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, Faculty of Medicine, University of Bergen, Bergen, Norway
| | - Christian Brand
- Swiss National Hip and Knee Joint Registry, Bern, Switzerland
- Institute of Social and Preventive Medicine, SwissRDL, University of Bern, Bern, Switzerland
| | - Bernhard Christen
- Swiss National Hip and Knee Joint Registry, Bern, Switzerland
- Articon, Bern, Switzerland
| | - Joanne Shapiro
- The National Joint Registry for England, Wales, Northern Ireland, The Isle of Man and Guernsey, London, United Kingdom
- NEC Software Solutions, Hemel Hempstead, United Kingdom
| | - J. Mark Wilkinson
- The National Joint Registry for England, Wales, Northern Ireland, The Isle of Man and Guernsey, London, United Kingdom
- Division of Clinical Medicine, School of Medicine and Population Health, University of Sheffield, Sheffield, United Kingdom
| | - Richard Armstrong
- The National Joint Registry for England, Wales, Northern Ireland, The Isle of Man and Guernsey, London, United Kingdom
- NEC Software Solutions, Hemel Hempstead, United Kingdom
| | - Kate Wooster
- The National Joint Registry for England, Wales, Northern Ireland, The Isle of Man and Guernsey, London, United Kingdom
- NEC Software Solutions, Hemel Hempstead, United Kingdom
| | - Geir Hallan
- The Norwegian Arthroplasty Register, Department of Orthopedic Surgery, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, Faculty of Medicine, University of Bergen, Bergen, Norway
| | - Jan-Erik Gjertsen
- The Norwegian Arthroplasty Register, Department of Orthopedic Surgery, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, Faculty of Medicine, University of Bergen, Bergen, Norway
| | - Richard N. Chang
- Medical Device Surveillance and Assessment, Kaiser Permanente, San Diego, California
| | - Heather A. Prentice
- Medical Device Surveillance and Assessment, Kaiser Permanente, San Diego, California
| | - Art Sedrakyan
- Department of Population Health Sciences, Weill Medical College of Cornell University, New York, New York
| | - Elizabeth W. Paxton
- Medical Device Surveillance and Assessment, Kaiser Permanente, San Diego, California
| | - Ove Furnes
- The Norwegian Arthroplasty Register, Department of Orthopedic Surgery, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, Faculty of Medicine, University of Bergen, Bergen, Norway
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Fraval A, Zhou Y, Parvizi J. Antibiotic-loaded cement in total joint arthroplasty: a comprehensive review. Arch Orthop Trauma Surg 2024:10.1007/s00402-024-05328-z. [PMID: 38687383 DOI: 10.1007/s00402-024-05328-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2024] [Accepted: 04/14/2024] [Indexed: 05/02/2024]
Abstract
This review evaluates the decision-making framework for using antibiotic-loaded cement (ALC) in the management of prosthetic joint infection (PJI). Drawing on available literature, we offer orthopaedic surgeons a guided discussion on several critical considerations. First, we explore the impact of antibiotic-loading on the mechanical properties of polymethylmethacrylate (PMMA) cement, assessing both strength and durability. We then explore the optimal antibiotic dosage to load into cement, aiming to achieve effective local concentrations for infection control without compromising mechanical stability. Furthermore, we explore how cement and antibiotic properties affect the overall antibiotic elution characteristics of ALC. Finally, we discuss risks of systemic toxicity, particularly acute kidney injury, when using ALC. The principal goal in this review is to provide a balanced approach based on best available evidence that optimises antibiotic elution from ALC whilst minimising potential harms associated with its use.
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Affiliation(s)
- Andrew Fraval
- Department of Orthopaedic Surgery, St. Vincent's Hospital Melbourne, 41 Victoria Parade, Fitzroy, VIC, 3065, Australia.
- Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, PA, USA.
| | - Yushy Zhou
- Department of Orthopaedic Surgery, St. Vincent's Hospital Melbourne, 41 Victoria Parade, Fitzroy, VIC, 3065, Australia
| | - Javad Parvizi
- Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, PA, USA
- International Joint Center, Acibadem University Hospital, Istanbul, Turkey
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Kato H, Hamada Y, Takano S, Ikeda S, Seto Y, Matsushita K, Yamada K, Uchiyama K. A systematic review and meta-analysis of antibiotic-loaded bone cement for prevention of deep surgical site infections following primary total joint replacement. J Infect Chemother 2024:S1341-321X(24)00078-3. [PMID: 38479573 DOI: 10.1016/j.jiac.2024.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Revised: 01/22/2024] [Accepted: 03/02/2024] [Indexed: 03/18/2024]
Abstract
BACKGROUND The use of antibiotic-loaded bone cement (ALBC) as a mean for preventing deep surgical site infections (SSI) after total joint replacement is controversial. Therefore, we have conducted a meta-analysis to evaluate the prophylactic effect of ALBC for SSI prevention in patients undergoing arthroplasty. This study was conducted to revise treatment guidelines for MRSA infections in Japan. METHODS PubMed (Medline), Scopus, Embase, Web of Science and Cochrane library were searched for relevant articles comparing preventive effect of ALBC for patients undergoing primary total joint arthroplasty by August 2022. Primary outcome was the incidence of deep SSI. Subgroup analyses by type of surgery (total hip (THA) or knee (TKA) arthroplasty) and by causative pathogen (methicillin-resistant Staphylococcus aureus (MRSA)) were performed. RESULTS Of the 3379 studies identified for screening, six studies involving 5745 patients were included. The use of ALBC significantly reduced the incidence of deep SSI in overall patients (risk ratio [RR] 0.60, 95% confidential interval [CI] 0.39-0.92), but the evidence level was very low. There was no significant preventive effect for ALBC compared with non-ALBC in both THA and TKA (THA, RR 0.52, 95% CI 0.23-1.16; TKA, RR 0.64, 95% CI 0.38-1.06), and for preventing MRSA-SSI (RR 0.27, 95% CI 0.03-2.41). CONCLUSIONS Although the overall preventive effect of ALBC was significant, the evidence level was very low. Thus, the routine use of ALBC as a mean to prevent SSI in arthroplasty may not be suggested.
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Affiliation(s)
- Hideo Kato
- Department of Pharmacy, Mie University Hospital, Mie, Japan
| | - Yukihiro Hamada
- Department of Pharmacy, Tokyo Women's Medical University, Tokyo, Japan; Department of Pharmacy, Kochi Medical School Hospital, Kochi, Japan.
| | - Shotaro Takano
- Department of Orthopaedic Surgery, School of Medicine, Kitasato University, Kanagawa, Japan
| | - Shinsuke Ikeda
- Department of Orthopaedic Surgery, School of Medicine, Kitasato University, Kanagawa, Japan
| | - Yoshinori Seto
- Department of Pharmacy, Kitasato University Hospital, Kanagawa, Japan
| | | | - Koji Yamada
- Nakanoshima Orthopaedics, Kanagawa, 214-0012, Japan
| | - Katsufumi Uchiyama
- Department of Patient Safety and Healthcare Administration, School of Medicine, Kitasato University Kanagawa, Japan
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Lutro O, Mo S, Tjørhom MB, Fenstad AM, Leta TH, Bruun T, Hallan G, Furnes O, Dale H. How good are surgeons at disclosing periprosthetic joint infection at the time of revision, based on pre- and intra-operative assessment? A study on 16,922 primary total hip arthroplasties reported to the Norwegian Arthroplasty Register. Acta Orthop 2024; 95:67-72. [PMID: 38288989 PMCID: PMC10826841 DOI: 10.2340/17453674.2024.39914] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Accepted: 12/14/2023] [Indexed: 02/01/2024] Open
Abstract
BACKGROUND AND PURPOSE Revision due to infection, as reported to the Norwegian Arthroplasty Register (NAR), is a surrogate endpoint to periprosthetic joint infection (PJI). We aimed to find the accuracy of the reported causes of revision after primary total hip arthroplasty (THA) compared with PJI to see how good surgeons were at disclosing infection, based on pre- and intraoperative assessment. PATIENTS AND METHODS We investigated the reasons for revision potentially caused by PJI following primary THA: infection, aseptic loosening, prolonged wound drainage, and pain only, reported to the NAR from surgeons in the region of Western Norway during the period 2010-2020. The electronic patient charts were investigated for information on clinical assessment, treatment, biochemistry, and microbiological findings. PJI was defined in accordance with the Musculoskeletal Infection Society (MSIS) definition. Sensitivity, specificity, and accuracy were calculated. RESULTS 363 revisions in the NAR were eligible for analyses. Causes of revision were (reported/validated): infection (153/177), aseptic loosening (139/133), prolonged wound drainage (37/13), and pain only (34/40). The sensitivity for reported revision due to infection compared with PJI was 80%, specificity was 94%, and accuracy-the surgeons' ability to disclose PJI or non-septic revision at time of revision-was 87%. The accuracy for the specific revision causes was highest for revision due to aseptic loosening (95%) and pain only (95%), and lowest for revision due to prolonged wound drainage (86%). CONCLUSION The accuracy of surgeon-reported revisions due to infection as representing PJI was 87% in the NAR. Our study shows the importance of systematic correction of the reported cause of revision in arthroplasty registers, after results from adequately taken bacterial samples.
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Affiliation(s)
- Olav Lutro
- Department of Medicine, Stavanger University Hospital, Stavanger.
| | - Synnøve Mo
- The Norwegian Arthroplasty Register, Department of Orthopaedic Surgery, Haukeland University Hospital, Bergen
| | | | - Anne Marie Fenstad
- The Norwegian Arthroplasty Register, Department of Orthopaedic Surgery, Haukeland University Hospital, Bergen
| | - Tesfaye Hordofa Leta
- The Norwegian Arthroplasty Register, Department of Orthopaedic Surgery, Haukeland University Hospital, Bergen; VID Specialized University, Bergen, Norway
| | - Trond Bruun
- Department of Medicine, Haukeland University Hospital, Bergen
| | - Geir Hallan
- The Norwegian Arthroplasty Register, Department of Orthopaedic Surgery, Haukeland University Hospital, Bergen; Department of Medicine, Haukeland University Hospital, Bergen
| | - Ove Furnes
- The Norwegian Arthroplasty Register, Department of Orthopaedic Surgery, Haukeland University Hospital, Bergen; Department of Clinical Medicine, University of Bergen, Bergen
| | - Håvard Dale
- The Norwegian Arthroplasty Register, Department of Orthopaedic Surgery, Haukeland University Hospital, Bergen; Department of Clinical Medicine, University of Bergen, Bergen
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Cieremans D, Muthusamy N, Singh V, Rozell JC, Aggarwal V, Schwarzkopf R. Does antibiotic bone cement reduce infection rates in primary total knee arthroplasty? EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2023; 33:3379-3385. [PMID: 37133753 DOI: 10.1007/s00590-023-03557-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Accepted: 04/23/2023] [Indexed: 05/04/2023]
Abstract
INTRODUCTION Infection after total knee arthroplasty (TKA) impacts the patient, surgeon, and healthcare system significantly. Surgeons routinely use antibiotic-loaded bone cement (ALBC) in attempts to mitigate infection; however, little evidence supports the efficacy of ALBC in reducing infection rates compared to non-antibiotic-loaded bone cement (non-ALBC) in primary TKA. Our study compares infection rates of patients undergoing TKA with ALBC to those with non-ALBC to assess its efficacy in primary TKA. METHODS A retrospective review of all primary, elective, cemented TKA patients over the age of 18 between 2011 and 2020 was conducted at an orthopedic specialty hospital. Patients were stratified into two cohorts based on cement type: ALBC (loaded with gentamicin or tobramycin) or non-ALBC. Baseline characteristics and infection rates determined by MSIS criteria were collected. Multilinear and multivariate logistic regressions were performed to limit significant differences in demographics. Independent samples t test and chi-squared test were used to compare means and proportions, respectively, between the two cohorts. RESULTS In total, 9366 patients were included in this study, 7980 (85.2%) of whom received non-ALBC and 1386 (14.8%) of whom received ALBC. There were significant differences in five of the six demographic variables analyzed; patients with higher Body Mass Index (33.40 ± 6.27 vs. 32.09 ± 6.21; kg/m2) and Charlson Comorbidity Index values (4.51 ± 2.15 vs. 4.04 ± 1.92) were more likely to receive ALBC. The infection rate in the non-ALBC was 0.8% (63/7,980), while the rate in the ALBC was 0.5% (7/1,386). After adjusting for confounders, the difference in rates was not significant between the two groups (OR [95% CI]: 1.53 [0.69-3.38], p = 0.298). Furthermore, a sub-analysis comparing the infection rates within various demographic categories also showed no significant differences between the two groups. CONCLUSION Compared to non-ALBC, the overall infection rate in primary TKA was slightly lower when using ALBC; however, the difference was not statistically significant. When stratifying by comorbidity, use of ALBC still showed no statistical significance in reducing the risk of periprosthetic joint infection. Therefore, the advantage of antibiotics in bone cement to prevent infection in primary TKA is not yet elucidated. Further prospective, multicenter studies regarding the clinical benefits of antibiotic use in bone cement for primary TKA are warranted.
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Affiliation(s)
- David Cieremans
- Division of Adult Reconstruction, Department of Orthopedic Surgery, NYU Langone Health, New York University, Langone Orthopedic Hospital, 301 East 17th Street, New York, NY, 10003, USA
| | - Nishanth Muthusamy
- Division of Adult Reconstruction, Department of Orthopedic Surgery, NYU Langone Health, New York University, Langone Orthopedic Hospital, 301 East 17th Street, New York, NY, 10003, USA
| | - Vivek Singh
- Division of Adult Reconstruction, Department of Orthopedic Surgery, NYU Langone Health, New York University, Langone Orthopedic Hospital, 301 East 17th Street, New York, NY, 10003, USA
| | - Joshua C Rozell
- Division of Adult Reconstruction, Department of Orthopedic Surgery, NYU Langone Health, New York University, Langone Orthopedic Hospital, 301 East 17th Street, New York, NY, 10003, USA
| | - Vinay Aggarwal
- Division of Adult Reconstruction, Department of Orthopedic Surgery, NYU Langone Health, New York University, Langone Orthopedic Hospital, 301 East 17th Street, New York, NY, 10003, USA
| | - Ran Schwarzkopf
- Division of Adult Reconstruction, Department of Orthopedic Surgery, NYU Langone Health, New York University, Langone Orthopedic Hospital, 301 East 17th Street, New York, NY, 10003, USA.
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Hailer NP, Furnes O, Mäkelä K, Overgaard S. Register-based randomized trials: the new power-tool in orthopedic research? Acta Orthop 2023; 94:490-492. [PMID: 37772890 PMCID: PMC10540786 DOI: 10.2340/17453674.2023.19661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Indexed: 09/30/2023] Open
Affiliation(s)
- Nils P Hailer
- Department of Surgical Sciences - Orthopaedics, Uppsala University, Uppsala, Sweden.
| | - Ove Furnes
- Department of Orthopaedic Surgery, Haukeland University Hospital, Bergen, Norway; Department of Clinical Medicine, University of Bergen, Norway
| | - Keijo Mäkelä
- Turku University Hospital and University of Turku, Finland
| | - Søren Overgaard
- Copenhagen University Hospital, Bispebjerg, Department of Orthopaedic Surgery and Traumatology & University of Copenhagen Department of Clinical Medicine, Faculty of Health and Medical Sciences, Denmark
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Bos PK, Spekenbrink-Spooren A, Croughs P, Bierma-Zeinstra SMA, Reijman M, Van Oldenrijk J. Risk for re-revision and type of antibiotic-loaded bone cement in hip or knee arthroplasty revisions: report of the Dutch Arthroplasty Register. Acta Orthop 2023; 94:471-476. [PMID: 37728200 PMCID: PMC10510150 DOI: 10.2340/17453674.2023.18645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2023] [Accepted: 08/17/2023] [Indexed: 09/21/2023] Open
Abstract
BACKGROUND AND PURPOSE High-dose dual antibiotic-loaded bone cement (ALBC) may reduce the risk of revision after total hip and knee replacements. The aim of our study therefore was to determine the risk of re-revision following first time aseptic hip or knee revision using single versus dual ALBC. PATIENTS AND METHODS Patients from the Dutch Arthroplasty Register treated from 2007 to 2018 with first time cemented aseptic hip (n = 2,529) or knee revisions (n = 7,124) were incorporated into 2 datasets. The primary endpoint of this observational cohort study was subsequent all-cause re-revision. Multivariable Cox proportional hazard and competing risk was analyzed for both groups. RESULTS There was no difference in re-revision rate (any reason) with single versus dual ALBC (hazard ratio 1.06, 95% confidence interval [CI] 0.83-1.35 for hip and 0.93, CI 0.80-1.07 for knee revisions). The 10-year crude cumulative re-revision rate also showed no differences for single versus dual ALBC use. The crude cumulative 7-year THA re-revision and 9-year TKA re-revision rates did not show any difference in implant survival for common cement types used. CONCLUSION We could not confirm the potential benefit of using dual ALBC compared with single ALBC for aseptic hip and knee revisions.
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Affiliation(s)
- Pieter K Bos
- Department of Orthopedics and Sports Medicine, Erasmus MC University Medical Center, Rotterdam.
| | | | - Peter Croughs
- Department of Medical Microbiology and Infectious Diseases, Erasmus MC University Medical Center, Rotterdam
| | - Sita M A Bierma-Zeinstra
- Department of Orthopedics and Sports Medicine, Erasmus MC University Medical Center, Rotterdam; Department of General Practice, Erasmus MC University Center Rotterdam, Rotterdam, the Netherlands
| | - Max Reijman
- Department of Orthopedics and Sports Medicine, Erasmus MC University Medical Center, Rotterdam
| | - Jakob Van Oldenrijk
- Department of Orthopedics and Sports Medicine, Erasmus MC University Medical Center, Rotterdam
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Alhammad AM, Almangour TA, Almasoudi I, Alalayet W, Almuqbil M, Alsowaida YS, Alotaibi NH. Effectiveness of antibiotic-loaded bone cement in total joint arthroplasty at a tertiary medical center: A retrospective cohort study. Saudi Pharm J 2023; 31:101739. [PMID: 37638217 PMCID: PMC10448162 DOI: 10.1016/j.jsps.2023.101739] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Accepted: 08/03/2023] [Indexed: 08/29/2023] Open
Abstract
Background Data regarding the effectiveness of antibiotic-loaded bone cement (ALBC) in preventing prosthetic joint infections (PJI) after total joint arthroplasty (TJA) is inconsistent. The objective of this study was to evaluate if the routine use of ALBC influenced the risk of revision surgery due to PJI. Methods This is a retrospective cohort study performed between January 2018 and September 2020. Adult patients aged ≥ 18 years who underwent TJA (knee or hip) and received either ALBC or plain cement (PC) were included. The outcome of this study was the rate of revision due to PJI. Multivariate analysis using logistic regression was used to identify factors that may be associated with increased risk of PJI, using STATA 15.1 (StataCorp LP, College Station, Texas, USA). Results A total of 844 patients were screened and 319 patients were included. There were 247 patients in ALBC group and 72 patients in the PC group. Only vancomycin powder was used in all ALBC cases, with a 2 g dose in 50% of the cases (dose ranged between 1 g and 8 g). The status of the prosthetic joint was assessed and recorded up to 2 years of the TJA. Overall, the difference in the rates of PJI between the two groups after primary arthroplasty was not statistically significant (5.6% vs 1.4%; p = 0.173; OR, 4.2; 95% CI, 0.5-33). Conclusion ALBC was not associated with a reduction in PJI rates after primary TJA. More research is needed to further evaluate the effectiveness of ALBC in preventing PJI.
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Affiliation(s)
- Abdullah M. Alhammad
- Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
| | - Thamer A. Almangour
- Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
| | - Imtinan Almasoudi
- Clinical Pharmacy Department, King Saud Medical City, Ministry of Health, Riyadh, Saudi Arabia
| | - Wesal Alalayet
- Pharmaceutical Care Department, King Saud University Medical City, Riyadh, Saudi Arabia
| | - Mansour Almuqbil
- Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
| | - Yazed S. Alsowaida
- Department of Clinical Pharmacy, College of Pharmacy, Hail University, P.O. Box 6166, Hail 81442, Saudi Arabia
| | - Naif H Alotaibi
- Division of Infectious Diseases, Department of Internal Medicine, College of Medicine, King Saud University, PO Box 7805, Riyadh 11472, Saudi Arabia
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Sabater-Martos M, Verdejo MA, Morata L, Muñoz-Mahamud E, Guerra-Farfan E, Martinez-Pastor JC, Soriano A. Antimicrobials in polymethylmethacrylate: from prevention to prosthetic joint infection treatment: basic principles and risk of resistance. ARTHROPLASTY 2023; 5:12. [PMID: 36864538 PMCID: PMC9983184 DOI: 10.1186/s42836-023-00166-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Accepted: 01/16/2023] [Indexed: 03/04/2023] Open
Abstract
BACKGROUND Excellent revisions about antibiotic-loaded bone cement (ALBC) have been recently published. In the present article, we review the principles and limitations of local antibiotic delivery in the context of recent advances in the pathogenesis of prosthetic joint infections (PJI), with particular attention paid to the potential association between ALBC and antimicrobial resistance. MAIN BODY Recalcitrance of PJI is related to the ability of pathogens to adapt to particular environments present in bone tissue and protect themselves from host immunity in different ways. Accordingly, delivery of high local antimicrobial concentrations using ALBC is needed. Most relevant clinical data showing the efficacy of ALBC for PJI prophylaxis and treatment are reviewed, and we dissected the limitations on the basis of the recent findings from animal models and suggested that aminoglycosides, in particular, could not be the best option. One of the major concerns associated with ALBC is the emergence of resistance because of theoretical prolonged exposure to low antibiotic concentrations. We summarize the mechanisms for the selection of resistant microorganisms, and we critically reviewed the evidence from animal models and clinical data from observational and registry studies and concluded that there is no evidence to support this association. CONCLUSION While waiting for better evidence from well-designed clinical trials, ALBC shows a beneficial effect as a prophylaxis in arthroplasty, and to avoid the colonization of spacers used for two-stage revision in patients with PJI. Experimental models and clinical evidence suggest the need to achieve high local antimicrobial concentrations to obtain the highest prophylactic and therapeutic effect. The current evidence does not support the risk of increasing resistance with use of ALBC. In the future, it is necessary to evaluate new carriers and different antimicrobials to improve clinical outcomes.
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Affiliation(s)
- Marta Sabater-Martos
- Department of Orthopedics and Traumatology, Hospital Clínic of Barcelona, Carrer Villarroel 170, 08036, Barcelona, Spain.
| | - Miguel A. Verdejo
- grid.410458.c0000 0000 9635 9413Department of Infectious Diseases, Hospital Clínic of Barcelona, Carrer Villarroel 170, 08036 Barcelona, Spain
| | - Laura Morata
- grid.410458.c0000 0000 9635 9413Department of Infectious Diseases, Hospital Clínic of Barcelona, Carrer Villarroel 170, 08036 Barcelona, Spain
| | - Ernesto Muñoz-Mahamud
- grid.410458.c0000 0000 9635 9413Department of Orthopedics and Traumatology, Hospital Clínic of Barcelona, Carrer Villarroel 170, 08036 Barcelona, Spain
| | - Ernesto Guerra-Farfan
- grid.411083.f0000 0001 0675 8654Department of Orthopedics and Traumatology, Hospital Vall d’Hebron of Barcelona, Passeig de la Vall d’Hebron 119, 08035 Barcelona, Spain
| | - Juan C. Martinez-Pastor
- grid.410458.c0000 0000 9635 9413Department of Orthopedics and Traumatology, Hospital Clínic of Barcelona, Carrer Villarroel 170, 08036 Barcelona, Spain
| | - Alex Soriano
- Department of Infectious Diseases, Hospital Clínic of Barcelona, Carrer Villarroel 170, 08036, Barcelona, Spain. .,University of Barcelona, CIBERINF, Carrer Casanova 143, 08036, Barcelona, Spain.
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Influence of chitosan and chitosan oligosaccharide on dual antibiotic-loaded bone cement: In vitro evaluations. PLoS One 2022; 17:e0276604. [PMID: 36449553 PMCID: PMC9710798 DOI: 10.1371/journal.pone.0276604] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2022] [Accepted: 10/11/2022] [Indexed: 12/05/2022] Open
Abstract
BACKGROUND AND PURPOSE The purpose of this study was to investigate the effect of incorporating chitosan (Ch) and chitosan oligosaccharides (ChO) into the commercially premixed antibiotic-loaded bone cement (ALBC). We compare antibiotic release profiles, antibacterial activity, and mechanical properties among different ALBC formulations. The hypothesis was that increasing the amount of Ch and ChO in the cement mixture would increase the antibiotics released and bacterial control. ALBC mixed with Ch or ChO may create a greater effect due to its superior dissolving property. MATERIALS AND METHODS The bone cement samples used in this project were made from Copal® G+V composed of vancomycin and gentamicin. To prepare the Ch and the ChO mixed bone cement samples, different amounts of Ch and ChO were added to the polymethylmethacrylate matrix with three concentrations (1%, 5%, and 10%). Drug elution assay, antimicrobial assay, in vitro cytotoxicity, and mechanical properties were conducted. RESULTS Bone cement samples made from Copal® G+V alone or combined with Ch or ChO can release vancomycin and gentamicin into the phosphate-buffered saline. Mixing ChO into the bone cements can increase the amount of drug released more than Ch. ChO 10% gave the highest amount of antibiotics released. All samples showed good antibacterial properties with good biocompatibility in vitro. The microhardness values of the Ch and ChO groups increased significantly compared to the control group. In all groups tested, the microhardness of bone cements was reduced after the drug eluted out. However, this reduction of the Ch and ChO groups was in line with the control. INTERPRETATION Various attempts have been made to improve the ALBC efficacy. In our study, the best bone cement formulation was bone cement mixed with ChO (10%), which had the highest drug release profiles, was biocompatible, and contained antibacterial properties with acceptable mechanical properties. This phenomenon could result from the superior water solubility of the ChO. When ChO leaves the bone cement specimens, it generates pores that could act as a path that exposes the bone cement matrix to the surrounding medium, increasing antibiotic elution. From all above, ChO is a promising substance that could be added to ALBC in order to increase the drug elution rate. However, more in vitro and in vivo experiments are needed before being used in the clinic.
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Eriksson JW, Eliasson B, Bennet L, Sundström J. Registry-based randomised clinical trials: a remedy for evidence-based diabetes care? Diabetologia 2022; 65:1575-1586. [PMID: 35902386 PMCID: PMC9334551 DOI: 10.1007/s00125-022-05762-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Accepted: 06/21/2022] [Indexed: 11/28/2022]
Abstract
This narrative review describes a new approach to navigation in a challenging landscape of clinical drug development in diabetes. Successful outcome studies in recent years have led to new indications and guidelines in type 2 diabetes, yet the number of clinical trials in diabetes is now declining. This is due to many environmental factors acting in concert, including the prioritisation of funding for other diseases, high costs of large randomised clinical trials, increase in regulatory requirements and limited entry of novel candidate drugs. There is a need for novel and cost-effective paradigms of clinical development to meet these and other challenges. The concept of registry-based randomised clinical trials (RRCTs) is an attractive option. In this review we focus on type 2 diabetes and the prevention of cardiovascular and microvascular comorbidities and mortality, using the Swedish SMARTEST trial as an example of an RRCT. We also give some examples from other disease areas. The RRCT concept is a novel, cost-effective and scientifically sound approach for conducting large-scale diabetes trials in a real-world setting.
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Affiliation(s)
- Jan W Eriksson
- Department of Medical Sciences, Clinical Diabetes and Metabolism, Uppsala University, Uppsala, Sweden.
| | - Björn Eliasson
- Department of Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden
- Swedish National Diabetes Register, Västra Götalandsregionen, Gothenburg, Sweden
| | - Louise Bennet
- Department of Clinical Sciences in Malmö, Lund University, Lund, Sweden
- Clinical Trials Unit, Skåne University Hospital in Lund, Lund, Sweden
| | - Johan Sundström
- Department of Medical Sciences, Clinical Epidemiology, Uppsala University, Uppsala, Sweden
- The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
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Rubinger L, Ekhtiari S, Gazendam A, Bhandari M. Registries: Big data, bigger problems? Injury 2021:S0020-1383(21)01001-9. [PMID: 34930582 DOI: 10.1016/j.injury.2021.12.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Accepted: 12/04/2021] [Indexed: 02/02/2023]
Abstract
Patient registries have grown in size and number along with general computing power and digitization of the healthcare world. In contrast to databases, registries are typically patient data systematically created and collected for the express purpose of answering health-related questions. Registries can be disease-, procedure-, pathology-, or product-based in nature. Registry-based studies typically fit into Level II or III in the hierarchy of evidence-based medicine. However, a recent advent in the use of registry data has been the development and execution of registry-based trials, such as the TASTE trial, which may elevate registry-based studies into the realm of Level I evidence. Some strengths of registries include the sheer volume of data, the inclusion of a diverse set of participants, and their ability to be linked to other registries and databases. Limitations of registries include variable quality of the collected data, and a lack of active follow-up (which may underestimate rates of adverse events). As with any study type, the intended design does not automatically lead to a study of a certain quality. While no specific tool exists for assessing the quality of a registry-based study, some important considerations include ensuring the registry is appropriate for the question being asked, whether the patient population is representative, the presence of an appropriate comparison group, and the validity and generalizability of the registry in question. The future of clinical registries remains to be seen, but the incorporation of big data and machine learning algorithms will certainly play an important role.
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Affiliation(s)
- Luc Rubinger
- Division of Orthopaedics, Department of Surgery, McMaster University, Hamilton, ON Canada.
| | - Seper Ekhtiari
- Division of Orthopaedics, Department of Surgery, McMaster University, Hamilton, ON Canada; Centre for Evidence-Based Orthopaedics, 293 Wellington St. N, Suite 110, Hamilton, ON L8L 8E7 Canada
| | - Aaron Gazendam
- Division of Orthopaedics, Department of Surgery, McMaster University, Hamilton, ON Canada; Centre for Evidence-Based Orthopaedics, 293 Wellington St. N, Suite 110, Hamilton, ON L8L 8E7 Canada
| | - Mohit Bhandari
- Division of Orthopaedics, Department of Surgery, McMaster University, Hamilton, ON Canada; Centre for Evidence-Based Orthopaedics, 293 Wellington St. N, Suite 110, Hamilton, ON L8L 8E7 Canada
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Mäkelä K, Hailer NP. Editorial: Different, yet strong together: the Nordic Arthroplasty Register Association (NARA). Acta Orthop 2021; 92:635-637. [PMID: 34231441 PMCID: PMC8648399 DOI: 10.1080/17453674.2021.1947006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Affiliation(s)
- Keijo Mäkelä
- Past NARA Chairman, Department of Orthopaedics and Traumatology, Turku University Hospital and University of Turku, Turku, Finland
| | - Nils P. Hailer
- Co-Editor/NARA Chairman, Department of Surgical Sciences—Orthopaedics, Uppsala University, Uppsala, Sweden,Correspondence: Nils P. Hailer, Department of Surgical Sciences—Orthopaedics, Uppsala University, Uppsala, Sweden,
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