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Um SH, Min BW, Lee KJ, Kim DW, Bae KC, Cho CH, Son ES. Screw augmented cement spacer for deficient acetabulum in periprosthetic infection following Total Hip Arthroplasty. Orthop Traumatol Surg Res 2022; 108:103041. [PMID: 34389497 DOI: 10.1016/j.otsr.2021.103041] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2020] [Revised: 01/30/2021] [Accepted: 02/15/2021] [Indexed: 02/03/2023]
Abstract
For periprosthetic joint infection (PJI) treatment, revision total hip arthroplasty using an antibiotic loaded cement spacer is one of the important surgical methods. However, revision total hip arthroplasty using antibiotic-loaded cement spacers poses a risk of spacer dislodgement in patients with acetabular deficiency. We hypothesized that screw augmentation would be more stable and result in lower rates of cement spacer dislodgement in acetabular deficient patients. Thus, we suggest a method of screw augmentation with cement spacers to treat periprosthetic infection in patients with a deficient acetabulum. And we aim to report better clinical outcomes after revision total hip arthroplasty for infection control using screw augmented cement spacer insertion technique. Level of evidence: IV.
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Affiliation(s)
- Sang-Hyun Um
- Department of Orthopedic Surgery, Dongsan Medical Center, Keimyung University, School of Medicine, Daegu, Republic of Korea
| | - Byung-Woo Min
- Department of Orthopedic Surgery, Dongsan Medical Center, Keimyung University, School of Medicine, Daegu, Republic of Korea
| | - Kyung-Jae Lee
- Department of Orthopedic Surgery, Dongsan Medical Center, Keimyung University, School of Medicine, Daegu, Republic of Korea.
| | - Dong-Wan Kim
- Department of Orthopedic Surgery, Dongsan Medical Center, Keimyung University, School of Medicine, Daegu, Republic of Korea
| | - Ki-Cheor Bae
- Department of Orthopedic Surgery, Dongsan Medical Center, Keimyung University, School of Medicine, Daegu, Republic of Korea
| | - Chul-Hyun Cho
- Department of Orthopedic Surgery, Dongsan Medical Center, Keimyung University, School of Medicine, Daegu, Republic of Korea
| | - Eun-Suck Son
- Department of Orthopedic Surgery, Dongsan Medical Center, Keimyung University, School of Medicine, Daegu, Republic of Korea
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Fu J, Xiang Y, Ni M, Chen J, Li X, Yu B, Liu K, Zhou Y, Hao L. The use of augmented antibiotic-loaded cement spacer in periprosthetic joint infection patients with acetabular bone defect. J Orthop Surg Res 2020; 15:448. [PMID: 32998728 PMCID: PMC7528588 DOI: 10.1186/s13018-020-01831-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Accepted: 07/29/2020] [Indexed: 02/08/2023] Open
Abstract
Background Spacer complications may affect final clinical outcome of the two-stage approach in periprosthetic joint infection (PJI) patients. This study aimed to investigate clinical outcomes and complications of augmented antibiotic-loaded cement spacer in PJI patients with acetabular bone defect. Methods Data on PJI patients with acetabular bone defect receiving two-stage revision from January 2009 to December 2016, in our hospital were retrospectively reviewed. Screw-cement-shell was used to improve the stability of the hip with acetabular wall defect. Handmade acetabular spacer could prevent femoral spacer entering into pelvis in patients with acetabular internal wall defect. A total of 26 patients (11 males and 15 females) were included in the current study. Their mean age was 46.7 ± 15.4 years old. Clinical outcomes and complications were measured. Results Twenty-one of total 26 hips (21/26, 80.8%) showed positive cultures and 15/26 (57.7%) samples were cultured with staphylococcus. Of enrolled patients, 5/26 (19.2%) developed mixed infection. There was one patient (3.8%) with spacer dislocation and two (7.7%) with spacer fracture. One patient developed acute PJI 5 years after the second-stage revision, so overall success rate among these patients was 96.2%. Differences in Paprosky classifications before the first and second stage did not reach significant level (p > 0.05). Hip Harris score was raised from 40.9 ± 14.0 to 81.2 ± 11.2 (p < 0.05). Conclusions Augmented antibiotic-loaded cement spacer could achieve satisfactory clinical outcomes in PJI patients with acetabular bone defect. It provided joint mobility, increased additional joint stability, and decreased iatrogenic bone defect caused by acetabular wear.
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Affiliation(s)
- Jun Fu
- Department of Orthopaedics, Chinese People's Liberation Army General Hospital (301 Hospital), Beijing, China
| | - Yi Xiang
- Department of Orthopaedics, The 985 Hospital of PLA, Taiyuan, Shanxi, China
| | - Ming Ni
- Department of Orthopaedics, Chinese People's Liberation Army General Hospital (301 Hospital), Beijing, China
| | - Jiying Chen
- Department of Orthopaedics, Chinese People's Liberation Army General Hospital (301 Hospital), Beijing, China.
| | - Xiang Li
- Department of Orthopaedics, Chinese People's Liberation Army General Hospital (301 Hospital), Beijing, China
| | - Baozhan Yu
- Department of Orthopaedics, Chinese People's Liberation Army General Hospital (301 Hospital), Beijing, China
| | - Kan Liu
- Department of Orthopaedics, Chinese People's Liberation Army General Hospital (301 Hospital), Beijing, China
| | - Yonggang Zhou
- Department of Orthopaedics, Chinese People's Liberation Army General Hospital (301 Hospital), Beijing, China
| | - Libo Hao
- Department of Orthopaedics, Chinese People's Liberation Army General Hospital (301 Hospital), Beijing, China.
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Luk MH, Ng FY, Fu H, Chan PK, Yan CH, Chiu KY. Retention of prosthetic articulating spacer after infected hip arthroplasty as a semipermanent implant: A case report. JOURNAL OF ORTHOPAEDICS, TRAUMA AND REHABILITATION 2019. [DOI: 10.1177/2210491719864115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Prosthesis with antibiotic-loaded acrylic cement was designed as a temporary articulating cement spacer in a two-stage procedure before definitive reimplantation for the treatment of periprosthetic joint infections. It is designed to remain in situ for about 6–12 weeks, until evidence of infection is controlled before reimplantation of a definitive total hip replacement. This study presents a case of a patient with prosthetic articulating spacer retention for 6 years, previously performed for an infected unipolar hemiarthroplasty for which he refused second-stage reimplantation. He remains relatively asymptomatic with no evidence of infection, implant loosening, or fracture. The patient is able to walk with a frame with minimal hip pain.
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Affiliation(s)
- Michelle Hilda Luk
- Department of Orthopaedics and Traumatology, Queen Mary Hospital, The University of Hong Kong, Pok Fu Lam, Hong Kong
| | | | - Henry Fu
- Department of Orthopaedics and Traumatology, Queen Mary Hospital, The University of Hong Kong, Pok Fu Lam, Hong Kong
| | - Ping Keung Chan
- Department of Orthopaedics and Traumatology, Queen Mary Hospital, The University of Hong Kong, Pok Fu Lam, Hong Kong
| | - Chun Hoi Yan
- Department of Orthopaedics and Traumatology, Queen Mary Hospital, The University of Hong Kong, Pok Fu Lam, Hong Kong
| | - Kwong Yuen Chiu
- Department of Orthopaedics and Traumatology, Queen Mary Hospital, The University of Hong Kong, Pok Fu Lam, Hong Kong
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Shirai T, Tsuchiya H, Nishida H, Yamamoto N, Watanabe K, Nakase J, Terauchi R, Arai Y, Fujiwara H, Kubo T. Antimicrobial megaprostheses supported with iodine. J Biomater Appl 2014; 29:617-23. [PMID: 24913616 DOI: 10.1177/0885328214539365] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Deep infection associated with implants remains a serious complication of orthopedic surgery. We developed iodine coating for titanium implants. In this study, we performed a clinical trial of iodine-coated megaprostheses to evaluate its safety and antibacterial effects. Forty-seven patients with malignant bone tumor or pyogenic arthritis were treated using iodine-supported titanium megaprostheses between July 2008 and May 2013. The mean age was 53.6 years (range, 15-85 years). Twenty-six patients were males and 21 were females. The diagnoses included malignant bone tumor in 29 cases, infected total knee arthroplasty in 11 cases, chronic osteomyelitis due to pyogenic arthritis in six cases and loosening of total knee arthroplasty in one case. The iodine-supported implants used were 42 Kyocera Limb Salvage System and five KOBELCO K-MAX K-3. These megaprostheses were used to prevent infection in 21 patients, treat active infections in 26 patients. The mean follow-up period was 30.1 months (range, 8-50). Infection was prevented in 20 out of 21 patients. Only one patient had surgical site infection caused by Pseudomonas aeruginosa and was cured by intravenous administration of antibiotics alone without removal of the implant. In 26 treatment cases involving one- or two-stage revision surgery, infection subsided without any additional surgery. In all cases, there were no signs of infection at the time of the last follow-up. White blood cell and C-reactive protein levels returned to normal within four weeks after surgery. To confirm systemic effects of iodine, thyroid hormone levels in the blood were examined. Abnormalities of thyroid gland function were not detected. Loosening of the implants was not observed. Excellent bone ingrowth and ongrowth were found around iodine-supported megaprostheses. The iodine-supported titanium megaprostheses are highly effective and show promise for the prevention and treatment of infections in large bone defects. No cytotoxicity or adverse effects were detected with this treatment.
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Affiliation(s)
- Toshiharu Shirai
- Department of Orthopaedic Surgery, Graduate School of Medical Science, Kanazawa University, Kanazawa, Japan Department of Orthopaedics, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kawaramachi-Hirokoji, Kamigyo-ku, Kyoto, Japan
| | - Hiroyuki Tsuchiya
- Department of Orthopaedic Surgery, Graduate School of Medical Science, Kanazawa University, Kanazawa, Japan
| | - Hideji Nishida
- Department of Orthopaedic Surgery, Graduate School of Medical Science, Kanazawa University, Kanazawa, Japan
| | - Norio Yamamoto
- Department of Orthopaedic Surgery, Graduate School of Medical Science, Kanazawa University, Kanazawa, Japan
| | - Koji Watanabe
- Department of Orthopaedic Surgery, Graduate School of Medical Science, Kanazawa University, Kanazawa, Japan
| | - Junsuke Nakase
- Department of Orthopaedic Surgery, Graduate School of Medical Science, Kanazawa University, Kanazawa, Japan
| | - Ryu Terauchi
- Department of Orthopaedics, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kawaramachi-Hirokoji, Kamigyo-ku, Kyoto, Japan
| | - Yuji Arai
- Department of Orthopaedics, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kawaramachi-Hirokoji, Kamigyo-ku, Kyoto, Japan
| | - Hiroyoshi Fujiwara
- Department of Orthopaedics, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kawaramachi-Hirokoji, Kamigyo-ku, Kyoto, Japan
| | - Toshikazu Kubo
- Department of Orthopaedics, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kawaramachi-Hirokoji, Kamigyo-ku, Kyoto, Japan
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Schwarzkopf R, Mikhael B, Wright E, Estok DM, Katz JN. Treatment failure among infected periprosthetic total hip arthroplasty patients. Open Orthop J 2014; 8:118-24. [PMID: 24963358 PMCID: PMC4066371 DOI: 10.2174/1874325020140515002] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2014] [Revised: 05/06/2014] [Accepted: 05/10/2014] [Indexed: 01/29/2023] Open
Abstract
Two-stage revision has been shown to be the most successful treatment in eradicating deep infection following total hiparthroplasty. We identified 62 patients treated by a two-stage revision. We defined "successful revision" as negative intraoperative cultures and no further infection-related procedure. We defined "eradication of infection" on the basis of negative cultures and clinical diagnosis at least one year after 2(nd) stage procedure. After a mean follow up of 2.7 years, eradication of the infection was documented in 91.1%, and a successful two-stage revision in 85.7% of patients. We observed no association between higher pre-reimplantation levels of ESR and C-reactive protein and lower likelihood of successful two-stage revision. We found an association between a history of another previous infected prosthetic joint and a failed 2(nd) stage procedure. Failure to achieve eradication of infection and successful two-stage revision occurs infrequently. Patients with prior history of a previous prosthetic joint infection are at higher risk of failure.
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Affiliation(s)
- Ran Schwarzkopf
- Department of Orthopaedics Surgery, University of California Irvine, 101 The City Drive South, Orange, CA 92868, USA
| | - Bassem Mikhael
- Orthopaedic Department, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Elizabeth Wright
- Orthopedic and Arthritis Center for Outcomes Research, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Daniel M Estok
- Orthopaedic Department, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Jeffrey N Katz
- Orthopedic and Arthritis Center for Outcomes Research, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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Kamath AF, Austin D, Lee GC. Mating of a PROSTALAC spacer with an intramedullary nail for reconstruction of an infected interprosthetic femoral shaft fracture: a case report. J Orthop Surg (Hong Kong) 2012; 20:263-8. [PMID: 22933694 DOI: 10.1177/230949901202000228] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Reconstruction for concurrent infection of an ipsilateral total hip arthroplasty (THA) and total knee arthroplasty (TKA) is a challenge. We report a 2-stage reconstruction of a THA for chronic infection of both the THA and TKA with severe femoral bone loss secondary to interprosthetic fractures. The reconstruction involved using a custom-made, temporary, antibiotic-impregnated PROSTALAC spacer mated with an intramedullary nail. The acetabulum was then exposed and the necrotic cartilage was removed and curetted. The acetabulum was reamed to accept a PROSTALAC acetabular shell. The shell was cemented into the acetabulum with antibiotic cement. The custom-made spacer was then inserted distally first into the tibia. The distal end of the intramedullary nail was interlocked with a bicortical bolt to minimise nail rotation. Antibiotic-impregnated cement was moulded around the nail and spacer. The proximal end of the spacer was then reduced into the acetabular socket, and the joint was irrigated and the wound closed. A customised abduction brace was fitted, and partial weight bearing was allowed. Sufficient leg length, soft-tissue tension, and range of hip motion were restored, and a total femur and constrained liner was re-implanted 4 months later. Mating of an intramedullary nail with a PROSTALAC spacer is a viable reconstructive option.
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Affiliation(s)
- Atul F Kamath
- Department of Orthopaedic Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA 19104, USA
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Ben-Lulu O, Farno A, Gross AE, Backstein DJ, Kosashvili Y, Safir OA. A modified cement spacer technique for infected total hip arthroplasties with significant bone loss. J Arthroplasty 2012; 27:613-9. [PMID: 21885243 DOI: 10.1016/j.arth.2011.06.031] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2011] [Accepted: 06/30/2011] [Indexed: 02/01/2023] Open
Abstract
Complications related to femoral spacers are common during addressing infected total hip arthroplasties by 2-stage revision. We evaluated 11 patients who had 2-stage revisions with massive bone loss after removal of the infected components by a trochanteric osteotomy. All femoral cement spacers were assembled on intramedullary nails. Femurs were protected by a plate, whereas acetabuli were augmented by a cage or roof ring depending on the remaining bone stock. This additional hardware was covered with antibiotic-impregnated cement. Infection was eradicated in 10 (90.9%) of 11 patients within 3.5 months in average. None of the patients had spacer fracture, periprosthetic fracture, or dislocation. Augmentation by hardware covered with antibiotic-impregnated cement is effective and may reduce complications until definitive treatment is performed.
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Affiliation(s)
- Oren Ben-Lulu
- Division of Orthopaedic Surgery, Department of Surgery, Mount Sinai Hospital, Toronto, Ontario, Canada
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Lange J, Troelsen A, Thomsen RW, Søballe K. Chronic infections in hip arthroplasties: comparing risk of reinfection following one-stage and two-stage revision: a systematic review and meta-analysis. Clin Epidemiol 2012; 4:57-73. [PMID: 22500127 PMCID: PMC3324993 DOI: 10.2147/clep.s29025] [Citation(s) in RCA: 119] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Two-stage revision is regarded by many as the best treatment of chronic infection in hip arthroplasties. Some international reports, however, have advocated one-stage revision. No systematic review or meta-analysis has ever compared the risk of reinfection following one-stage and two-stage revisions for chronic infection in hip arthroplasties. METHODS The review was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis. Relevant studies were identified using PubMed and Embase. We assessed studies that included patients with a chronic infection of a hip arthroplasty treated with either one-stage or two-stage revision and with available data on occurrence of reinfections. We performed a meta-analysis estimating absolute risk of reinfection using a random-effects model. RESULTS We identified 36 studies eligible for inclusion. None were randomized controlled trials or comparative studies. The patients in these studies had received either one-stage revision (n = 375) or two-stage revision (n = 929). Reinfection occurred with an estimated absolute risk of 13.1% (95% confidence interval: 10.0%-17.1%) in the one-stage cohort and 10.4% (95% confidence interval: 8.5%-12.7%) in the two-stage cohort. The methodological quality of most included studies was considered low, with insufficient data to evaluate confounding factors. CONCLUSIONS Our results may indicate three additional reinfections per 100 reimplanted patients when performing a one-stage versus two-stage revision. However, the risk estimates were statistically imprecise and the quality of underlying data low, demonstrating the lack of clear evidence that two-stage revision is superior to one-stage revision among patients with chronically infected hip arthroplasties. This systematic review underscores the need for improvement in reporting and collection of high-quality data and for large comparative prospective studies on this issue.
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Affiliation(s)
- Jeppe Lange
- Lundbeck Foundation Center for Fast-Track Hip and Knee Surgery, Aarhus C
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Tsuchiya H, Shirai T, Nishida H, Murakami H, Kabata T, Yamamoto N, Watanabe K, Nakase J. Innovative antimicrobial coating of titanium implants with iodine. J Orthop Sci 2012; 17:595-604. [PMID: 22806173 PMCID: PMC3462916 DOI: 10.1007/s00776-012-0247-3] [Citation(s) in RCA: 108] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2011] [Accepted: 05/15/2012] [Indexed: 11/24/2022]
Abstract
BACKGROUND Postoperative infection associated with implants remains a serious complication in orthopedic surgery. Several biomaterial surface treatments have been proposed as a means of reducing the incidence of implant-associated infections. In this study, a clinical trial was performed using an iodine-supported titanium that suppresses the microbial activities. METHODS A total of 222 patients with postoperative infection or compromised status were treated using iodine-supported titanium implants. The mean age of the patients was 49.4 years (range 5-85 years). One hundred twenty-seven patients were male and 95 were female. In 158 patients, iodine-supported implants were used to prevent infection, such as compromised hosts and conditions, and in 64 patients to treat active infection. White blood cell (WBCs) and C-reactive protein (CRP) levels were measured pre- and postoperatively in all patients. To confirm whether iodine from the implant affected physiological functions, thyroid hormone levels in the blood were examined. Both examinations were conducted sequentially for a year. Radiological evaluations were performed regularly after the operation. The chronological changes of the iodine amount were evaluated using half pins removed after completion of external fixation. RESULTS The mean follow-up period was 18.4 months (range 3-44 months). Acute infection developed in three tumor cases among the 158 patients on preventive therapy. All three recovered without removal of the implants. Infection was cured in all 64 patients with infection. Median WBC levels were in the normal range, and median CRP levels returned to <0.5 within 4 weeks after surgery. Abnormalities of thyroid gland function were not detected. None of the patients experienced loosening of the implants. There were two patients with mechanical implant failure, which was treated by re-implantation. Excellent bone ingrowth and ongrowth were found around all hip and tumor prostheses. One year later, the amount of iodine on external fixation pins remained about 20-30%. CONCLUSIONS Iodine-supported titanium implants can be very effective for preventing and treating infections after orthopedic surgery. Cytotoxicity and adverse effects were not detected.
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Affiliation(s)
- Hiroyuki Tsuchiya
- Department of Orthopaedic Surgery, Graduate School of Medical Science, Kanazawa University, 13-1 Takaramachi, Kanazawa, 920-8641 Japan
| | - Toshiharu Shirai
- Department of Orthopaedic Surgery, Graduate School of Medical Science, Kanazawa University, 13-1 Takaramachi, Kanazawa, 920-8641 Japan
| | - Hideji Nishida
- Department of Orthopaedic Surgery, Graduate School of Medical Science, Kanazawa University, 13-1 Takaramachi, Kanazawa, 920-8641 Japan
| | - Hideki Murakami
- Department of Orthopaedic Surgery, Graduate School of Medical Science, Kanazawa University, 13-1 Takaramachi, Kanazawa, 920-8641 Japan
| | - Tamon Kabata
- Department of Orthopaedic Surgery, Graduate School of Medical Science, Kanazawa University, 13-1 Takaramachi, Kanazawa, 920-8641 Japan
| | - Norio Yamamoto
- Department of Orthopaedic Surgery, Graduate School of Medical Science, Kanazawa University, 13-1 Takaramachi, Kanazawa, 920-8641 Japan
| | - Koji Watanabe
- Department of Orthopaedic Surgery, Graduate School of Medical Science, Kanazawa University, 13-1 Takaramachi, Kanazawa, 920-8641 Japan
| | - Junsuke Nakase
- Department of Orthopaedic Surgery, Graduate School of Medical Science, Kanazawa University, 13-1 Takaramachi, Kanazawa, 920-8641 Japan
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Geurts J, Chris Arts JJ, Walenkamp GHIM. Bone graft substitutes in active or suspected infection. Contra-indicated or not? Injury 2011; 42 Suppl 2:S82-6. [PMID: 21762911 DOI: 10.1016/j.injury.2011.06.189] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Treatment of infection in clinical orthopaedic and trauma care is a time consuming and costly endeavour. More than once, it will lead to extraction of implant material and additional surgical interventions. Currently, debridement, implantation of PMMA beads impregnated with antibiotics most often with implant exchange are the gold standard for deep infection treatment. Recently bone graft substitute materials such as calcium phosphate, collagen fleeces and bioglasses have appeared for specific use in infection treatment. Although these materials show great potential, their supporting level of evidence is still limited. This review paper provides an overview of current understanding and therapies for infection treatment and provides concepts for the use of new developed biomaterials in infection treatment. Furthermore, the benefits and risks of using biomaterials in infection treatment are discussed and the level of evidence of a number of new materials is presented.
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Affiliation(s)
- Jan Geurts
- Department of Orthopaedic Surgery, Research School Caphri, Maastricht University Medical Centre, Maastricht, The Netherlands.
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11
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Kamath AF, Anakwenze O, Lee GC, Nelson CL. Staged custom, intramedullary antibiotic spacers for severe segmental bone loss in infected total hip arthroplasty. Adv Orthop 2011; 2011:398954. [PMID: 21991412 PMCID: PMC3170761 DOI: 10.4061/2011/398954] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2011] [Accepted: 06/30/2011] [Indexed: 01/29/2023] Open
Abstract
Introduction. Total hip arthroplasty (THA) infections with severe bone loss pose significant reconstructive challenges. We present our experience with two-stage hip reimplantation using an intramedullary, antibiotic-impregnated nail. Methods. Three patients with infected THA with severe proximal femoral bone loss (Mallory type IIIB or greater) were treated using a custom antibiotic spacer. Clinical outcomes and any complications were recorded. Average followup was 49 months from final reimplantation. Results. Mean age at spacer placement (stage 1) was 53 years. The mean Harris Hip Score at final followup was 80. Two patients had asymptomatic heterotopic ossification, and one patient had a 2 cm leg-length discrepancy. Conclusions. A custom intramedullary nail antibiotic spacer is a reliable option in the staged management of the infected THA with severe proximal femoral bone loss. Benefits of this technique include limb salvage with maintenance of leg length, soft tissue tension, and functional status.
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Affiliation(s)
- Atul F. Kamath
- Department of Orthopaedic Surgery, University of Pennsylvania, 3400 Spruce Street, 2 Silverstein, Philadelphia, PA 19104, USA
| | - Okechukwu Anakwenze
- Department of Orthopaedic Surgery, University of Pennsylvania, 3400 Spruce Street, 2 Silverstein, Philadelphia, PA 19104, USA
| | - Gwo-Chin Lee
- Department of Orthopaedic Surgery, Penn Presbyterian Medical Center, Cupp 1, 39th and Market Streets, Philadelphia, PA 19104, USA
| | - Charles L. Nelson
- Department of Orthopaedic Surgery, Geisinger Medical Center, Danville, PA 17822, USA
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Kusuma SK, Ward J, Jacofsky M, Sporer SM, Della Valle CJ. What is the role of serological testing between stages of two-stage reconstruction of the infected prosthetic knee? Clin Orthop Relat Res 2011; 469:1002-8. [PMID: 20941647 PMCID: PMC3048278 DOI: 10.1007/s11999-010-1619-7] [Citation(s) in RCA: 130] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Two-stage exchange arthroplasty is the gold standard for treatment of infected TKA. The erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), and synovial fluid white blood cell (WBC) count with differential are often used to determine treatment response; however, it is unclear whether these tests can answer the critical question of whether joint sepsis has been controlled between stages and if reimplantation is indicated. QUESTIONS/PURPOSES We therefore asked if (1) these serologies respond between stage one explantation and stage two reimplantation during two-stage knee reconstruction for infection; and (2) changes in the values of these serologies are predictive of resolution of joint infection. METHODS We retrospectively reviewed the serologies of 76 infected patients treated with a two-stage exchange protocol. The ESR, CRP, and aspiration were repeated a minimum of 2 weeks following antibiotic cessation and prior to second stage reoperation. Comparisons were made to identify trends in these serologies between the first and second stage procedures. RESULTS Eight knees (12%) were persistently infected at the time of second stage reoperation. The ESR remained persistently elevated in 37 knees (54%), and the CRP remained elevated in 14 knees (21%) where infection had been controlled. We were unable to identify an optimum cutoff value for the ESR, CRP, or the two combined. The best test for confirmation of infection control was the synovial fluid WBC count. CONCLUSIONS Although the ESR, CRP, and synovial fluid WBC counts decreased in cases of infection control, these values frequently remained elevated. We were unable to identify any patterns in these tests indicative of persistent infection. LEVEL OF EVIDENCE Level II, diagnostic study. See Guidelines for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Sharat K. Kusuma
- Grant Medical Center, 340 East Town Street, Suite 7-250, Columbus, OH 43215-5081 USA
| | - Joseph Ward
- Loyola University School of Medicine, New Orleans, LA USA
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13
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Perioperative testing for persistent sepsis following resection arthroplasty of the hip for periprosthetic infection. J Arthroplasty 2010; 25:87-91. [PMID: 20732621 DOI: 10.1016/j.arth.2010.05.006] [Citation(s) in RCA: 81] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2009] [Accepted: 05/17/2010] [Indexed: 02/01/2023] Open
Abstract
Eighty-seven hips with an infected total hip arthroplasty were treated with an antibiotic spacer and 6 weeks of antibiotics. The erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) measurements were repeated before attempted reimplanation, and a synovial fluid white blood cell (WBC) count was obtained intraoperatively. Nine hips (10.1%) had persistent infections. The mean ESR, CRP, and synovial fluid WBC count and differential decreased significantly (P < .001) between stages; however, the ESR remained elevated (>30 mm/h) in 50 patients (62.5%) and the CRP remained elevated (>10 mg/L) in 22 patients (27.5%) in whom the infection had been eradicated. The synovial fluid WBC count was the best test for identifying persistent infection, with an optimum cutoff of 3528 WBCs/microL(sensitivity, 78%; specificity, 96%) and an area under the curve of 0.91. The ESR and CRP were not sufficiently rigorous to aid in diagnosis and frequently failed to normalize even in patients without persistent infection.
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Cyrochristos DJ, Papadopoulos O, Liapis C, Felekouras EL, Giannopoulos AM, Bastounis E. Coverage Strategies in Exposed Implants. Am Surg 2009. [DOI: 10.1177/000313480907501122] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Implants are widely used and are not without complications. The most serious complication is infection with consequent exposure of the implant and is characterized by increased morbidity and mortality. Until recently, infected implants were removed and replaced with another one. These operations are accompanied by increased morbidity and might result in permanent disability. Coverage of the implant with a flap is an alternative solution. The objective of this article is to study the effectiveness of muscle or myocutaneous flaps in covering infected and exposed implants. A series of 17 patients with infected implants, which were treated with coverage of the implant with muscle or myocutaneous flap, is presented. Eight patients had an orthopedic implant, seven a vascular implant, and two had a pacemaker. The flaps ensured immediate coverage of the implant and the biologic ability of eliminating the infectious process with the increased concentration of antibiotics resulting from increased blood flow of the muscle. In all the patients, the implants were preserved and the infectious process was eliminated. The use of muscle and myocutaneous flaps in the treatment of infected implants is therefore effective and in some cases it is superior to other methods because of lower morbidity and cost.
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Affiliation(s)
- Dimitris J. Cyrochristos
- From the First Department of Surgery of the National and Kapodistrian University of Athens, Laikon Hospital, Athens, Greece
| | - Othon Papadopoulos
- From the First Department of Surgery of the National and Kapodistrian University of Athens, Laikon Hospital, Athens, Greece
| | - Christos Liapis
- From the First Department of Surgery of the National and Kapodistrian University of Athens, Laikon Hospital, Athens, Greece
| | - Evagelos L. Felekouras
- From the First Department of Surgery of the National and Kapodistrian University of Athens, Laikon Hospital, Athens, Greece
| | - Athanasios M. Giannopoulos
- From the First Department of Surgery of the National and Kapodistrian University of Athens, Laikon Hospital, Athens, Greece
| | - Elias Bastounis
- From the First Department of Surgery of the National and Kapodistrian University of Athens, Laikon Hospital, Athens, Greece
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15
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Sukeik M, Haddad F. (vi) Management of periprosthetic infection in total hip arthroplasty. ACTA ACUST UNITED AC 2009. [DOI: 10.1016/j.mporth.2009.08.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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16
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Sukeik M, Haddad FS. Two-stage procedure in the treatment of late chronic hip infections--spacer implantation. Int J Med Sci 2009; 6:253-7. [PMID: 19834591 PMCID: PMC2755121 DOI: 10.7150/ijms.6.253] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2009] [Accepted: 09/02/2009] [Indexed: 12/17/2022] Open
Abstract
Infection after total hip arthroplasties (THA) is a devastating complication with significant consequences for both the patients and the healthcare systems. In recent times, a two stage procedure using antibiotic-impregnated interim spacers has become the most popular treatment for late chronic hip joint infections after THA with success rates over 90%. In this review, we discuss the different types of spacers used in the treatment of chronically infected THA and conclude that hip spacers are effective in the treatment of hip joint infections.
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Affiliation(s)
- Mohamed Sukeik
- Department of Orthopaedics, University College London Hospital, 235 Euston Road, London, NW1 2BU, United Kingdom.
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17
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Al-Anazi KA, Jafar SA, Al-Jasser AM, Al-Omar H, Al-Mohareb FI. Brucella bacteremia in a recipient of an allogeneic hematopoietic stem cell transplant: a case report. CASES JOURNAL 2009; 2:91. [PMID: 19173733 PMCID: PMC2637260 DOI: 10.1186/1757-1626-2-91] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/25/2008] [Accepted: 01/27/2009] [Indexed: 11/10/2022]
Abstract
Background Brucellosis is an important cause of morbidity and mortality in patients living in areas that are endemic for the infection. Case Presentation A 20 years old Saudi male was diagnosed to have severe aplastic anemia at King Faisal Specialist Hospital and Research Centre in Riyadh in April 2006. One hundred and twelve days following his successful allogeneic hematopoietic stem cell transplant, he presented with pyrexia in addition to neutropenia and mild thrombocytopenia. Brucella serology was strongly positive and blood cultures grew Brucella melitensis. The bacteremic episode of brucellosis was successfully treated with streptomycin, doxycyclin and ciprofloxacin at the outpatient clinic. To our knowledge, this is the first case of a naturally occurring Brucella infection complicated by Brucella bacteremia in a recipient of hematopoietic stem cell transplant. Conclusion Brucellosis may cause systemic infections, complicated bacteremias and serious morbidity in immunocompromised patients living in countries that are endemic for the infection. It should be considered as a possible cause of fever and pancytopenia in hematopoietic stem cell transplant recipients living in these geographical locations. Nevertheless, the infection is curable provided the diagnosis is made early and an appropriate antimicrobial therapy is promptly initiated.
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Affiliation(s)
- Khalid A Al-Anazi
- Section of Adult Hematology and Hematopoietic, Stem Cell Transplant, King Faisal Cancer Centre, King Faisal Specialist Hospital and Research Centre, P,O, Box: 3345, Riyadh 11211, Saudi Arabia.
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18
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Flint MN, Griffin AM, Bell RS, Wunder JS, Ferguson PC. Two-stage revision of infected uncemented lower extremity tumor endoprostheses. J Arthroplasty 2007; 22:859-65. [PMID: 17826277 DOI: 10.1016/j.arth.2006.11.003] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2006] [Accepted: 11/13/2006] [Indexed: 02/01/2023] Open
Abstract
We reviewed our experience with 2-stage revision of uncemented Kotz Modular Femoral and Tibial Replacement System prostheses from 1989 to 2004. A total of 180 lower extremity tumor prostheses were inserted, 15 of which underwent removal of the prosthesis for infection. Eleven patients underwent subsequent second-stage revision, and 4 underwent amputation. Of the 11 patients who underwent revision, 8 continue to be free of infection an average of 33 months postoperatively. Of these 8 patients, 6 were revised without removal of the diaphyseal anchorage piece, which were all well ingrown. Most successful revisions were in the group that developed infection within 6 months of their original procedure. Two-stage revision of uncemented tumor endoprostheses with retention of a well-ingrown stem can be associated with successful eradication of infection.
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Affiliation(s)
- Michael N Flint
- Orthopaedic Oncology Unit, Middlemore Hospital, Auckland, New Zealand
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19
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Morshed S, Malek F, Silverstein RM, O'Donnell RJ. Clostridium cadaveris septic arthritis after total hip arthroplasty in a metastatic breast cancer patient. J Arthroplasty 2007; 22:289-92. [PMID: 17275650 DOI: 10.1016/j.arth.2006.02.158] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2005] [Accepted: 02/20/2006] [Indexed: 02/01/2023] Open
Abstract
We report the first known case of septic arthritis in the setting of total hip arthroplasty caused by Clostridium cadaveris, a gas-forming anaerobic enteric organism usually considered a non-pathogen. This case occurred in a patient treated with total hip arthroplasty for metastatic breast cancer involving the acetabulum. The patient was managed successfully with debridement, prosthetic retention, and chronic antibiotic suppression. We propose this mode of care as a successful alternative for some patients with prosthetic joint infection and prohibitive comorbid conditions.
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Affiliation(s)
- Saam Morshed
- Department of Orthopaedic Surgery, Orthopaedic Oncology Service, UCSF Comprehensive Cancer Center, San Francisco, California 94115, USA
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20
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Krebs V, Yerger ES, Barsoum WK, Bauer TW, Borden LS. Treatment of the Infected Total Hip Arthroplasty. ACTA ACUST UNITED AC 2005. [DOI: 10.1053/j.sart.2005.06.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Tang WM, Chiu KY, Ng TP, Yau WP, Ching PTY, Seto WH. Efficacy of a single dose of cefazolin as a prophylactic antibiotic in primary arthroplasty. J Arthroplasty 2003; 18:714-8. [PMID: 14513443 DOI: 10.1016/s0883-5403(03)00201-8] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
We analyzed the wound infection rate of 1,367 primary total hip and knee arthroplasties performed between 1991 and 1999. Two hundred and fifteen arthroplasties were performed with 3 doses (3 x 750 mg) of cefuroxime, and 1,152 arthroplasties were performed with a single preoperative dose (1 x 1 g) of cefazolin as antimicrobial prophylaxis. All wound infections that occurred within 2 years of the index surgery were analyzed. The deep wound infection rate of total hip arthroplasty was 1.1% (95% confidence interval [CI], 0%-3.3%) in the cefuroxime group and 1.1% (95% CI, 0%-2.2%) in the cefazolin group (Fisher's exact test, P = 1.0). The deep wound infection rate of total knee arthroplasty in the cefuroxime group (1.6%; 95% CI, 0%-3.8%) was not significantly different from the cefazolin group (1.0%; 95% CI, 0.3%-1.7%) (Fisher's exact test, P =.63). We concluded that a single dose (1 g) of cefazolin given at anesthetic induction offered similar protection to 3 doses (3 x 750 mg) of cefuroxime in preventing infection in primary total joint arthroplasty.
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Affiliation(s)
- W M Tang
- Department of Orthopaedic Surgery, The University of Hong Kong, Hong Kong SAR, China
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