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Roscetto E, Di Gennaro D, Ascione T, Galdiero U, Aversa M, Festa E, Catania MR, Balato G. Antiseptics' Concentration, Combination, and Exposure Time on Bacterial and Fungal Biofilm Eradication. Arthroplast Today 2024; 28:101468. [PMID: 39139360 PMCID: PMC11320471 DOI: 10.1016/j.artd.2024.101468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2024] [Revised: 05/20/2024] [Accepted: 06/10/2024] [Indexed: 08/15/2024] Open
Abstract
Background This study aims to assess the activity of solutions containing povidone-iodine (PI) and hydrogen peroxide (H2O2) alone or combined on the biofilm of microbial species in the contest of periprosthetic joint infection (PJI). Methods Different antiseptic solutions were tested on 2-day-old biofilms of Gram-positive and Gram-negative bacteria and fungi at 1 and 3 minutes of exposure. The efficacy of these solutions was evaluated by measuring the biofilm metabolic activity by methoxynitrosulfophenyl-tetrazolium carboxanilide (XTT) reduction assay. The anti-biofilm effect of 5% PI and 0.3% PI + 0.5% H2O2 was tested on a 5-day-old biofilm using colony-forming unit counts and an XTT reduction assay. Results PI and H2O2 solutions showed concentration-dependent anti-biofilm activity except for E. faecalis. PI at 5% was the most active solution against the 2-day-old biofilm of all test microorganisms. The 0.3% PI + 0.5% H₂O₂ solution had a significant effect only at 3 minutes. The 5% PI and 0.3% PI + 0.5% H₂O₂ effect was evaluated on 5-day-old biofilms. PI at 5% produced a significant reduction in metabolic activity at both 1 and 3 minutes; 0.3% PI + 0.5% H₂O₂ caused a significant activity against all Gram-positive strains after 3 minutes, with a greater metabolic activity reduction than 5% PI. Conclusions In the case of PJI caused by Gram-positive bacteria, 0.3% PI + 0.5% H₂O₂ could be used for wound irrigation for 3 minutes of exposure. In the case of PJI with a different etiological agent or PJI with an unknown etiology, it is advisable to use 5% PI for 1 minute of exposure.
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Affiliation(s)
- Emanuela Roscetto
- Department Molecular Medicine and Medical Biotechnology, “Federico II” University, Naples, Italy
| | - Donato Di Gennaro
- Section of Orthopaedic Surgery, Department of Public Health, “Federico II” University, Naples, Italy
| | - Tiziana Ascione
- Department of Medicine, Service of Infectious Disease, Cardarelli Hospital Naples, Naples, Italy
| | - Umberto Galdiero
- Department Molecular Medicine and Medical Biotechnology, “Federico II” University, Naples, Italy
| | - Martina Aversa
- Department Molecular Medicine and Medical Biotechnology, “Federico II” University, Naples, Italy
| | - Enrico Festa
- Section of Orthopaedic Surgery, Department of Public Health, “Federico II” University, Naples, Italy
| | - Maria Rosaria Catania
- Department Molecular Medicine and Medical Biotechnology, “Federico II” University, Naples, Italy
| | - Giovanni Balato
- Section of Orthopaedic Surgery, Department of Public Health, “Federico II” University, Naples, Italy
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Festa E, Ascione T, Di Gennaro D, De Mauro D, Mariconda M, Balato G. Synovial calprotectin in prosthetic joint infection. A systematic review and meta-analysis of the literature. Arch Orthop Trauma Surg 2024:10.1007/s00402-024-05416-0. [PMID: 38972902 DOI: 10.1007/s00402-024-05416-0] [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: 02/28/2024] [Accepted: 06/22/2024] [Indexed: 07/09/2024]
Abstract
INTRODUCTION Calprotectin is a protein endowed with antimicrobial properties, rendering it a distinctive marker for infection. Two methods are currently available for the assay of calprotectin: the enzyme-linked immunosorbent assay (ELISA) and the lateral flow test (LFT). We aimed to assess the diagnostic accuracy of synovial fluid calprotectin and to compare the accuracy of the laboratory-based test and the qualitative assessment for the diagnosis of hip and knee prosthetic infection. MATERIALS AND METHODS We searched (from inception to November 2023) MEDLINE, Scopus, EMBASE, Web of Science, and Cochrane for studies on calprotectin in the diagnosis of periprosthetic joint infection (PJI). Sensitivity, specificity, positive and negative likelihood ratio (LR), and diagnostic odds ratio were analyzed. The receiver-operating curve for each method was calculated. RESULTS We included 14 articles in our meta-analysis, including 902 patients who underwent total hip and knee arthroplasties revision; 331 (37%) had a joint infection according to MSIS, MSIS-modified criteria, ICM 2018 and EBJIS 2021. Considering the false-positive result rate of 6% and false-negative result rate of 7%, pooled sensitivity and specificity were 0.92 (95% CI 0.89-0.94) and 0.93 (0.91-0.95), respectively. The area under the curve (AUC) was 0.93 (95% CI 0.91-0.94). No statistical differences in terms of sensitivity and specificity were found between ELISA and LFT. The pooled sensitivity and specificity of the two calprotectin assessment methods were: LFT 0.90 (95% CI 0.869-0.935) and 0.92 (95% CI 0.894-0.941), respectively; ELISA 0.96 (95% CI 0.914-0.986) and 0.97 (95% CI 0.934-0.988), respectively. The diagnostic odds ratio of the ELISA was superior to that of the LFT (906.6667, 95% CI 271.2686-3030.3712 versus 113.8886, 95% CI 70.4001-184.2414; p < 0.001). The AUC for ELISA and LFT was 0.968 (95% CI 0.944-0.984) and 0.915 (95% CI 0.895-0.933), respectively. CONCLUSIONS Detection of synovial calprotectin is an accurate test for diagnosis of hip and knee prosthetic infections. The diagnostic accuracy of the two calprotectin assessment methods is almost comparable. The LFT is a valid, rapid, and more available diagnostic tool, particularly to rule out PJI.
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Affiliation(s)
- E Festa
- Department of Public Health, Orthopedic Unit, "Federico II" University, Naples, Italy
| | - T Ascione
- Service of Infectious Diseases, Cardarelli Hospital, Naples, Italy
| | - D Di Gennaro
- Department of Public Health, Orthopedic Unit, "Federico II" University, Naples, Italy
| | - D De Mauro
- Department of Public Health, Orthopedic Unit, "Federico II" University, Naples, Italy
- Department of Orthopedics and Geriatric Sciences, Catholic University of Sacred Heart, Rome, Italy
| | - M Mariconda
- Department of Public Health, Orthopedic Unit, "Federico II" University, Naples, Italy
| | - G Balato
- Department of Public Health, Orthopedic Unit, "Federico II" University, Naples, Italy.
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Di Gennaro D, Coletta G, Festa E, De Mauro D, Rizzo M, Diana L, Balato G, Mariconda M. The Effect of Spacer Treatment of Infected Hip and Knee Arthroplasties on Patients' Mental Health: A Narrative Review of the Literature. Healthcare (Basel) 2024; 12:790. [PMID: 38610212 PMCID: PMC11011799 DOI: 10.3390/healthcare12070790] [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: 02/13/2024] [Revised: 04/01/2024] [Accepted: 04/03/2024] [Indexed: 04/14/2024] Open
Abstract
BACKGROUND The gold standard treatment for periprosthetic joint infections is the two-stage revision that includes the spacer placement before definitive reimplantation. The management of PJI affects patients' joint function and, subsequently, their mental health. Even though significant advances have been achieved, little to no attention has been paid to the psychological implications. So, based on standardized patient-reported outcome measures (PROMs), this study aimed to clarify the effect of spacer treatment of infected hip and knee arthroplasties on patients' mental health. METHODS We performed research on the literature on PJIs in the English language using the MEDLINE database with the search strings "spacer" OR "spacers" AND "hip" OR "knee" AND "SF-12" OR "SF-36" OR "EQ-5" OR "mental" OR "depression" OR "anxiety." The reference lists of selected articles were also hand-searched for any additional articles. RESULTS A total of 973 published papers were extracted, and 9 papers were finally included. A total of 384 patients who underwent spacer placement for PJI were identified. Of these 384 patients, 54% were female. The mean age ranged from 62 to 78.2 years. Of the11 papers identified for this review, 4 analyzed only hip spacers, including 119 patients; 4 only knee spacers, evaluating 153 patients; while a single study included 112 patients for both joints. CONCLUSIONS Patients with the spacer are living in a state of mental upset, albeit better than the preoperative state. Clinical improvement with the review is not assured. The alteration of mental state turns out not to be transient for all the patients.
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Affiliation(s)
- Donato Di Gennaro
- Orthopedic Unit, Department of Public Health, “Federico II” University, 80131 Naples, Italy; (D.D.G.); (G.C.); (E.F.); (M.R.); (L.D.); (M.M.)
| | - Giannantonio Coletta
- Orthopedic Unit, Department of Public Health, “Federico II” University, 80131 Naples, Italy; (D.D.G.); (G.C.); (E.F.); (M.R.); (L.D.); (M.M.)
| | - Enrico Festa
- Orthopedic Unit, Department of Public Health, “Federico II” University, 80131 Naples, Italy; (D.D.G.); (G.C.); (E.F.); (M.R.); (L.D.); (M.M.)
| | - Domenico De Mauro
- Department of Orthopedics and Geriatric Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy;
| | - Maria Rizzo
- Orthopedic Unit, Department of Public Health, “Federico II” University, 80131 Naples, Italy; (D.D.G.); (G.C.); (E.F.); (M.R.); (L.D.); (M.M.)
| | - Luca Diana
- Orthopedic Unit, Department of Public Health, “Federico II” University, 80131 Naples, Italy; (D.D.G.); (G.C.); (E.F.); (M.R.); (L.D.); (M.M.)
| | - Giovanni Balato
- Orthopedic Unit, Department of Public Health, “Federico II” University, 80131 Naples, Italy; (D.D.G.); (G.C.); (E.F.); (M.R.); (L.D.); (M.M.)
| | - Massimo Mariconda
- Orthopedic Unit, Department of Public Health, “Federico II” University, 80131 Naples, Italy; (D.D.G.); (G.C.); (E.F.); (M.R.); (L.D.); (M.M.)
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De Mauro D, Balato G, Festa E, Di Cristo A, Marasco L, Loffredo G, Di Lauro P, Di Gennaro D, Maccauro G, Rosa D. Role of bariatric surgery in reducing periprosthetic joint infections in total knee arthroplasty. A systematic review and meta-analysis. BMC Musculoskelet Disord 2024; 25:248. [PMID: 38561717 PMCID: PMC10983737 DOI: 10.1186/s12891-024-07288-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Accepted: 02/18/2024] [Indexed: 04/04/2024] Open
Abstract
BACKGROUND Obesity represents an epidemic of rising numbers worldwide year after year. In the Orthopedic field, obesity is one of the major causes leading to osteoarthritis needing Total Joint Arthroplasty (TJA). Still, contextually, it represents one of the most significant risk factors for joint replacement complications and failures. So, bariatric Surgery (BS) is becoming a valuable option for weight control and mitigating obesity-related risk factors. This review of the literature and meta-analysis aims to evaluate periprosthetic joint infections (PJI) and surgical site infections (SSI) rates in patients who underwent TKA after BS compared to obese patients without BS. METHODS Systematic review was performed according to Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines up to October 2023. We included longitudinal studies comparing obese patients who underwent total knee arthroplasty after bariatric surgery (study group) and obese patients who underwent TKA (control group). The surgical site infection and Periprosthetic joint infection rate were compared among groups using a meta-analytical approach. RESULTS The online database and references investigation identified one hundred and twenty-five studies. PJI rate differed significantly among groups, (z = -21.8928, p < 0.0001), with a lower risk in the BS group (z = -10.3114, p < 0.0001), for SSI, instead, not statistically significance were recorded (z = -0.6784, p = 0.4975). CONCLUSIONS The current Literature suggests that Bariatric Surgery can reduce infectious complications in TKA, leading to better outcomes and less related costs treating of knee osteoarthritis in obese patients.
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Affiliation(s)
- D De Mauro
- Department of Public Health, Orthopedic Unit, "Federico II" University, Via Sergio Pansini, 5, Naples, 80130, Italy.
- Department of Orthopedics and Geriatric Sciences, Catholic University of the Sacred Heart, Rome, Italy.
- Department of Orthopedics and Rheumatological Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.
| | - G Balato
- Department of Public Health, Orthopedic Unit, "Federico II" University, Via Sergio Pansini, 5, Naples, 80130, Italy
| | - E Festa
- Department of Public Health, Orthopedic Unit, "Federico II" University, Via Sergio Pansini, 5, Naples, 80130, Italy.
| | - A Di Cristo
- Department of Public Health, Orthopedic Unit, "Federico II" University, Via Sergio Pansini, 5, Naples, 80130, Italy
| | - L Marasco
- Department of Public Health, Orthopedic Unit, "Federico II" University, Via Sergio Pansini, 5, Naples, 80130, Italy
| | - G Loffredo
- Department of Public Health, Orthopedic Unit, "Federico II" University, Via Sergio Pansini, 5, Naples, 80130, Italy
| | - P Di Lauro
- Department of Public Health, Orthopedic Unit, "Federico II" University, Via Sergio Pansini, 5, Naples, 80130, Italy
| | - D Di Gennaro
- Department of Public Health, Orthopedic Unit, "Federico II" University, Via Sergio Pansini, 5, Naples, 80130, Italy
| | - G Maccauro
- Department of Orthopedics and Geriatric Sciences, Catholic University of the Sacred Heart, Rome, Italy
- Department of Orthopedics and Rheumatological Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - D Rosa
- Department of Public Health, Orthopedic Unit, "Federico II" University, Via Sergio Pansini, 5, Naples, 80130, Italy
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Low J, Hoellwarth JS, Akhtar MA, Tetsworth K, Al-Muderis M. Transfemoral amputation versus knee arthrodesis for failed total knee replacement: A systematic review of outcomes. Knee 2024; 47:63-80. [PMID: 38245922 DOI: 10.1016/j.knee.2023.12.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2023] [Revised: 11/21/2023] [Accepted: 12/18/2023] [Indexed: 01/23/2024]
Abstract
BACKGROUND The options available to salvage a failed total knee replacement (TKR) include transfemoral amputation (TFA) and knee arthrodesis (KA). This systematic review aims to evaluate outcomes following either TFA or KA, comparing ambulatory status, additional subsequent surgery, postoperative infection, pain, health-related quality of life (HRQoL), and mortality rate. METHODS A literature search was conducted in EMBASE, Ovid Medline, and PubMed. Only primary research studies were included and data were independently extracted using a standardized form. The methodological quality of the studies was evaluated using Newcastle-Ottawa Scale. RESULTS Forty-four papers were included, comprising 470 TFA and 1034 KA patients. The methodological quality of the studies was moderate. No TFA versus KA randomized controlled trials could be identified. Pooled data totals via subgroup analyses were performed, owing to inconsistent reporting methods in the included studies. Prosthesis use rate by TFA patients was 157/316 = 49.7%. Significant differences included that TFA patients had lower rates of ambulatory capacity than KA patients (139/294 = 45.6% versus 248/287 = 86.4%, p < 0.001), TFA ambulators were less likely to use an ambulatory aid (55/135 = 40.7% versus 167/232 = 72.0%, p < 0.001), and TFA was associated with a greater postoperative infection rate than KA (29/118 = 24.6% versus 129/650 = 17.2%, p = 0.054). There was a similar rate of revision surgery between TFA and KA (37/183 = 20.2% versus 145/780 = 18.6%, p = 0.612). Data on HRQoL for both TFA and KA were limited, contradictory, and heterogeneous. CONCLUSION No randomized controlled trials comparing TFA versus KA exist;therefore, current data likely reflects substantial selection bias. The currently available evidence suggests that KA patients are significantly more likely to achieve independent bipedal ambulation than TFA patients. In both treatment cohorts, subsequent infection and revision surgery remain a relatively common occurrence.
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Affiliation(s)
- Juin Low
- The University of Edinburgh, Scotland, United Kingdom.
| | - Jason Shih Hoellwarth
- Limb Lengthening and Complex Reconstruction Service, Osseointegration Limb Replacement Centre, Hospital for Special Surgery, New York, United States
| | - Muhammad Adeel Akhtar
- The University of Edinburgh, Scotland, United Kingdom; University of St. Andrews, Scotland, United Kingdom; Department of Trauma and Orthopaedic Surgery, Victoria Hospital Kirkcaldy, Scotland, United Kingdom
| | - Kevin Tetsworth
- Royal Brisbane and Women's Hospital, Brisbane, Australia; University of Queensland School of Medicine, Brisbane, Australia
| | - Munjed Al-Muderis
- The University of Notre Dame Australia, Auburn, New South Wales, Australia; Limb Reconstruction Centre, Macquarie University Hospital, Macquarie Park, Australia
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Savvidou OD, Kaspiris A, Goumenos S, Trikoupis I, Melissaridou D, Kalogeropoulos A, Serenidis D, Georgoulis JD, Lianou I, Koulouvaris P, Papagelopoulos PJ. Knee Arthrodesis with a Modular Silver-Coated Endoprosthesis for Infected Total Knee Arthroplasty with Extensive Bone Loss: A Retrospective Case-Series Study. J Clin Med 2023; 12:jcm12103600. [PMID: 37240706 DOI: 10.3390/jcm12103600] [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: 04/11/2023] [Revised: 05/14/2023] [Accepted: 05/17/2023] [Indexed: 05/28/2023] Open
Abstract
INTRODUCTION Knee arthrodesis is a limb salvage intervention for persistent periprosthetic joint infection (PJI) when revision total knee arthroplasty fails. Conventional arthrodesis techniques are associated with the increased rate of complications, especially in patients with extensive bone loss and extensor tendon deficiency. METHODS Eight patients with a modular silver-coated arthrodesis implant after failed exchange arthroplasty for infection, were retrospectively reviewed. All patients had significant bone loss, while 5 displayed extensor tendon deficiency. Survivorship, complications, leg length discrepancy, median Visual Analogue Scale (VAS) and Oxford Knee score (OKS) were evaluated. RESULTS The median follow up was 32 months (range 24-59 months). The survivorship rate of the prosthesis was 86% during the minimum time of follow up of 24 months. In one patient recurrence of the infection was observed and above-knee amputation was performed. The median postoperative leg length discrepancy was 2.07 ± 0.67 cm. Patients were able to ambulate with mild or no pain. The median VAS and OKS was 2.14 ± 0.9 and 34.7 ± 9.3, respectively. CONCLUSIONS The results of our study demonstrated that knee arthrodesis with a silver coated arthrodesis implant, performed for persistent PJI in patients with significant bone loss and extensor tendon deficit, provided a stable construct, allowed eradication of infection and was associated with good functional outcome.
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Affiliation(s)
- Olga D Savvidou
- Medical School, First Department of Orthopedics, Attikon University Hospital, National and Kapodistrian University of Athens, 12462 Athens, Greece
| | - Angelos Kaspiris
- Laboratory of Molecular Pharmacology, School of Health Sciences, University of Patras, 26504 Patras, Greece
| | - Stavros Goumenos
- Medical School, First Department of Orthopedics, Attikon University Hospital, National and Kapodistrian University of Athens, 12462 Athens, Greece
| | - Ioannis Trikoupis
- Medical School, First Department of Orthopedics, Attikon University Hospital, National and Kapodistrian University of Athens, 12462 Athens, Greece
| | - Dimitra Melissaridou
- Medical School, First Department of Orthopedics, Attikon University Hospital, National and Kapodistrian University of Athens, 12462 Athens, Greece
| | | | - Dimitris Serenidis
- Medical School, First Department of Orthopedics, Attikon University Hospital, National and Kapodistrian University of Athens, 12462 Athens, Greece
| | - Jim-Dimitris Georgoulis
- Medical School, First Department of Orthopedics, Attikon University Hospital, National and Kapodistrian University of Athens, 12462 Athens, Greece
| | - Ioanna Lianou
- Department of Orthopaedics, Rion University Hospital University of Patras, 26504 Patras, Greece
| | - Panagiotis Koulouvaris
- Medical School, First Department of Orthopedics, Attikon University Hospital, National and Kapodistrian University of Athens, 12462 Athens, Greece
| | - Panayiotis J Papagelopoulos
- Medical School, First Department of Orthopedics, Attikon University Hospital, National and Kapodistrian University of Athens, 12462 Athens, Greece
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Cibura C, Rosteius T, Brinkemper A, Ull C, Hufnagel S, Jettkant B, Godolias P, Rausch V, Schildhauer TA, Kruppa C. The impact of knee arthrodesis on gait kinematics, muscle activity and patient-reported outcome. Knee 2023; 42:273-280. [PMID: 37119600 DOI: 10.1016/j.knee.2023.04.006] [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: 12/29/2022] [Revised: 02/17/2023] [Accepted: 04/03/2023] [Indexed: 05/01/2023]
Abstract
BACKGROUND The aim of this retrospective study was to analyze gait kinematicsandoutcome parameters after knee arthrodesis. METHODS Fifteenpatients with a mean follow-up of 5.9 (range0.8-36) years after unilateral knee arthrodesis were included. A 3D gait analysis was performed and compared to a healthy control group of14patients. Comparative electromyography was performed bilaterally at the rectus femoris, vastuslateralis/medialisand tibialis anterior muscles. The assessment further included standardized outcome scores- Lower Extremity Functional Scale (LEFS) andShort Form Health Survey (SF-36). RESULTS The 3D analysis showed a significantly shortened stance phase (p = 0.000), an extended swing phase (p = 0.000), and an increased time per step (p = 0.009) for the operated side compared with thenonoperatedside. There were statistically significant differences in the extent of movement of the hips, knees and ankles among the operated andnonoperatedsides and the control group. For the mean EMG measurement, no significant difference was found between the healthy control group and the patients with arthrodesis.The average LEFSscorewas 27.5 ± 10.6out of a maximum of 80 points,and the mean physical total scale and mean emotional total scale scores for the SF-36 were 27.9 ± 8.5and 52.9 ± 9.9, respectively. CONCLUSIONS Arthrodesis of the knee joint causes significant kinematic changes in gait pattern,and patients achieve poor results in subjective and functional outcomes(SF- 36, LEFS).Arthrodesis ensures that the extremities are preserved and can enable walking, but it must be viewed as a severe handicap for the patient.
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Affiliation(s)
- Charlotte Cibura
- Department of General and Trauma Surgery, BG-University Hospital Bergmannsheil, Ruhr-University Bochum, Germany.
| | - Thomas Rosteius
- Department of General and Trauma Surgery, BG-University Hospital Bergmannsheil, Ruhr-University Bochum, Germany
| | - Alexis Brinkemper
- Department of General and Trauma Surgery, BG-University Hospital Bergmannsheil, Ruhr-University Bochum, Germany
| | - Christopher Ull
- Department of General and Trauma Surgery, BG-University Hospital Bergmannsheil, Ruhr-University Bochum, Germany
| | - Silvia Hufnagel
- Department of General and Trauma Surgery, BG-University Hospital Bergmannsheil, Ruhr-University Bochum, Germany
| | - Birger Jettkant
- Department of General and Trauma Surgery, BG-University Hospital Bergmannsheil, Ruhr-University Bochum, Germany
| | - Periklis Godolias
- Department of General and Trauma Surgery, BG-University Hospital Bergmannsheil, Ruhr-University Bochum, Germany
| | - Valentin Rausch
- Department of General and Trauma Surgery, BG-University Hospital Bergmannsheil, Ruhr-University Bochum, Germany
| | - Thomas A Schildhauer
- Department of General and Trauma Surgery, BG-University Hospital Bergmannsheil, Ruhr-University Bochum, Germany
| | - Christiane Kruppa
- Department of General and Trauma Surgery, BG-University Hospital Bergmannsheil, Ruhr-University Bochum, Germany
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Marwan Y, Muir R, Barron E, Hadland Y, Moulder E, Sharma H. Circular external fixation for knee fusion in complex indications. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2023:10.1007/s00590-023-03493-2. [PMID: 36774409 PMCID: PMC9922099 DOI: 10.1007/s00590-023-03493-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/07/2023] [Accepted: 02/05/2023] [Indexed: 02/13/2023]
Abstract
PURPOSE Reconstructive surgery for complex knee problems is limited and challenging. The aim of this study is to report the technique, outcomes and complications of circular external fixation for knee fusion in complex indications. METHODS Retrospective review of a prospectively collected database of a complex limb reconstruction unit was done during December 2022. Patients with complex knee problems who underwent knee fusion with circular external fixator were included. RESULTS Fourteen patients met the inclusion criteria. The mean age of the patients was 63 ± 16.8 years. Deep infection was the indication for surgery in 11 patients (78.5%), of which 10 cases were related to previously failed revision arthroplasty. The mean duration of treatment in frame was 13 ± 4.1 months, while the mean follow-up duration following frame removal was 7.1 ± 4.2 years. Fusion was achieved in 13 patients (92.9%). The most common complication was pin site infection (6; 42.9%), of which three (21.4%) required pin/wire revision. One (7.1%) patient had fracture at the fusion site following frame removal that was treated with reapplication of the frame. CONCLUSION Knee fusion using circular external fixation is a reliable surgical option for complex knee problems especially in infected failed revision total knee replacements.
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Affiliation(s)
- Yousef Marwan
- Department of Surgery, Faculty of Medicine, Health Sciences Center, Kuwait University, Kuwait City, Kuwait.
| | - Ross Muir
- grid.9481.40000 0004 0412 8669Limb Reconstruction Unit, Department of Trauma and Orthopaedic Surgery, Hull University Teaching Hospitals, Hull, HU3 2JZ UK
| | - Elizabeth Barron
- grid.9481.40000 0004 0412 8669Limb Reconstruction Unit, Department of Trauma and Orthopaedic Surgery, Hull University Teaching Hospitals, Hull, HU3 2JZ UK
| | - Yvonne Hadland
- grid.9481.40000 0004 0412 8669Limb Reconstruction Unit, Department of Trauma and Orthopaedic Surgery, Hull University Teaching Hospitals, Hull, HU3 2JZ UK
| | - Elizabeth Moulder
- grid.9481.40000 0004 0412 8669Limb Reconstruction Unit, Department of Trauma and Orthopaedic Surgery, Hull University Teaching Hospitals, Hull, HU3 2JZ UK
| | - Hemant Sharma
- grid.9481.40000 0004 0412 8669Limb Reconstruction Unit, Department of Trauma and Orthopaedic Surgery, Hull University Teaching Hospitals, Hull, HU3 2JZ UK
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Stavrakis AI, Mayer EN, Devana SK, Chowdhry M, Dipane MV, McPherson EJ. Outcomes of Modular Knee Arthrodesis for Challenging Periprosthetic Joint Infections. Arthroplast Today 2022; 13:199-204. [PMID: 35118184 PMCID: PMC8791855 DOI: 10.1016/j.artd.2021.10.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Revised: 09/05/2021] [Accepted: 10/26/2021] [Indexed: 11/16/2022] Open
Abstract
Background Methods Results Discussion
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Affiliation(s)
- Alexandra I. Stavrakis
- Corresponding author. Department of Orthopaedic Surgery, University of California Los Angeles, 1250 16th St Suite 2100, 90404, Santa Monica, CA 90404, USA. Tel.: +1 424 259 9892.
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Pellegrini A, Suardi V, Legnani C. Classification and management options for prosthetic joint infection. ANNALS OF JOINT 2022; 7:3. [PMID: 38529157 PMCID: PMC10929296 DOI: 10.21037/aoj-20-86] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2020] [Accepted: 09/10/2020] [Indexed: 03/27/2024]
Abstract
Periprosthetic joint infection (PJI) is one of the major complications following arthroplasty implantation. Management of PJIs is a challenge for surgeons and various classification systems have been introduced, which consider variables such as onset of symptoms, pathogenesis and clinical manifestation. In an attempt to overcome the shortcomings which may limit their usefulness in borderline cases, a new classification system focusing on the topography of the infectious process has been proposed. This theory relies on the identification of the exact location of the bacterial colonization thus allowing to decide between a conservative or a more radical intervention irrespectively of the timing. The use of nuclear medicine device like radiolabelled white blood cells (WBC) scan could lead the path in identifying pathogenetic processes and their exact location thus guiding orthopaedic surgeons to the most appropriate diagnosis and treatment options. Currently management relies on debridement, antibiotics and implant retention (DAIR), which is traditionally performed at early stages, 1- or 2-stage revision arthroplasty which is commonly limited to chronic cases. Reports have demonstrated similar rates of infection recurrence following one and two-stage revisions, and the use of one-stage revision surgery is gaining popularity. More recently, satisfying results following partial implant retention during revision total arthroplasty for septic failures have been reported. In addition, in severe cases, definitive articulating antibiotic spacer, excision arthroplasty, arthrodesis or amputation can be performed.
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Affiliation(s)
- Antonio Pellegrini
- IRCCS Istituto Ortopedico Galeazzi, Centre for Reconstructive Surgery and Osteoarticular Infections, Milan, Italy
| | | | - Claudio Legnani
- IRCCS Istituto Ortopedico Galeazzi, Sport Traumatology and Minimally Invasive Surgery Center, Milan, Italy
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11
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Hanusrichter Y, Frieler S, Gessmann J, Schulte M, Krejczy M, Schildhauer T, Baecker H. Does the Implementation of the PRO-IMPLANT Foundation Treatment Algorithm Improve the Outcome of Chronic Periprosthetic Knee Infections? Mid-Term Results of a Prospective Study. ZEITSCHRIFT FUR ORTHOPADIE UND UNFALLCHIRURGIE 2021. [PMID: 34753193 DOI: 10.1055/a-1562-2874] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND Several treatment options for chronic periprosthetic joint infections have been published in the current literature, with an on-going discussion to determine effective management algorithms. OBJECTIVES To compare outcomes of the two-stage exchange procedure in revision TKA prior to and after implementation of the PRO-IMPLANT Foundation treatment algorithm. The primary endpoints were defined as (i) revisions during the interval time, (ii) duration of the interval time and (iii) successful PJI eradication. MATERIAL AND METHODS Between 02/2013 and 09/2016, 122 patients were included in a single-centre cohort analysis. 55 patients were treated according to the previously used algorithm (K1) and 67 according to the PRO-IMPLANT Foundation algorithm (K2). A minimum follow-up period of 3 years was set as the inclusion criterion. Successful eradication of infection was defined in accordance with the consensus criteria by Diaz-Ledezma et al. RESULTS: Successful eradication was achieved in 42 (67%) patients in K1 and 47 (85.5%) in K2 (p ≤ 0.005). The mean interval time was 88 days (range 51 - 353) in K1 and 52 days (range 42 - 126) in K2 (p ≤ 0.005). In K1, a mean of 0.8 (range 0 - 6) revisions were necessary during the interval period compared with 0.5 (range 0 - 4) in K2 (p = 0.066). CONCLUSION Implementation of the PRO-IMPLANT treatment algorithm led to significant improvement in the outcome of periprosthetic joint infections. During mid-term follow-up, infection eradication was highly successful, with decreases in the interval time as well as the number of revisions.
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Affiliation(s)
- Yannik Hanusrichter
- Department of General and Trauma Surgery, BG University Hospital Bergmannsheil, Ruhr-University Bochum, Bochum, Germany
| | - Sven Frieler
- Department of General and Trauma Surgery, BG University Hospital Bergmannsheil, Ruhr-University Bochum, Bochum, Germany.,Swedish Neuroscience Institute, Swedish Medical Center, Seattle, Washington, United States.,Seattle Science Foundation, Seattle Science Foundation, Seattle, Washington, United States.,Hansjörg Wyss Hip and Pelvic Center, Swedish Hospital, Seattle, Washington, United States
| | - Jan Gessmann
- Department of General and Trauma Surgery, BG University Hospital Bergmannsheil, Ruhr-University Bochum, Bochum, Germany
| | - Martin Schulte
- Department of General and Trauma Surgery, BG University Hospital Bergmannsheil, Ruhr-University Bochum, Bochum, Germany
| | - Martin Krejczy
- Department of General and Trauma Surgery, BG University Hospital Bergmannsheil, Ruhr-University Bochum, Bochum, Germany
| | - Thomas Schildhauer
- Department of General and Trauma Surgery, BG University Hospital Bergmannsheil, Ruhr-University Bochum, Bochum, Germany
| | - Hinnerk Baecker
- Department of General and Trauma Surgery, BG University Hospital Bergmannsheil, Ruhr-University Bochum, Bochum, Germany
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12
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Mohamed NS, Etcheson JI, Wilkie WA, Remily EA, Kluk MW, Thompson J, Plate JF, Mont MA, Delanois RE. Two-Stage Exchange Using a Short Intramedullary Nail for Treatment of Periprosthetic Knee Infections: A Technique Worth Questioning. J Knee Surg 2021; 34:1322-1328. [PMID: 32330974 DOI: 10.1055/s-0040-1708856] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Periprosthetic joint infections (PJIs) following total knee arthroplasty (TKA) are serious orthopaedic complications that pose marked burdens to both patients and health care systems. At our institution, two-stage exchange with a temporary short antibiotic cement-coated intramedullary nail was utilized for the treatment of repeat PJIs in a series of compromised patients with considerable bone loss. This study reports on (1) success rates, (2) functional and pain outcomes, (3) and complications for patients receiving a temporary short intramedullary nail for the treatment of PJI. Our institutional database was queried for all repeat knee PJI patients between March 1st, 2009 and February 28th, 2015. Patients with type II/III Anderson Orthopaedic Research Institute (AORI) bone defects who underwent two-stage exchange arthroplasty with a short antibiotic-coated intramedullary nail were included for analysis (n = 31). Treatment success was determined using the Delphi-based consensus definition of a successfully treated PJI: infection eradication (healed wound with no recurrence of infection by the same organism), no further surgical intervention for infection after reimplantation, and no PJI-related mortality. A paired t-test was performed to assess for continuous variables. A total of 26 patients went on to reimplantation, while 5 patients retained the intramedullary nail. Overall treatment success was 74.2%. Range of motion significantly decreased postoperatively (102.1 vs. 87.3 degrees; p < 0.001), while Knee Society Scores (function) significantly increased (55.6 vs. 77.7, p < 0.001). A majority of patients were full weight-bearing immediately following surgery (38.7%). Treating poor health status patients with PJI of the knee can be difficult after multiple revisions. With a success rate similar to conventional methods, our results demonstrate that two-stage exchange with a temporary short intramedullary nail may be a desirable treatment option for patients with bony defects wishing to avoid amputation or permanent arthrodesis. However, this method does not outperform other treatment modalities, and may not be suitable for all patients. Patient expectations and health status should be carefully assessed to determine if this procedure is appropriate in this complex patient population.
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Affiliation(s)
- Nequesha S Mohamed
- Center for Joint Preservation and Replacement, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Jennifer I Etcheson
- Department of Orthopaedic Surgery and Rehabilitation Medicine, SUNY Downstate Medical Center, Brooklyn, New York
| | - Wayne A Wilkie
- Center for Joint Preservation and Replacement, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Ethan A Remily
- Center for Joint Preservation and Replacement, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Matthew W Kluk
- Center for Joint Preservation and Replacement, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - John Thompson
- Center for Joint Preservation and Replacement, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Johannes F Plate
- Department of Orthopedic Surgery, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, North Carolina
| | - Michael A Mont
- Department of Orthopedic Surgery, Lenox Hill Hospital, New York City, New York
| | - Ronald E Delanois
- Center for Joint Preservation and Replacement, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland
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13
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Luyet A, Steinmetz S, Gallusser N, Roche D, Fischbacher A, Tissot C, Borens O. Fusion rate of 89% after knee arthrodesis using an intramedullary nail: a mono-centric retrospective review of 48 cases. Knee Surg Sports Traumatol Arthrosc 2021; 31:1299-1306. [PMID: 34458941 PMCID: PMC10050040 DOI: 10.1007/s00167-021-06693-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Accepted: 07/07/2021] [Indexed: 11/25/2022]
Abstract
PURPOSE Knee arthrodesis is an established procedure for limb salvage in cases of recurrent infection, total knee arthroplasty soft tissue defect, poor bone stock or a deficient extensor mechanism. Surgical options include compression plate, external fixator and arthrodesis nail. Different types of nail exist: long fusion nail, short modular nail and bridging nail. This study presents the results on knee arthrodesis using different types of intramedullary nails. The aim is to assess if a specific type of nail has a better fusion rate, clinical outcome and lower complication rate. METHODS A mono-centric retrospective study of 48 knees arthrodesis was performed between 2000 and 2018. 15 T2™ Arthrodesis Nail, 6 OsteoBridge® Knee Arthrodesis and 27 Wichita® fusion nail were used. The mean clinic and radiological follow-up was 9.8 ± 3.8 years (2.6-18 years). RESULTS Fusion rate was 89.6%. Time to fusion was 6.9 months. Mean Parker score was 6.9/9 points. Visual Analogic Scale was 1.9. The Wichita® fusion nail showed better results in terms of fusion, time to fusion and clinical outcome measured by Parker score and VAS but without statistical significance. The early revision rate was 10.4% and 20.8% presented a late complication requiring a surgery, due to nonunion or infection. 93.3% of infection was cured. Two patients live with a fistula (4.2%) and 1 was amputated (2.1%). CONCLUSION Although burdened by a big complication rate, knee arthrodesis with an intramedullary nail provides satisfactory results and is a good alternative to above-knee-amputation. The Wichita® fusion nail shows a tendency to better results compared to the two other nails. LEVEL OF EVIDENCE Case series, level IV.
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Affiliation(s)
- Anaïs Luyet
- Department of Orthopaedics and Traumatology, Lausanne University Hospital, University of Lausanne, Rue du Bugnon 46, 1011, Lausanne, Switzerland
| | - Sylvain Steinmetz
- Department of Orthopaedics and Traumatology, Lausanne University Hospital, University of Lausanne, Rue du Bugnon 46, 1011, Lausanne, Switzerland.
| | - Nicolas Gallusser
- Department of Orthopaedics and Traumatology, Lausanne University Hospital, University of Lausanne, Rue du Bugnon 46, 1011, Lausanne, Switzerland
| | - David Roche
- Department of Orthopaedics and Traumatology, Lausanne University Hospital, University of Lausanne, Rue du Bugnon 46, 1011, Lausanne, Switzerland
| | - Arnaud Fischbacher
- Department of Orthopaedics and Traumatology, Lausanne University Hospital, University of Lausanne, Rue du Bugnon 46, 1011, Lausanne, Switzerland
| | - Christophe Tissot
- Clinique de la Source, Avenue Bergières 2, 1004, Lausanne, Switzerland
| | - Olivier Borens
- Department of Orthopaedics and Traumatology, Lausanne University Hospital, University of Lausanne, Rue du Bugnon 46, 1011, Lausanne, Switzerland
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14
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Gramlich Y, Steinkohl D, Kremer M, Kemmerer M, Hoffmann R, Klug A. Modular knee arthrodesis secures limb, mobility, improves quality of life, and leads to high infection control in periprosthetic knee infection, when revision knee arthroplasty is not an option. Arch Orthop Trauma Surg 2021; 141:1349-1360. [PMID: 33893531 DOI: 10.1007/s00402-021-03907-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Accepted: 04/12/2021] [Indexed: 10/21/2022]
Abstract
INTRODUCTION This study compared the outcome of knee arthrodesis versus hinged total knee arthroplasty (TKA) in patients suffering from periprosthetic joint infection (PJI). METHODS 104 patients with PJI were treated using a two-stage exchange of failed TKA. In case of non reconstructable bone loss or loss of extension mechanism, a modular intramedullary arthrodesis nail was used for reimplantation [Knee Arthrodesis Module (KAM); n = 52]. The control group was retrospectively matched treated using a hinged revision TKA [Rotating Hinge Knee (RHK); n = 52]. PJI remission rates, functional outcome (WOMAC; KSS) and quality of life (SF-12), as well as comorbidities and pain were evaluated. RESULTS Mean age was 72.5 years. Charlson Comorbidity Index was higher in the KAM group (3.3 vs. 2.8). PJI remission rate was 89.4% (88.5% vs. 90.4%, respectively). In case of reinfection, implant retention was mostly possible in the RHK group (7.7%), whereas amputations were mostly performed in the KAM group (9.6%). Significant pain reduction (VAS 7.9-2.8) was achieved in both groups. Walking distance was significantly reduced in the KAM groups versus the RHK group (504 vs. 1064 m). WOMAC and KSS function scores were significantly reduced in the KAM group (25 vs. 40 and 35 vs. 64). Only moderate reduction in quality of life in the KAM group was observed (SF-12 physical: 34 vs. 40; SF-12 mental: 51 vs. 56) respectively. CONCLUSIONS Arthrodesis using a modular intramedullary nail is an alternative for limb salvage, pain reduction, and preservation of quality of life and everyday mobility, when revision TKA is not an option. This study presents the largest number of case, comparing the outcome after performing an arthrodesis versus hinged TKA after septic failed TKA.
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Affiliation(s)
- Y Gramlich
- Department of Trauma and Orthopedic Surgery, Berufsgenossenschaftliche Unfallklinik Frankfurt Am Main, Friedberger Landstr. 430, 60389, Frankfurt am Main, Germany.
| | - D Steinkohl
- Department of Trauma and Orthopedic Surgery, Berufsgenossenschaftliche Unfallklinik Frankfurt Am Main, Friedberger Landstr. 430, 60389, Frankfurt am Main, Germany
| | - M Kremer
- Department of Trauma and Orthopedic Surgery, Berufsgenossenschaftliche Unfallklinik Frankfurt Am Main, Friedberger Landstr. 430, 60389, Frankfurt am Main, Germany
| | - M Kemmerer
- Department of Trauma and Orthopedic Surgery, Berufsgenossenschaftliche Unfallklinik Frankfurt Am Main, Friedberger Landstr. 430, 60389, Frankfurt am Main, Germany
| | - R Hoffmann
- Department of Trauma and Orthopedic Surgery, Berufsgenossenschaftliche Unfallklinik Frankfurt Am Main, Friedberger Landstr. 430, 60389, Frankfurt am Main, Germany
| | - A Klug
- Department of Trauma and Orthopedic Surgery, Berufsgenossenschaftliche Unfallklinik Frankfurt Am Main, Friedberger Landstr. 430, 60389, Frankfurt am Main, Germany
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15
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Vivacqua T, Moraes R, Barretto J, Cavanelas N, Albuquerque R, Mozella A. Functional Outcome of Patients Undergoing Knee Arthrodesis after Infected Total Arthroplasty. Rev Bras Ortop 2021; 56:320-325. [PMID: 34239196 PMCID: PMC8249054 DOI: 10.1055/s-0040-1709198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2019] [Accepted: 01/27/2020] [Indexed: 10/28/2022] Open
Abstract
Objective Retrospectively assess the functional outcome of patients undergoing arthrodesis after septic failure of total knee arthroplasty. Methods Eighteen patients were evaluated, with a mean time of 3.7 years of follow-up. Arthrodesis surgery was performed using a narrow anterior dynamic compression plate, and medial or external fixator in two planes of the joint (Orthofix Bone Growth Therapy, Lewisville, TS, USA), at the surgeon's discretion. Results The most frequent pathogen found was Staphylococcus aureus methicillin sensitive (38.9%). The mean lower limb discrepancy was 3.63 cm. The mean knee society score was 68 points. According to the visual analog scale for pain, 44% of the patients had a 0 score at the time of assessment, and 22.2% were very dissatisfied, despite the bone healing achieved. Patients were assessed for the ability to walk with or without assistance. Conclusion Knee arthrodesis surgery was effective in controlling the infectious process and decreasing pain complaints, but satisfaction with the procedure was low.
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Affiliation(s)
- Thiago Vivacqua
- Instituto Nacional de Traumatologia e Ortopedia Jamill Haddad, Rio de Janeiro, RJ, Brasil
| | - Rui Moraes
- Instituto Nacional de Traumatologia e Ortopedia Jamill Haddad, Rio de Janeiro, RJ, Brasil
| | - João Barretto
- Instituto Nacional de Traumatologia e Ortopedia Jamill Haddad, Rio de Janeiro, RJ, Brasil
| | - Naasson Cavanelas
- Instituto Nacional de Traumatologia e Ortopedia Jamill Haddad, Rio de Janeiro, RJ, Brasil
| | - Rodrigo Albuquerque
- Instituto Nacional de Traumatologia e Ortopedia Jamill Haddad, Rio de Janeiro, RJ, Brasil
| | - Alan Mozella
- Instituto Nacional de Traumatologia e Ortopedia Jamill Haddad, Rio de Janeiro, RJ, Brasil
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16
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Suda AJ, Brachtendorf X, Tinelli M, Wagokh R, Abou-Nouar G, Bischel OE. Low complication rate and better results for intramedullary nail - arthrodesis for infected knee joints compared to external fixator-a series of one hundred fifty two patients. INTERNATIONAL ORTHOPAEDICS 2021; 45:1735-1744. [PMID: 33893523 DOI: 10.1007/s00264-021-05054-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/23/2021] [Accepted: 04/19/2021] [Indexed: 01/27/2023]
Abstract
PURPOSE Arthrodesis of the knee joint is still a salvage procedure after recurrent prosthetic joint infections (PJI) of total knee arthroplasties (TKA) with substantial bone loss and seems to be a good solution to avoid amputation. Until now, intramedullary arthrodesis has increasingly been performed; no study has yet been published to compare these techniques after septic removal of TKA in terms of functional assessment and quality of daily life. METHODS In a single-centre retrospective setting, clinical and radiographic evaluation of consecutive patients after knee arthrodesis using intramedullary and external fixation for infected knee joints was performed. All patients were evaluated clinically, with x-ray and questionnaire including analysis regarding any complications at latest follow-up of a minimum 12 months postoperatively. RESULTS We included 152 patients (75 females, 77 males) in this study. The mean age of the patients at surgery was 63.6 years (range 12 to 90 years). The minimum follow-up was 12 months (mean 3.1 years, range 12 to 49 months). Arthrodesis with external fixator (83 patients, 52.2%) showed less blood loss and less peri-operative complications (1.6%) but a high rate of post-operative, pin-track infections (35.5%); loose pins (12.7%); and pin fractures (4.8%), and therefore risk factors for instability and nonunion (30.9%). Revision rate was 22.6% for arthrodesis with external fixator, and the primary union rate was 65.6%. Intramedullary arthrodesis (69 patients, 43.4%) showed a similar re-infection rate to external fixation (16.1% and 15.9%, respectively) but a significantly lower revision rate (5.4%, p < 0.001). Eighty percent of patients with intramedullary arthrodesis showed very good patient-related outcomes regarding pain, function and daily life activities in the questionnaire. CONCLUSION Despite similar results regarding patient satisfaction and everyday competences in questionnaires, intramedullary arthrodesis of the knee is superior to the external fixator, as it results in fewer complications, lower revision rate, and union rates/loosening.
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Affiliation(s)
- Arnold J Suda
- AUVA Trauma Center Salzburg, Department of Orthopaedics and Trauma Surgery, Academic Teaching Hospital of Paracelsus Medical University, Dr. Franz-Rehrl-Platz 5, 5010, Salzburg, Austria.
| | - Xaver Brachtendorf
- BG Trauma Center Ludwigshafen, Department of Trauma and Orthopaedics, Ludwig-Guttmann-Strasse 13, 67071, Ludwigshafen, Germany
| | - Marco Tinelli
- Sinsheim Hospital, Department of Orthopaedics and Trauma Surgery, Sinsheim, Germany
| | - Raed Wagokh
- Jordanian Royal Medical Services, Department of Orthopaedics, Amman, Jordan
| | - Ghaith Abou-Nouar
- Jordanian Royal Medical Services, Department of Orthopaedics, Amman, Jordan
| | - Oliver E Bischel
- BG Trauma Center Ludwigshafen, Department of Trauma and Orthopaedics, Ludwig-Guttmann-Strasse 13, 67071, Ludwigshafen, Germany
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17
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Zajonz D, Zimmerlich B, Möbius R, Edel M, Przybyl J, Höch A, Fakler JKM, Roth A, Ghanem M. Knee arthrodesis as last resort for persistent knee joint infections : Comparison of extramedullary and intramedullary treatment. DER ORTHOPADE 2021; 50:207-213. [PMID: 32666143 PMCID: PMC7925473 DOI: 10.1007/s00132-020-03939-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Background Knee joint arthrodesis is an established treatment for periprosthetic infections (PPI) providing stability and pain relief. In this study the outcome after arthrodesis of the knee joint for persistent infections was compared and evaluated depending on the surgical procedure (intramedullary vs. extramedullary). Material and methods In a retrospective case analysis, all patients who underwent knee joint arthrodesis between 1 January 2010 and 31 December 2016 were identified and divided into two groups: IMA and EMA. All patients were examined clinically and radiologically and the patient files were evaluated. In addition, the FIM score, the LEFS, the WHOQOL-BREF and NRS were evaluated. Results The median LEFS score for the IMA group was 26 points and in the EMA group 2 points (p = 0.03). The IMA patients showed a median pain scale at rest of 0 and during exercise of 2. The EMA group recorded a pain scale of 3 at rest and 5 during exercise (p = 0.28 at rest; p = 0.43 during exercise). In the IMA group the median postsurgical leg length difference was −2.0 cm and −2.5 cm in the EMA group (p = 0.31). At the end of the follow-up examinations, the FIM score of patients in the IMA group was 74.5 points and 22 points in the EMA group (p = 0.07). Conclusion The study showed that no arthrodesis procedure is obviously superior with respect to the postoperative outcome. The IMA combines advantages especially in the early phase after surgery in terms of function as well as patient comfort and is therefore currently the procedure of choice. The attending physician should be familiar with the advantages and disadvantages of the various procedures in order to be able to make an individual decision and thus maximize the chance of treatment success.
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Affiliation(s)
- Dirk Zajonz
- Department of Orthopaedics, Trauma and Plastic Surgery, University Hospital Leipzig, Liebigstraße 20, 04103, Leipzig, Germany. .,Center for Research on Musculoskeletal Systems, ZESBO, Semmelweisstraße 14, 04103, Leipzig, Germany. .,Department of Orthopaedic Surgery, Traumatology and Reconstructive Surgery, Zeisigwald Hospital Chemnitz, Zeisigwaldstraße 101, 09130, Chemnitz, Germany.
| | - Benedikt Zimmerlich
- Department of Orthopaedics, Trauma and Plastic Surgery, University Hospital Leipzig, Liebigstraße 20, 04103, Leipzig, Germany.,Clinic for Orthopaedics and Trauma Surgery, Sana Kliniken Leipziger Land, Rudolf-Virchow-Straße 2, 04552, Borna, Germany
| | - Robert Möbius
- Center for Research on Musculoskeletal Systems, ZESBO, Semmelweisstraße 14, 04103, Leipzig, Germany
| | - Melanie Edel
- Department of Orthopaedics, Trauma and Plastic Surgery, University Hospital Leipzig, Liebigstraße 20, 04103, Leipzig, Germany.,Center for Research on Musculoskeletal Systems, ZESBO, Semmelweisstraße 14, 04103, Leipzig, Germany
| | - Johanna Przybyl
- Department of Orthopaedics, Trauma and Plastic Surgery, University Hospital Leipzig, Liebigstraße 20, 04103, Leipzig, Germany
| | - Andreas Höch
- Department of Orthopaedics, Trauma and Plastic Surgery, University Hospital Leipzig, Liebigstraße 20, 04103, Leipzig, Germany.,Center for Research on Musculoskeletal Systems, ZESBO, Semmelweisstraße 14, 04103, Leipzig, Germany
| | - Johannes K M Fakler
- Department of Orthopaedics, Trauma and Plastic Surgery, University Hospital Leipzig, Liebigstraße 20, 04103, Leipzig, Germany
| | - Andreas Roth
- Department of Orthopaedics, Trauma and Plastic Surgery, University Hospital Leipzig, Liebigstraße 20, 04103, Leipzig, Germany
| | - Mohamed Ghanem
- Department of Orthopaedics, Trauma and Plastic Surgery, University Hospital Leipzig, Liebigstraße 20, 04103, Leipzig, Germany
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18
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Leira MS. Periprosthetic complications of the extensor mechanism of the knee. J Orthop 2021; 23:160-168. [PMID: 33542594 DOI: 10.1016/j.jor.2020.12.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2020] [Accepted: 12/08/2020] [Indexed: 11/26/2022] Open
Abstract
Complications of the extensor mechanism after total knee arthroplasty are uncommon and present a challenge to the surgical team. No commonly accepted classifications or treatment strategies exist since these depend on institutional, national, and healthcare-system restrictions and possibilities. The goal of this chapter is to provide an overview of existing treatment options for the different possible scenarios. These treatment options reflect the experience of the author and do not display all possibilities available.
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Affiliation(s)
- Marco Strauch Leira
- Departamento Cirugía Ortopédica y Traumatología, Hospital de Manises, Avd. De la Generalitat Valenciana 50, 46940, Manises, Valencia, Spain
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19
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Zardi EM, Franceschi F. Prosthetic joint infection. A relevant public health issue. J Infect Public Health 2020; 13:1888-1891. [PMID: 33289642 DOI: 10.1016/j.jiph.2020.09.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Revised: 06/01/2020] [Accepted: 09/06/2020] [Indexed: 12/19/2022] Open
Abstract
Prosthetic joint infection (PJI) is a common complication of the knee and hip arthroplasty and represents a huge challenge for physicians. PJI raises serious social, economic and clinical concerns in the public health that need a comprehensive approach to better focus on proven strategies for disease prevention and treatment. History and clinical signs on joint site are useful means for suspecting PJI that need to be confirmed through major and minor diagnostic criteria. The pathogen isolation and the resulting antibiogram are crucial to guide the correct antibiotic strategy and together with surgical treatment (prosthesis revision and spacer implantation) represent the cornerstones to eradicate the infection before attempting a new arthroplasty. External fixator with removal of the spacer may be an option before performing a new arthroplasty when the infection does not heal. Arthrodesis may also be considered if the arthroplasty is contraindicated. Limb amputation is the last chance when pathogen eradication failed and might lead to life-threatening situations.
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Affiliation(s)
- Enrico Maria Zardi
- Internistic Ultrasound Service, "Campus Bio-Medico" University, Rome, Italy.
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20
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Conway JD. Knee Arthrodesis for Recurrent Periprosthetic Knee Infection. JBJS Essent Surg Tech 2020; 10:ST-D-19-00027. [PMID: 32983604 DOI: 10.2106/jbjs.st.19.00027] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Knee arthrodesis for recurrent periprosthetic knee infection is a limb salvage procedure that simultaneously provides a stable limb for weight-bearing and effective eradication of the chronic infection. Knee arthrodesis is a final resort for limb salvage that is appropriate for patients with multiple recurrent revisions for infection, a history of failed 2-stage exchanges, medical comorbidities, and an inability to tolerate multiple additional procedures. Another important consideration is whether the patient has a poor soft-tissue envelope that leaves knee arthrodesis as the only viable option. The procedure is a definitive surgery to eliminate return trips to the operating room. Description This technique involves knee arthrodesis using a long intramedullary rod inserted proximally through the piriformis fossa that spans the entire medullary canal of the femur and the tibia. Before insertion, the surgeon may elect to create a long antibiotic cement-coated intramedullary rod. The rod is locked proximally and distally. An alternative method for large bone defects (>6 cm) at the level of the knee is to create intercalary antibiotic-impregnated cement spacers. Alternatives Alternative surgical treatments for this problem include above-the-knee amputation or resection arthroplasty, neither of which provides a functional limb for weight-bearing. The most common alternative methods for knee arthrodesis include external fixation using circular or biplanar frames, as well as short intramedullary modular rods. Rationale Knee arthrodesis using a long intramedullary rod is a very effective and efficient method of fusion. With recurrent periprosthetic knee infections, metaphyseal bone loss is common and short knee-fusion rods may not provide adequate stability. Long rods for knee arthrodesis use the diaphysis for stability and have the additional advantage of being easily accessible for removal in the event of a recurrent infection with a well-healed fusion. Long intramedullary rods also provide the additional advantages of immediate weight-bearing. Immediate weight-bearing on the affected limb is critical because often these patients have been unable to bear weight preoperatively secondary to pain and infection. External fixation techniques are effective but come with pin-site problems. Pin-site problems are amplified in patients with obesity who have large soft-tissue envelopes, and the long intramedullary rod avoids pin problems in such patients. Antibiotic cement coating of the long intramedullary rod also provides local antibiotic delivery.
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Affiliation(s)
- Janet D Conway
- Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland
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Corona PS, Jurado M, Scott-Tennent A, Fraile R, Carrera L, Vicente M. Uniplanar versus biplanar monolateral external fixator knee arthrodesis after end-stage failed infected total knee arthroplasty: a comparative study. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2020; 30:815-825. [PMID: 32020375 DOI: 10.1007/s00590-020-02633-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Accepted: 01/22/2020] [Indexed: 12/22/2022]
Abstract
BACKGROUND External fixator knee arthrodesis is a salvage procedure used primarily in cases of end-stage infected total knee replacement (iTKR). Stable fixation combined with bone-end compression is essential to achieve knee fusion, but providing sufficient stability can be challenging in the presence of severe bone loss. Our hypothesis is that using an external fixation biplanar configuration would bring about a fusion rate superior to that of a monolateral frame. METHODS This study compares outcomes of biplanar external fixator knee fusion due to non-revisable iTKR with those of a historical cohort control study with patients managed with a monoplanar configuration. Primary endpoints were fusion rate, time to achieve bone fusion and infection eradication rate. Limb-length discrepancy, pain level, patient satisfaction and health-related quality of life were evaluated. RESULTS A total of 29 knee fusion cases were included. In the biplanar group, infection was eradicated in 100% of the patients and fusion was achieved in all cases within an average of 5.24 months. In comparison, in the monolateral group, infection was eradicated in 86% of the cases and fusion was achieved in 81% of the patients after a mean of 10.3 months (p < 0.05). In both groups, postoperative pain was mild and patients expressed a high degree of satisfaction once fusion was achieved. CONCLUSIONS According to our data, external fixation knee fusion is a useful limb-salvage procedure in end-stage cases of knee PJI. We conclude that a biplanar configuration can halve the time required to achieve solid bone fusion in such a complex scenario.
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Affiliation(s)
- Pablo S Corona
- Septic and Reconstructive Surgery Unit, Orthopaedic Surgery Department, Vall D'Hebron University Hospital, Universitat Autónoma de Barcelona, Pg. Vall d'Hebron 119-129, 08035, Barcelona, Spain.,Septic and Reconstructive Surgery Unit, Orthopaedic Surgery Department, Vall D'Hebron University, Barcelona, Spain.,Musculoskeletal Tissue Engineering Group, Vall D'Hebron Research Institute, Universidad Autónoma de Barcelona (UAB), Barcelona, Spain
| | - Maria Jurado
- Septic and Reconstructive Surgery Unit, Orthopaedic Surgery Department, Vall D'Hebron University Hospital, Universitat Autónoma de Barcelona, Pg. Vall d'Hebron 119-129, 08035, Barcelona, Spain.,Musculoskeletal Tissue Engineering Group, Vall D'Hebron Research Institute, Universidad Autónoma de Barcelona (UAB), Barcelona, Spain
| | - Ana Scott-Tennent
- Orthopaedic Surgery Department, Arnau de Vilanova University Hospital, Lleida, Spain
| | - Rosa Fraile
- Septic and Reconstructive Surgery Unit, Orthopaedic Surgery Department, Vall D'Hebron University, Barcelona, Spain.,Surgical Nurse Team, Vall D'Hebron University Hospital, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Luis Carrera
- Septic and Reconstructive Surgery Unit, Orthopaedic Surgery Department, Vall D'Hebron University Hospital, Universitat Autónoma de Barcelona, Pg. Vall d'Hebron 119-129, 08035, Barcelona, Spain.,Septic and Reconstructive Surgery Unit, Orthopaedic Surgery Department, Vall D'Hebron University, Barcelona, Spain.,Musculoskeletal Tissue Engineering Group, Vall D'Hebron Research Institute, Universidad Autónoma de Barcelona (UAB), Barcelona, Spain
| | - Matías Vicente
- Septic and Reconstructive Surgery Unit, Orthopaedic Surgery Department, Vall D'Hebron University Hospital, Universitat Autónoma de Barcelona, Pg. Vall d'Hebron 119-129, 08035, Barcelona, Spain. .,Septic and Reconstructive Surgery Unit, Orthopaedic Surgery Department, Vall D'Hebron University, Barcelona, Spain. .,Musculoskeletal Tissue Engineering Group, Vall D'Hebron Research Institute, Universidad Autónoma de Barcelona (UAB), Barcelona, Spain.
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