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Kreinces JB, Ashkenazi I, Shichman I, Roof MA, Schwarzkopf R, Aggarwal VK. The James A. Rand Young Investigator's Award: Keeping It Simple: Are all Musculoskeletal Infection Society Tests Useful to Diagnose Periprosthetic Joint Infection? J Arthroplasty 2024:S0883-5403(24)00520-5. [PMID: 38810813 DOI: 10.1016/j.arth.2024.05.048] [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: 10/27/2023] [Revised: 05/18/2024] [Accepted: 05/20/2024] [Indexed: 05/31/2024] Open
Abstract
BACKGROUND Current data evaluating the clinical value and cost-effectiveness of advanced diagnostic tests for periprosthetic joint infection (PJI) diagnosis, including alpha-defensin and synovial C-reactive protein (CRP), is conflicting. This study aimed to evaluate the adequacy of preoperative and intraoperative PJI workups without utilizing these tests. METHODS This retrospective analysis identified all patients who underwent revision total knee or hip arthroplasty (rTKA and rTHA, respectively) for suspected PJI between 2018 and 2020 and had a minimum follow-up of 2 years. Perioperative data and lab results were collected, and cases were dichotomized based on whether they met the 2018 Musculoskeletal Infection Society (MSIS) criteria for PJI. In total, 204 rTKA and 158 rTHA cases suspected of PJI were reviewed. RESULTS Nearly 100% of the cases were categorized as "infected" for meeting the 2018 MSIS criteria without utilization of alpha-defensin or synovial CRP (rTKA: n = 193, 94.6%; rTHA: n = 156, 98.7%). Most cases were classified as PJI preoperatively by meeting either the major MSIS or the combinational minor MSIS criteria of traditional lab tests (rTKA: n = 177, 86.8%; rTHA: n = 143, 90.5%). A subset of cases was classified as PJI by meeting combinational preoperative and intraoperative MSIS criteria (rTKA: 16, 7.8%; rTHA: 13, 8.2%). Only 3.6% of all cases were considered "inconclusive" using preoperative and intraoperative data. CONCLUSIONS Given the high rate of cases satisfying PJI criteria during preoperative workup using our available tests, the synovial alpha-defensin and synovial CRP tests may not be necessary in the routine diagnostic workup of PJI. We suggest that the primary PJI workup process should be based on a stepwise algorithmic approach with the most economical testing necessary to determine a diagnosis first. The use of advanced, commercialized, and costly biomarkers should be utilized only when traditional testing is indeterminate.
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Affiliation(s)
| | - Itay Ashkenazi
- NYU Langone, Adult Reconstructive Division, New York, New York; Division of orthopedic surgery, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel
| | - Ittai Shichman
- NYU Langone, Adult Reconstructive Division, New York, New York; Division of orthopedic surgery, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel
| | | | - Ran Schwarzkopf
- NYU Langone, Adult Reconstructive Division, New York, New York
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Youssef Y, Roschke E, Dietze N, Dahse AJ, Chaberny IF, Ranft D, Pempe C, Goralski S, Ghanem M, Kluge R, Lübbert C, Rodloff AC, Roth A. Early-Outcome Differences between Acute and Chronic Periprosthetic Joint Infections-A Retrospective Single-Center Study. Antibiotics (Basel) 2024; 13:198. [PMID: 38534633 DOI: 10.3390/antibiotics13030198] [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: 01/28/2024] [Revised: 02/14/2024] [Accepted: 02/17/2024] [Indexed: 03/28/2024] Open
Abstract
Periprosthetic joint infections (PJI) are serious complications after arthroplasty, associated with high morbidity, mortality, and complex treatment processes. The outcomes of different PJI entities are largely unknown. The aim of this study was to access the early outcomes of different PJI entities. A retrospective, single-center study was conducted. The characteristics and outcomes of patients with PJI treated between 2018 and 2019 were evaluated 12 months after the completion of treatment. Primary endpoints were mortality, relapse free survival (RFS) and postoperative complications (kidney failure, sepsis, admission to ICU). A total of 115 cases were included [19.1% early (EI), 33.0% acute late (ALI), and 47.8% chronic infections (CI)]. Patients with ALI were older (p = 0.023), had higher ASA scores (p = 0.031), preoperative CRP concentrations (p = 0.011), incidence of kidney failure (p = 0.002) and sepsis (p = 0.026). They also tended towards higher in-house mortality (ALI 21.1%, 13.6% EI, 5.5% CI) and admission to ICU (ALI 50.0%, 22.7% EI, 30.9% CI). At 12 months, 15.4% of patients with EI had a relapse, compared to 38.1% in ALI and 36.4% in CI. There are differences in patient characteristics and early outcomes between PJI entities. Patients with EI have better early clinical outcomes. Patients with ALI require special attention during follow-up because they have higher occurrences of relapses and postoperative complications than patients with EI and CI.
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Affiliation(s)
- Yasmin Youssef
- Department of Orthopedics, Traumatology and Plastic Surgery, University Hospital Leipzig, Liebigstraße 20, 04103 Leipzig, Germany
| | - Elisabeth Roschke
- Department of Orthopedics, Traumatology and Plastic Surgery, University Hospital Leipzig, Liebigstraße 20, 04103 Leipzig, Germany
| | - Nadine Dietze
- Institute of Medical Microbiology and Virology, University Hospital Leipzig, Liebigstraße 21, 04103 Leipzig, Germany
| | - Anna-Judith Dahse
- Hospital Pharmacy, University Hospital Leipzig, Liebigstraße 20, 04103 Leipzig, Germany
| | - Iris F Chaberny
- Institute of Hygiene, Hospital Epidemiology and Environmental Health, University Hospital Leipzig, Liebigstraße 22, 04103 Leipzig, Germany
- Institute of Hospital Epidemiology and Environmental Hygiene, University Medical Center Schleswig-Holstein, Arnold-Heller-Str. 3, 24105 Kiel, Germany
| | - Donald Ranft
- Hospital Pharmacy, University Hospital Leipzig, Liebigstraße 20, 04103 Leipzig, Germany
| | - Christina Pempe
- Department of Orthopedics, Traumatology and Plastic Surgery, University Hospital Leipzig, Liebigstraße 20, 04103 Leipzig, Germany
| | - Szymon Goralski
- Department of Orthopedics, Traumatology and Plastic Surgery, University Hospital Leipzig, Liebigstraße 20, 04103 Leipzig, Germany
| | - Mohamed Ghanem
- Department of Orthopedics, Traumatology and Plastic Surgery, University Hospital Leipzig, Liebigstraße 20, 04103 Leipzig, Germany
| | - Regine Kluge
- Department of Nuclear Medicine, University Hospital Leipzig, Liebigstraße 18, 04103 Leipzig, Germany
| | - Christoph Lübbert
- Division of Infectious Diseases and Tropical Medicine, Department of Medicine I, University Hospital Leipzig, Liebigstraße 20, 04103 Leipzig, Germany
- Interdisciplinary Center for Infectious Diseases, University Hospital Leipzig, Liebigstraße 20, 04103 Leipzig, Germany
| | - Arne C Rodloff
- Institute of Medical Microbiology and Virology, University Hospital Leipzig, Liebigstraße 21, 04103 Leipzig, Germany
| | - Andreas Roth
- Department of Orthopedics, Traumatology and Plastic Surgery, University Hospital Leipzig, Liebigstraße 20, 04103 Leipzig, Germany
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Richter A, Altemeier A, Hold M, Lenhof S, Stauss R, Ettinger M, Omar M. Drain fluid cultures can rule in but cannot rule out infection persistence after surgical treatment of periprosthetic joint infections. J Orthop Sci 2024; 29:177-182. [PMID: 36462996 DOI: 10.1016/j.jos.2022.11.014] [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: 08/06/2022] [Revised: 09/28/2022] [Accepted: 11/16/2022] [Indexed: 12/03/2022]
Abstract
BACKGROUND Periprosthetic joint infection (PJI) is one of the most common reason for implant failure in arthroplasty. Surgical therapy is essential but there is no standardized guideline to determine infection eradication in multiple-step revision surgery. To date, clinical and laboratory inflammation markers and preoperative arthrocentesis are controversial to evaluate the infection status before reimplantation and therefore are often combined. Drain fluid cultures enable a microbiological analysis without need for further invasive procedure after revision surgery. This retrospective study evaluates the diagnostic performance of drain fluid cultures in diagnosing infection persistence according to the MSIS definition of PJI. METHODS Drain samples have been taken after every revision surgery for microbiological testing. Afterwards, the results have been assigned to the infection status according to the diagnostic criteria of the MSIS definition of PJI. RESULTS 1084 revision surgeries in 183 patients have been included, resulting in a total sample size of 1552 drain fluid cultures. Overall sensitivity was 36.0%, specificity was 90.7% and ROC-AUC was 0.63. CONCLUSION Due to a high specificity and a low sensitivity drain fluid cultures can rule in but cannot rule out infection persistence in PJI.
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Affiliation(s)
- Alena Richter
- Orthopaedic Department - DIAKOVERE Annastift, Hannover Medical School, Anna-von-Borries-Str. 1-7, 30625 Hannover, Germany.
| | - Anna Altemeier
- Orthopaedic Department - DIAKOVERE Annastift, Hannover Medical School, Anna-von-Borries-Str. 1-7, 30625 Hannover, Germany.
| | - Mara Hold
- Orthopaedic Department - DIAKOVERE Annastift, Hannover Medical School, Anna-von-Borries-Str. 1-7, 30625 Hannover, Germany.
| | - Stefan Lenhof
- Trauma Department - Hannover Medical School, Carl-Neuberg-Str 130625 Hannover, Germany.
| | - Ricarda Stauss
- Trauma Department - Hannover Medical School, Carl-Neuberg-Str 130625 Hannover, Germany.
| | - Max Ettinger
- Orthopaedic Department - DIAKOVERE Annastift, Hannover Medical School, Anna-von-Borries-Str. 1-7, 30625 Hannover, Germany.
| | - Mohamed Omar
- Trauma Department - Hannover Medical School, Carl-Neuberg-Str 130625 Hannover, Germany.
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Berberich C, Kühn KD, Alt V. [Bone cement as a local antibiotic carrier]. ORTHOPADIE (HEIDELBERG, GERMANY) 2023; 52:981-991. [PMID: 37831092 DOI: 10.1007/s00132-023-04447-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 09/01/2023] [Indexed: 10/14/2023]
Abstract
BACKGROUND There is widespread consensus that adjuvant local use of antimicrobial agents in combination with their systemic administration can better prevent and treat implant-associated musculoskeletal infections. The advantage of local antibiotics lies in their particular pharmacokinetics with initially high antibiotic concentrations at the implant site with only low systemic uptake. AIM OF TREATMENT The aim of local application is to protect the foreign bodies directly at the implantation site from bacterial colonization and biofilm formation (prophylaxis) and to support the eradication of an already established infection after surgical debridement (treatment). Since the observations of Prof. Buchholz, bone cement has been the most frequently used local carrier system. APPLICATION In cases of infection, surgeons should ideally work together with microbiologists, infectiologists or clinical pharmacists to determine which anti-infective agents are indicated systemically for the patient and which ones are indicated locally with PMMA cement, based on the pathogen(s) and antibiograms. However, for the anti-infective agents administered with bone cement, there is still uncertainty about which agents can be added to this carrier material and at what concentrations. Accordingly, the authors of this review article not only summarize the rationale and evidence for local antibiotic use but also elaborate on the points that must be considered for admixing these agents to the cement.
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Affiliation(s)
- Christof Berberich
- Heraeus Medical GmbH, Philipp-Reis-Str. 8/11, 61273, Wehrheim, Deutschland.
| | - Klaus-Dieter Kühn
- Heraeus Medical GmbH, Philipp-Reis-Str. 8/11, 61273, Wehrheim, Deutschland
- Universitätsklinik für Orthopädie und Orthopädische Chirurgie, Medizinische Universität Graz, Graz, Österreich
| | - Volker Alt
- Klinik und Poliklinik für Unfallchirurgie, Universitätsklinikum Regensburg, Regensburg, Deutschland
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Schneider J, Maffulli N, Eschweiler J, Bell A, Hildebrand F, Migliorini F. Efficacy of ibuprofen and indomethacin as prophylaxis of heterotopic ossification: a comparative study. Sci Rep 2023; 13:20210. [PMID: 37980449 PMCID: PMC10657366 DOI: 10.1038/s41598-023-47508-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2022] [Accepted: 11/14/2023] [Indexed: 11/20/2023] Open
Abstract
The prophylactic action of non-steroidal anti-inflammatory drugs (NSAIDs) in heterotopic ossification (HO) was first described following analgesic therapy with indomethacin. Following that evidence, several compounds have been successfully used for prophylaxes of HO. Ibuprofen has been also proposed for the prevention of HO following THA. The present study compared the administration of ibuprofen for three weeks versus indomethacin as prophylaxis for HO following primary THA. In all THA procedures, pre- and post-operative protocols were conducted in a highly standardized fashion. The type of HO prophylaxis (indomethacin 100 mg/daily or ibuprofen 100 mg/daily) was chosen according to a chronological criterion: from 2017 to 2019 indomethacin was used, whereas from 2019 to 2022 ibuprofen was administered. In case of allergy or intolerance to NSAIDs, no prophylaxis was performed, and patients were included as a control group. All patients who underwent an anteroposterior radiography of the pelvis at a minimum of 12 months following THA were considered for inclusion. On admission, the age and sex of the patients were recorded. Moreover, the causes of osteoarthritis and the date of surgery were recorded. The grade of HO was assigned by a blinded assessor who was not involved in the clinical management of the patients. The modified Brooker Staging System was used to rate the efficacy of the interventions. Data from 1248 patients were collected. 62% (767 of 1248 patients) were women. The mean age was 67.0 ± 2.9 years. The mean follow-up was 21.1 ± 10.8 months. In the ibuprofen group, 73% of patients evidenced Brooker 0, 17% Brooker I, and 10% Brooker II. In the indomethacin group, 77% of patients evidenced Brooker 0, 16% Brooker I, 6% Brooker II. No patient in the ibuprofen and indomethacin group developed Brooker III or IV. In the control group, 64% of patients evidenced Brooker 0, 21% Brooker I, 3% Brooker II, and 12% Brooker III. No patient in the control group developed Brooker IV HO. Concluding, three weeks of administration of ibuprofen demonstrated similar efficacy to indomethacin in preventing HO following primary THA. The prophylaxis with ibuprofen or indomethacin was more effective in preventing HO compared to a control group who did not receive any pharmacological prophylaxis.
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Affiliation(s)
- Jens Schneider
- Department of Orthopedics and Trauma Surgery, University Clinic Aachen, RWTH Aachen University Clinic, 52064, Aachen, Germany
- Department of Orthopedics and Trauma Surgery, Eifelklinik St. Brigida, 52152, Simmerath, Germany
| | - Nicola Maffulli
- Department of Medicine and Psychology, University of Rome "La Sapienza", Rome, Italy
- Faculty of Medicine, School of Pharmacy and Bioengineering, Keele University, Stoke on Trent, ST4 7QB, UK
- Barts and the London School of Medicine and Dentistry, Centre for Sports and Exercise Medicine, Mile End Hospital, Queen Mary University of London, London, E1 4DG, UK
| | - Jörg Eschweiler
- Department of Orthopedics and Trauma Surgery, University Clinic Aachen, RWTH Aachen University Clinic, 52064, Aachen, Germany
| | - Andreas Bell
- Department of Orthopedics and Trauma Surgery, Eifelklinik St. Brigida, 52152, Simmerath, Germany
| | - Frank Hildebrand
- Department of Orthopedics and Trauma Surgery, University Clinic Aachen, RWTH Aachen University Clinic, 52064, Aachen, Germany
| | - Filippo Migliorini
- Department of Orthopedics and Trauma Surgery, University Clinic Aachen, RWTH Aachen University Clinic, 52064, Aachen, Germany.
- Department of Orthopedics and Trauma Surgery, Eifelklinik St. Brigida, 52152, Simmerath, Germany.
- Department of Orthopaedic and Trauma Surgery, Academic Hospital of Bolzano (SABES-ASDAA), Teaching Hospital of Paracelsus Medical University, 39100, Bolzano, Italy.
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Migliorini F, Maffulli N, Schäfer L, Schneider J, Nobili AM, Kämmer D, Michalak M, Bell A. Robotic-assisted total knee arthroplasty in clinical practice: protocol for a randomised controlled trial. J Orthop Surg Res 2023; 18:623. [PMID: 37626412 PMCID: PMC10464371 DOI: 10.1186/s13018-023-04101-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2022] [Accepted: 08/14/2023] [Indexed: 08/27/2023] Open
Abstract
Between 2 and 20% of patients who undergo total knee arthroplasty (TKA) report restricted motion and anterior knee pain. Non-optimal alignment of the implant components is a common cause of such complaints. Robotic-assisted TKA has been advocated to improve the accuracy of component positioning to match patients' anatomy and biomechanics. However, the advantages of robotic surgery over conventional freehand TKA are still unclear. The present study is a protocol for a single-blind clinical trial in which patients will be randomly allocated to undergo either robotic-assisted TKA or conventional freehand TKA. A restricted kinematic alignment with medial para-stellar approach shall be made in all patients. The present study follows the SPIRIT guidelines. The primary outcome of interest is to compare robotic TKA versus traditional freehand TKA in terms of patient-reported outcome measures (PROMs), length of hospitalisation, blood values, blood transfusion units, and range of motion. The second outcome of interest is to evaluate the accuracy of component positioning of robotic-assisted TKA compared to the conventional freehand TKA.Level of evidence Level I, randomised controlled trial.Registration German Registry of Clinical Trials (ID: DRKS00030614).
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Affiliation(s)
- Filippo Migliorini
- Department of Orthopaedic, Trauma, and Reconstructive Surgery, RWTH University Hospital, Pauwelsstraße 30, 52074, Aachen, Germany.
- Department of Orthopaedic and Trauma Surgery, Eifelklinik St.Brigida, 52152, Simmerath, Germany.
- Department of Orthopaedic and Trauma Surgery, Academic Hospital of Bolzano (SABES-ASDAA), 39100, Bolzano, Italy.
| | - Nicola Maffulli
- Department of Medicine, Surgery and Dentistry, University of Salerno, 84081, Baronissi, SA, Italy
- School of Pharmacy and Bioengineering, Faculty of Medicine, Keele University, Stoke on Trent, ST4 7QB, England
- Queen Mary University of London, Barts and the London School of Medicine and Dentistry, Centre for Sports and Exercise Medicine, Mile End Hospital, London, E1 4DG, England
| | - Luise Schäfer
- Department of Orthopaedic, Trauma, and Reconstructive Surgery, RWTH University Hospital, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Jens Schneider
- Department of Orthopaedic and Trauma Surgery, Eifelklinik St.Brigida, 52152, Simmerath, Germany
| | - Andrea Maria Nobili
- Department of Orthopaedic and Trauma Surgery, Eifelklinik St.Brigida, 52152, Simmerath, Germany
| | - Daniel Kämmer
- Department of Orthopaedic and Trauma Surgery, Eifelklinik St.Brigida, 52152, Simmerath, Germany
| | - Milosch Michalak
- Department of Orthopaedic and Trauma Surgery, Eifelklinik St.Brigida, 52152, Simmerath, Germany
| | - Andreas Bell
- Department of Orthopaedic and Trauma Surgery, Eifelklinik St.Brigida, 52152, Simmerath, Germany
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Polyak A, Harting H, Angrisani N, Herrmann T, Ehlert N, Meißner J, Willmann M, Al-Bazaz S, Ross TL, Bankstahl JP, Reifenrath J. Preparation and PET/CT imaging of implant directed 68Ga-labeled magnetic nanoporous silica nanoparticles. J Nanobiotechnology 2023; 21:270. [PMID: 37592318 PMCID: PMC10433681 DOI: 10.1186/s12951-023-02041-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Accepted: 07/31/2023] [Indexed: 08/19/2023] Open
Abstract
BACKGROUND Implant infections caused by biofilm forming bacteria are a major threat in orthopedic surgery. Delivering antibiotics directly to an implant affected by a bacterial biofilm via superparamagnetic nanoporous silica nanoparticles could present a promising approach. Nevertheless, short blood circulation half-life because of rapid interactions of nanoparticles with the host's immune system hinder them from being clinically used. The aim of this study was to determine the temporal in vivo resolution of magnetic nanoporous silica nanoparticle (MNPSNP) distribution and the effect of PEGylation and clodronate application using PET/CT imaging and gamma counting in an implant mouse model. METHODS PEGylated and non-PEGylated MNPSNPs were radiolabeled with gallium-68 (68Ga), implementing the chelator tris(hydroxypyridinone). 36 mice were included in the study, 24 mice received a magnetic implant subcutaneously on the left and a titanium implant on the right hind leg. MNPSNP pharmacokinetics and implant accumulation was analyzed in dependence on PEGylation and additional clodronate application. Subsequently gamma counting was performed for further final analysis. RESULTS The pharmacokinetics and biodistribution of all radiolabeled nanoparticles could clearly be visualized and followed by dynamic PET/CT imaging. Both variants of 68Ga-labeled MNPSNP accumulated mainly in liver and spleen. PEGylation of the nanoparticles already resulted in lower liver uptakes. Combination with macrophage depletion led to a highly significant effect whereas macrophage depletion alone could not reveal significant differences. Although MNPSNP accumulation around implants was low in comparison to the inner organs in PET/CT imaging, gamma counting displayed a significantly higher %I.D./g for the tissue surrounding the magnetic implants compared to the titanium control. Additional PEGylation and/or macrophage depletion revealed no significant differences regarding nanoparticle accumulation at the implantation site. CONCLUSION Tracking of 68Ga-labeled nanoparticles in a mouse model in the first critical hours post-injection by PET/CT imaging provided a better understanding of MNPSNP distribution, elimination and accumulation. Although PEGylation increases circulation time, nanoparticle accumulation at the implantation site was still insufficient for infection treatment and additional efforts are needed to increase local accumulation.
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Affiliation(s)
- Andras Polyak
- NIFE - Lower Saxony Centre for Biomedical Engineering, Implant Research and Development, Stadtfelddamm 34, 30625, Hannover, Germany
- Department of Prosthetic Dentistry and Biomedical Materials Science, Hannover Medical School, Carl-Neuberg-Straße 1, 30625, Hannover, Germany
- Department of Nuclear Medicine, Hannover Medical School, Carl-Neuberg-Straße 1, 30625, Hannover, Germany
| | - Heidi Harting
- NIFE - Lower Saxony Centre for Biomedical Engineering, Implant Research and Development, Stadtfelddamm 34, 30625, Hannover, Germany.
- Clinic for Orthopedic Surgery, Hannover Medical School, Carl-Neuberg-Straße 1, 30625, Hannover, Germany.
| | - Nina Angrisani
- NIFE - Lower Saxony Centre for Biomedical Engineering, Implant Research and Development, Stadtfelddamm 34, 30625, Hannover, Germany
- Clinic for Orthopedic Surgery, Hannover Medical School, Carl-Neuberg-Straße 1, 30625, Hannover, Germany
| | - Timo Herrmann
- Institute for Inorganic Chemistry, Leibniz University Hannover, Callinstraße 9, 30167, Hannover, Germany
| | - Nina Ehlert
- Institute for Inorganic Chemistry, Leibniz University Hannover, Callinstraße 9, 30167, Hannover, Germany
| | - Jessica Meißner
- Department of Pharmacology, Toxicology and Pharmacy, University of Veterinary Medicine Hanover, Foundation, Buenteweg 17, 30559, Hannover, Germany
| | - Michael Willmann
- Department of Nuclear Medicine, Hannover Medical School, Carl-Neuberg-Straße 1, 30625, Hannover, Germany
| | - Silav Al-Bazaz
- Department of Nuclear Medicine, Hannover Medical School, Carl-Neuberg-Straße 1, 30625, Hannover, Germany
| | - Tobias L Ross
- Department of Nuclear Medicine, Hannover Medical School, Carl-Neuberg-Straße 1, 30625, Hannover, Germany
| | - Jens P Bankstahl
- Department of Nuclear Medicine, Hannover Medical School, Carl-Neuberg-Straße 1, 30625, Hannover, Germany
| | - Janin Reifenrath
- NIFE - Lower Saxony Centre for Biomedical Engineering, Implant Research and Development, Stadtfelddamm 34, 30625, Hannover, Germany
- Clinic for Orthopedic Surgery, Hannover Medical School, Carl-Neuberg-Straße 1, 30625, Hannover, Germany
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8
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Migliorini F, Weber CD, Bell A, Betsch M, Maffulli N, Poth V, Hofmann UK, Hildebrand F, Driessen A. Bacterial pathogens and in-hospital mortality in revision surgery for periprosthetic joint infection of the hip and knee: analysis of 346 patients. Eur J Med Res 2023; 28:177. [PMID: 37208700 DOI: 10.1186/s40001-023-01138-y] [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: 03/02/2023] [Accepted: 05/09/2023] [Indexed: 05/21/2023] Open
Abstract
INTRODUCTION The management of periprosthetic joint infections (PJI) of the lower limb is challenging, and evidence-based recommendations are lacking. The present clinical investigation characterized the pathogens diagnosed in patients who underwent revision surgery for PJI of total hip arthroplasty (THA) and total knee arthroplasty (TKA). METHODS The present study follows the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE). The institutional databases of the RWTH University Medical Centre of Aachen, Germany, were accessed. The OPS (operation and procedure codes) 5-823 and 5-821 and the ICD (International Statistical Classification of Diseases and Related Health Problems) codes T84.5, T84.7 or T84.8 were used. All patients with PJI of a previous THA and TKA who underwent revision surgery were retrieved and included for analysis. RESULTS Data from 346 patients were collected (181 THAs and 165 TKAs). 44% (152 of 346 patients) were women. Overall, the mean age at operation was 67.8 years, and the mean BMI was 29.2 kg/m2. The mean hospitalization length was 23.5 days. 38% (132 of 346) of patients presented a recurrent infection. CONCLUSION PJI remain a frequent cause for revisions after total hip and knee arthroplasty. Preoperative synovial fluid aspiration was positive in 37%, intraoperative microbiology was positive in 85%, and bacteraemia was present in 17% of patients. Septic shock was the major cause of in-hospital mortality. The most common cultured pathogens were Staph. epidermidis, Staph. aureus, Enterococcus faecalis, and Methicillin-resistant Staph aureus (MRSA). An improved understanding of PJI pathogens is important to plan treatment strategies and guide the choice of empirical antibiotic regimens in patients presenting with septic THAs and TKAs. LEVEL OF EVIDENCE Level III, retrospective cohort study.
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Affiliation(s)
- Filippo Migliorini
- Department of Orthopaedic, Trauma, and Reconstructive Surgery, RWTH University Hospital, Pauwelsstraße 30, 52074, Aachen, Germany.
- Department of Orthopaedic and Trauma Surgery, Eifelklinik St. Brigida, 52152, Simmerath, Germany.
| | - Christian David Weber
- Department of Orthopaedic, Trauma, and Reconstructive Surgery, RWTH University Hospital, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Andreas Bell
- Department of Orthopaedic and Trauma Surgery, Eifelklinik St. Brigida, 52152, Simmerath, Germany
| | - Marcel Betsch
- Department of Orthopaedic and Trauma Surgery, University Hospital of Erlangen, 91054, Erlangen, Germany
| | - Nicola Maffulli
- Department of Medicine, Surgery and Dentistry, University of Salerno, 84081, Baronissi, Italy.
- School of Pharmacy and Bioengineering, Faculty of Medicine, Keele University, Stoke On Trent, ST4 7QB, UK.
- Centre for Sports and Exercise Medicine, Barts and the London School of Medicine and Dentistry, Mile End Hospital, Queen Mary University of London, 275 Bancroft Road, London, E1 4DG, UK.
| | - Vanessa Poth
- Department of Orthopaedic, Trauma, and Reconstructive Surgery, RWTH University Hospital, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Ulf Krister Hofmann
- Department of Orthopaedic, Trauma, and Reconstructive Surgery, RWTH University Hospital, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Frank Hildebrand
- Department of Orthopaedic, Trauma, and Reconstructive Surgery, RWTH University Hospital, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Arne Driessen
- Department of Orthopaedic, Trauma, and Reconstructive Surgery, RWTH University Hospital, Pauwelsstraße 30, 52074, Aachen, Germany
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Ohlmeier M, Alrustom F, Citak M, Rolvien T, Gehrke T, Frings J. The Clinical Outcome of Different Total Knee Arthroplasty Designs in One-Stage Revision for Periprosthetic Infection. J Arthroplasty 2022; 37:359-366. [PMID: 34648923 DOI: 10.1016/j.arth.2021.10.002] [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: 08/18/2021] [Revised: 09/25/2021] [Accepted: 10/04/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Despite the growing number of studies reporting on the best surgical treatment in the management of periprosthetic joint infection, there are no robust data regarding the type of infected prosthesis before any kind of exchange arthroplasty. To overcome these shortcomings, we asked the following questions: (1) What is the survivorship of nonhinged and hinged knee implants after one-stage exchange arthroplasty and (2) what is the functional outcome after one-stage exchange procedure focusing on knee prostheses and the type of prior infected knee implant. In a secondary radiographic analysis, we also investigated if (3) the type of femoral bone morphology measured by the inner femoral diameter influences the rate of aseptic failures also in patients with periprosthetic joint infection. METHODS Between January 2011 and December 2017, we performed a retrospective designed study including 211 patients with infected knee prostheses. After all, seventy-six percent (161 of 211 patients) were available for final data analysis. These patients were divided into four groups as per the performed implant revision: (1) bicondylar total knee arthroplasty to rotating hinge implant, (2) rotating hinge to rotating hinge implant, (3) rotating hinge to full hinge implant, and (4) full hinge to full hinge implant. The mean follow-up (FU) was six years (range 3 to 9; standard deviation = 1.9), whereas a minimum FU of three years was required for inclusion. Survivorship and group analysis were performed, and the functional outcome was assessed using postoperative Oxford Knee Scores at the latest FU (60-point scale with lower scores representing less pain and greater function). Furthermore, in all cases, femoral bone morphology was determined as per the Citak classification system. RESULTS At the final FU, the overall surgical revision rate was 23% (37/161 patients) with nine percent (15/161 patients) suffering a periprosthetic joint infection relapse. Group 1 consisted of 51, group 2 consisted of 67, group 3 consisted of 24, and group 4 consisted of 19 patients. The lowest overall revision rate was found in group 2 (16%, n = 11), compared with 28% (n = 14) in group 1, 29% (n = 7) in group 3, and 26% (n = 5) in group 4; however, no significant differences were found (P = .902). The functional outcome (Oxford Knee Score) was clinically constant in all groups, with 32 points in group 1, 37 points in group 2, 33 points in group 3, and 35 points in group 4 (P = .107). Concerning the number of patients with aseptic loosening as per bone morphology, 74% (14/19) of all aseptic loosening cases appeared in femoral bone type C morphologies according to Citak (75% in group 1, 56% in group 2, 100% in group 3, and 100% in group 4). CONCLUSIONS The results obtained suggest a generally high overall revision rate (25%) with a good infection control rate (91%). Although we were unable to work out a specific group of patients with a statistically significant differing outcome, it is interesting to see that hinged implants can reach more or less the same functional outcome and revision rates as nonhinged implants, when it comes to revision surgeries. In this study, a relatively high number of aseptic failures contributed to a high overall revision rate. In this context, the bone morphology, measured as per the Citak classification system, could be confirmed as a risk factor for aseptic failures also in septic patients. Therefore, further research might focus on revision knee implant design.
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Affiliation(s)
- Malte Ohlmeier
- Department of Orthopedic Surgery, ENDO-Klinik Hamburg, Hamburg, Germany
| | - Fadi Alrustom
- Department of Orthopedic Surgery, ENDO-Klinik Hamburg, Hamburg, Germany
| | - Mustafa Citak
- Department of Orthopedic Surgery, ENDO-Klinik Hamburg, Hamburg, Germany
| | - Tim Rolvien
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg- Eppendorf, Hamburg, Germany
| | - Thorsten Gehrke
- Department of Orthopedic Surgery, ENDO-Klinik Hamburg, Hamburg, Germany
| | - Jannik Frings
- Department of Orthopedic Surgery, ENDO-Klinik Hamburg, Hamburg, Germany; Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg- Eppendorf, Hamburg, Germany
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Enz A, Müller S, Mittelmeier W, Klinder A. Severe polymicrobial and fungal periprosthetic osteomyelitis persisting after hip disarticulations treated with caspofungin in risk patients: a case series. Ann Clin Microbiol Antimicrob 2021; 20:86. [PMID: 34972536 PMCID: PMC8720203 DOI: 10.1186/s12941-021-00490-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Accepted: 12/15/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Periprosthetic fungal infections are considered rare and opportunistic infections. Treatment is difficult, and established standards do not yet exist. The choice of the appropriate antifungal drug might affect the patient outcome. CASES All the three cases presented showed polybacterial recurrent infection of the revision hip arthroplasty. All patients were of younger age, had multiple revisions of the endoprosthesis, each had a large partial femoral replacement greater than 40% of the femoral length, gentamycin-loaded cement, and a long anchoring distance of the used intramedullary stem. Due to the severe life-threatening infection with deep osteomyelitis, an amputation had to be performed. However, despite surgical intervention, the fungal dominated infection persisted. Finally, only the use of caspofungin allowed permanent infection control. CONCLUSION The polybacterial infection is driven by the symbiosis between fungi and bacteria. Therefore, eradication of the fungus is required to achieve elimination of the bacteria. Antimycotics of the echinocandin-class, such as caspofungin, may be considered as initial treatment.
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Affiliation(s)
- Andreas Enz
- Orthopedic Clinic and Policlinic, University Medical Center Rostock, Doberaner Str. 142, 18057, Rostock, Germany.
| | - Silke Müller
- Institute of Pharmacology and Toxicology, University medical center Rostock, Schillingallee 70, 18057, Rostock, Germany
| | - Wolfram Mittelmeier
- Orthopedic Clinic and Policlinic, University Medical Center Rostock, Doberaner Str. 142, 18057, Rostock, Germany
| | - Annett Klinder
- Orthopedic Clinic and Policlinic, University Medical Center Rostock, Doberaner Str. 142, 18057, Rostock, Germany
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Osmanski-Zenk K, Klinder A, Rimke C, Wirtz DC, Lohmann CH, Haas H, Kladny B, Mittelmeier W. Evaluation of the standard procedure for treatment of periprosthetic joint infections of total knee and hip arthroplasty: a comparison of the 2015 and 2020 census in total joint replacement centres in Germany. BMC Musculoskelet Disord 2021; 22:791. [PMID: 34525989 PMCID: PMC8444384 DOI: 10.1186/s12891-021-04661-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Accepted: 08/26/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND There are different procedures for both, the diagnosis and the therapy of a periprosthetic joint infection (PJI), however, national or international guidelines for a standardised treatment regime are still lacking. The present paper evaluates the use of the predominant treatment protocols for PJI in certified total joint replacement centres (EPZ) in Germany based on an EndoCert questionnaire. MATERIALS AND METHODS The questionnaire was developed in cooperation with the EndoCert Certification Commission to survey the treatment protocols for septic revision arthroplasties in EPZ. Questions targeted the various treatment options including prosthesis preserving procedures (DAIR - Debridement, antibiotics, irrigation, and retention of the prosthesis), one-stage revision, two-stage revision, removal of the endoprosthesis and diagnostic sampling prior to re-implantation. All certified EPZ participated (n = 504) and the results from the current survey in 2020 were compared to data from a previous analysis in 2015. RESULTS The number of centres that performed DAIR up to a maximum of 4 weeks and more than 10 weeks after index surgery decreased since 2015, while the number of centres that provided a one-stage revision as a treatment option increased (hip: + 6.3%; knee: + 6.6%). The majority of the centres (73.2%) indicated a 4-8 week period as the preferred interval between prosthesis removal and re-implantation in two-stage revision in hip as well as knee revisions. Centres with a higher number of revision surgeries (> 200 revisions/year), opted even more often for the 4-8 week period (92.3%). In two-stage revision the use of metal-based spacers with/without reinforcement with antibiotic-containing cement as an interim placeholder was significantly reduced in 2020 compared to 2015. There was also a clear preference for cemented anchoring in two-stage revision arthroplasty in the knee in 2020, whereas the majority of hip replacements was cementless. Additionally, in 2020 the number of samples for microbiological testing during the removal of the infected endoprosthesis increased and 72% of the centres took five or more samples. Overall, the number of EPZ with a standardised protocol for the procedure expanded from 2015 to 2020. CONCLUSION While there was a trend towards standardised therapeutic algorithms for PJI with more uniform choices among the centres in 2020 compared to 2015, the treatment often remains an individual decision. However, since a consistent treatment regime is of vital importance with an expected rise of total numbers of revision arthroplasties, uniform definitions with regard to comparability and standardisation are necessary for the further development of the EndoCert system.
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Affiliation(s)
- Katrin Osmanski-Zenk
- Orthopädische Klinik und Poliklinik, Universitätsmedizin Rostock, Doberaner Straße 142, 18057, Rostock, Germany.
| | - Annett Klinder
- Orthopädische Klinik und Poliklinik, Universitätsmedizin Rostock, Doberaner Straße 142, 18057, Rostock, Germany
| | - Christina Rimke
- Orthopädische Klinik und Poliklinik, Universitätsmedizin Rostock, Doberaner Straße 142, 18057, Rostock, Germany
| | - Dieter C Wirtz
- Klinik und Poliklinik für Orthopädie und Unfallchirurgie, Universitätsklinikum Bonn, 53127, Bonn, Germany
| | - Christoph H Lohmann
- Department of Orthopaedic Surgery, Otto-von-Guericke-Universität, 39120, Magdeburg, Germany
| | - Holger Haas
- Zentrum für Orthopädie, Unfallchirurgie und Sportmedizin, Gemeinschaftskrankenhaus Bonn, 53113, Bonn, Germany
| | - Bernd Kladny
- Fachklinik Herzogenaurach, 91074, Herzogenaurach, Germany
| | - Wolfram Mittelmeier
- Orthopädische Klinik und Poliklinik, Universitätsmedizin Rostock, Doberaner Straße 142, 18057, Rostock, Germany
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Rupp M, Walter N, Lau E, Worlicek M, Kurtz SM, Alt V. Recent trends in revision knee arthroplasty in Germany. Sci Rep 2021; 11:15479. [PMID: 34326421 PMCID: PMC8322047 DOI: 10.1038/s41598-021-94988-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Accepted: 07/13/2021] [Indexed: 12/12/2022] Open
Abstract
We aimed to answer the following questions: (1) How did numbers of revision knee arthroplasty procedures develop in Germany over the last decade compared to primary TKA? (2) How high was the percentage of septic interventions in knee prosthesis revisions? (3) Which treatment strategy was chosen for surgical treatment of knee PJI? Revision arthroplasty rates as a function of age, gender, infection and type of prosthesis were quantified based on Operation and Procedure Classification System codes using revision knee arthroplasty data from 2008 to 2018, provided by the Federal Statistical Office of Germany (Destatis). In 2018, a total number 23,812 revision knee arthroplasties were performed in Germany, yielding an overall increase of 20.76% between 2008 and 2018. In comparison, primary TKA procedures increased by 23.8% from 152,551 performed procedures in 2008 to 188,866 procedures in 2018. Hence, 12.6% of knee arthroplasties required a revision in 2018. Septic interventions increased by 51.7% for all revisions. A trend towards higher numbers in younger patients was observed. Compared to 2008, 17.41% less DAIR procedures were performed, whereby single-stage and two- or multi-stage change increased by 38.76% and 42.76% in 2018, respectively. The increasing number of revision knee arthroplasty in Germany, especially in younger patients and due to infection, underlines the need for future efforts to improve treatment strategies to delay primary arthroplasty and avoid periprosthetic joint infection.
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Affiliation(s)
- Markus Rupp
- Department of Trauma Surgery, University Medical Center Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Germany.
| | - Nike Walter
- Department of Trauma Surgery, University Medical Center Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Germany
| | | | - Michael Worlicek
- Department of Trauma Surgery, University Medical Center Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Germany
| | | | - Volker Alt
- Department of Trauma Surgery, University Medical Center Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Germany
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Enz A, Mueller SC, Warnke P, Ellenrieder M, Mittelmeier W, Klinder A. Periprosthetic Fungal Infections in Severe Endoprosthetic Infections of the Hip and Knee Joint-A Retrospective Analysis of a Certified Arthroplasty Centre of Excellence. J Fungi (Basel) 2021; 7:404. [PMID: 34064002 PMCID: PMC8224054 DOI: 10.3390/jof7060404] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Revised: 05/19/2021] [Accepted: 05/20/2021] [Indexed: 01/01/2023] Open
Abstract
The treatment of periprosthetic joint infections (PJI), and especially of re-infections, poses a highly complex problem in orthopaedic surgery. While fungal infections are rare, they present a special challenge. The therapy is often protracted and based on limited evidence. A total of 510 hip and knee revision surgeries were analysed for the occurrence of bacterial and fungal PJI. In patients with PJI, the duration of the hospital stay and the incidence of disarticulation of the infected joint were recorded. Out of the analysed revision arthroplasties, 43.5% were due to PJI. Monomicrobial infection occurred in 55.2%, dual microbial infection in 21.4%, and polymicrobial (≥3 different bacterial or fungal species) infection in 17.2% of the cases. Overall, Candida species were detected in 12.4% cases. Candida albicans was the main fungal pathogen. In 6.9% of cases, disarticulation of the joint was the only option to control PJI. The detection of polymicrobial infection more than doubled in follow-up revisions and there was a strong association between detection of Candida infection and disarticulation (OR 9.39). The majority of fungal infections were mixed infections of bacteria and Candida albicans. The choice of a biofilm penetrating antimycotic, e.g., caspofungin, together with a sufficient standard procedure for detection and surgical treatment can help to control the infection situation. Fungal infection often proves to be more difficult to treat than anticipated and is more frequent than expected.
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Affiliation(s)
- Andreas Enz
- Orthopaedic Clinic and Policlinic, University Medicine Rostock, 18057 Rostock, Germany; (M.E.); (W.M.); (A.K.)
| | - Silke C. Mueller
- Institute of Pharmacology and Toxicology, University Medicine Rostock, 18057 Rostock, Germany;
| | - Philipp Warnke
- Institute for Medical Microbiology, Virology and Hygiene, University Medicine Rostock, 18057 Rostock, Germany;
| | - Martin Ellenrieder
- Orthopaedic Clinic and Policlinic, University Medicine Rostock, 18057 Rostock, Germany; (M.E.); (W.M.); (A.K.)
| | - Wolfram Mittelmeier
- Orthopaedic Clinic and Policlinic, University Medicine Rostock, 18057 Rostock, Germany; (M.E.); (W.M.); (A.K.)
| | - Annett Klinder
- Orthopaedic Clinic and Policlinic, University Medicine Rostock, 18057 Rostock, Germany; (M.E.); (W.M.); (A.K.)
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