1
|
Ahrens H, Steinicke AC, Gosheger G, Schwarze J, Bockholt S, Moellenbeck B, Theil C. Do Organism Profile and Resistance Patterns Change between First and Subsequent Two-Stage Revision for Periprosthetic Joint Infection? Antibiotics (Basel) 2024; 13:771. [PMID: 39200071 PMCID: PMC11352185 DOI: 10.3390/antibiotics13080771] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2024] [Revised: 08/04/2024] [Accepted: 08/14/2024] [Indexed: 09/01/2024] Open
Abstract
Increasing antibiotic resistance has been reported as an issue in the treatment of periprosthetic joint infection (PJI). A repeat two-stage revision for recurrent PJI is at high risk of reinfection. However, it is unclear if the microorganism profile plays a role with potentially more resistant or polymicrobial infections. This is a retrospective, single-center analysis of two-stage revisions performed between 2011 and 2017. We identified 46 patients who underwent a repeat resection arthroplasty for recurrent PJI of the same joint after a previous two-stage revision of the same joint at the same department. All microbiological findings were analyzed focusing on microbiological spectrum and resistance testing as well as the potential impact on reinfection-free survival. The most common organism found at the time of recurrent PJI were coagulase-negative Staphylococci (39%) followed by Gram-negative organisms (28%). The risk of polymicrobial infections, difficult-to-treat resistant organisms, and Gram-negative infections increased significantly. Among staphylococcal infections, there was a high percentage of methicillin-resistant species and resistance to oral antibiotics. Patients with Gram-negative organisms had a reduced infection-free survivorship, while resistant organisms were not associated with decreased survival. Patients who undergo a repeat two-stage revision for recurrent PJI have more polymicrobial and resistant organisms, although the impact on survivorship is unclear.
Collapse
|
2
|
Hanusrichter Y, Gebert C, Frieler S, Moellenbeck B, Dudda M, Wessling M, Theil C. Mouldable Collagen-Tricalciumphosphate Is a Safe Carrier for Local Antibiotics-Short-Term Results in Revision Hip Arthroplasty. Antibiotics (Basel) 2024; 13:510. [PMID: 38927177 PMCID: PMC11200538 DOI: 10.3390/antibiotics13060510] [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: 03/30/2024] [Revised: 05/23/2024] [Accepted: 05/28/2024] [Indexed: 06/28/2024] Open
Abstract
BACKGROUND Improving local antibiotic delivery is a promising approach to improve infection control and potentially shorten systemic treatment in periprosthetic joint infection (PJI). This study investigates the use of an antibiotic-loaded, mouldable collagen-tricalciumphosphate composite in treatment of hip PJI. METHODS 124 application cases in 79 patients were included from a referral centre; systemic adverse infects, local complications, and infection control were analysed. RESULTS In most cases, either vancomycin or meropenem were used. Pathogens were previously known in 82 (66%) cases with polymicrobial infection in 20 (25%) patients. There were no cases of hypercalcaemia. Acute kidney injure was present in 14 (11%) cases. Chronic kidney failure persisted in two cases. During a mean follow-up of 12 (SD 9.3; range 3-35) months, implant survival was achieved in 73 (92%) patients; revision due to PJI was performed in 19 cases. CONCLUSION Mouldable collagen-tricalciumphosphate composite bone substitute as a local antibiotic carrier in revision hip arthroplasty appears to be a valid option for local antibiotic delivery without systemic complications. Implant survival of 92% supports the hypothesis that local antibiotic therapy is an important component in the treatment of PJI.
Collapse
Affiliation(s)
- Yannik Hanusrichter
- Department of Tumour Orthopaedics and Revision Arthroplasty, Orthopaedic Hospital Volmarstein, 58300 Wetter, Germany
- Center for Musculoskeletal Surgery, University Hospital of Essen, 45147 Essen, Germany
| | - Carsten Gebert
- Department of Tumour Orthopaedics and Revision Arthroplasty, Orthopaedic Hospital Volmarstein, 58300 Wetter, Germany
- Department of Orthopedics and Tumor Orthopedics, Muenster University Hospital, 48149 Muenster, Germany
| | - Sven Frieler
- Department of Tumour Orthopaedics and Revision Arthroplasty, Orthopaedic Hospital Volmarstein, 58300 Wetter, Germany
- Department of Trauma and Orthopedic Surgery, BG University Hospital Bergmannsheil, Ruhr University Bochum, 44879 Bochum, Germany
| | - Burkhard Moellenbeck
- Department of Orthopedics and Tumor Orthopedics, Muenster University Hospital, 48149 Muenster, Germany
| | - Marcel Dudda
- Center for Musculoskeletal Surgery, University Hospital of Essen, 45147 Essen, Germany
- Department of Trauma Surgery, University Hospital Essen, 45147 Essen, Germany
- Department of Orthopedics and Trauma Surgery, BG-Klinikum Duisburg, University Duisburg-Essen, 47249 Duisburg, Germany
| | - Martin Wessling
- Department of Tumour Orthopaedics and Revision Arthroplasty, Orthopaedic Hospital Volmarstein, 58300 Wetter, Germany
- Center for Musculoskeletal Surgery, University Hospital of Essen, 45147 Essen, Germany
| | - Christoph Theil
- Department of Orthopedics and Tumor Orthopedics, Muenster University Hospital, 48149 Muenster, Germany
| |
Collapse
|
3
|
Goumenos S, Hardt S, Kontogeorgakos V, Trampuz A, Perka C, Meller S. Success Rate After 2-Stage Spacer-Free Total Hip Arthroplasty Exchange and Risk Factors for Reinfection: A Prospective Cohort Study of 187 Patients. J Arthroplasty 2024:S0883-5403(24)00444-3. [PMID: 38759820 DOI: 10.1016/j.arth.2024.05.010] [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: 12/04/2023] [Revised: 05/02/2024] [Accepted: 05/03/2024] [Indexed: 05/19/2024] Open
Abstract
BACKGROUND Two-stage prosthesis exchange is the treatment of choice for chronic periprosthetic joint infection (PJI) of a total hip arthroplasty (THA), especially when the bone and surrounding soft tissues are compromised or difficult-to-treat pathogens are implicated. The aims of our study were as follows: (1) to determine the outcome of 2-stage prosthesis exchange for the treatment of PJI after THA and (2) to determine the risk factors for reinfection leading to subsequent revision surgeries after reimplantation. METHODS We prospectively enrolled 187 consecutive patients who underwent a 2-stage THA exchange with resection arthroplasty for PJI from 2013 to 2019. The mean (± SD) duration of follow-up was 54.2 ± 24.9 months (range, 36 to 96), and the mean interval until reimplantation was 9.8 ± 8.9 weeks (range, 2 to 38). All patients remained in a spacer-free girdlestone situation between the 2 stages of treatment. Patients who remained infection-free after their 2-stage treatment were considered to have achieved treatment success. RESULTS The overall success rate was 85.6%. The cumulative probability of reinfection was 11.5% after one year and 14% after 2 years after reimplantation. High virulence or difficult-to-treat pathogens were significant and independent risk factors for reinfection (HR [hazard ratio] = 3.71, 95% CI [confidence interval]: 1.47 to 9.36, P = .006 and HR = 3.85, 95% CI: 1.73 to 8.57, respectively, P = .001), as was previous 2-stage hip prosthesis exchange (HR = 3.58, 95% CI: 1.33 to 9.62, P = .01). Overall reoperation and revision rates were 26.2 and 16.6%, respectively. Re-infected patients had an 80% higher probability of reoperation than noninfected ones (P < .001, log-rank = 102.6), and they were 55% more likely to undergo revision surgery during their follow-up (P < .001, log-rank = 55.4). CONCLUSIONS Reinfection rates after 2-stage spacer-free THA revision for PJI still remain high but are comparable to those including cement spacers. Patients who have had prior failed 2-stage implant exchanges or are infected by high-grade or difficult-to-treat pathogens are at high risk for treatment failure.
Collapse
Affiliation(s)
- Stavros Goumenos
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Center for Musculoskeletal Surgery (CMSC), Berlin, Germany
| | - Sebastian Hardt
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Center for Musculoskeletal Surgery (CMSC), Berlin, Germany
| | - Vasileios Kontogeorgakos
- 1st Department of Orthopaedics and Trauma Surgery, "Attikon" University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Andrej Trampuz
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Center for Musculoskeletal Surgery (CMSC), Berlin, Germany
| | - Carsten Perka
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Center for Musculoskeletal Surgery (CMSC), Berlin, Germany
| | - Sebastian Meller
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Center for Musculoskeletal Surgery (CMSC), Berlin, Germany
| |
Collapse
|
4
|
Umbel BD, Haghverdian BA, Schweitzer KM, Adams SB. Diagnosis and Management of Infected Total Ankle Replacements. Orthop Clin North Am 2024; 55:285-297. [PMID: 38403374 DOI: 10.1016/j.ocl.2023.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/27/2024]
Abstract
As the number of primary total ankle replacements increases for treatment of end-stage ankle arthritis, failures are also expected to rise. Periprosthetic joint infection is among the causes of failures and has been reported to be as high as 5%. Diagnosis is usually made by a combination of clinical examination findings, imaging, laboratory, and microbiological workup. Management is generally separated into limb salvage or amputation. Limb salvage can be challenging and may involve a single versus staged approach. Options include revision arthroplasty or arthrodesis procedures (ankle versus tibiotalocalcaneal), and a multidisciplinary approach is sought to eradicate infection before definitive management.
Collapse
Affiliation(s)
- Benjamin D Umbel
- Department of Orthopedic Surgery, Duke University Medical Center, 200 Trent Drive, Durham, NC 27710, USA.
| | - Brandon A Haghverdian
- Department of Orthopedic Surgery, Duke University Medical Center, 200 Trent Drive, Durham, NC 27710, USA
| | - Karl M Schweitzer
- Duke Orthopaedics of Raleigh, 3480 Wake Forest Road, Suite 204, Raleigh, NC 27609, USA
| | - Samuel B Adams
- Department of Orthopedic Surgery, Duke University Medical Center, 200 Trent Drive, Durham, NC 27710, USA
| |
Collapse
|
5
|
Theil C, Bockholt S, Gosheger G, Dieckmann R, Schwarze J, Schulze M, Puetzler J, Moellenbeck B. Surgical Management of Periprosthetic Joint Infections in Hip and Knee Megaprostheses. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:583. [PMID: 38674229 PMCID: PMC11051768 DOI: 10.3390/medicina60040583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/24/2024] [Revised: 03/20/2024] [Accepted: 03/28/2024] [Indexed: 04/28/2024]
Abstract
Periprosthetic joint infection is a feared complication after the megaprosthetic reconstruction of oncologic and non-oncologic bone defects of including the knee or hip joint. Due to the relative rarity of these procedures, however, optimal management is debatable. Considering the expanding use of megaprostheses in revision arthroplasty and the high revision burden in orthopedic oncology, the risk of PJI is likely to increase over the coming years. In this non-systematic review article, we present and discuss current management options and the associated results focusing on studies from the last 15 years and studies from dedicated centers or study groups. The indication, surgical details and results in controlling infection are presented for debridement, antibiotics, irrigation and retention (DAIR) procedure with an exchange of the modular components, single-stage implant exchange, two-stage exchanges and ablative procedures.
Collapse
Affiliation(s)
- Christoph Theil
- Department of Orthopedics and Tumor Orthopedics, Muenster University Hospital, Albert-Schweitzer-Campus 1, 48149 Muenster, Germany
| | - Sebastian Bockholt
- Department of Orthopedics and Tumor Orthopedics, Muenster University Hospital, Albert-Schweitzer-Campus 1, 48149 Muenster, Germany
| | - Georg Gosheger
- Department of Orthopedics and Tumor Orthopedics, Muenster University Hospital, Albert-Schweitzer-Campus 1, 48149 Muenster, Germany
| | - Ralf Dieckmann
- Department of Orthopedics and Tumor Orthopedics, Muenster University Hospital, Albert-Schweitzer-Campus 1, 48149 Muenster, Germany
- Department of Orthopedics, Brüderkrankenhaus Trier, Medical Campus Trier, Nordallee 1, 54292 Trier, Germany
| | - Jan Schwarze
- Department of Orthopedics and Tumor Orthopedics, Muenster University Hospital, Albert-Schweitzer-Campus 1, 48149 Muenster, Germany
| | - Martin Schulze
- Department of Orthopedics and Tumor Orthopedics, Muenster University Hospital, Albert-Schweitzer-Campus 1, 48149 Muenster, Germany
| | - Jan Puetzler
- Department of Orthopedics and Tumor Orthopedics, Muenster University Hospital, Albert-Schweitzer-Campus 1, 48149 Muenster, Germany
| | - Burkhard Moellenbeck
- Department of Orthopedics and Tumor Orthopedics, Muenster University Hospital, Albert-Schweitzer-Campus 1, 48149 Muenster, Germany
| |
Collapse
|
6
|
Mirghaderi P, Eshraghi N, Sheikhbahaei E, Razzaghof M, Roustai-Geraylow K, Pouramini A, Eraghi MM, Kafi F, Javad Mortazavi SM. Does Using Highly Porous Tantalum in Revision Total Hip Arthroplasty Reduce the Rate of Periprosthetic Joint Infection? A Systematic Review and Meta-Analysis. Arthroplast Today 2024; 25:101293. [PMID: 38298809 PMCID: PMC10827600 DOI: 10.1016/j.artd.2023.101293] [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: 05/15/2023] [Revised: 10/15/2023] [Accepted: 11/05/2023] [Indexed: 02/02/2024] Open
Abstract
Background Studies suggest tantalum (Ta) implants may have inherent antibacterial properties. However, there is no consensus regarding the effectiveness of Ta in preventing periprosthetic joint infection (PJI) after revision total hip arthroplasty (rTHA). Methods We searched 5 main databases for articles reporting the rate of PJI following rTHA using Ta implants from inception to February 2022. The PJI rates of the Ta group were meta-analyzed, compared with the control group, and represented as relative risks (RRs) in forest plots. Results We identified 67 eligible studies (28,414 joints) for assessing the prevalence of PJI following rTHA using Ta implants. Among these studies, only 9 compared the Ta implant group with a control group. The overall PJI rate following rTHA using Ta implants was 2.9% (95% confidence interval [CI]: 2.2%-3.8%), while it was 5.7% (95% CI = 4.1%-7.8%) if only septic revisions were considered. Comparing the Ta and control groups showed a significantly lower PJI rate following all-cause rTHA with an RR = 0.80 (95% CI = 0.65-0.98, P < .05). There was a trend toward lower reinfection rates in the Ta group after rTHA in septic cases, although the difference was not statistically significant (RR = 0.75, 95% CI = 0.44-1.29, P = .30). Conclusions Ta implants are associated with a lower PJI rate following all-cause rTHA but not after septic causes. Despite positive results, the clinical significance of Ta still remains unclear since the PJI rate was only reduced by 20%. Level of Evidence IV.
Collapse
Affiliation(s)
- Peyman Mirghaderi
- Surgical Research Society (SRS), Students’ Scientific Research Center, Tehran University of Medical Sciences, Tehran, Iran
- Joint Reconstruction Research Center (JRRC), Tehran University of Medical Sciences, Tehran, Iran
| | - Nasim Eshraghi
- Surgical Research Society (SRS), Students’ Scientific Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Erfan Sheikhbahaei
- Surgical Research Society (SRS), Students’ Scientific Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammadreza Razzaghof
- Joint Reconstruction Research Center (JRRC), Tehran University of Medical Sciences, Tehran, Iran
| | - Kiarash Roustai-Geraylow
- Surgical Research Society (SRS), Students’ Scientific Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Alireza Pouramini
- Surgical Research Society (SRS), Students’ Scientific Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammad Mirahmadi Eraghi
- Surgical Research Society (SRS), Students’ Scientific Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Fatemeh Kafi
- Surgical Research Society (SRS), Students’ Scientific Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | | |
Collapse
|
7
|
McPherson EJ, Crawford BM, Kenny SG, Dipane MV, Salarkia S, Stavrakis AI, Chowdhry M. Point-of-Care Coating of Revision Femoral Stems With Antibiotic-Loaded Calcium Sulfate: Reduction in Infection After 2nd Stage Reimplantation but Not With Aseptic Revisions. Arthroplast Today 2024; 25:101302. [PMID: 38304243 PMCID: PMC10830497 DOI: 10.1016/j.artd.2023.101302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Revised: 08/24/2023] [Accepted: 11/04/2023] [Indexed: 02/03/2024] Open
Abstract
Background Infection rates in revision total hip arthroplasty are lower when antibiotic loaded cemented stems are utilized. Inspired by this technique, a point-of-care coating of antibiotic-loaded calcium sulfate (CaSO4) was applied to cementless revision stems in aseptic revision and 2nd stage reimplantation total hip arthroplasty. Methods One hundred eleven consecutive femoral stems were coated. Just prior to insertion, 10 cc of CaSO4 was mixed with 1 g vancomycin and 240 mg tobramycin with the paste applied to the stem. The results were compared to a matched cohort (N = 104) performed across the previous 5 years. The surgical methods were comparable, but for the stem coating. The study group was followed for a minimum of 3 years. Results In the study cohort of 111 patients, there were 69 aseptic revisions with one periprosthetic joint infection (PJI) (1.4%) and 42 second-stage reimplantations with 2 PJIs (4.8%). In the control cohort of 104 patients, there were 74 aseptic revisions with one PJI (1.4%) and 30 second-stage reimplantations with 7 PJIs (23.3%). There was no significant reduction in PJI rate in the aseptic revision subgroup (1.4% study vs 1.4% control group), P = 1.000. Antibiotic stem coating reduced PJI rate in the 2nd stage reimplantation subgroup (23.3% control vs 4.8% study group), P = .028. In both groups, there were no cases of aseptic stem loosening. Conclusions Point-of-care antibiotic coating of cementless revision femoral stems reduces PJI infection rate in 2nd stage reimplantations only. We theorize that microbes persist in the endosteal cortices after resection and may contribute to infection recurrence.
Collapse
Affiliation(s)
- Edward J. McPherson
- Department of Orthopedic Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Brooke M. Crawford
- Department of Orthopedic Surgery, The University of Miami Miller School of Medicine, Miami, FL, USA
| | - Steven G. Kenny
- Department of Orthopedic Surgery, The Permanente Medical Group, San Rafael, CA, USA
| | - Matthew V. Dipane
- Department of Orthopedic Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Shahrzad Salarkia
- Department of Orthopedic Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Alexandra I. Stavrakis
- Department of Orthopedic Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Madhav Chowdhry
- Department of Orthopedic Surgery, Jawaharlal Nehru Medical College, AMU, Aligarh, Uttar Pradesh, India
| |
Collapse
|
8
|
Lee JJ, Oladeji K, Sweeney BF, Chakoma TL, Arora P, Finlay AK, Amanatullah DF. Single, Recurrent, Synchronous, and Metachronous Periprosthetic Joint Infections in Patients With Multiple Hip and Knee Arthroplasties. J Arthroplasty 2023; 38:1846-1853. [PMID: 36924855 DOI: 10.1016/j.arth.2023.03.014] [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: 10/20/2022] [Revised: 03/05/2023] [Accepted: 03/09/2023] [Indexed: 03/18/2023] Open
Abstract
BACKGROUND The rate for periprosthetic joint infection (PJI) exceeds 1% for primary arthroplasties. Over 30% of patients who have a primary arthroplasty require an additional arthroplasty, and the impact of PJI on this population is understudied. Our objective was to assess the prevalence of recurrent, synchronous, and metachronous PJI in patients who had multiple arthroplasties and to identify risk factors for a subsequent PJI. METHODS We identified 337 patients who had multiple arthroplasties and at least 1 PJI that presented between 2003 and 2021. The mean follow-up after revision arthroplasty was 3 years (range, 0 to 17.2). Patients who had multiple infected prostheses were categorized as synchronous (ie, presenting at the same time as the initial infection) or metachronous (ie, presenting at a different time as the initial infection). The PJI diagnosis was made using the MusculoSkeletal Infection Society (MSIS) criteria. RESULTS There were 39 (12%) patients who experienced recurrent PJI in the same joint, while 31 (9%) patients developed PJI in another joint. Positive blood cultures were more likely in the second joint PJI (48%) compared to recurrent PJI (23%) or a single PJI (15%, P < .001). Synchronous PJI represented 42% of the second joint PJI cases (n = 13), while metachronous PJI represented 58% (n = 18). Tobacco users had 75% higher odds of metachronous PJI (odds ratio 1.75, 95% confidence interval: 1.1-2.9, P = .041). CONCLUSION Over 20% of the patients with multiple arthroplasties and a single PJI will develop a subsequent PJI in another arthroplasty with 12% recurring in the initial arthroplasty and nearly 10% ocurring in another arthroplasty. Particular caution should be taken in patients who use tobacco, have bacteremia, or have Staphylococcus aureus isolation at time of their initial PJI. Optimizing the management of this high-risk patient population is necessary to reduce the additional burden of subsequent PJI. LEVEL OF EVIDENCE Prognostic Level IV.
Collapse
Affiliation(s)
- Jonathan J Lee
- Department of Orthopaedic Surgery, Stanford University, Redwood City, California; Stanford University School of Medicine, Stanford, California
| | - Kingsley Oladeji
- Department of Orthopaedic Surgery, Stanford University, Redwood City, California
| | - Brian F Sweeney
- Stanford University School of Medicine, Stanford, California
| | | | - Prerna Arora
- Department of Orthopaedic Surgery, Stanford University, Redwood City, California
| | - Andrea K Finlay
- Department of Orthopaedic Surgery, Stanford University, Redwood City, California
| | - Derek F Amanatullah
- Department of Orthopaedic Surgery, Stanford University, Redwood City, California
| |
Collapse
|
9
|
Metcalf RW, Rowe T, Tersteeg M, Dombrowski ME, Odum S, Otero JE. The Influence of Patient Sex on Outcomes Following One-Stage and Two-Stage Revision for Periprosthetic Joint Infection in Total Joint Arthroplasty. Antibiotics (Basel) 2023; 12:1392. [PMID: 37760688 PMCID: PMC10525713 DOI: 10.3390/antibiotics12091392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Revised: 08/21/2023] [Accepted: 08/25/2023] [Indexed: 09/29/2023] Open
Abstract
Although females have a higher rate of primary total joint arthroplasty (TJA), males have a higher rate of revision. The literature lacks studies examining the relationship between sex and outcomes following single and two-stage exchange for periprosthetic joint infection (PJI). The purpose of this study was to examine if differences exist in outcomes following revision for chronic PJI between sexes. A retrospective review was performed on all patients with an MSIS confirmed PJI who underwent a single or two-stage exchange at our institution from January 2010 to January 2021. Patient demographics, comorbidity characteristics, and outcomes were collected and compared between males and females. The primary outcome variable was disease-free survival at 1 year following definitive revision. Multivariable logistic regression analysis was performed to determine risk factors for failure. Of the 470 patients meeting final eligibility criteria, 250 were male and 226 were female (2 males and 4 females had a joint infection of either the contralateral side or a different joint and were treated as separate records). Of the patients in the cohort, 80% of the males (200/250) and 80% of the females (181/226) were found to be disease-free at 1-year follow-up (p > 0.99). Multivariable logistic regression analysis showed that nicotine use and diabetes, but not sex, were significant predictors of failure. Our study did not find a relationship between sex and outcome of revision for PJI. Further research is required to determine whether differences exist between males and females in the expression of PJI and outcomes following treatment.
Collapse
Affiliation(s)
- Rory W. Metcalf
- OrthoCarolina Research Institute, Charlotte, NC 28207, USA; (R.W.M.)
| | - Taylor Rowe
- OrthoCarolina Research Institute, Charlotte, NC 28207, USA; (R.W.M.)
| | - Megan Tersteeg
- Saint Louis University School of Medicine, St. Louis, MO 63104, USA
| | | | - Susan Odum
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, NC 28207, USA
| | - Jesse E. Otero
- OrthoCarolina Hip & Knee Center, Atrium Health Musculoskeletal Institute, Charlotte, NC 28207, USA
| |
Collapse
|
10
|
Ryan SP, Warne CN, Osmon DR, Tande AJ, Ledford CK, Hyun M, Berry DJ, Abdel MP. Short Course of Oral Antibiotic Treatment After Two-Stage Exchange Arthroplasty Appears to Decrease Early Reinfection. J Arthroplasty 2023; 38:909-913. [PMID: 36496045 PMCID: PMC10430476 DOI: 10.1016/j.arth.2022.12.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Revised: 11/28/2022] [Accepted: 12/02/2022] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Recent evidence has suggested a benefit to extended postoperative prophylactic oral antibiotics after two-stage exchange arthroplasty for treatment of periprosthetic joint infections. We sought to determine reinfection rates with and without a short course of oral antibiotics after two-stage exchange procedures. METHODS A retrospective review identified patients undergoing two-stage exchange arthroplasty for periprosthetic joint infection of the hip or knee. Patients were excluded if they failed a prior two-stage exchange, had positive cultures at reimplantation, prolonged intravenous antibiotics postoperatively, and/or life-long suppression. This resulted in 444 reimplantations (210 hips and 234 knees). Patients were divided into three cohorts based on the duration of oral antibiotics after reimplantation: no antibiotics (102), ≤2 weeks (266), or >2 weeks (76). The primary endpoint was reinfection within 1 year of reimplantation. RESULTS Within 1 year of reimplantation, there were 34 reinfections. In the no-antibiotic, ≤ 2-week, and >2-week cohorts the reinfection rates were 14.1, 7.0, and 6.4%, respectively. Multivariate Cox regression showed a reduced reinfection rate in the ≤2-week cohort relative to no antibiotics (hazard ratio [HR]: 0.38, P = .01). While the smaller cohort with >2 weeks of antibiotics did not significantly reduce the reinfection rate (HR: 0.41, P = .12), when combined with the ≤2-week cohort, use of oral antibiotics had an overall reduction of the reinfection rate (HR: 0.39, P = .01). CONCLUSIONS These data support the hypothesis that a short course of oral antibiotics after reimplantation decreases the 1-year reinfection rate. Future randomized studies should seek to examine the efficacy of different durations of oral antibiotics to reduce reinfection. LEVEL OF EVIDENCE Prognostic Level IV.
Collapse
Affiliation(s)
- Sean P. Ryan
- Department of Orthopedic Surgery, Mayo Clinic, 200 First Street S.W., Rochester, MN 55905
| | - Christopher N. Warne
- Department of Orthopedic Surgery, Mayo Clinic, 200 First Street S.W., Rochester, MN 55905
| | - Douglas R. Osmon
- Division of Infectious Diseases, Department of Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905
| | - Aaron J. Tande
- Division of Infectious Diseases, Department of Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905
| | - Cameron K. Ledford
- Department of Orthopedic Surgery, Mayo Clinic, 200 First Street S.W., Rochester, MN 55905
| | - Meredith Hyun
- Department of Quantitative Health Sciences, Division of Clinical Trials and Biostatistics, Mayo Clinic, 200 First Street S.W., Rochester, MN 55905
| | - Daniel J. Berry
- Department of Orthopedic Surgery, Mayo Clinic, 200 First Street S.W., Rochester, MN 55905
| | - Matthew P. Abdel
- Department of Orthopedic Surgery, Mayo Clinic, 200 First Street S.W., Rochester, MN 55905
| |
Collapse
|
11
|
Steinicke AC, Schwarze J, Gosheger G, Moellenbeck B, Ackmann T, Theil C. Repeat two-stage exchange arthroplasty for recurrent periprosthetic hip or knee infection: what are the chances for success? Arch Orthop Trauma Surg 2023; 143:1731-1740. [PMID: 34982202 PMCID: PMC10030533 DOI: 10.1007/s00402-021-04330-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Accepted: 12/18/2021] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Two-stage revision is a frequently chosen approach to treat chronic periprosthetic joint infection (PJI). However, management of recurrent infection after a two-stage exchange remains debated and the outcome of a repeat two-stage procedure is unclear. This study investigates the success rates of repeat two-stage exchange arthroplasty and analyzes possible risk factors for failure. MATERIALS AND METHODS We retrospectively identified 55 patients (23 hips, 32 knees) who were treated with repeat resection arthroplasty and planned delayed reimplantation for recurrent periprosthetic joint infection between 2010 and 2019 after a prior two-stage revision at the same institution. The minimum follow-up was 12 months with a median follow-up time of 34 months (IQR 22-51). The infection-free survival, associated revision surgeries, and potential risk factors for further revision were analyzed using Kaplan-Meier survival curves and comparative non-parametric testing. RESULTS 78% (43/55) underwent reimplantation after a repeat implant removal. Of those who completed the second-stage surgery, 37% (16/43) underwent additional revision for infection and 14% (6/55) underwent amputation. The reinfection-free implant survivorship amounted to 77% (95% CI 64-89%) after 1 year and 38% (95% CI 18-57%) after 5 years. Patients with a higher comorbidity score were less likely to undergo second-stage reimplantation (median 5 vs. 3, p = 0.034). Furthermore, obese patients (p = 0.026, Fisher's exact test) and diabetics (p < 0.001, log-rank test) had a higher risk for further infection. Most commonly cultures yielded polymicrobial growth at the repeat two-stage exchange (27%, 15/55) and at re-reinfection (32%, 9/28). Pathogen persistence was observed in 21% (6/28) of re-reinfected patients. CONCLUSION The success rates after repeat two-stage exchange arthroplasty are low. Patients must be counseled accordingly and different modes of treatment should be considered.
Collapse
Affiliation(s)
- A C Steinicke
- Department of Orthopedics and Tumor Orthopedics, Muenster University Hospital, Muenster, Albert-Schweitzer-Campus 1, 48149, Muenster, Germany
| | - J Schwarze
- Department of Orthopedics and Tumor Orthopedics, Muenster University Hospital, Muenster, Albert-Schweitzer-Campus 1, 48149, Muenster, Germany
| | - G Gosheger
- Department of Orthopedics and Tumor Orthopedics, Muenster University Hospital, Muenster, Albert-Schweitzer-Campus 1, 48149, Muenster, Germany
| | - B Moellenbeck
- Department of Orthopedics and Tumor Orthopedics, Muenster University Hospital, Muenster, Albert-Schweitzer-Campus 1, 48149, Muenster, Germany
| | - T Ackmann
- Department of Orthopedics and Tumor Orthopedics, Muenster University Hospital, Muenster, Albert-Schweitzer-Campus 1, 48149, Muenster, Germany
| | - C Theil
- Department of Orthopedics and Tumor Orthopedics, Muenster University Hospital, Muenster, Albert-Schweitzer-Campus 1, 48149, Muenster, Germany.
| |
Collapse
|
12
|
Saade A, Urvoy JM, Luque Paz D, Baldeyrou M, Common H, Ropars M, Tattevin P, Jolivet-Gougeon A, Arvieux C. Microbiology and antibiotics after second-stage revision of periprosthetic joint infections: A two-year follow-up cohort. Infect Dis Now 2022; 52:358-364. [DOI: 10.1016/j.idnow.2022.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Revised: 06/16/2022] [Accepted: 06/20/2022] [Indexed: 11/29/2022]
|
13
|
Jaubert M, Le Baron M, Jacquet C, Couvreur A, Fabre-Aubrespy M, Flecher X, Ollivier M, Argenson JN. Failure analysis of articulating polymethyl methacrylate spacers in two-stage revision total hip arthroplasty. Bone Jt Open 2022; 3:485-494. [PMID: 35695030 PMCID: PMC9233427 DOI: 10.1302/2633-1462.36.bjo-2022-0024.r1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Aims Two-stage exchange revision total hip arthroplasty (THA) performed in case of periprosthetic joint infection (PJI) has been considered for many years as being the gold standard for the treatment of chronic infection. However, over the past decade, there have been concerns about its safety and its effectiveness. The purposes of our study were to investigate our practice, collecting the overall spacer complications, and then to analyze their risk factors. Methods We retrospectively included 125 patients with chronic hip PJI who underwent a staged THA revision performed between January 2013 and December 2019. All spacer complications were systematically collected, and risk factors were analyzed. Statistical evaluations were performed using the Student's t-test, Mann-Whitney U test, and Fisher's exact test. Results Our staged exchange practice shows poor results, which means a 42% mechanical spacer failure rate, and a 20% recurrent infection rate over the two years average follow-up period. Moreover, we found a high rate of spacer dislocation (23%) and a low rate of spacer fracture (8%) compared to the previous literature. Our findings stress that the majority of spacer complications and failures is reflecting a population with high comorbid burden, highlighted by the American Society of Anesthesiology grade, Charlson Comorbidity Index, and Lee score associations, as well as the cardiac, pulmonary, kidney, or hepatic chronic conditions. Conclusion Our experience of a two-stage hip exchange revision noted important complication rates associated with high failure rates of polymethylmethacrylate spacers. These findings must be interpreted in the light of the patient’s comorbidity profiles, as the elective population for staged exchange has an increasing comorbid burden leading to poor results. In order to provide better results for this specific population, our conclusion suggests that comparative strategy studies are required to improve our therapeutic indication. Cite this article: Bone Jt Open 2022;3(6):485–494.
Collapse
Affiliation(s)
- Maxime Jaubert
- Institute for Locomotion, Department of Orthopedics and Traumatology, Northern Hospital, Marseille, France
| | - Marie Le Baron
- Institute for Locomotion, Department of Orthopedics and Traumatology, Northern Hospital, Marseille, France
| | - Christophe Jacquet
- Institute for Locomotion, Department of Orthopedics and Traumatology ISM, CNRS, Aix-Marseille University, St. Marguerite Hospital, Marseille, France
| | - Antoine Couvreur
- Institute for Locomotion, Department of Orthopedics and Traumatology ISM, CNRS, Aix-Marseille University, St. Marguerite Hospital, Marseille, France
| | - Maxime Fabre-Aubrespy
- Institute for Locomotion, Department of Orthopedics and Traumatology ISM, CNRS, Aix-Marseille University, St. Marguerite Hospital, Marseille, France
| | - Xavier Flecher
- Institute for Locomotion, Department of Orthopedics and Traumatology, Northern Hospital, Marseille, France
- Institute for Locomotion, Department of Orthopedics and Traumatology ISM, CNRS, Aix-Marseille University, St. Marguerite Hospital, Marseille, France
| | - Matthieu Ollivier
- Institute for Locomotion, Department of Orthopedics and Traumatology ISM, CNRS, Aix-Marseille University, St. Marguerite Hospital, Marseille, France
| | - Jean-Noel Argenson
- Institute for Locomotion, Department of Orthopedics and Traumatology ISM, CNRS, Aix-Marseille University, St. Marguerite Hospital, Marseille, France
| |
Collapse
|
14
|
Kozaily E, Tan TL, Yacovelli S, Anis H, Higuera C, Piuzzi NS, Parvizi J. Interim Spacer Exchange for Treatment of Periprosthetic Joint Infection: Almost Half the Patients Subsequently Fail. J Arthroplasty 2022; 37:150-155. [PMID: 34563436 DOI: 10.1016/j.arth.2021.08.028] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Revised: 08/13/2021] [Accepted: 08/23/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Interim spacer exchange may be performed in patients undergoing 2-stage exchange for periprosthetic joint infection. Several studies have demonstrated that interim spacer exchange is associated with poor outcomes. This study investigated the survivorship and risk factors for failure in patients with an interim spacer exchange. METHODS Two institutional databases identified 182 patients who underwent spacer exchange from 2000 to 2017. Primary outcomes included progression to reimplantation, treatment success, and mortality. Bivariate analysis was performed to evaluate risk factors associated with failure. Kaplan-Meier curves using host and local grades were generated to evaluate for primary outcomes and differences in survivorship. RESULTS The overall failure rate was 49% in patients with a spacer exchange. Most patients (60%) failed before 2 years. Higher comorbidity scores, elevated erythrocyte sedimentation rate, and non-White race were more prevalent in patients who failed. Negative cultures at the time of exchange were more prevalent in patients who did not fail. Failure rate was higher in immunocompromised conditions, and those who had revision prior to exchange. After considering clinically relevant variables, advanced host grade C was the single factor associated with treatment failure. Although survivorship curves were not significantly different between extremity local grades, higher host grades were associated with treatment failure. CONCLUSION Almost 1 out of 2 patients with spacer exchange were found to fail the intended 2-stage revision arthroplasty. Benefits of delivering additional antibiotic load with a new spacer should be balanced against poor outcomes in patients with the aforementioned risk factors.
Collapse
Affiliation(s)
- Elie Kozaily
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA
| | - Timothy L Tan
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA
| | - Steven Yacovelli
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA
| | - Hiba Anis
- Cleveland Clinic, Department of Orthopaedic Surgery, Cleveland, OH
| | - Carlos Higuera
- Cleveland Clinic, Department of Orthopaedic Surgery, Cleveland, OH
| | - Nicolas S Piuzzi
- Cleveland Clinic, Department of Orthopaedic Surgery, Cleveland, OH
| | - Javad Parvizi
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA
| |
Collapse
|
15
|
Liechti EF, Neufeld ME, Soto F, Linke P, Busch SM, Gehrke T, Citak M. Favourable outcomes of repeat one-stage exchange for periprosthetic joint infection of the hip. Bone Joint J 2022; 104-B:27-33. [PMID: 34969284 DOI: 10.1302/0301-620x.104b1.bjj-2021-0970.r1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AIMS One-stage exchange for periprosthetic joint infection (PJI) in total hip arthroplasty (THA) is gaining popularity. The outcome for a repeat one-stage revision THA after a failed one-stage exchange for infection remains unknown. The aim of this study was to report the infection-free and all-cause revision-free survival of repeat one-stage exchange, and to investigate the association between the Musculoskeletal Infection Society (MSIS) staging system and further infection-related failure. METHODS We retrospectively reviewed all repeat one-stage revision THAs performed after failed one-stage exchange THA for infection between January 2008 and December 2016. The final cohort included 32 patients. The mean follow-up after repeat one-stage exchange was 5.3 years (1.2 to 13.0). The patients with a further infection-related failure and/or all-cause revision were reported, and Kaplan-Meier survival for these endpoints determined. Patients were categorized according to the MSIS system, and its association with further infection was analyzed. RESULTS A total of eight repeat septic revisions (25%) developed a further infection-related failure, and the five-year infection-free survival was 81% (95% confidence interval (CI) 57 to 92). Nine (28%) underwent a further all-cause revision and the five-year all-cause revision-free survival was 74% (95% CI 52 to 88). Neither the MSIS classification of the host status (p = 0.423) nor the limb status (p = 0.366) was significantly associated with further infection-related failure. CONCLUSION Repeat one-stage exchange for PJI in THA is associated with a favourable five-year infection-free and all-cause revision-free survival. Notably, the rate of infection control is encouraging when compared with the reported rates after repeat two-stage exchange. The results can be used to counsel patients and help clinicians make informed decisions about treatment. With the available number of patients, further infection-related failure was not associated with the MSIS host or limb status. Cite this article: Bone Joint J 2022;104-B(1):27-33.
Collapse
Affiliation(s)
- Emanuel F Liechti
- Department of Orthopaedic Surgery, HELIOS ENDO-Klinik Hamburg, Hamburg, Hamburg, Germany.,Department of Orthopaedic Surgery and Traumatology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Michael E Neufeld
- Department of Orthopaedic Surgery, HELIOS ENDO-Klinik Hamburg, Hamburg, Hamburg, Germany.,Department of Orthopaedic Surgery, Lower Limb (Adult Hip & Knee) Reconstruction, The University of British Columbia, Vancouver, Canada
| | - Fernando Soto
- Department of Orthopaedic Surgery, HELIOS ENDO-Klinik Hamburg, Hamburg, Hamburg, Germany.,Department of Orthopaedic Surgery, Hospital Naval de Viña del Mar Almirante Nef, Vina del Mar, Chile
| | - Philip Linke
- Department of Orthopaedic Surgery, HELIOS ENDO-Klinik Hamburg, Hamburg, Hamburg, Germany
| | - Sophia-Marlene Busch
- Department of Orthopaedic Surgery, HELIOS ENDO-Klinik Hamburg, Hamburg, Hamburg, Germany
| | - Thorsten Gehrke
- Department of Orthopaedic Surgery, HELIOS ENDO-Klinik Hamburg, Hamburg, Hamburg, Germany
| | - Mustafa Citak
- Department of Orthopaedic Surgery, HELIOS ENDO-Klinik Hamburg, Hamburg, Hamburg, Germany
| |
Collapse
|
16
|
Dagneaux L, Limberg AK, Osmon DR, Leung N, Berry DJ, Abdel MP. Renal Toxicity Associated With Resection and Spacer Insertion for Chronic Hip PJI. J Arthroplasty 2021; 36:3289-3293. [PMID: 33933331 DOI: 10.1016/j.arth.2021.04.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Revised: 04/05/2021] [Accepted: 04/14/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Two-stage exchange arthroplasty with high-dose antibiotic-loaded bone cement spacer and intravenous (IV) antibiotics is the most common method of managing infected total hip arthroplasties. However, the contemporary incidence, risk factors, and outcomes of acute kidney injuries (AKIs) in this cohort are unknown. METHODS We identified 227 patients treated with 256 antibiotic-loaded bone cement spacers after resection of an infected primary total hip arthroplasty between 2000 and 2017. Mean age was 65 years, mean body mass index was 30 mg/kg2, 55% were men, and 16% had pre-existing chronic kidney disease (CKD). Spacers were in situ for a mean of 15 weeks, concomitantly associated with IV or oral antibiotics for a mean of 6 weeks. AKI was defined as a creatinine ≥1.5X baseline or ≥0.3 mg/dL. Mean follow-up was 8 years. RESULTS AKI occurred in 13 patients without pre-existing CKD (7%) vs 10 patients with CKD (28%; OR 5; P = .0001). None required acute dialysis. Postoperative fluid depletion (β = 0.31; P = .0001), ICU requirement (β = 0.40; P = .0001), and acute atrial fibrillation (β = 0.43; P = .0001) were independent predictors for AKI in patients without pre-existing CKD. Duration of in situ spacer, mean antibiotic dose in cement, use of amphotericin B, and type of IV antibiotics were not significant risk factors. At last follow-up, 8 AKIs progressed to CKD, with one receiving dialysis 7 years later. CONCLUSION AKIs occurred in 7% of patients with normal renal function, with 5-fold greater risk in those with CKD, and 4% did develop CKD. Importantly, causes of acute renal blood flow impairment were independent predictors for AKI. LEVEL OF EVIDENCE Level III, comparative study.
Collapse
Affiliation(s)
- Louis Dagneaux
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN
| | - Afton K Limberg
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN
| | - Douglas R Osmon
- Division of Infectious Diseases, Department of Medicine, Mayo Clinic, Rochester, MN
| | - Nelson Leung
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN
| | - Daniel J Berry
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN
| | - Matthew P Abdel
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN
| |
Collapse
|
17
|
Li K, Cuadra M, Scarola G, Odum S, Otero J, Griffin W, Springer BD. Complications in the treatment of periprosthetic joint infection of the hip: when do they occur? J Bone Jt Infect 2021; 6:295-303. [PMID: 34377629 PMCID: PMC8339596 DOI: 10.5194/jbji-6-295-2021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Accepted: 05/23/2021] [Indexed: 11/29/2022] Open
Abstract
Prosthetic joint infection (PJI) is a devastating complication after total
hip arthroplasty (THA). The common treatment in the USA is a two-stage
exchange which can be associated with significant morbidity and mortality.
The purpose of this study was to analyze complications in the treatment
course of patients undergoing two-stage exchange for PJI THA and determine
when they occur.
Methods:
We analyzed all patients that underwent two-stage exchange arthroplasty for
treatment of PJI after THA from January 2005 to January 2018 at a single
institution. Complications were categorized as medical or surgical and divided
into interstage and post-reimplantation. Minimum follow-up was 1 year.
Success was based on the MusculoSkeletal Infection Society (MSIS)
definition.
Results:
205 hips (203 patients) underwent first stage of planned two-stage exchange.
The median age was 68 (interquartile range (IQR) 18). There were 97 males and 106 females.
Overall, 73/205 (38 %) patients had at least one complication during
treatment: 13.5 % (25/185) of patients experienced a medical complication
and 28.1 % (52/185) a surgical complication; 2.4 % died within 1 year
of surgery, and 4.9 % (15/203) had mortality at a median of 2.5 years (IQR 4.9); 27 % of patients had complications during the interstage period, most commonly being recurrence of infection requiring additional surgery
(63 %); and 14 % of patients experienced a complication following
reimplantation, most commonly persistence or recurrence of infection
(59 %). While 92 % of patients that initiated treatment were ultimately
reimplanted, only 69 % were infection free at 1 year and required no
additional treatment.
Conclusions:
While two-stage exchanges for PJI in THA have been reported as successful,
there are few reports of the complications during the process. In our
series, significant numbers of patients experienced complications, often
during the interstage period, highlighting the morbidity of this method of
treatment.
Collapse
Affiliation(s)
- Katherine Li
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, 1025 Morehead Medical Dr., Suite 300, Charlotte, NC 28203, USA
| | - Mario Cuadra
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, 1320 Scott Ave., Charlotte, NC 28204, USA
| | - Gregory Scarola
- OrthoCarolina Research Institute, Inc., 2001 Vail Ave., Suite 300, Charlotte, NC 28207, USA
| | - Susan Odum
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, 1025 Morehead Medical Dr., Suite 300, Charlotte, NC 28203, USA.,OrthoCarolina Research Institute, Inc., 2001 Vail Ave., Suite 300, Charlotte, NC 28207, USA
| | - Jesse Otero
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, 1025 Morehead Medical Dr., Suite 300, Charlotte, NC 28203, USA.,OrthoCarolina Hip and Knee Center, 2001 Vail Ave. Suite 200A, Charlotte, NC 28207, USA
| | - William Griffin
- OrthoCarolina Hip and Knee Center, 2001 Vail Ave. Suite 200A, Charlotte, NC 28207, USA
| | - Bryan D Springer
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, 1025 Morehead Medical Dr., Suite 300, Charlotte, NC 28203, USA.,OrthoCarolina Hip and Knee Center, 2001 Vail Ave. Suite 200A, Charlotte, NC 28207, USA
| |
Collapse
|
18
|
Tian B, Cui L, Jiang W. The diagnostic effect of α-defensin, D-dimer, and IL-6 in periprosthetic joint infection: A systematic review and diagnostic meta-analysis. J Orthop Surg (Hong Kong) 2021; 28:2309499020971861. [PMID: 33225796 DOI: 10.1177/2309499020971861] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Periprosthetic joint infection (PJI) is the most common complication after artificial joint replacement as previously reported. However, the main problem at present is its difficulty in diagnosis. This systematic review and meta-analysis aimed to compare the diagnostic accuracy of α-defensin, D-dimer, and interleukin-6 (IL-6) in clinical practice. METHOD Online databases were systematically searched until June 18th, 2020 with keywords and medical sub-headings terms. Studies mentioned the sensitivity and specificity of biological markers in detecting PJI were included in our study. The sensitivity, specificity, and diagnostic odds ratios (DORs) were obtained after integration. RESULTS A total of 34 studies with 1036 patients diagnosing as PJI were included for comparing α-defensin, D-dimer, and IL-6. The sensitivity and specificity of α-defensin for PJI were 0.88 and 0.96, and the DOR was 189 (95% CI 72-496), respectively. The sensitivity and specificity of D-dimer (0.82 and 0.72) and IL-6 (0.80 and 0.89) were lower than α-defensin. CONCLUSION The detection of α-defensin is a promising biomarker for diagnosing PJI. The optional cut-off needs to be curtained when using other biomarkers.
Collapse
Affiliation(s)
- Baozhong Tian
- Bone surgery, Affiliated Hospital of Jilin Medical University, Jilin City, China
| | - Liwen Cui
- Changyi District Center for Disease Control and Prevention, Jilin City, China
| | | |
Collapse
|
19
|
Frank BJH, Aichmair A, Simon S, Schwarz GM, Dominkus M, Hofstaetter JG. Analysis of Culture Positive First and Second Stage Procedures in Periprosthetic Knee and Hip Joint Infections. J Arthroplasty 2021; 36:2158-2164. [PMID: 33608181 DOI: 10.1016/j.arth.2021.01.074] [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: 12/09/2020] [Revised: 01/24/2021] [Accepted: 01/27/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND A positive microbiological result at reimplantation may lead to a failed 2-stage revision arthroplasty in the treatment of periprosthetic joint infections. Little is known about changes in microbiological spectrum and resistance pattern between culture positive first and second stage procedures in revision knee and hip arthroplasty. METHODS Between January 2011 and December 2019, we performed 327 two-stage revision arthroplasties on 312 patients. There were 37 of 312 (11.9%) patients (20 hips/17 knees) who had a positive microbiological culture during the first and second stage procedure. We analyzed the microbiological spectrum, antimicrobial resistance pattern, and clinical outcome of culture positive first and second stage procedures as well as subsequent re-revisions. RESULTS Re-revision was necessary in 40.5% (15/37) of patients with culture positive first and second stage procedure at a median follow-up of 3.5 years. We found microbiological changes in 83.8% (31/37) of patients between the first and second stage and in 88.9% (8/9) between the second stage and subsequent culture positive re-revision. Polymicrobial infections were found in 21.6% (8/37) of first and in 16.2% (6/37) of second stage procedures. In 27% (10/37) of patients, microorganisms persisted between the first and second stage procedure. The antimicrobial resistance pattern changed in 60% of persistent microorganisms between the first and second stage procedure. CONCLUSION Changes in microbiological spectrum and resistance pattern are common between culture positive first and second stage procedures as well as subsequent re-revisions. This has to be considered in the antimicrobial treatment of periprosthetic joint infections.
Collapse
Affiliation(s)
- Bernhard J H Frank
- Michael Ogon Laboratory for Orthopaedic Research, Orthopaedic Hospital Vienna-Speising, Vienna, Austria
| | - Alexander Aichmair
- Michael Ogon Laboratory for Orthopaedic Research, Orthopaedic Hospital Vienna-Speising, Vienna, Austria; 2nd Department, Orthopaedic Hospital Vienna-Speising, Vienna, Austria
| | - Sebastian Simon
- Michael Ogon Laboratory for Orthopaedic Research, Orthopaedic Hospital Vienna-Speising, Vienna, Austria; 2nd Department, Orthopaedic Hospital Vienna-Speising, Vienna, Austria
| | - Gilbert M Schwarz
- Michael Ogon Laboratory for Orthopaedic Research, Orthopaedic Hospital Vienna-Speising, Vienna, Austria; Department of Orthopaedics and Trauma-Surgery, Medical University of Vienna, Vienna, Austria
| | - Martin Dominkus
- 2nd Department, Orthopaedic Hospital Vienna-Speising, Vienna, Austria; School of Medicine, Sigmund Freud University Vienna, Vienna, Austria
| | - Jochen G Hofstaetter
- Michael Ogon Laboratory for Orthopaedic Research, Orthopaedic Hospital Vienna-Speising, Vienna, Austria; 2nd Department, Orthopaedic Hospital Vienna-Speising, Vienna, Austria
| |
Collapse
|
20
|
Ackmann T, Schwarze J, Gosheger G, Schmidt-Braekling T, Schneider KN, Dieckmann R, Klingebiel S, Moellenbeck B, Theil C. The change in plasma D-dimer does not help to guide the timing of reimplantation in two stage exchange for periprosthetic joint infection. Sci Rep 2021; 11:7323. [PMID: 33795812 PMCID: PMC8016946 DOI: 10.1038/s41598-021-86890-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2020] [Accepted: 03/22/2021] [Indexed: 11/12/2022] Open
Abstract
D-dimer has been included in the criteria by the Musculoskeletal Infection Society in 2018 as a novel parameter to diagnose prosthetic joint infection (PJI). However, it is unclear how D-dimer levels change in between stages of a two-stage exchange. We prospectively investigated 30 patients who underwent a two-stage exchange using a spacer for PJI. D-Dimer, CRP and IL-6 were collected before first and second stage surgery and the difference (Δ) in between stages was calculated. The levels of plasma D-Dimer did not change from first to second stage surgery (2770 ng/ml (IQR, 1600–3770 ng/ml) versus 2340 ng/ml (IQR, 1270–4100 ng/ml); p = 0.8) while CRP (4.0 mg/dl (IQR, 1.7–5.5 mg/dl) versus 0.6 mg/dl (IQR, 0.5–0.8 mg/dl); p < 0.001) and IL-6 (21 pg/ml (IQR, 10–29 pg/ml) versus 6 pg/ml (4–9 pg/ml); p < 0.001) decreased. The ΔD-dimer between both stages was 300 ng/ml (range: − 2820 to 4280 ng/ml), the median ΔCRP was − 3.4 mg/dl (IQR, − 1.2 to − 4.8 mg/dl) and ΔIL-6 was − 13 pg/ml (IQR, − 4 to − 20 pg/ml). In 15 of 30 cases (50%) the D-dimer level increased between both stages, whereas the level of CRP (93%; 28/30) and IL-6 (96%; 28/29) decreased in most patients. As the level of serum D-dimers varies greatly, lacks a uniform decrease and does not identify persisting infection, surgeons should be cautious when using it at the timing of reimplantation.
Collapse
Affiliation(s)
- Thomas Ackmann
- Department of Orthopedics and Tumor Orthopedics, Muenster University Hospital, Muenster, Albert-Schweitzer-Campus 1, 48149, Muenster, Germany.
| | - Jan Schwarze
- Department of Orthopedics and Tumor Orthopedics, Muenster University Hospital, Muenster, Albert-Schweitzer-Campus 1, 48149, Muenster, Germany
| | - Georg Gosheger
- Department of Orthopedics and Tumor Orthopedics, Muenster University Hospital, Muenster, Albert-Schweitzer-Campus 1, 48149, Muenster, Germany
| | - Tom Schmidt-Braekling
- Department of Orthopedics and Tumor Orthopedics, Muenster University Hospital, Muenster, Albert-Schweitzer-Campus 1, 48149, Muenster, Germany
| | - Kristian Nikolaus Schneider
- Department of Orthopedics and Tumor Orthopedics, Muenster University Hospital, Muenster, Albert-Schweitzer-Campus 1, 48149, Muenster, Germany
| | - Ralf Dieckmann
- Department of Orthopedic Surgery, Barmherzige Brüder Hospital, 54292, Trier, Germany
| | - Sebastian Klingebiel
- Department of Orthopedics and Tumor Orthopedics, Muenster University Hospital, Muenster, Albert-Schweitzer-Campus 1, 48149, Muenster, Germany
| | - Burkhard Moellenbeck
- Department of Orthopedics and Tumor Orthopedics, Muenster University Hospital, Muenster, Albert-Schweitzer-Campus 1, 48149, Muenster, Germany
| | - Christoph Theil
- Department of Orthopedics and Tumor Orthopedics, Muenster University Hospital, Muenster, Albert-Schweitzer-Campus 1, 48149, Muenster, Germany
| |
Collapse
|
21
|
Acute Renal Failure After the First Stage of a 2-Stage Exchange for Periprosthetic Joint Infection. J Arthroplasty 2021; 36:717-721. [PMID: 32893061 DOI: 10.1016/j.arth.2020.08.028] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Revised: 07/27/2020] [Accepted: 08/13/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Two-stage exchange using antibiotic-loaded spacers is a common approach in treating periprosthetic joint infections. Acute kidney injury (AKIN) can be a systemic complication of this procedure. This study investigates the prevalence of AKIN and identifies potential risk factors. METHODS This is a single-center retrospective analysis of patients undergoing 2-stage exchange using a spacer in 285 patients treated between 2010 and 2017. Risk factors were evaluated using parametric and nonparametric analyses and a multivariate, binary logistic regression model. RESULTS Thirty-three percent of patients (95/285) developed an AKIN postoperatively. Twenty-four percent (23/95) of these patients had an acute on chronic kidney failure with a previously impaired renal function. In multivariate analysis, a higher age (hazard ratio [HR], 1.034; 95% confidence interval [CI], 1-1.068; P = .046) and a higher baseline creatinine level (HR, 1.94; 95% CI, 1.237-3.052; P = .004) were risk factors for AKIN. Treatment with vancomycin in the spacer or systemically was not associated with AKIN while a high vancomycin blood level (HR, 1.91; 95% CI, 0.913-3.992; P = .086) and fungal infections were (HR, 3.482; 95% CI, 0.968-12.521; P = .056). Furthermore, in univariate analysis, a higher median Charlson comorbidity index (4 vs 3, P = .007), a lower preoperative hemoglobin (10.9 vs 11.7 g/dL, P = .008), and a higher number of blood transfusions (1 vs 0, P = .004) were associated with AKIN. CONCLUSION AKIN is common in patients undergoing 2-stage exchange. Associated patient factors, particularly in patients with chronic renal dysfunction, should be optimized. The general use of glycopeptide antibiotics was no risk factor for AKIN.
Collapse
|
22
|
Slullitel PA, Oñativia JI, Cima I, Zanotti G, Comba F, Piccaluga F, Buttaro MA. Patients with no recurrence of infection five years after two-stage revision hip arthroplasty may be classified as periprosthetic infection 'in remission'. Bone Joint J 2021; 103-B:79-86. [PMID: 33380194 DOI: 10.1302/0301-620x.103b1.bjj-2020-0955.r1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
AIMS We aimed to report the mid- to long-term rates of septic and aseptic failure after two-stage revision surgery for periprosthetic joint infection (PJI) following total hip arthroplasty (THA). METHODS We retrospectively reviewed 96 cases which met the Musculoskeletal Infection Society criteria for PJI. The mean follow-up was 90 months (SD 32). Septic failure was assessed using a Delphi-based consensus definition. Any further surgery undertaken for aseptic mechanical causes was considered as aseptic failure. The cumulative incidence with competing risk analysis was used to predict the risk of septic failure. A regression model was used to evaluate factors associated with septic failure. The cumulative incidence of aseptic failure was also analyzed. RESULTS There were 23 septic failures at final follow-up, with a cumulative incidence of 14% (95% confidence interval (CI) 8% to 22%) at one year, 18% (95% CI 11% to 27%) at two years, 22% (95% CI 14% to 31%) at five years, and 23% (95% CI 15% to 33%) at ten years. Having at least one positive culture (hazard ratio (HR) 2.38 (interquartile range (IQR) 1.19 to 4.74); p = 0.013), or a positive intraoperative frozen section (HR 2.55 (IQR 1.06 to 6.15); p = 0.037) was significantly associated with septic failure after reimplantation. With dislocation being the most common cause of aseptic revision (5.2%), the cumulative incidence of aseptic failure was 1% (95% CI 0% to 5%) at one year, 6% (95% CI 1% to 8%) at five years, and 8% (95%CI 3% to 17%) at ten years. CONCLUSION If there is no recurrent infection in the five years following reimplantation, the chances of further infection thereafter are remote. While the results of a frozen section may be a reliable guide to the timing of reimplantation, intraoperative culture has, currently, only prognostic value. Surgeons should be aware that instability remains a potential indication for further revision surgery. Cite this article: Bone Joint J 2021;103-B(1):79-86.
Collapse
Affiliation(s)
- Pablo A Slullitel
- 'Sir John Charnley' Hip Surgery Unit, Institute of Orthopaedics 'Carlos E. Ottolenghi', Italian Hospital of Buenos Aires, Buenos Aires, Argentina
| | - José I Oñativia
- 'Sir John Charnley' Hip Surgery Unit, Institute of Orthopaedics 'Carlos E. Ottolenghi', Italian Hospital of Buenos Aires, Buenos Aires, Argentina
| | - Ignacio Cima
- 'Sir John Charnley' Hip Surgery Unit, Institute of Orthopaedics 'Carlos E. Ottolenghi', Italian Hospital of Buenos Aires, Buenos Aires, Argentina
| | - Gerardo Zanotti
- 'Sir John Charnley' Hip Surgery Unit, Institute of Orthopaedics 'Carlos E. Ottolenghi', Italian Hospital of Buenos Aires, Buenos Aires, Argentina
| | - Fernando Comba
- 'Sir John Charnley' Hip Surgery Unit, Institute of Orthopaedics 'Carlos E. Ottolenghi', Italian Hospital of Buenos Aires, Buenos Aires, Argentina
| | - Francisco Piccaluga
- 'Sir John Charnley' Hip Surgery Unit, Institute of Orthopaedics 'Carlos E. Ottolenghi', Italian Hospital of Buenos Aires, Buenos Aires, Argentina
| | - Martin A Buttaro
- 'Sir John Charnley' Hip Surgery Unit, Institute of Orthopaedics 'Carlos E. Ottolenghi', Italian Hospital of Buenos Aires, Buenos Aires, Argentina
| |
Collapse
|
23
|
Corona PS, Vicente M, Carrera L, Rodríguez-Pardo D, Corró S. Current actual success rate of the two-stage exchange arthroplasty strategy in chronic hip and knee periprosthetic joint infection. Bone Joint J 2020; 102-B:1682-1688. [PMID: 33249903 DOI: 10.1302/0301-620x.102b12.bjj-2020-0792.r1] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
AIMS The success rates of two-stage revision arthroplasty for infection have evolved since their early description. The implementation of internationally accepted outcome criteria led to the readjustment of such rates. However, patients who do not undergo reimplantation are usually set aside from these calculations. The aim of this study was to investigate the outcomes of two-stage revision arthroplasty when considering those who do not undergo reimplantation, and to investigate the characteristics of this subgroup. METHODS A retrospective cohort study was conducted. Patients with chronic hip or knee periprosthetic joint infection (PJI) treated with two-stage revision between January 2010 and October 2018, with a minimum follow-up of one year, were included. Variables including demography, morbidity, microbiology, and outcome were collected. The primary endpoint was the eradication of infection. Patients who did not undergo reimplantation were analyzed in order to characterize this subgroup better. RESULTS A total of 162 chronic PJIs were included in the study. After a mean follow-up of 57.3 months (12.1 to 115.7), 18 patients (11.1%) did not undergo reimplantation, due either to medical issues (10), the patient's choice (4), or death (4). When only considering those who underwent reimplantation, the success rate was 80.6%. However, when those who did not undergo reimplantation were included, the success rate dropped to 71.6%. Advanced age, American Society of Anesthesiologists grade ≥ III, McPherson's C host, and Gram-negative related PJI were independent risk factors for retention of the spacer. The mortality was higher in the non-reimplanted group. CONCLUSION The real success rate of two-stage revision may not be as high as previously reported. The exclusion of patients who do not undergo reimplantation resulted in a 9% overestimation of the success rate in this series. Many comorbidity-related risk factors for retention of the spacer were identified, as well as higher death rates in this group. Efforts should be made to optimize these patients medically in order to increase reimplantation and success rates, while decreasing mortality. Cite this article: Bone Joint J 2020;102-B(12):1682-1688.
Collapse
Affiliation(s)
- Pablo S Corona
- Orthopaedic Surgery Department, Vall d'Hebron University Hospital, Universitat Autònoma de Barcelona, Barcelona, Spain.,Septic and Reconstructive Surgery Unit, Orthopaedic Surgery Department, Vall d'Hebron University Hospital, Universitat Autònoma de Barcelona, Barcelona, Spain.,Musculoskeletal Tissue Engineering Group, Vall d'Hebron Research Institute, Universitat Autònoma de Barcelona, Barcelona, Spain.,Vall d´Hebron Official Multidisciplinary Committee on Musculoskeletal Infections, Vall d'Hebron University Hospital, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Matías Vicente
- Orthopaedic Surgery Department, Vall d'Hebron University Hospital, Universitat Autònoma de Barcelona, Barcelona, Spain.,Septic and Reconstructive Surgery Unit, Orthopaedic Surgery Department, Vall d'Hebron University Hospital, Universitat Autònoma de Barcelona, Barcelona, Spain.,Musculoskeletal Tissue Engineering Group, Vall d'Hebron Research Institute, Universitat Autònoma de Barcelona, Barcelona, Spain.,Vall d´Hebron Official Multidisciplinary Committee on Musculoskeletal Infections, Vall d'Hebron University Hospital, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Lluís Carrera
- Orthopaedic Surgery Department, Vall d'Hebron University Hospital, Universitat Autònoma de Barcelona, Barcelona, Spain.,Septic and Reconstructive Surgery Unit, Orthopaedic Surgery Department, Vall d'Hebron University Hospital, Universitat Autònoma de Barcelona, Barcelona, Spain.,Musculoskeletal Tissue Engineering Group, Vall d'Hebron Research Institute, Universitat Autònoma de Barcelona, Barcelona, Spain.,Vall d´Hebron Official Multidisciplinary Committee on Musculoskeletal Infections, Vall d'Hebron University Hospital, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Dolors Rodríguez-Pardo
- Vall d´Hebron Official Multidisciplinary Committee on Musculoskeletal Infections, Vall d'Hebron University Hospital, Universitat Autònoma de Barcelona, Barcelona, Spain.,Infectious Diseases Department, Vall d'Hebron University Hospital, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Sebastián Corró
- Orthopaedic Surgery Department, Vall d'Hebron University Hospital, Universitat Autònoma de Barcelona, Barcelona, Spain.,Musculoskeletal Tissue Engineering Group, Vall d'Hebron Research Institute, Universitat Autònoma de Barcelona, Barcelona, Spain
| |
Collapse
|
24
|
Contemporary 2-Stage Treatment of Periprosthetic Hip Infection with Evidence-Based Standardized Protocols Yields Excellent Results: Caveats and Recommendations. J Arthroplasty 2020; 35:2983-2995. [PMID: 32540305 DOI: 10.1016/j.arth.2020.05.028] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Revised: 05/05/2020] [Accepted: 05/14/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND This study quantified the effectiveness of contemporary and evidence-based standardized 2-stage treatment for periprosthetic hip infection. Findings illustrate potential limitations of criticisms of 2-stage protocols and potential consequences of adopting single-stage protocols before definitive data are available. METHODS Fifty-four consecutive hips treated with 2-stage resection and reimplantation were retrospectively reviewed. Standardized protocols were adhered to including implant resection, meticulous surgical debridement, antibiotic spacer, 6-week intravenous antibiotics, a 2-week drug holiday, and laboratory assessment of infection eradication before reimplantation. After reimplantation, patients were placed on prophylactic intravenous antibiotics until discharge and discharged on oral antibiotics for a minimum of 7 days until intraoperative cultures were final. Successful treatment was defined per Delphi-based International Multidisciplinary Consensus. RESULTS The overall treatment success rate was 95.7% (44 of 46 cases) with mean infection-free survivorship of 67.2 (range, 23.8-106.4) months. Success rates were 100% for early and acute hematogenous infections regardless of host type and 100% for chronic infections in uncompromised hosts. 95% (19/20) of chronic infections in compromised hosts and 83.3% (5/6) of chronic infections in significantly compromised hosts were successfully treated. About 4% of primary hips and 20% of revision hips required repeat debridement and spacer exchange after initial resection. No patients died because of treatment. CONCLUSION Details from this consecutive series of patients undergoing 2-stage treatment for hip infection suggest that some criticisms of 2-stage treatment as well as some arguments in support of single-stage treatment may be overstated. Promotion and uncritical adoption of single-stage treatment protocols are discouraged until further and more definitive data exist.
Collapse
|
25
|
Coughlan A, Taylor F. Classifications in Brief: The McPherson Classification of Periprosthetic Infection. Clin Orthop Relat Res 2020; 478:903-908. [PMID: 31977434 PMCID: PMC7282566 DOI: 10.1097/corr.0000000000001133] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Accepted: 12/23/2019] [Indexed: 01/31/2023]
Affiliation(s)
- Adam Coughlan
- A. Coughlan, F. Taylor, The Gold Coast University Hospital, Southport, Queensland, Australia
| | - Fraser Taylor
- A. Coughlan, F. Taylor, The Gold Coast University Hospital, Southport, Queensland, Australia
| |
Collapse
|
26
|
Troendlin F, Frieler S, Hanusrichter Y, Yilmaz E, Schildhauer TA, Baecker H. Persistent Fistula for Treatment of a Failed Periprosthetic Joint Infection: Relic From the Past or a Viable Salvage Procedure? J Arthroplasty 2020; 35:544-549. [PMID: 31611161 DOI: 10.1016/j.arth.2019.09.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2019] [Revised: 08/14/2019] [Accepted: 09/07/2019] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND New treatment algorithms for periprosthetic joint infections (PJIs) show high success rates in achieving permanent infection eradication with some degree of failure. Different salvage procedures are described, but there is no evidence for persistent fistula (PF). The purpose of this study was to analyze PF as a salvage procedure in patients with therapy-resistant PJIs. METHODS This retrospective analysis included all patients treated with PF (2005-2018) in a maximum care center with PJI (knee or hip). The baseline parameters (age, sex, BMI) and other data (number of surgeries, pathogen spectrum, American Society of Anesthesiologists classification) were recorded. The function was documented using the Harris Hip Score, the Knee Society Score, and the quality of life using the SF-36 Health Survey. RESULTS A total of 159 patients were included (80 ± 12 years) and subdivided into four groups: hip (n = 66), knee (n = 13), Girdlestone resection arthroplasty (n = 50), knee arthrodesis (n = 27). Patients stayed 111 ± 87 days in the hospital, underwent six operations and three revisions after establishing PF. The mean American Society of Anesthesiologists score was 2.7. The BMI was 31 ± 3 kg/m2 (P = .1). The follow-up was 2.8 ± 0.5 years including 27 patients. The Harris Hip Score and Knee Society Score were 38 and 34, respectively. SF-36 showed no significant difference. CONCLUSION The study showed poor outcomes regarding quality of life and the function of the infected joint. Therefore, the indication for establishing a PF in the treatment of PJI must be assessed very critically. PF is only an option for multimorbid patients with a limited life expectancy.
Collapse
Affiliation(s)
- Florian Troendlin
- 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
| | - Yannik Hanusrichter
- Department of General and Trauma Surgery, BG University Hospital Bergmannsheil, Ruhr University Bochum, Bochum, Germany
| | - Emre Yilmaz
- Department of General and Trauma Surgery, BG University Hospital Bergmannsheil, Ruhr University Bochum, Bochum, Germany
| | - Thomas A 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
| |
Collapse
|
27
|
What are the Factors Associated with Re-revision After One-stage Revision for Periprosthetic Joint Infection of the Hip? A Case-control Study. Clin Orthop Relat Res 2019; 477:2258-2263. [PMID: 31135547 PMCID: PMC6999925 DOI: 10.1097/corr.0000000000000780] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Despite increased interest in one-stage revision arthroplasty for periprosthetic joint infection (PJI) of the hip, the reported infection-free proportions after the one-stage approach are still comparable to that of two-stage revision. However, we still lack studies that analyze factors associated with any re-revision after one-stage revision arthroplasty for PJI. QUESTIONS/PURPOSES After one-stage revision arthroplasty for PJI of the hip, what factors were associated with an increased risk of re-revision, and what factors were associated with an increased risk of reinfection? METHODS We performed a single-center retrospective case-control analysis. Patients who underwent one-stage revision arthroplasty for PJI of the hip in our hospital between 2009 and 2017, and who were subsequently re-revised due to any reason, including reinfection, were identified from our electronic medical records. A total of 121 patients who underwent repeat revision for any reason after one-stage exchange for PJI of the hip were identified. The re-revision procedures were performed after a mean of 407 days. The primary reasons for re-revision were repeated hip dislocation in 53 of 121 patients (44%), reinfection including both new and persistent infections in 40 of 121 patients (33%), and aseptic loosening in 16 patients (13%). Forty-three patients underwent another revision procedure after the re-revision procedure (43 of 121; 36%). More than 40 potential patient-, joint- and surgery-related risk factors were investigated and compared with a 1:1 matched control participants by age, sex and year of the one-stage revision. Similar to the re-revision patients, controls were treated for PJI with one-stage revision arthroplasty; however, they did not undergo subsequent revision for any reason by the latest followup examination. The mean followup of the control group was 66 months (range, 17-119 months). The mean length of hospital stay was 26 days in the re-revised group (SD, 11.6 days) compared with 22 days for the controls (SD, 6.6 days). All analyses were performed to identify factors associated with general re-revision and reinfection. RESULTS The independent factors associated with repeat revision for any reason were persistent wound drainage for at least 1 week (odds ratio [OR], 7.4; 95% CI, 2.6-20.6; p < 0.001), isolation of enterococci (OR, 4.8; 95% CI, 1.4-15.7; p = 0.010), and prior surgery due to infection before the one-stage hip revision (OR, 3.6; 95% CI, 2.0-6.4; p < 0.001). The factors associated with reinfection including both new and persistent infections were prolonged wound drainage (OR, 6.9; 95% CI, 2.2-21.5; p = 0.001) and prior surgery due to infection (OR, 4.3; 95% CI, 1.9-9.5; p < 0.001). CONCLUSIONS Prolonged wound drainage after the one-stage revision arthroplasty for PJI of the hip must be treated rigorously. Patients with a history of a prior surgical procedure due to hip infection should be informed about the risk of further re-revision when deciding for the one-stage exchange. In case of enterococcal isolation, surgeons may consider another treatment approach rather than the one-stage exchange. Furthermore, we recommend the use of dual mobility cups when performing the one-stage revision hip arthroplasty to reduce the risk of dislocation.Level of Evidence Level III, therapeutic study.
Collapse
|
28
|
Periprosthetic Joint Infection Caused by Gram-Positive Versus Gram-Negative Bacteria: Lipopolysaccharide, but not Lipoteichoic Acid, Exerts Adverse Osteoclast-Mediated Effects on the Bone. J Clin Med 2019; 8:jcm8091289. [PMID: 31450783 PMCID: PMC6780630 DOI: 10.3390/jcm8091289] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Revised: 08/15/2019] [Accepted: 08/20/2019] [Indexed: 01/03/2023] Open
Abstract
Periprosthetic joint infection (PJI)-the most common cause of knee arthroplasty failure-may result from Gram-positive (GP) or Gram-negative (GN) bacterial infections. The question as to whether PJI due to GP or GN bacteria can lead to different rates of aseptic loosening after reimplantation remains open. We have investigated this issue through a retrospective review of clinical records obtained from 320 patients with bacterial PJI. The results revealed that, compared with GP infections, GN infections were associated with an increased risk of aseptic loosening. In animal studies, mice underwent intrafemoral injection of lipopolysaccharide (LPS) from GN bacteria or lipoteichoic acid (LTA) from GP bacteria. We demonstrate that LPS-but not LTA-reduced both the number of trabeculae and the bone mineral density in mice. In addition, LPS-treated mice exhibited a reduced body weight, higher serum osteocalcin levels, and an increased number of osteoclasts. LPS accelerated monocyte differentiation into osteoclast-like cells, whereas LTA did not. Finally, ibudilast-a toll-like receptor (TLR)-4 antagonist-was found to inhibit LPS-induced bone loss and osteoclast activation in mice. Taken together, our data indicate that PJI caused by GN bacteria portends a higher risk of aseptic loosening after reimplantation, mainly because of LPS-mediated effects on osteoclast differentiation.
Collapse
|
29
|
Fehring TK, Fehring KA, Hewlett A, Higuera CA, Otero JE, Tande A. What's New in Musculoskeletal Infection. J Bone Joint Surg Am 2019; 101:1237-1244. [PMID: 31318802 DOI: 10.2106/jbjs.19.00403] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
| | | | | | | | - Jesse E Otero
- OrthoCarolina Hip & Knee Center, Charlotte, North Carolina
| | | |
Collapse
|
30
|
Khan N, Parmar D, Ibrahim MS, Kayani B, Haddad FS. Outcomes of repeat two-stage exchange hip arthroplasty for prosthetic joint infection. Bone Joint J 2019; 101-B:110-115. [DOI: 10.1302/0301-620x.101b6.bjj-2018-1556.r1] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Aims The increasing infection burden after total hip arthroplasty (THA) has seen a rise in the use of two-stage exchange arthroplasty and the use of increasingly powerful antibiotics at the time of this procedure. As a result, there has been an increase in the number of failed two-stage revisions during the past decade. The aim of this study was to clarify the outcome of repeat two-stage revision THA following a failed two-stage exchange due to recurrent prosthetic joint infection (PJI). Patients and Methods We identified 42 patients who underwent a two-stage revision THA having already undergone at least one previous two stage procedure for infection, between 2000 and 2015. There were 23 women and 19 men. Their mean age was 69.3 years (48 to 81). The outcome was analyzed at a minimum follow-up of two years. Results A satisfactory control of infection and successful outcome was seen in 26 patients (57%). There therefore remained persistent symptoms that either required further surgery or chronic antibiotic suppression in 16 patients (38%). One-third of patients had died by the time of two years’ follow-up. Conclusion The rate of failure and complication rate of repeat two-stage exchange THA for PJI is high and new methods of treatment including host optimization, immunomodulation, longer periods between stages, and new and more powerful forms of antimicrobial treatment should be investigated. Cite this article: Bone Joint J 2019;101-B(6 Supple B):110–115.
Collapse
Affiliation(s)
- N. Khan
- Trauma and Orthopaedics, University College London Hospitals NHS Foundation Trust, London, UK
| | - D. Parmar
- Trauma and Orthopaedics, University College London Hospitals NHS Foundation Trust, London, UK
| | - M. S. Ibrahim
- Trauma and Orthopaedics, University College London Hospitals NHS Foundation Trust, London, UK
| | - B. Kayani
- Trauma and Orthopaedics, University College London Hospitals NHS Foundation Trust, London, UK
| | - F. S. Haddad
- University College London Hospitals NHS Foundation Trust, The Princess Grace Hospital, and the NIHR Biomedical Research Centre at UCLH, London, UK
| |
Collapse
|
31
|
Theil C, Schmidt-Braekling T, Gosheger G, Idelevich EA, Moellenbeck B, Dieckmann R. Fungal prosthetic joint infection in total hip or knee arthroplasty. Bone Joint J 2019; 101-B:589-595. [DOI: 10.1302/0301-620x.101b5.bjj-2018-1227.r2] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Aims Fungal prosthetic joint infections (PJIs) are rare and account for about 1% of total PJIs. Our aim was to present clinical and microbiological results in treating these patients with a two-stage approach and antifungal spacers. Patients and Methods We retrospectively reviewed our institutional database and identified 26 patients with positive fungal cultures and positive Musculoskeletal Infection Society (MSIS) criteria for PJI who were treated between 2009 and 2017. We identified 18 patients with total hip arthroplasty (THA) and eight patients with total knee arthroplasty (TKA). The surgical and antifungal treatment, clinical and demographic patient data, complications, relapses, and survival were recorded and analyzed. Results The median follow-up was 33 months. The success rate was 38.5% (10/26). Fluconazole resistance was found in 15%. Bacterial co-infection was common in 44% of patients for THA and 66% of patients with TKA. Mortality, reoperations, and treatment failure were common complications. Conclusion Treatment with a two-stage exchange is a possible option for treatment, although fungal infections have a high failure rate. Therapeutic factors for treatment success remain unclear. Cite this article: Bone Joint J 2019;101-B:589–595.
Collapse
Affiliation(s)
- C. Theil
- Department of Orthopedics and Tumour Orthopedics, Muenster University Hospital, Muenster, Germany
| | - T. Schmidt-Braekling
- Department of Orthopedics and Tumour Orthopedics, Muenster University Hospital, Muenster, Germany
| | - G. Gosheger
- Department of Orthopedics and Tumour Orthopedics, Muenster University Hospital, Muenster, Germany
| | - E. A. Idelevich
- Institute of Medical Microbiology, Muenster University Hospital, Muenster, Germany
| | - B. Moellenbeck
- Department of Orthopedics and Tumour Orthopedics, Muenster University Hospital, Muenster, Germany
| | - R. Dieckmann
- Department of Orthopedics and Tumour Orthopedics, Muenster University Hospital, Muenster, Germany
| |
Collapse
|