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Lutro O, Mo S, Tjørhom MB, Fenstad AM, Leta TH, Bruun T, Hallan G, Furnes O, Dale H. How good are surgeons at disclosing periprosthetic joint infection at the time of revision, based on pre- and intra-operative assessment? A study on 16,922 primary total hip arthroplasties reported to the Norwegian Arthroplasty Register. Acta Orthop 2024; 95:67-72. [PMID: 38288989 PMCID: PMC10826841 DOI: 10.2340/17453674.2024.39914] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Accepted: 12/14/2023] [Indexed: 02/01/2024] Open
Abstract
BACKGROUND AND PURPOSE Revision due to infection, as reported to the Norwegian Arthroplasty Register (NAR), is a surrogate endpoint to periprosthetic joint infection (PJI). We aimed to find the accuracy of the reported causes of revision after primary total hip arthroplasty (THA) compared with PJI to see how good surgeons were at disclosing infection, based on pre- and intraoperative assessment. PATIENTS AND METHODS We investigated the reasons for revision potentially caused by PJI following primary THA: infection, aseptic loosening, prolonged wound drainage, and pain only, reported to the NAR from surgeons in the region of Western Norway during the period 2010-2020. The electronic patient charts were investigated for information on clinical assessment, treatment, biochemistry, and microbiological findings. PJI was defined in accordance with the Musculoskeletal Infection Society (MSIS) definition. Sensitivity, specificity, and accuracy were calculated. RESULTS 363 revisions in the NAR were eligible for analyses. Causes of revision were (reported/validated): infection (153/177), aseptic loosening (139/133), prolonged wound drainage (37/13), and pain only (34/40). The sensitivity for reported revision due to infection compared with PJI was 80%, specificity was 94%, and accuracy-the surgeons' ability to disclose PJI or non-septic revision at time of revision-was 87%. The accuracy for the specific revision causes was highest for revision due to aseptic loosening (95%) and pain only (95%), and lowest for revision due to prolonged wound drainage (86%). CONCLUSION The accuracy of surgeon-reported revisions due to infection as representing PJI was 87% in the NAR. Our study shows the importance of systematic correction of the reported cause of revision in arthroplasty registers, after results from adequately taken bacterial samples.
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Affiliation(s)
- Olav Lutro
- Department of Medicine, Stavanger University Hospital, Stavanger.
| | - Synnøve Mo
- The Norwegian Arthroplasty Register, Department of Orthopaedic Surgery, Haukeland University Hospital, Bergen
| | | | - Anne Marie Fenstad
- The Norwegian Arthroplasty Register, Department of Orthopaedic Surgery, Haukeland University Hospital, Bergen
| | - Tesfaye Hordofa Leta
- The Norwegian Arthroplasty Register, Department of Orthopaedic Surgery, Haukeland University Hospital, Bergen; VID Specialized University, Bergen, Norway
| | - Trond Bruun
- Department of Medicine, Haukeland University Hospital, Bergen
| | - Geir Hallan
- The Norwegian Arthroplasty Register, Department of Orthopaedic Surgery, Haukeland University Hospital, Bergen; Department of Medicine, Haukeland University Hospital, Bergen
| | - Ove Furnes
- The Norwegian Arthroplasty Register, Department of Orthopaedic Surgery, Haukeland University Hospital, Bergen; Department of Clinical Medicine, University of Bergen, Bergen
| | - Håvard Dale
- The Norwegian Arthroplasty Register, Department of Orthopaedic Surgery, Haukeland University Hospital, Bergen; Department of Clinical Medicine, University of Bergen, Bergen
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Broom J, Broom A, Kenny K, Konecny P, J Post J. Multidisciplinary team meetings in prosthetic joint infection management: A qualitative study. Infect Dis Health 2023; 28:145-150. [PMID: 36788048 DOI: 10.1016/j.idh.2023.01.002] [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] [Received: 09/02/2022] [Revised: 11/30/2022] [Accepted: 01/15/2023] [Indexed: 02/16/2023]
Abstract
BACKGROUND Prosthetic joint infections (PJIs) cause substantial morbidity to patients and are extremely challenging for clinicians. Their management can include multiple operations, antibiotics, and prolonged hospital admissions. Multidisciplinary team meetings (MDTM) are increasingly used for collaborative decision-making around the management of PJIs, but thus far there has been no examination of the role of MDTM in decisions and management. This study aimed to examine interactions in a PJI MDTM to identify the dynamics in decision-making, and inter-specialty relationships more broadly. METHODS Twelve MDTMs over 7 months at an Australian tertiary referral hospital were video recorded, transcribed, and thematic analysis was performed. RESULTS Thematic analysis revealed four key areas of collaborative discussion 1. Achieving Inter-specialty Balance: The role of the multidisciplinary team discussion in providing balance between specialty views, and traversing the barriers between specialty interactions. 2. Negotiating Grey zones: there was frequent discussion of the limits of tests, interpretation of symptoms, and the limits of proposed operative strategies, and the resultant tensions of balancing ideal care vs pragmatic decision-making, and divergent goals of care. 3. Tailoring Treatment: identification of individual patient factors (both physiological and behavioural) and risks into collaborative decision-making. 4. Affording Failure: creating affordances in communication to openly discuss 'failure' to eliminate infection and likely negative outcomes. CONCLUSIONS MDTM in the management of prosthetic joint infections serve multiple functions including: achieving interdisciplinary balance; effective grey zone management, tailoring reconfigured care; and most critically, recognition of 'failure' to eliminate infection, a communicative affordance most likely leading to better care.
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Affiliation(s)
- Jennifer Broom
- Infection Research Network Sunshine Coast, Sunshine Coast Hospital and Health Service, 6 Doherty Street, Birtinya, QLD, Australia; University of Queensland, Brisbane, QLD, Australia.
| | - Alex Broom
- Sydney Centre for Healthy Societies, School of Social and Political Sciences, The University of Sydney, Camperdown, NSW, Australia.
| | - Katherine Kenny
- Sydney Centre for Healthy Societies, School of Social and Political Sciences, The University of Sydney, Camperdown, NSW, Australia.
| | - Pamela Konecny
- Department of Infectious Diseases, Immunology & Sexual Health, St George Hospital, Kogarah, Sydney, Australia; St George and Sutherland Clinical School, University of New South Wales, Sydney, Australia.
| | - Jeffrey J Post
- Department of Infectious Diseases, Prince of Wales Hospital and Community Health Services, Randwick, NSW, Australia; School of Clinical Medicine, University of New South Wales, Kensington, NSW, Australia.
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Wimalan B, Rupp M, Alt V, Walter N. The patients' perspective - a qualitative analysis of experiencing a fracture-related infection. Front Psychol 2023; 14:1126826. [PMID: 37325738 PMCID: PMC10267399 DOI: 10.3389/fpsyg.2023.1126826] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2022] [Accepted: 05/03/2023] [Indexed: 06/17/2023] Open
Abstract
Introduction Fracture-related infection is a devastating complication confronting the patient with several challenges. To improve the management and to enhance the patients' wellbeing the focus of this study was to understand the emotional impact and patients' experiences during the process to identify challenges, difficulties, and resources. For this, a qualitative content analysis of semi-structured interviews according to Graneheim and Lundman was performed. Methods In total n = 20 patients of a German university orthopedic trauma centre specialized in bone and joint infections were recruited using a purposive sampling strategy. The patients were treated at the hospital between 2019 and 2021 and underwent at least one surgery. Individual in-person interviews were performed by one researcher based on a semi-structured guide, which was previously conceptualized. Content analysis according to Graneheim and Lundman was performed on the transcripts by two of the researchers independently. Results The following major themes emerged: (i) the emotional and mental aspects highlighting the fact that FRI patients faced severe restrictions in their day-to-day life, which resulted in dependency on others and frustration, as well as future concerns showing that patients could not overcome a state of anxiety and fear even after successful treatment, (ii) socioeconomic consequences confronting patients with consequences on the job and in finances where they often feel helpless, and (iii) resources emphasizing the role of spirituality as a coping strategy and yoga exercises for keeping the positivity. Conclusion This study emphasized the challenge of fracture-related infection management and associated consequences from the patients' perspective. Not being well informed about possible negative outcomes or restrictions makes it harder for patients to accept the situation and patients expressed a need for better information and certainty. Also, patients developed constant anxiety and other psychological disturbances, highlighting the potential benefit of psychological support and patient-peer support to exchange experiences.
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Affiliation(s)
- Bravena Wimalan
- Department for Trauma Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Markus Rupp
- Department for Trauma Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Volker Alt
- Department for Trauma Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Nike Walter
- Department for Trauma Surgery, University Medical Center Regensburg, Regensburg, Germany
- Department for Psychosomatic Medicine, University Medical Center Regensburg, Regensburg, Germany
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Rajput V, Meek RMD, Haddad FS. Periprosthetic joint infection: what next? Bone Joint J 2022; 104-B:1193-1195. [DOI: 10.1302/0301-620x.104b11.bjj-2022-0944] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Periprosthetic joint infection (PJI) remains an extremely challenging complication. We have focused on this issue more over the last decade than previously, but there are still many unanswered questions. We now have a workable definition that everyone should align to, but we need to continue to focus on identifying the organisms involved. Surgical strategies are evolving and care is becoming more patient-centred. There are some good studies under way. There are, however, still numerous problems to resolve, and the challenge of PJI remains a major one for the orthopaedic community. This annotation provides some up-to-date thoughts about where we are, and the way forward. There is still scope for plenty of research in this area. Cite this article: Bone Joint J 2022;104-B(11):1193–1195.
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Affiliation(s)
- Vishal Rajput
- University College London Hospital, London, UK
- The Mid Yorkshire Hospitals NHS Trust, Wakefield, UK
| | | | - Fares S. Haddad
- University College London Hospital, London, UK
- The Bone & Joint Journal, London, UK
- The Princess Grace Hospital, London, UK
- The NIHR Biomedical Research Centre, University College London Hospitals, London, UK
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5
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Walter N, Wimalan B, Baertl S, Lang S, Hinterberger T, Alt V, Rupp M. Managing periprosthetic joint infection-a qualitative analysis of nursing staffs' experiences. BMC Nurs 2022; 21:190. [PMID: 35850726 PMCID: PMC9294832 DOI: 10.1186/s12912-022-00978-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Accepted: 07/06/2022] [Indexed: 11/17/2022] Open
Abstract
Background Periprosthetic joint infection represents a major complication in orthopaedics and trauma surgery. For an ideal management approach, it is important to understand the distinct challenges for all persons involved in the treatment. Therefore, it was aimed at investigating (1) the impact of periprosthetic joint infection (PJI) on the well-being of nursing staff to (2) identify challenges, which could be improved facilitating the management of PJI. Methods This is a qualitative interview study. In total, 20 nurses of a German university orthopedic trauma center specialized on infectious complications were recruited using a purposive sampling strategy. Content analysis was performed on transcripts of individual in-person interviews conducted between March 2021 and June 2021. Results Three major themes could be extracted including (i) feelings associated with the management of PJI and the need for emotional support, illustrating the negative emotional impact on nurses, whereby receiving collegial support was perceived as an important coping strategy, (ii) patients’ psychological burden, highlighting the nurses’ lack of time to address mental issues adequately and, (iii) realization of the severity of PJI and compliance problems. Conclusion Identified facilitating factors for PJI management include strengthening of mental care in the treatment of PJI, providing opportunities for exchange among multidisciplinary team members and implementing compliance-enhancing strategies. The findings of this study can be beneficial for improving professionals’ satisfaction, optimising the work environment, creating organizational structures which enhance opportunities for exchange and preventing mental health issues among the nursing team.
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Affiliation(s)
- Nike Walter
- Department for Trauma Surgery, University Medical Center Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Germany.,Department for Psychosomatic Medicine, University Medical Center Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Germany
| | - Bravena Wimalan
- Department for Trauma Surgery, University Medical Center Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Germany
| | - Susanne Baertl
- Department for Trauma Surgery, University Medical Center Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Germany
| | - Siegmund Lang
- Department for Trauma Surgery, University Medical Center Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Germany
| | - Thilo Hinterberger
- Department for Psychosomatic Medicine, University Medical Center Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Germany
| | - Volker Alt
- Department for Trauma Surgery, University Medical Center Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Germany
| | - Markus Rupp
- Department for Trauma Surgery, University Medical Center Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Germany.
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Haddad FS, Malchau H. The International Hip Society Meeting 2021. Bone Joint J 2022; 104-B:765-766. [PMID: 35775185 DOI: 10.1302/0301-620x.104b7.bjj-2022-0490] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Fares S Haddad
- University College London Hospitals, The Princess Grace Hospital, and The NIHR Biomedical Research Centre at UCLH, London, UK.,The Bone & Joint Journal , London, UK
| | - Henrik Malchau
- Harvard Medical School, Boston, Massachusetts, USA.,Department of Orthopedics, Sahlgrenska University Hospital, Mölndal, Sweden
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Genomics of Staphylococcus aureus and Staphylococcus epidermidis from Periprosthetic Joint Infections and Correlation to Clinical Outcome. Microbiol Spectr 2022; 10:e0218121. [PMID: 35762769 PMCID: PMC9430453 DOI: 10.1128/spectrum.02181-21] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
The approach of sequencing or genotyping to characterize the pathogenic potential of staphylococci from orthopedic device-related infection (ODRI) has been applied in recent studies. These studies described the genomic carriage of virulence in clinical strains and compared it with those in commensal strains. Only a few studies have directly correlated genomic profiles to patient outcome and phenotypic virulence properties in periprosthetic joint infections (PJIs). We investigated the association between genomic variations and virulence-associated phenotypes (biofilm-forming ability and antimicrobial resistance) in 111 staphylococcal strains isolated from patients with PJI and the infection outcome (resolved/unresolved). The presence of a strong biofilm phenotype in Staphylococcus aureus and an antibiotic-resistant phenotype in Staphylococcus epidermidis were both associated with treatment failure of PJI. In S. epidermidis, multidrug resistance (MDR) and resistance to rifampicin were associated with unresolved infection. Sequence type 45 (ST45) and ST2 were particularly enriched in S. aureus and S. epidermidis, respectively. S. epidermidis ST2 caused the majority of relapses and was associated with MDR and strong biofilm production, whereas ST215 correlated with MDR and non/weak biofilm production. S. aureusagr II correlated with resolved infection, while S. epidermidisagr I was associated with strong biofilm production and agr III with non/weak production. Collectively, our results highlight the importance of careful genomic and phenotypic characterization to anticipate the probability of the strain causing treatment failure in PJI. Due to the high rate of resistant S. epidermidis strains identified, this study provides evidence that the current recommended treatment of rifampicin and a fluoroquinolone should not be administered without knowledge of the resistance pattern. IMPORTANCE This study addresses the presence and frequency of particular genetic variants and virulence factors found in staphylococcal bacteria causing periprosthetic joint infection (PJI) of the hip and knee to ascertain their clinical relevance as predictors of treatment failure. We characterized the genetic virulence traits of a large collection of clinical staphylococci isolated from patients with PJI and evaluated their association with the patient’s infection outcome. The results showed that S. aureus strains that produced strong biofilms and S. epidermidis strains with resistance to several antibiotics associated significantly with unresolved infection. Some particular genetic variants associated with biofilm formation and multidrug resistance. These traits should be considered important risk factors for the diagnosis and treatment guidance in PJI.
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Caous JS, Malchau KS, Petzold M, Fridell Y, Malchau H, Ahlstrom L, Grant P, Andersson AE. Instrument tables equipped with local unidirectional airflow units reduce bacterial contamination during orthopedic implant surgery in an operating room with a displacement ventilation system. Infect Prev Pract 2022; 4:100222. [PMID: 35722048 PMCID: PMC9198428 DOI: 10.1016/j.infpip.2022.100222] [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: 04/23/2022] [Accepted: 05/18/2022] [Indexed: 11/26/2022] Open
Abstract
Background Airborne bacteria present in the operating room may be a cause of surgical site infection, either contaminating the surgical wound directly, or indirectly via e.g. surgical instruments. The aim of this study was to evaluate if instrument and assistant tables equipped with local unidirectional airflow reduce bacterial contamination of the instrument area to ultra clean levels, during orthopedic implant surgery in an operating room with displacement ventilation. Methods Local airflow units of instrument and assistant tables were either active or inactive. Colony forming units were sampled intraoperatively from the air above the instruments and from instrument dummies. A minimum of three air samples and two-three samples from instrument dummies were taken during each surgery. Samples were incubated on agar for total aerobic bacterial count. The mean air and instrument contamination during each surgery was calculated and used to analyze the difference in contamination depending on use of local airflow or not. All procedures were performed in the same OR. Results 188 air and 124 instrument samples were collected during 48 orthopedic implant procedures. Analysis showed that local unidirectional airflow above the surgical instruments significantly reduced the bacterial count in the air above assistant table (P<0.001) and instrument table (P=0.002), as well as on the instrument dummies from the assistant table (P=0.001). Conclusions Instrumentation tables equipped with local unidirectional airflow protect the surgical instruments from bacterial contamination during orthopedic implant surgery and may therefore reduce the risk of indirect wound contamination.
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Asokan A, Ibrahim MS, Thompson JW, Haddad FS. Debridement, antibiotics, and implant retention in non-oncological femoral megaprosthesis infections: minimum 5 year follow-up. J Exp Orthop 2022; 9:32. [PMID: 35403987 PMCID: PMC9001793 DOI: 10.1186/s40634-022-00469-9] [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: 12/22/2021] [Accepted: 03/17/2022] [Indexed: 05/31/2023] Open
Abstract
Purpose Megaprostheses are increasingly utilised outside of the oncological setting, and remain at significant risk of periprosthetic joint infection (PJI). Debridement, antibiotic, and implant retention (DAIR) is an established treatment for PJI, however its use in non-oncological patients with femoral megaprostheses has not been widely reported. There are significant differences in patient physiology, treatment goals, and associated risks between these patient cohorts. Methods We identified 14 patients who underwent DAIR for a PJI of their femoral megaprostheses, between 2000 and 2014, whom had their index procedure secondary to non-oncological indications. Patients were managed as part of a multidisciplinary team, with our standardised surgical technique including exchange of all mobile parts, and subsequent antibiotic therapy for a minimum of 3 months. Patients were followed up for a minimum of 5 years. Results Patients included six proximal femoral replacements, five distal femoral replacements, and three total femoral replacements. No patients were lost to follow-up. There were six males and eight females, with a mean age of 67.2 years, and mean ASA of 2.3. Nine patients (64.3%) successfully cleared their infection following DAIR at a minimum of 5 year follow-up. Five patients (35.7%) required further revision surgery, with four patients cleared of infection. No patients who underwent DAIR alone suffered complications as a result of the procedure. Conclusions The use of DAIR in these complex patients can lead to successful outcomes, but the risk of further revision remains high. The success rate (64.3%) remains on par with other studies evaluating DAIR in megaprostheses and in primary arthroplasty. This study indicates judicious use of DAIR can be an appropriate part of the treatment algorithm. Level of evidence II
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Affiliation(s)
- A Asokan
- Department of Trauma and Orthopaedic Surgery, University College Hospital, 235 Euston Road, Fitzrovia, London, NW1 2BU, UK.
| | - M S Ibrahim
- Department of Trauma and Orthopaedic Surgery, University College Hospital, 235 Euston Road, Fitzrovia, London, NW1 2BU, UK
| | - J W Thompson
- Department of Trauma and Orthopaedic Surgery, University College Hospital, 235 Euston Road, Fitzrovia, London, NW1 2BU, UK
| | - F S Haddad
- Department of Trauma and Orthopaedic Surgery, University College Hospital, 235 Euston Road, Fitzrovia, London, NW1 2BU, UK
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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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11
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Fehring TK, Fehring KA, Hewlett A, Higuera CA, Otero JE, Tande AJ. What's New in Musculoskeletal Infection. J Bone Joint Surg Am 2021; 103:1251-1258. [PMID: 34048412 DOI: 10.2106/jbjs.21.00311] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- Thomas K Fehring
- OrthoCarolina Hip & Knee Center, Charlotte, North Carolina.,Atrium Musculoskeletal Institute, Charlotte, North Carolina
| | | | | | | | - Jesse E Otero
- OrthoCarolina Hip & Knee Center, Charlotte, North Carolina.,Atrium Musculoskeletal Institute, Charlotte, North Carolina
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Phelps EE, Tutton E, Costa M, Hing C. Unattainable equipoise in randomized controlled trials : staff views of a feasibility study of surgical treatments for segmental tibial fractures. Bone Jt Open 2021; 2:486-492. [PMID: 34236209 PMCID: PMC8325976 DOI: 10.1302/2633-1462.27.bjo-2021-0055.r1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Aims To explore staff experiences of a multicentre pilot randomized controlled trial (RCT) comparing intramedullary nails and circular frame external fixation for segmental tibial fractures. Methods A purposeful sample of 19 staff (nine surgeons) involved in the study participated in an interview. Interviews explored participants’ experience and views of the study and the treatments. The interviews drew on phenomenology, were face-to-face or by telephone, and were analyzed using thematic analysis. Results The findings identify that for the treatment of segmental tibial fractures equipoise was a theoretical ideal that was most likely unattainable in clinical practice. This was conveyed through three themes: the ambiguity of equipoise, where multiple definitions of equipoise and a belief in community equipoise were evident; an illusion of equipoise, created by strong treatment preferences and variation in collective surgical skills; and treating the whole patient, where the complexity and severity of the injury required a patient-centred approach and doing the best for the individual patient took priority over trial recruitment. Conclusion Equipoise can be unattainable for rare injuries such as segmental tibial fractures, where there are substantially different surgical treatments requiring specific expertise, high levels of complexity, and a concern for poor outcomes. Surgeons are familiar with community equipoise. However, a shared understanding of factors that limit the feasibility of RCTs may identify instances where community equipoise is unlikely to translate into practice. Cite this article: Bone Jt Open 2021;2(7):486–492.
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Affiliation(s)
- Emma Elizabeth Phelps
- Kadoorie, Oxford Trauma and Emergency Care, Nuffield Department Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Elizabeth Tutton
- Kadoorie, Oxford Trauma and Emergency Care, Nuffield Department Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK.,Trauma and MTC, Oxford University NHS Foundation Hospital Trust, John Radcliffe, Oxford, UK
| | - Matthew Costa
- Kadoorie, Oxford Trauma and Emergency Care, Nuffield Department Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Caroline Hing
- Department of Trauma and Orthopaedics, St George's University Hospitals NHS Foundation Trust, London, UK
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Haddad FS. High-quality research and technology to the forefront. Bone Joint J 2021; 103-B:1005-1006. [PMID: 34058881 DOI: 10.1302/0301-620x.103b6.bjj-2021-0647] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Fares S Haddad
- University College London Hospitals NHS Foundation Trust, London, UK.,The Bone & Joint Journal, London, UK
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Abstract
This article is an expansion of a lecture given in the British Orthopaedic Association (BOA) Congress in Liverpool in 2019 as part of a symposium on infected knee replacement. It is designed to provide pointers and advice to surgeons on how these patients can be referred, investigated, and managed. The management of periprosthetic infection necessitates many decisions to be made to provide the patient with the best advice and treatment. This is a discussion of the philosophies of periprosthetic knee infection. It is not a definitive guide nor a metanalysis of scientific papers. These are the subjective views of the author and generalise decision making. All decisions should remain tailored to the patient's needs.
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Affiliation(s)
- Jonathan Miles
- Royal National Orthopaedic Hospital, Brockley Hill, Stanmore, Middlesex HA7 4LP, United Kingdom of Great Britain and Northern Ireland.
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Svensson K, Rolfson O, Nauclér E, Lazarinis S, Sköldenberg O, Schilcher J, Johanson PE, Mohaddes M, Kärrholm J. Exchange of Modular Components Improves Success of Debridement, Antibiotics, and Implant Retention: An Observational Study of 575 Patients with Infection After Primary Total Hip Arthroplasty. JB JS Open Access 2020; 5:e20.00110. [PMID: 33376927 PMCID: PMC7757835 DOI: 10.2106/jbjs.oa.20.00110] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
Debridement, antibiotics, and implant retention (DAIR) is a surgical treatment for periprosthetic joint infection (PJI). DAIR is a desirable treatment option from an economic and patient perspective, if successful. The aim of this observational study was to compare the rates of success, defined as no additional reoperations due to PJI, between DAIR with exchange of modular components and DAIR without exchange in patients who had first-time PJI after primary total hip arthroplasty (THA). METHODS Patients with PJI at the site of a primary THA who were treated with DAIR in Sweden between January 1, 2009, and December 31, 2016, were identified in the Swedish Hip Arthroplasty Register. Supplementary questionnaires were sent to orthopaedic departments for additional variables of interest related to PJI. The primary end point was another reoperation due to PJI within 2 years after the first-time DAIR. DAIR with exchange was compared with DAIR without exchange using Kaplan-Meier survival analysis and Cox regression analysis. RESULTS A total of 575 patients treated with DAIR for a first-time PJI at the site of a primary THA were analyzed; 364 underwent component exchange and 211 did not. The exchange of components was associated with a lower rate of reoperations due to PJI after DAIR (28.0%) compared with non-exchange (44.1%). The Kaplan-Meier implant survival estimate for exchange was 71.4% (95% confidence interval [CI] = 66.9% to 76.3%) compared with 55.5% (95% CI = 49.1% to 62.7%) for non-exchange. With the analysis adjusted for confounders, DAIR with exchange was associated with a significantly decreased risk of another reoperation due to PJI compared with non-exchange (hazard ratio [HR] = 0.51 [95% CI = 0.38 to 0.68]). CONCLUSIONS In patients with a first-time PJI at the site of a primary THA, DAIR with exchange of modular components was superior to non-exchange DAIR. Surgeons should strive to exchange components when they perform DAIR, but there is a need to further identify how DAIR best should be practiced and which patients benefit from it. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Karin Svensson
- Department of Orthopedics, Institute of Clinical Sciences, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- The Swedish Hip Arthroplasty Register, Gothenburg, Sweden
| | - Ola Rolfson
- Department of Orthopedics, Institute of Clinical Sciences, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- The Swedish Hip Arthroplasty Register, Gothenburg, Sweden
| | - Emma Nauclér
- The Swedish Hip Arthroplasty Register, Gothenburg, Sweden
| | - Stergios Lazarinis
- Department of Orthopedics, Institute of Surgical Sciences, Uppsala University Hospital, Uppsala, Sweden
| | - Olof Sköldenberg
- Division of Orthopedics, Department of Clinical Sciences, Karolinska Institutet, Danderyd Hospital, Stockholm, Sweden
| | - Jörg Schilcher
- Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
| | - Per-Erik Johanson
- Department of Orthopedics, Institute of Clinical Sciences, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- The Swedish Hip Arthroplasty Register, Gothenburg, Sweden
| | - Maziar Mohaddes
- Department of Orthopedics, Institute of Clinical Sciences, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- The Swedish Hip Arthroplasty Register, Gothenburg, Sweden
| | - Johan Kärrholm
- Department of Orthopedics, Institute of Clinical Sciences, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- The Swedish Hip Arthroplasty Register, Gothenburg, Sweden
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Haddad FS. COVID-19 and beyond. Bone Joint J 2020; 102-B:653-654. [PMID: 32475238 DOI: 10.1302/0301-620x.102b6.bjj-2020-0759] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Fares S Haddad
- The Bone & Joint Journal, Professor of Orthopaedic Surgery, University College London Hospitals, The Princess Grace Hospital, and The NIHR Biomedical Research Centre at UCLH, London, UK
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