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Bourget-Murray J, Tubin N, Bureau A, Morris J, Ann Azad M, Abdelbary H, Grammatopoulos G, Garceau S. Lower Rates of Reoperation Following Partial or Complete Revision Arthroplasty Compared to Debridement, Antibiotics, and Implant Retention for Early Postoperative and Acute Hematogenous Periprosthetic Hip Infection. J Arthroplasty 2024:S0883-5403(24)00270-5. [PMID: 38531489 DOI: 10.1016/j.arth.2024.03.054] [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: 07/03/2023] [Revised: 03/17/2024] [Accepted: 03/19/2024] [Indexed: 03/28/2024] Open
Abstract
BACKGROUND This study aimed to: 1) compare treatment outcomes between debridement, antibiotics, and implant retention (DAIR) and partial or complete revision arthroplasty (RA) for early postoperative and acute hematogenous total hip arthroplasty periprosthetic joint infection (PJI) and 2) identify factors associated with treatment outcome. METHODS The study consisted of a retrospective cohort of patients who underwent surgery for PJI between 2004 and 2021. There were 76 patients (74.5%) who underwent DAIR and 26 patients (25.5%) who underwent RA. Treatment success was defined as treatment eradication at a minimum of a 2-year follow up. Bivariate regression analysis was used to assess the effect of different factors on treatment outcomes. Kaplan-Meier survivorship was performed to compare survivorship between cohorts. RESULTS At a mean follow-up of 8.2 years (range, 2.2 to 16.4), significantly more DAIR failed treatment (DAIR, 50 [65.8%]; 10 [38.5%]; P = .015). The 8-year Kaplan-Meier survivorship was 35.1% [95% confidence interval (CI), 24.3 to 45.9] for patients treated with DAIR and 61.5% [95% CI, 42.9 to 80.1] for those treated with RA (log rank = 0.039). Bivariate regression analysis showed performing a RA was associated with a higher likelihood of treatment success (odds ratio 4.499, 95% CI 1.600 to 12.647, P = .004), whereas a higher body mass index was associated with treatment failure (odds ratio 0.934, 95% CI 0.878 to 0.994, P = .032). CONCLUSIONS To reduce the rate of recalcitrant infection following early postoperative or acute hematogenous total hip arthroplasty PJI, RA may be of benefit over DAIR. This is especially relevant in the early postoperative period, when components can be readily exchanged.
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Affiliation(s)
- Jonathan Bourget-Murray
- Division of Orthopaedic Surgery, Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
| | - Nicholas Tubin
- Division of Orthopaedic Surgery, Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
| | - Antoine Bureau
- Division of Infectious Diseases, Department of Medicine, The Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
| | - Jared Morris
- Division of Orthopaedic Surgery, Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
| | - Marisa Ann Azad
- Hôtel-Dieu de Lévis, Université Laval, Quebec City, Quebec, Canada
| | - Hesham Abdelbary
- Division of Orthopaedic Surgery, Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
| | - George Grammatopoulos
- Division of Orthopaedic Surgery, Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
| | - Simon Garceau
- Division of Orthopaedic Surgery, Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
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Lora-Tamayo J, Mancheño-Losa M, Meléndez-Carmona MÁ, Hernández-Jiménez P, Benito N, Murillo O. Appropriate Duration of Antimicrobial Treatment for Prosthetic Joint Infections: A Narrative Review. Antibiotics (Basel) 2024; 13:293. [PMID: 38666969 PMCID: PMC11047716 DOI: 10.3390/antibiotics13040293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Revised: 03/16/2024] [Accepted: 03/19/2024] [Indexed: 04/29/2024] Open
Abstract
Prosthetic joint infections are considered difficult to treat they needing aggressive surgery and long antimicrobial treatments. However, the exact duration of these therapies has been established empirically. In the last years, several studies have explored the possibility of reducing the length of treatment in this setting, with conflicting results. In this narrative review, we critically appraise the published evidence, considering the different surgical approaches (implant retention [DAIR] and one-step and two-step exchange procedures) separately. In patients managed with DAIR, usually treated for at least 12 weeks, a large, randomized trial failed to show that 6 weeks were non-inferior. However, another randomized clinical trial supports the use of 8 weeks, as long as the surgical conditions are favorable and antibiotics with good antibiofilm activity can be administered. In patients managed with a two-step exchange procedure, usually treated during 6 weeks, a randomized clinical trial showed the efficacy of a 4-week course of antimicrobials. Also, the use of local antibiotics may allow the use of even shorter treatments. Finally, in the case of one-step exchange procedures, there is a trend towards reducing the length of therapy, and the largest randomized clinical trial supports the use of 6 weeks of therapy.
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Affiliation(s)
- Jaime Lora-Tamayo
- Department of Internal Medicine, Hospital Universitario 12 de Octubre, Instituto de Investigación Biomédica imas12 Hospital 12 de Octubre, Facultad de Medicina, Universidad Complutense de Madrid, 28041 Madrid, Spain; (M.M.-L.); (P.H.-J.)
- Spanish Group for the Study of Bone and Joint Infections, Spanish Society of Clinical Microbiology and Infectious Diseases (GEIO-SEIMC), 28003 Madrid, Spain; (N.B.); (O.M.)
- CIBERINFEC—CIBER Enfermedades Infecciosas, Instituto de Salud Carlos III, 28029 Madrid, Spain
| | - Mikel Mancheño-Losa
- Department of Internal Medicine, Hospital Universitario 12 de Octubre, Instituto de Investigación Biomédica imas12 Hospital 12 de Octubre, Facultad de Medicina, Universidad Complutense de Madrid, 28041 Madrid, Spain; (M.M.-L.); (P.H.-J.)
- Spanish Group for the Study of Bone and Joint Infections, Spanish Society of Clinical Microbiology and Infectious Diseases (GEIO-SEIMC), 28003 Madrid, Spain; (N.B.); (O.M.)
| | - María Ángeles Meléndez-Carmona
- Department of Microbiology, Hospital Universitario 12 de Octubre, Instituto de Investigación Biomédica imas12 Hospital 12 de Octubre, 28041 Madrid, Spain;
| | - Pilar Hernández-Jiménez
- Department of Internal Medicine, Hospital Universitario 12 de Octubre, Instituto de Investigación Biomédica imas12 Hospital 12 de Octubre, Facultad de Medicina, Universidad Complutense de Madrid, 28041 Madrid, Spain; (M.M.-L.); (P.H.-J.)
| | - Natividad Benito
- Spanish Group for the Study of Bone and Joint Infections, Spanish Society of Clinical Microbiology and Infectious Diseases (GEIO-SEIMC), 28003 Madrid, Spain; (N.B.); (O.M.)
- CIBERINFEC—CIBER Enfermedades Infecciosas, Instituto de Salud Carlos III, 28029 Madrid, Spain
- Infectious Diseases Unit, Hospital de la Santa Creu i Sant Pau, Institut d’Investigació Biomèdica Sant Pau (IIB SANT PAU), Universitat Autònoma de Barcelona, 08193 Barcelona, Spain
- UQ Centre for Clinical Research (UQCCR), The University of Queensland, Brisbane 4072, Australia
| | - Oscar Murillo
- Spanish Group for the Study of Bone and Joint Infections, Spanish Society of Clinical Microbiology and Infectious Diseases (GEIO-SEIMC), 28003 Madrid, Spain; (N.B.); (O.M.)
- CIBERINFEC—CIBER Enfermedades Infecciosas, Instituto de Salud Carlos III, 28029 Madrid, Spain
- Department of Infectious Diseases, Hospital Universitario Bellvitge, IDIBELL (Instituto de Investigación Biomédica de Bellvitge), 08908 L’Hospitalet de Llobregat, Spain
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Bunting AC, Costi K, Chimutengwende-Gordon M, Callary SA, Pannach S, Nelson R, Howie DW, Solomon LB. Staged Revision Hip Arthroplasty With Femoral Impaction Bone Grafting for Prosthetic Joint Infections: Radiostereometric Analyses and Clinical Outcomes at Minimum 5-Year Follow-Up. J Arthroplasty 2023; 38:2716-2723.e1. [PMID: 37321515 DOI: 10.1016/j.arth.2023.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2022] [Revised: 06/01/2023] [Accepted: 06/03/2023] [Indexed: 06/17/2023] Open
Abstract
BACKGROUND There are ongoing concerns regarding the use of bone graft following prosthetic joint infection and subsequent implant subsidence. The aim of this study was to determine whether the use of a cemented stem combined with femoral impaction bone grafting (FIBG) at second stage revision for infection results in stable femoral stem fixation, determined by accurate methods, and good clinical results. METHODS A prospective cohort of 29 patients underwent staged revision total hip arthroplasty for infection using an interval prosthesis followed by FIBG at the final reconstruction. The mean follow-up was 89 months (range, 8 to 167 months). Femoral implant subsidence was measured with radiostereometric analysis. Clinical outcomes included the Harris Hip Score, Harris Pain score and Société Internationale de Chirurgie Orthopédique et de Traumatologie activity scores. RESULTS At 2-years follow-up the median stem subsidence relative to femur was -1.36 mm (range, -0.31 to -4.98), while the cement subsidence relative to femur was -0.05 mm (range, 0.36 to -0.73). At 5-years follow-up, the median stem subsidence relative to femur was -1.89 mm (range, -0.27 to -6.35), while the cement subsidence relative to femur was -0.06 mm (range, 0.44 to -0.55). There were 25 patients who were confirmed infection-free after the second stage revision with FIBG. The median Harris Hip Score improved from 51 pre-operatively to 79 at 5 years (P = .0130), and Harris Pain score from 20 to 40 (P = .0038). CONCLUSIONS Stable femoral component fixation can be achieved with FIBG when reconstructing the femur after revision for infection without compromising infection cure rates and patient-reported outcomes.
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Affiliation(s)
- Alexandra C Bunting
- Centre for Orthopaedic and Trauma Research, The University of Adelaide, Adelaide, South Australia; Department of Orthopaedics and Trauma, Royal Adelaide Hospital, Adelaide, South Australia
| | - Kerry Costi
- Centre for Orthopaedic and Trauma Research, The University of Adelaide, Adelaide, South Australia
| | | | - Stuart A Callary
- Centre for Orthopaedic and Trauma Research, The University of Adelaide, Adelaide, South Australia; Department of Orthopaedics and Trauma, Royal Adelaide Hospital, Adelaide, South Australia
| | - Susan Pannach
- Department of Orthopaedics and Trauma, Royal Adelaide Hospital, Adelaide, South Australia
| | - Renjy Nelson
- Department of Infectious Diseases, Royal Adelaide Hospital, Adelaide, South Australia
| | - Donald W Howie
- Centre for Orthopaedic and Trauma Research, The University of Adelaide, Adelaide, South Australia; Department of Orthopaedics and Trauma, Royal Adelaide Hospital, Adelaide, South Australia
| | - Lucian Bogdan Solomon
- Centre for Orthopaedic and Trauma Research, The University of Adelaide, Adelaide, South Australia; Department of Orthopaedics and Trauma, Royal Adelaide Hospital, Adelaide, South Australia
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Gonzalez MR, Bedi ADS, Karczewski D, Lozano-Calderon SA. Treatment and Outcomes of Fungal Prosthetic Joint Infections: A Systematic Review of 225 Cases. J Arthroplasty 2023; 38:2464-2471.e1. [PMID: 37172795 DOI: 10.1016/j.arth.2023.05.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Revised: 04/30/2023] [Accepted: 05/03/2023] [Indexed: 05/15/2023] Open
Abstract
BACKGROUND Fungal prosthetic joint infections (PJIs) after a total joint arthroplasty are a rare, yet severe, occurrence not often reported in the literature. Unlike in bacterial PJIs, no clear consensus exists on fungal PJI optimal management. METHODS A systematic review was performed using the PubMed and Embase databases. Manuscripts were assessed for inclusion and exclusion criteria. The Strengthening the Reporting of Observational Studies in Epidemiology checklist was applied for quality assessment. Individual demographic, clinical, and treatment information was retrieved from included manuscripts. RESULTS Seventy one patients who had a PJI of the hip and 126 of the knee were included. Infection recurrence occurred in 29.6% and 18.3% of patients with hip or knee PJI, respectively. Patients who had knee PJIs recurrence had a significantly higher Charlson Comorbidity Index (CCI). For knee PJIs, infection recurrence was more common in patients with Candida albicans (CA) PJIs (P = .022). Two-stage exchange arthroplasty was the most common procedure in both joints. Multivariate analysis found that CCI ≥ 3 was associated with an 18.5-fold increase in the risk of knee PJI recurrence (Odds ratio [OR] = 18.57). Additional risk factors for recurrence in the knee included CA etiology (OR = 3.56) and C-reactive protein at presentation ≥ 6 (OR = 6.54). Compared to debridement, antibiotics, and implant retention, 2-stage procedure was a protective factor for PJI recurrence in the knee (OR = 0.18). No risk factors were found in patients who had hip PJIs. CONCLUSION Treatment of fungal PJIs varies widely, but 2-stage revision is the most common. Risk factors for knee fungal PJI recurrence include elevated CCI, infection by CA, and high C-reactive protein at presentation.
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Affiliation(s)
- Marcos R Gonzalez
- Division of Orthopaedic Oncology, Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Angad D S Bedi
- Division of Orthopaedic Oncology, Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Daniel Karczewski
- Division of Orthopaedic Oncology, Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Santiago A Lozano-Calderon
- Division of Orthopaedic Oncology, Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
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Bormann N, Schmock A, Hanke A, Eras V, Ahmed N, Kissner MS, Wildemann B, Brune JC. Analysis of the Ability of Different Allografts to Act as Carrier Grafts for Local Drug Delivery. J Funct Biomater 2023; 14:305. [PMID: 37367268 DOI: 10.3390/jfb14060305] [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: 05/09/2023] [Revised: 05/26/2023] [Accepted: 05/29/2023] [Indexed: 06/28/2023] Open
Abstract
Bone defects and infections pose significant challenges for treatment, requiring a comprehensive approach for prevention and treatment. Thus, this study sought to evaluate the efficacy of various bone allografts in the absorption and release of antibiotics. A specially designed high-absorbency, high-surface-area carrier graft composed of human demineralized cortical fibers and granulated cancellous bone (fibrous graft) was compared to different human bone allograft types. The groups tested here were three fibrous grafts with rehydration rates of 2.7, 4, and 8 mL/g (F(2.7), F(4), and F(8)); demineralized bone matrix (DBM); cortical granules; mineralized cancellous bone; and demineralized cancellous bone. The absorption capacity of the bone grafts was assessed after rehydration, the duration of absorption varied from 5 to 30 min, and the elution kinetics of gentamicin were determined over 21 days. Furthermore, antimicrobial activity was assessed using a zone of inhibition (ZOI) test with S. aureus. The fibrous grafts exhibited the greatest tissue matrix absorption capacity, while the mineralized cancellous bone revealed the lowest matrix-bound absorption capacity. For F(2.7) and F(4), a greater elution of gentamicin was observed from 4 h and continuously over the first 3 days when compared to the other grafts. Release kinetics were only marginally affected by the varied incubation times. The enhanced absorption capacity of the fibrous grafts resulted in a prolonged antibiotic release and activity. Therefore, fibrous grafts can serve as suitable carrier grafts, as they are able to retain fluids such as antibiotics at their intended destinations, are easy to handle, and allow for a prolonged antibiotic release. Application of these fibrous grafts can enable surgeons to provide longer courses of antibiotic administration for septic orthopedic indications, thus minimizing infections.
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Affiliation(s)
- Nicole Bormann
- Julius Wolff Institut und BIH-Center für Regenerative Therapien und Center, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin und Berlin Institute of Health, 13353 Berlin, Germany
| | - Aysha Schmock
- Julius Wolff Institut und BIH-Center für Regenerative Therapien und Center, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin und Berlin Institute of Health, 13353 Berlin, Germany
| | - Anja Hanke
- German Institute for Cell and Tissue Replacement (DIZG, gemeinnützige GmbH), 12555 Berlin, Germany
| | - Volker Eras
- German Institute for Cell and Tissue Replacement (DIZG, gemeinnützige GmbH), 12555 Berlin, Germany
| | - Norus Ahmed
- German Institute for Cell and Tissue Replacement (DIZG, gemeinnützige GmbH), 12555 Berlin, Germany
| | - Maya S Kissner
- Julius Wolff Institut und BIH-Center für Regenerative Therapien und Center, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin und Berlin Institute of Health, 13353 Berlin, Germany
| | - Britt Wildemann
- Julius Wolff Institut und BIH-Center für Regenerative Therapien und Center, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin und Berlin Institute of Health, 13353 Berlin, Germany
- Experimental Trauma Surgery, Department of Trauma, Hand and Reconstructive Surgery, Jena University Hospital, Friedrich Schiller University, 07747 Jena, Germany
| | - Jan C Brune
- German Institute for Cell and Tissue Replacement (DIZG, gemeinnützige GmbH), 12555 Berlin, Germany
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Mohamed NS, Dávila Castrodad IM, Etcheson JI, George NE, Aitken JS, Kelemen MN, Nace J, Delanois RE. Utilisation of calcium sulphate beads in one-stage aseptic revision total hip arthroplasty. Hip Int 2022; 32:656-660. [PMID: 33241953 DOI: 10.1177/1120700020973973] [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: 02/04/2023]
Abstract
INTRODUCTION Periprosthetic joint infection (PJI) affects many revision total hip arthroplasty (THA) patients, contributing to a concomitant rise in revision costs. Means of decreasing the risk of PJI include the use of antibiotic adjuncts, such as calcium sulphate beads (CSBs). Mixed with antibiotics, the potential benefits of CSBs include dissolvability and antibiotic drug elution. However, information comparing them in aseptic revision is scarce. Therefore, this study investigated CSB utilisation for infection prevention in aseptic revision THA. Specifically, we compared (1) infection rates; (2) lengths of stay; (3) subsequent infection procedures; and (4) final surgical outcome in 1-stage aseptic revision THA patients who did received CSBs to 1-stage aseptic revision THA patients who did not. METHODS A retrospective chart review was performed to identify all patients who underwent an aseptic revision THA between January 2013 and December 2017. Patients who received CSBs (n = 48) were compared to non-CSB patients (n = 58) on the following outcomes: postoperative infections, lengths of stay (LOS), subsequent irrigation and debridements (I+Ds), and final surgical outcome, classified as successful THA reimplantation, retained antibiotic spacer, or Girdlestone procedure. Chi-square and t-testing were used to analyse the variables. RESULTS There was no significant differences found between CSB patients and non-CSB patients in postoperative infections (p = 0.082), LOS (p = 0.179), I+Ds (p = 0.068), and final surgical outcome (p = 0.211). CONCLUSION This study did not find any statistical difference between CSBs and standard of care in infection rates and surgical outcomes. The advantage of these beads for 1-stage aseptic revisions is questionable.
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Affiliation(s)
- Nequesha S Mohamed
- Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, MD, USA
| | - Iciar M Dávila Castrodad
- Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, MD, USA
| | - Jennifer I Etcheson
- Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, MD, USA
| | - Nicole E George
- Department of Graduate Medical Education, Aultman Hospital, Canton, OH, USA
| | - James S Aitken
- Department of Orthopaedic Surgery, Philadelphia College of Osteopathic Medicine, Philadelphia, PA, USA
| | - Margaret N Kelemen
- Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, MD, USA
| | - James Nace
- Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, MD, USA
| | - Ronald E Delanois
- Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, MD, USA
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SARACCO M, SACCOMANNO MF, CIRIELLO V, TARANTINO A, ROMANINI E, LOGROSCINO G. One stage vs. two stage in hip periprosthetic joint infections. MINERVA ORTHOPEDICS 2022; 73. [DOI: 10.23736/s2784-8469.21.04188-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/31/2023]
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8
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Kuehling T, Schilling P, Bernstein A, Mayr HO, Serr A, Wittmer A, Bohner M, Seidenstuecker M. A human bone infection organ model for biomaterial research. Acta Biomater 2022; 144:230-241. [PMID: 35304323 DOI: 10.1016/j.actbio.2022.03.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Revised: 03/03/2022] [Accepted: 03/09/2022] [Indexed: 02/07/2023]
Abstract
The aim of this work was to establish an organ model for staphylococcal infection of human bone samples and to investigate the influence and efficacy of a microporous β-tricalcium phosphate ceramic (β-TCP, RMS Foundation) loaded with hydrogels (alginate, alginate-di-aldehyde (ADA)-gelatin) and clindamycin on infected human bone tissue over a period of 28 days. For this purpose, human tibia plateaus, collected during total knee replacement surgery, were used as a source of bone material. Samples were infected with S. aureus ATCC29213 and treated with differently loaded β-TCP composites (alginate +/- clindamycin, ADA-gelatin +/- clindamycin, unloaded). The loading of the composites was carried out by means of a flow chamber. The infection was observed for 28 days, quantifying bacteria in the medium and the osseus material on day 1, 7, 14, 21 and 28. All samples were histologically processed for bone vitality evaluation. Bone infection could be consistently performed within the organ model. In addition, a strong reduction in bacterial counts was recorded in the groups treated with ADA-gelatin + clindamycin and alginate + clindamycin, while the bacterial count in the control groups remained constant. No significant differences between groups could be observed in the number of lacunae filled with osteocytes suggesting no differences in bone vitality among groups. In an ex-vivo human bone infection model, over a period of 28 days bacterial growth could be reduced by treatment with ADA-Gel + CLI and ALG + CLI -releasing β-TCP composites. This could be relevant for its clinical use. Further work will be necessary to improve the loading of β-TCP and the bone infection organ model itself. STATEMENT OF SIGNIFICANCE: The common treatment of bone infections is debridement and systemic administration of antibiotics. In some cases, antibiotic-containing carriers are already used, but these must be removed again. Our work is intended to show another treatment option. The scaffold we have developed, made of a calcium phosphate ceramic and a hydrogel as the active substance carrier, can, in addition to releasing the active substance, also assume a load-bearing function of the bone and is biodegradable. In addition, the model we developed can also be used for the analysis and treatment of bone infections other than those of the musculoskeletal system. More importantly, it can also serve as a substitute for previously used animal experiments.
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Sotiriou D, Stigbrand H, Ullmark G. Is two-stage revision surgery for infected hip arthroplasty worth the suffering, resources and results compared to one-stage? Hip Int 2022; 32:205-212. [PMID: 32777947 DOI: 10.1177/1120700020949162] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
PURPOSE Periprosthetic joint infection (PJI) is the most serious complication of total hip arthroplasty. The treatment is usually revision in either 1 or 2 stages. This study analyses revision with impaction bone grafting for periprosthetic joint infection of the hip and compares 1- and 2-stage strategies. PATIENTS AND METHODS We reviewed 55 consecutive cases (54 patients) of revision arthroplasty for PJI carried out at our hospital between 2002 and 2016. Of these, 46 were 2-stage procedures. 21 had vancomycin mixed in with the bone graft, and all had gentamycin-containing bone cement. The total perioperative blood loss, duration of operation, and length of hospital stay were recorded. Clinical and radiological results were analysed for 48 hips at 2-16 years follow-up. RESULTS No PJI remained at follow-up. 3 patients (6%) had undergone revision for all causes. 1 had radiological signs of mechanical loosening but was not revised. 2-stage procedures had a significantly longer operating time (409 vs. 238 min) and hospital stay (34 vs. 13 days), greater blood loss (2764 vs. 1638 ml), and lower mean functional hip score (15.9 vs. 17.5) at follow-up than the one-stage procedures. INTERPRETATION Revision total hip arthroplasty for PJI with vancomycin-loaded impaction bone grafting is a safe method that achieves both the restoration of bone stock and resolution of the infection. This single-stage procedure could therefore be the new gold standard for treatment of non-complicated PJI in the hip.
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Affiliation(s)
- Dimitrios Sotiriou
- Department of Orthopaedics, Gävle Hospital and Centre for Research and Development Uppsala University/County Council of Gävleborg, Sweden
| | - Hampus Stigbrand
- Department of Orthopaedics, Gävle Hospital and Centre for Research and Development Uppsala University/County Council of Gävleborg, Sweden
| | - Gösta Ullmark
- Department of Orthopaedics, Gävle Hospital and Centre for Research and Development Uppsala University/County Council of Gävleborg, Sweden
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Periprosthetic Joint Infection (PJI)—Results of One-Stage Revision with Antibiotic-Impregnated Cancellous Allograft Bone—A Retrospective Cohort Study. Antibiotics (Basel) 2022; 11:antibiotics11030310. [PMID: 35326773 PMCID: PMC8944641 DOI: 10.3390/antibiotics11030310] [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: 02/11/2022] [Revised: 02/21/2022] [Accepted: 02/23/2022] [Indexed: 02/04/2023] Open
Abstract
Controversy exists regarding the optimal treatment of periprosthetic joint infection (PJI), considering control of infection, functional results as well as quality of life. Difficulties in treatment derive from the formation of biofilms within a few days after infection. Biofilms are tolerant to systemically applied antibiotics, requiring extreme concentrations for a prolonged period. Minimum biofilm eradicating concentrations (MBEC) are only feasible by the local application of antibiotics. One established approach is the use of allograft bone as a carrier, granting a sustained release of antibiotics in very high concentrations after appropriate impregnation. The purpose of this study was to determine the rate of reinfection after a one-stage revision of infected hip or knee prostheses, using antibiotic-impregnated allograft bone as the carrier and avoiding cement. Between 1 January 2004 and 31 January 2018, 87 patients with PJI, according to MSIS, underwent a one-stage revision with antibiotic-impregnated cancellous allograft bone. An amount of 17 patients had insufficient follow-ups. There were 70 remaining patients (34 male, 36 female) with a mean follow-up of 5.6 years (range 2–15.6) and with a mean age of 68.2 years (range 31.5–86.9). An amount of 38 hips and 11 knees were implanted without any cement; and 21 knees were implanted with moderate cementing at the articular surface with stems always being uncemented. Within 2 years after surgery, 6 out of 70 patients (8.6%, CI 2–15.1) showed reinfection and after more than 2 years, an additional 6 patients showed late-onset infection. Within 2 years after surgery, 11 out of 70 patients (15.7%, CI 7.2–24.2) had an implant failure for any reason (including infection) and after more than 2 years, an additional 7 patients had an implant failure. Using Kaplan-Meier analysis for all 87 patients, the estimated survival for reinfection was 93.9% (CI 88.8–99.1) at 1 year, 89.9% (CI 83.2–96.6) at 2 years and 81.5% (CI 72.1–90.9) at 5 years. The estimated survival for implant failure for any reason was 90.4% (CI 84.1–96.7) at 1 year, 80.9% (CI 72.2–89.7) at 2 years and 71.1% (CI 60.3–81.8) at 5 years. One-stage revision with antibiotic-impregnated cancellous allograft bone grants comparable results regarding infection control as with multiple stages, while shortening rehabilitation, improving quality of life for the patients and reducing costs for the health care system.
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11
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Riemer K, Lange J. Early periprosthetic hip joint infection managed by cementless one-stage revision – a case series. J Bone Jt Infect 2022; 7:43-50. [PMID: 35251904 PMCID: PMC8892566 DOI: 10.5194/jbji-7-43-2022] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Accepted: 01/29/2022] [Indexed: 12/01/2022] Open
Abstract
Background: Early periprosthetic hip joint infection (PJI) is traditionally treated with
debridement, antibiotics, and implant retention (DAIR). However, infection
control rates after DAIR-treated periprosthetic hip joint infection do not exceed 77 %.
Cementless one-stage revision of chronic PJI by the Cementless One-stage Revision of Infected Hip Arthroplasty (CORIHA) protocol has been evaluated positively with a 91 % success rate. We wanted to evaluate the
effectiveness of cementless one-stage revision following the CORIHA protocol
for early PJI in elective primary total hip arthroplasty, regarding risk of
re-operation with exchange of implants. Methods: We identified 18 patients in our center with early (≤6-week postoperative) PJI after primary total hip arthroplasty (THA) treated with one-stage cementless
revision in the period January 2012–March 2018. Treatment followed the
CORIHA protocol. Primary outcome was retention of implants at the most recent follow-up. Patients were followed for a minimum of 3 years. Results: Mean follow-up time was 60 months (39–105). All patients retained their
implants, but two required superficial soft tissue debridement due to
persistent wound seepage. Conclusion: Cementless one-stage revision appears to be an effective treatment of early
PJI after primary THA and at least an equal choice of treatment compared with DAIR. Whether the potential benefit of a lower re-revision rate for
postoperative PJI outweighs the increased surgical complexity of the CORIHA
procedure needs further evaluation.
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Affiliation(s)
- Kristoffer Riemer
- Elective Surgery Center, Silkeborg Regional Hospital, HE Midt,
Silkeborg, 8600, Denmark
| | - Jeppe Lange
- Department of Orthopaedic Surgery, Horsens Regional Hospital, Horsens,
8700, Denmark
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Unfried RI, Krause LMF, Cezimbra HM, Pacheco LS, Larangeira JA, Ribeiro TA. A Retrospective Observational Cohort Study of Periprosthetic Hip Infection Treated by one-stage Method Including Cases With Bone Graft Reconstruction. CLINICAL MEDICINE INSIGHTS: ARTHRITIS AND MUSCULOSKELETAL DISORDERS 2022; 15:11795441221090344. [PMID: 35547099 PMCID: PMC9081729 DOI: 10.1177/11795441221090344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/16/2021] [Accepted: 03/03/2022] [Indexed: 11/17/2022]
Abstract
Purpose: Prosthetic joint infection (PJI) is a devastating complication that can affect hip arthroplasty. Its treatment is extremely difficult, and issues regarding the optimal treatment remain unanswered. This study intended to show the effectiveness of the one-stage treatment of PJI. Materials and Methods: A retrospective observational cohort study performed from July 2014- August 2018. All patients with suspected PJI were included. Major and minor criteria developed by the International Consensus on Periprosthetic Joint Infection (ICPJI) was used to define infection. Laboratory tests and image exams were performed, and all patients were followed for at least 2 years. Outcomes: Success rate (2018 ICPJI definition to success) in treatment of PJI using one-stage revision method. Clinical and functional outcomes defined by Harris Hip Score (HHS). Results: Thirty-one patients were screened and 18 analyzed. 69.85 ± 9.76 years was the mean age. Mean follow-up time was 63.84 ± 18.55 months. Ten patients had acetabular defects and required bone graft reconstruction. Sixteen patients were classified as Tier 1, 1 as Tier 3D, and as 1 Tier 3E. Almost 90% of patients submitted to one-stage revision with acetabulum graft reconstruction were free of infection. The overall infection survival rate was 78.31±6.34 months. Candida albicans and sinus tract were statistically significant in univariate Cox’s analysis. The predictor of one-stage revision surgery failure that remained final Cox’s regression model was C. albicans (hazard ratio [HR]: 4.47). Conclusion: Treatment through one-stage revision surgery associated with 6 months of antimicrobial is a viable option with acceptable results even when bone graft reconstruction is necessary. C. albicans was a strong predictor of failure in this cohort.
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Affiliation(s)
- Ricardo Issler Unfried
- Department of and Traumatology, University Hospital of Santa Maria (SOT-HUSM), Federal University of Santa Maria (UFSM), Santa Maria, Brazil
- Master’s Course in Health and Life Sciences, Universidade Franciscana (UFN), Santa Maria, Brazil
| | | | - Helen Minussi Cezimbra
- Department of Infectious Diseases, University Hospital of Santa Maria, Federal University of Santa Maria (UFSM), Santa Maria, Brazil
| | - Liliane Souto Pacheco
- Medicine School, Hospital São Francisco de Assis (HSFA), Universidade Franciscana (UFN), Santa Maria, Brazil
- Department of Infectious Diseases, University Hospital of Santa Maria, Federal University of Santa Maria (UFSM), Santa Maria, Brazil
| | - João Alberto Larangeira
- Department of and Traumatology, University Hospital of Santa Maria (SOT-HUSM), Federal University of Santa Maria (UFSM), Santa Maria, Brazil
| | - Tiango Aguiar Ribeiro
- Department of and Traumatology, University Hospital of Santa Maria (SOT-HUSM), Federal University of Santa Maria (UFSM), Santa Maria, Brazil
- Master’s Course in Health and Life Sciences, Universidade Franciscana (UFN), Santa Maria, Brazil
- Medicine School, Hospital São Francisco de Assis (HSFA), Universidade Franciscana (UFN), Santa Maria, Brazil
- Postgraduate Program of Health Science, Federal University of Santa Maria (UFSM), Santa Maria, Brazil
- Department of Surgery in Orthopaedic, Medicine School, Federal University of Santa Maria (UFSM), Santa Maria, Brazil
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13
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Pannu TS, Villa JM, Higuera CA. Diagnosis and management of infected arthroplasty. SICOT J 2021; 7:54. [PMID: 34723789 PMCID: PMC8559719 DOI: 10.1051/sicotj/2021054] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Accepted: 10/09/2021] [Indexed: 12/19/2022] Open
Abstract
Periprosthetic joint infection (PJI) is one of the most dreadful complications after THA and TKA. Though prevention is of utmost importance in PJI management, the last decade has seen many remarkable developments in PJI diagnosis, including the introduction of several standardized PJI diagnostic definitions and biomarkers. Depending on the specific clinical situation, a myriad of treatment options for PJI are offered. Our review aims to summarize the pertinent information on PJI diagnosis and synthesize literature on the different treatment methods currently used in clinical practice. One of the most accepted PJI diagnostic definitions was developed by the Musculoskeletal Infection Society (MSIS) in 2011, later modified in the 2013 International Consensus Meeting (ICM). After promising results from studies, alpha-defensins and D-dimer were recently incorporated into the 2018 ICM PJI definition. The management choices for PJI include irrigation and debridement (DAIR), one-stage exchange arthroplasty, or two-stage exchange arthroplasty, to name a few. While two-stage revision has traditionally been the treatment of choice in the United States, there has been a growing body of evidence framing one-stage revision as a comparable choice. One-stage revision should be offered in patients meeting strict selection criteria: no sinus tract, proper soft tissue available for wound closure, appropriate bone stock, a favorable identifiable organism with encouraging antibiotic sensitivities (for cement and oral suppression later), and robust immunological status. DAIR can be considered in case of early infections with sensitive infecting organisms. Patients with multiple unsuccessful revisions or those who refuse further surgical intervention for PJI can be offered antibiotic suppression. If nothing seems to work, salvage procedures (resection arthroplasty and arthrodesis) are available as a last resort. Further research is encouraged to improve on diagnostic capabilities and develop evidence on the best treatment of choice for PJI.
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Affiliation(s)
- Tejbir S Pannu
- Levitetz Department of Orthopaedic Surgery, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd., Weston, 33331 FL, USA
| | - Jesus M Villa
- Levitetz Department of Orthopaedic Surgery, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd., Weston, 33331 FL, USA
| | - Carlos A Higuera
- Levitetz Department of Orthopaedic Surgery, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd., Weston, 33331 FL, USA
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Comparison of patient reported outcome measures after single versus two-stage revision for chronic infection of total hip arthroplasty: a retrospective propensity score matched cohort study. Arch Orthop Trauma Surg 2021; 141:1789-1796. [PMID: 33783636 DOI: 10.1007/s00402-021-03810-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Accepted: 02/01/2021] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Two-stage revision is the current gold standard treatment for infected total hip arthroplasties (THA) with good clinical outcomes. Single-stage revision THA offers the advantage of only a single surgical intervention, potentially leading to improved functional outcomes. This study aimed to compare the differences in patient-reported outcome measures (PROMs) and complications between single and two-stage revision THA for chronic periprosthetic joint infection (PJI). METHODS A total of 159 consecutive revision THA patients for chronic PJI with complete pre-and post-operative patient-reported outcome measures (PROM) was investigated. A total of 46 patients with single-stage revision THA was matched to 92 patients following two-stage revision THA using propensity score matching, yielding a total of 136 propensity score-matched patients for analysis. RESULTS Single and two-stage revision THA improved PROM scores post-operatively, with significantly higher PROMs for single-stage revision THA (HOOS-PS: 50.7 vs 46.4, p = 0.04; Physical SF 10A: 42.1 vs 36.6, p < 0.001; PROMIS SF Physical: 41.4 vs 37.4, p < 0.001; PROMIS SF Mental: 52.8 vs 47.6, p < 0.001). There was no significant difference between both cohorts for reinfection rates (p = 0.81) and 90-day mortality rates (p = 1.0). CONCLUSION This study found a demonstrable functional benefit of single-stage revision compared to two-stage revision for THA with chronic periprosthetic joint infection, suggesting that single-stage revision THA may provide an effective alternative to two-stage revision in selected patients with chronic PJI. LEVEL OF EVIDENCE Level III, case-control retrospective analysis.
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15
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Melicherčík P, Klapková E, Nyč O, Kotaška K, Neščáková M, Landor I, Jahoda D. Antimicrobial efficacy and activity perseverance in arthroplasty of calcium sulfate beads containing vancomycin prepared ahead of time and stored in ready-to-use formula. Folia Microbiol (Praha) 2021; 67:63-69. [PMID: 34505961 DOI: 10.1007/s12223-021-00916-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Accepted: 08/20/2021] [Indexed: 10/20/2022]
Abstract
The use of local therapy with antibiotics in a suitable carrier is essential in the treatment and prevention of infections in orthopedic surgery and traumatology. In our orthopedic surgery department, a synthetic calcium sulfate hemihydrate (CaSO4·½H2O) is used as an antibiotic carrier, enabling the application of most types of intravenous antibiotics in the form of powder and liquid. This type of carrier with antibiotics is prepared in the theater during the procedure. During a surgical procedure, a small dead space is created (hand and foot area), which must be filled with an antibiotic carrier, and the situations arise where a large amount of the carrier is not used and thrown away. Therefore, we verified the efficacy of vancomycin in the pre-prepared carrier by an orientation microbiological method and by measuring the concentrations of the vancomycin released in active form and its two crystalline degradation products. Based on the agar diffusion test, we did not measure any difference in the effectiveness of the antibiotic in the carrier after its 12-day storage. Although vancomycin concentrations decreased by approximately 32% at the end of 12 days of storage, the concentrations of the released active form of vancomycin are many times higher than the minimum inhibitory concentrations for resistant strains of Staphylococcus aureus. Thus, the calcium sulfate carrier with vancomycin can be prepared several days in advance before its application, certainly up to 12 days.
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Affiliation(s)
- P Melicherčík
- Department of Orthopedics, First Faculty of Medicine, University Hospital Motol, Charles University, V Úvalu 84, 150 06, Prague 5, Czech Republic
| | - E Klapková
- Department of Medical Chemistry and Clinical Biochemistry, Second Faculty of Medicine, University Hospital Motol, Charles University, V Úvalu 84, 150 06, Prague, Czech Republic.
| | - O Nyč
- Department of Medical Microbiology, Second Faculty of Medicine, University Hospital Motol, Charles University, V Úvalu 84, 150 06, Prague, Czech Republic
| | - K Kotaška
- Department of Medical Chemistry and Clinical Biochemistry, Second Faculty of Medicine, University Hospital Motol, Charles University, V Úvalu 84, 150 06, Prague, Czech Republic
| | - M Neščáková
- Department of Medical Chemistry and Clinical Biochemistry, Second Faculty of Medicine, University Hospital Motol, Charles University, V Úvalu 84, 150 06, Prague, Czech Republic.,Department of Internal Medicine, Second Faculty of Medicine, University Hospital Motol, Charles University, V Úvalu 84, 150 06, Prague, Czech Republic
| | - I Landor
- Department of Orthopedics, First Faculty of Medicine, University Hospital Motol, Charles University, V Úvalu 84, 150 06, Prague 5, Czech Republic
| | - D Jahoda
- Department of Orthopedics, First Faculty of Medicine, University Hospital Motol, Charles University, V Úvalu 84, 150 06, Prague 5, Czech Republic
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16
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Sandiford NA, McHale A, Citak M, Kendoff D. What is the optimal duration of intravenous antibiotics following single-stage revision total hip arthroplasty for prosthetic joint infection? A systematic review. Hip Int 2021; 31:286-294. [PMID: 32459114 DOI: 10.1177/1120700020922850] [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: 02/04/2023]
Abstract
Prosthetic joint infection (PJI) is 1 of the most challenging potential complications following total joint arthroplasty. Several surgical treatment strategies have been proposed for management of this diagnosis. The single-stage approach has been gaining popularity in contemporary literature. 1 fundamental aspect in the management of hip PJI is the administration of antibiotics, usually intravenously immediately after surgery, followed by a period of oral antibiotics. The optimal duration of the period of antibiotic therapy is undecided. The aim of this paper is to examine the trend in intravenous antibiotic use over the last 18 years and examine the influence this has had on the results of single-stage revision over that time period.
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Affiliation(s)
| | | | | | - Daniel Kendoff
- Orthopaedics and Traumatology, HELIOS Kliniken GmbH, Berlin, Germany
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17
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Quayle J, Barakat A, Klasan A, Mittal A, Chan G, Gibbs J, Edmondson M, Stott P. Management of peri-prosthetic joint infection and severe bone loss after total hip arthroplasty using a long-stemmed cemented custom-made articulating spacer (CUMARS). BMC Musculoskelet Disord 2021; 22:358. [PMID: 33863329 PMCID: PMC8052787 DOI: 10.1186/s12891-021-04237-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Accepted: 04/09/2021] [Indexed: 02/02/2023] Open
Abstract
Background There is little evidence on techniques for management of peri-prosthetic infection (PJI) in the context of severe proximal femoral bone loss. Custom-made articulating spacers (CUMARS) utilising cemented femoral stems as spacers was described providing better bone support and longer survival compared to conventional articulating spacers. We retrospectively report our experience managing PJI by adaptation of this technique using long cemented femoral stems where bone loss precludes use of standard stems. Methods Patients undergoing 1st stage revision for infected primary and revision THA using a cemented long stem (> 205 mm) and standard all-polyethylene acetabulum between 2011 and 2018 were identified. After excluding other causes of revision (fractures or aseptic loosening), Twenty-one patients remained out of total 721 revisions. Medical records were assessed for demographics, initial microbiological and operative treatment, complications, eradication of infection and subsequent operations. 2nd stage revision was undertaken in the presence of pain or subsidence. Results Twenty-one patients underwent 1st stage revision with a cemented long femoral stem. Mean follow up was 3.9 years (range 1.7–7.2). Infection was eradicated in 15 (71.4%) patients. Two patients (9.5%) required repeat 1st stage and subsequently cleared their infection. Three patients (14.3%) had chronic infection and are on long term suppressive antibiotics. One patient (4.8%) was lost to follow up before 2 years. Complications occurred in seven patients (33%) during or after 1st stage revision. Where infection was cleared, 2nd stage revision was undertaken in 12 patients (76.5%) at average of 9 months post 1st stage. Five (23.8%) CUMARS constructs remained in-situ at an average of 3.8 years post-op (range 2.6–5.1). Conclusions Our technique can be used in the most taxing of reconstructive scenarios allowing mobility, local antibiotic delivery, maintenance of leg length and preserves bone and soft tissue, factors not afforded by alternative spacer options.
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Affiliation(s)
- J Quayle
- Brighton and Sussex University Hospitals, Brighton, UK.
| | - A Barakat
- Brighton and Sussex University Hospitals, Brighton, UK
| | - A Klasan
- Department for Orthopaedics and Traumatology, Kepler University Hospital GmbH, Krankenhausstrasse 9, 4020, Linz, Austria.,Johannes Kepler University Linz, Altenberger Strasse 69, 4040, Linz, Austria
| | - A Mittal
- Brighton and Sussex University Hospitals, Brighton, UK
| | - G Chan
- Brighton and Sussex University Hospitals, Brighton, UK
| | - J Gibbs
- Brighton and Sussex University Hospitals, Brighton, UK
| | - M Edmondson
- Brighton and Sussex University Hospitals, Brighton, UK
| | - P Stott
- Brighton and Sussex University Hospitals, Brighton, UK
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18
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Wolff M, Lausmann C, Gehrke T, Zahar A, Ohlmeier M, Citak M. Results at 10-24 years after single-stage revision arthroplasty of infected total hip arthroplasty in patients under 45 years of age. Hip Int 2021; 31:237-241. [PMID: 31766882 DOI: 10.1177/1120700019888877] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
INTRODUCTION The management of periprosthetic joint infection (PJI) of the hip is a challenging procedure. One-stage exchange is carried out in specialist centres with comparable infection free survival rates. However, there is a paucity of long-term results of this approach in young patients. METHODS All patients undergoing one-stage exchange due to PJI with a known causative organism ⩽45 years of age with a minimum of 10-year follow-up (mean 15 years; range 10-24 years) were enrolled in this retrospective study. Patients older than 45 years of age or patients with a two-stage procedure were excluded from the study. The primary outcome measure was failure rate with special focus on reinfection at latest follow-up. Failure was defined as revision surgery for infection. Furthermore, functional outcome using the Harris Hip Score was determined initially and at latest follow-up. 26 patients fulfilled the inclusion criteria and were available for final follow-up. RESULTS The study cohort consists of 16 male and 10 female patients with a mean age of 36.8 years (range 20-45 years) and a mean BMI of 29.8 kg/m2 (range 20.7-40.6 kg/m2). Prior to the single-stage procedure, the patients underwent an average of 3.1 previous surgical interventions (range 1-9). The mean hospital stay after septic revision was 19.7 days (11-33 days). Most infections were caused by Staphylococcus epidermidis (n = 8, 30.8%), followed by Staph. aureus (n = 7, 26.9%) and Propionibacterium acnes (n = 6, 23.1%). At latest follow-up, the overall survival rate was 76.9 %, while infection control could be achieved in 96.2%. At final examination, the mean Harris Hip Score improved from 46.2 to 78.9 (range 18.0-99; SD, 22.6). CONCLUSIONS Single-stage revision surgery for the management of PJI in patients ⩽45 years is a successful treatment option with high infection control, even after long-term follow-up.
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Affiliation(s)
- Matthias Wolff
- Prosthetic Joint Infection Centre, Helios ENDO-Klinik, Hamburg, Germany
| | | | - Thorsten Gehrke
- Prosthetic Joint Infection Centre, Helios ENDO-Klinik, Hamburg, Germany
| | - Akos Zahar
- Prosthetic Joint Infection Centre, Helios ENDO-Klinik, Hamburg, Germany
| | - Malte Ohlmeier
- Prosthetic Joint Infection Centre, Helios ENDO-Klinik, Hamburg, Germany
| | - Mustafa Citak
- Prosthetic Joint Infection Centre, Helios ENDO-Klinik, Hamburg, Germany
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19
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Pellegrini A, Legnani C. High rate of infection eradication following cementless one-stage revision hip arthroplasty with an antibacterial hydrogel coating. Int J Artif Organs 2021; 45:113-117. [PMID: 33594902 DOI: 10.1177/0391398821995507] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
PURPOSE We conducted a retrospective study to evaluate the outcomes of one-stage revision total hip arthroplasty (THA) following periprosthetic joint infection (PJI) in terms of eradication of the infection, improvement of pain and joint function. We hypothesized that this treatment strategy could lead to satisfying results in selected patients after preoperative microorganism isolation. METHODS Ten patients underwent cementless one-stage revision hip arthroplasty with antibacterial hydrogel coating for the treatment of an infected THA. Inclusion criteria were: the presence of a known organism with known sensitivity, patients non-immunocompromised with healthy soft tissues with minimal or moderate bone loss. Mean age at surgery was 69.4 years. Assessment included objective examination, Harris hip score, visual analog scale pain score, standard X-rays. RESULTS At a mean follow-up of 3.1 years (range, 2-5 years), none of the patients had clinical or radiographic signs suggesting recurrent infection. Follow-up examination showed significant improvement of all variables compared to pre-operative values (p < 0.05). Radiographs did not show progressive radiolucent lines or change in the position of the implant. CONCLUSIONS One-stage revision THA with antibacterial hydrogel coated implants represents a safe and effective procedure providing infection eradication and satisfying subjective functional outcomes in selected patients.
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Affiliation(s)
- Antonio Pellegrini
- IRCCS Istituto Ortopedico Galeazzi, Reconstructive Surgery and Septic Complications Surgery Center, Milan, Italy
| | - Claudio Legnani
- IRCCS Istituto Ortopedico Galeazzi, Sport Traumatology and Minimally-Invasive Articular Surgery Center, Milan, Italy
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20
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Lum ZC, Holland CT, Meehan JP. Systematic review of single stage revision for prosthetic joint infection. World J Orthop 2020; 11:559-572. [PMID: 33362992 PMCID: PMC7745489 DOI: 10.5312/wjo.v11.i12.559] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2020] [Revised: 10/20/2020] [Accepted: 11/29/2020] [Indexed: 02/06/2023] Open
Abstract
While advanced technology, increased medical knowledge and improved surgical technique has improved patient outcomes in total joint arthroplasty, prosthetic joint infection still remains one of the leading causes of increased healthcare costs, medical resources and societal burdens in orthopaedic care. Two stage arthroplasty revision remains the gold standard for treatment of prosthetic joint infection. Proponents of single stage revision arthroplasty for infection argue that it results in lower healthcare costs while improving patient reported functional outcomes and with equivalent success rates. Here we review the history of single stage revision arthroplasty, discuss the key principles, highlight the indications and contraindications, and review the reported outcomes with a focus on future developments of single stage revision arthroplasty for hip and knee periprosthetic joint infections.
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Affiliation(s)
- Zachary C Lum
- Department of Orthopaedic Surgery, Davis Medical Center, University of California, Sacramento, CA 95817, United States
| | - Christopher Thomas Holland
- Department of Orthopaedics, University of California, Davis Medical Center, Sacramento, CA 95817, United States
| | - John P Meehan
- Department of Orthopaedics, University of California, Davis Medical Center, Sacramento, CA 95817, United States
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21
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Marmor S, Kerroumi Y, Meyssonnier V, Lhotellier L, Mouton A, Graff W, Zeller V. One-Stage Exchange Arthroplasty for Fistulizing Periprosthetic Joint Infection of the Hip: An Effective Strategy. Front Med (Lausanne) 2020; 7:540929. [PMID: 33178708 PMCID: PMC7596676 DOI: 10.3389/fmed.2020.540929] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Accepted: 09/08/2020] [Indexed: 01/03/2023] Open
Abstract
Background: Prosthetic hip infection (PHI) is a disastrous scenario after an arthroplasty. International guidelines contraindicate one-stage exchange arthroplasty for fistulizing chronic prosthetic hip infection (FCPHI), nevertheless few surgical teams, mostly from Europe, support one stage procedure for this indication. Questions/Purposes: Analysis of infection recurrence and implant failure of a series of FCPHIs treated with one stage arthroplasty. Patients and Methods: Sixty-six FCPHIs treated with one-stage exchange arthroplasty were prospectively followed up at least 2 years. Clinical, radiological and bacteriological signs suggestive of reinfection were sought, as well as implant failures and PHI related deaths. Results: Thirty-four females and thirty-two males with median age of 69.5 years [61–77] and BMI of 26 kg/m2 [22-31] were included. Fistulae were productive in 50 patients (76%). Staphylococcus was responsible for 45% of PHI and 21% were polymicrobial. Twenty-nine patients (44%) received preoperative antibiotic therapy. After a median 60-month follow-up [35–82], 3 patients (4.5%) presented reinfection (two new infections, one relapse) and 3 patients experienced implant failure (1 femoral fracture, 1 stem breakage, 1 recurrent dislocation). One death was related to PHI. After a minimum of 2 years, the infection control rate was of 95.3% (±0.02). Conclusion: One-stage exchange arthroplasty for FCPHIs showed a good infection control rate similar to that of non-fistulizing PHI. Systematic preoperative microbiological documentation with joint aspiration and, in some specific cases, the use of preoperative antibiotic therapy are among the optimizations accounting for the success of the one-stage arthroplasty. In light of these results, and those of other studies, international recommendations could evolve. Level of Evidence: Descriptive therapeutic prospective cohort study. Level of evidence: IV.
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Affiliation(s)
- Simon Marmor
- Department of Orthopedic Surgery, Diaconesses Croix Saint-Simon Hospital, Paris, France.,Referral Center for Osteoarticular Infections, Diaconesses Croix Saint-Simon Hospital, Paris, France
| | - Younes Kerroumi
- Department of Orthopedic Surgery, Diaconesses Croix Saint-Simon Hospital, Paris, France.,Referral Center for Osteoarticular Infections, Diaconesses Croix Saint-Simon Hospital, Paris, France
| | - Vanina Meyssonnier
- Referral Center for Osteoarticular Infections, Diaconesses Croix Saint-Simon Hospital, Paris, France
| | - Luc Lhotellier
- Department of Orthopedic Surgery, Diaconesses Croix Saint-Simon Hospital, Paris, France.,Referral Center for Osteoarticular Infections, Diaconesses Croix Saint-Simon Hospital, Paris, France
| | - Antoine Mouton
- Department of Orthopedic Surgery, Diaconesses Croix Saint-Simon Hospital, Paris, France.,Referral Center for Osteoarticular Infections, Diaconesses Croix Saint-Simon Hospital, Paris, France
| | - Wilfrid Graff
- Department of Orthopedic Surgery, Diaconesses Croix Saint-Simon Hospital, Paris, France.,Referral Center for Osteoarticular Infections, Diaconesses Croix Saint-Simon Hospital, Paris, France
| | - Valérie Zeller
- Referral Center for Osteoarticular Infections, Diaconesses Croix Saint-Simon Hospital, Paris, France
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22
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Govoni M, Lamparelli EP, Ciardulli MC, Santoro A, Oliviero A, Palazzo I, Reverchon E, Vivarelli L, Maso A, Storni E, Donati ME, Ruspaggiari G, Maffulli N, Fini M, Della Porta G, Dallari D. Demineralized bone matrix paste formulated with biomimetic PLGA microcarriers for the vancomycin hydrochloride controlled delivery: Release profile, citotoxicity and efficacy against S. aureus. Int J Pharm 2020; 582:119322. [PMID: 32298742 DOI: 10.1016/j.ijpharm.2020.119322] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Revised: 04/07/2020] [Accepted: 04/08/2020] [Indexed: 12/13/2022]
Abstract
Infection and resulting bone defects caused by Staphylococcus aureus is one of the major issues in orthopaedic surgeries. Vancomycin hydrochloride (VaH) is largely used to manage these events. Here, a human derived bone paste supplemented with biopolymer microcarriers for VaH sustained delivery to merge osteoinductive and antimicrobial actions is described. In detail, different emulsion formulations were tested to fabricate micro-carriers of poly-lactic-co-glycolic acid (PLGA) and hydroxyapatite (HA) by a proprietary technology (named Supercritical Emulsion Extraction). These carriers (mean size 827 ± 68 μm; loading 47 mgVaH/gPLGA) were assembled with human demineralized bone matrix (DBM) to obtain an antimicrobial bone paste system (250 mg/0.5 cm3 w/v, carrier/DBM). Release profiles in PBS indicated a daily drug average release of about 4 µg/mL over two weeks. This concentration was close to the minimum inhibitory concentration and able to effectively inhibit the S. aureus growth in our experimental sets. Carriers cytotoxicity tests showed absence of adverse effects on cell viability at the concentrations used for paste assembly. This approach points toward the potential of the DBM-carrier-antibiotic system in hampering the bacterial growth with accurately controlled antibiotic release and opens perspectives on functional bone paste with PLGA carriers for the controlled release of bioactive molecules.
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Affiliation(s)
- Marco Govoni
- Reconstructive Orthopaedic Surgery and Innovative Techniques - Musculoskeletal Tissue Bank, IRCCS Istituto Ortopedico Rizzoli, Via G.C. Pupilli 1, 40136 Bologna, Italy.
| | - Erwin P Lamparelli
- Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana", University of Salerno, Via S. Allende, Baronissi (SA), Italy.
| | - Maria C Ciardulli
- Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana", University of Salerno, Via S. Allende, Baronissi (SA), Italy.
| | - Antonietta Santoro
- Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana", University of Salerno, Via S. Allende, Baronissi (SA), Italy.
| | - Antonio Oliviero
- Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana", University of Salerno, Via S. Allende, Baronissi (SA), Italy.
| | - Ida Palazzo
- Department. of Industrial Engineering, University of Salerno, Via G. Paolo II, Fisciano (SA), Italy.
| | - Ernesto Reverchon
- Department. of Industrial Engineering, University of Salerno, Via G. Paolo II, Fisciano (SA), Italy.
| | - Leonardo Vivarelli
- Reconstructive Orthopaedic Surgery and Innovative Techniques - Musculoskeletal Tissue Bank, IRCCS Istituto Ortopedico Rizzoli, Via G.C. Pupilli 1, 40136 Bologna, Italy.
| | - Alessandra Maso
- Laboratory of Microbiology and GMP Quality Control, IRCCS Istituto Ortopedico Rizzoli, Via Di Barbiano 1/10, 40136 Bologna, Italy.
| | - Elisa Storni
- Laboratory of Microbiology and GMP Quality Control, IRCCS Istituto Ortopedico Rizzoli, Via Di Barbiano 1/10, 40136 Bologna, Italy.
| | - Maria E Donati
- Laboratory of Microbiology and GMP Quality Control, IRCCS Istituto Ortopedico Rizzoli, Via Di Barbiano 1/10, 40136 Bologna, Italy.
| | - Gianluca Ruspaggiari
- Reconstructive Orthopaedic Surgery and Innovative Techniques - Musculoskeletal Tissue Bank, IRCCS Istituto Ortopedico Rizzoli, Via G.C. Pupilli 1, 40136 Bologna, Italy.
| | - Nicola Maffulli
- Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana", University of Salerno, Via S. Allende, Baronissi (SA), Italy.
| | - Milena Fini
- Laboratory of Preclinical and Surgical Studies, IRCCS Istituto Ortopedico Rizzoli, Via Di Barbiano 1/10, 40136 Bologna, Italy.
| | - Giovanna Della Porta
- Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana", University of Salerno, Via S. Allende, Baronissi (SA), Italy.
| | - Dante Dallari
- Reconstructive Orthopaedic Surgery and Innovative Techniques - Musculoskeletal Tissue Bank, IRCCS Istituto Ortopedico Rizzoli, Via G.C. Pupilli 1, 40136 Bologna, Italy.
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23
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Palmer JR, Pannu TS, Villa JM, Manrique J, Riesgo AM, Higuera CA. The treatment of periprosthetic joint infection: safety and efficacy of two stage versus one stage exchange arthroplasty. Expert Rev Med Devices 2020; 17:245-252. [DOI: 10.1080/17434440.2020.1733971] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Joseph R. Palmer
- Levitetz Department of Orthopaedic Surgery, Cleveland Clinic Florida, Weston, FL, USA
| | - Tejbir S. Pannu
- Levitetz Department of Orthopaedic Surgery, Cleveland Clinic Florida, Weston, FL, USA
| | - Jesus M. Villa
- Levitetz Department of Orthopaedic Surgery, Cleveland Clinic Florida, Weston, FL, USA
| | - Jorge Manrique
- Levitetz Department of Orthopaedic Surgery, Cleveland Clinic Florida, Weston, FL, USA
| | - Aldo M. Riesgo
- Levitetz Department of Orthopaedic Surgery, Cleveland Clinic Florida, Weston, FL, USA
| | - Carlos A. Higuera
- Levitetz Department of Orthopaedic Surgery, Cleveland Clinic Florida, Weston, FL, USA
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24
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Peng HM, Wang LC, Cheng JY, Zhou YX, Tian H, Lin JH, Guo WS, Lin Y, Qu TB, Guo A, Cao YP, Weng XS. Rates of periprosthetic infection and surgical revision in Beijing (China) between 2014 and 2016: a retrospective multicenter cross-sectional study. J Orthop Surg Res 2019; 14:463. [PMID: 31878949 PMCID: PMC6933879 DOI: 10.1186/s13018-019-1520-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Accepted: 12/17/2019] [Indexed: 01/22/2023] Open
Abstract
Background Periprosthetic joint infection (PJI) is a rare but devastating complication after total joint arthroplasty. There is a paucity of data on the incidence and prevalence of periprosthetic infection in mainland China. This study aimed to analyze the rates of surgical revision after arthroplasty due to PJI and the procedures followed in Beijing, China. Methods The study involved a retrospective multicenter cross-sectional survey of patients undergoing revisions for periprosthetic infection after hip/knee arthroplasty at nine hospitals in Beijing from 2014 to 2016. Age, gender, body mass index, primary diagnosis, comorbidity, primary surgery, treatment methods, and post-revision complications were analyzed. Results A total of 38,319 hip/knee arthroplasties and 366 (0.96%) revisions for PJI were identified. Of these, 161 (161/14,110; 1.14%) revisions involved hip arthroplasty, whereas 205 (205/24,209; 0.85%) revisions were due to knee arthroplasty. Procedures for revisions of infected hip included 7 (4.3%) cases of open debridement and prosthesis retention, 32 (19.9%) cases of one-stage exchange, 121 (75.2%) cases of two-stage exchange, and 1 (0.007%) case of hip dissection. As for the infected knee, the procedures included 45 (22.0%) cases of open debridement and prosthesis retention, 13 (6.3%) cases of one-stage exchange, 143 (69.8%) cases of two-stage exchange, and 4 (0.02%) cases of knee fusion. Conclusions The study found the rates of revision due to PJI to be low. Nonetheless, the incidence of PJI in mainland China could be higher and calls for more elaborate studies in geographically and socioeconomically diverse health institutions.
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Affiliation(s)
- Hui-Ming Peng
- Department of Orthopedics, Peking Union Medical College Hospital, CAMS & PUMC, No.1 Shuaifuyuan, Wangfujing, Dongcheng District, Beijing, 100730, China
| | - Long-Chao Wang
- Department of Orthopedics, Peking Union Medical College Hospital, CAMS & PUMC, No.1 Shuaifuyuan, Wangfujing, Dongcheng District, Beijing, 100730, China
| | - Ji-Ying Cheng
- Department of Orthopedics, Chinese PLA General Hospital, Beijing, 100853, China
| | - Yi-Xin Zhou
- Department of Orthopedics, Beijing Jishuitan Hospital, Beijing, 100035, China
| | - Hua Tian
- Department of Orthopedics, Peking University Third Hospital, Beijing, 100083, China
| | - Jian-Hao Lin
- Department of Orthopedics, Peking University People's Hospital, Beijing, 100044, China
| | - Wan-Shou Guo
- Department of Orthopedics, Sino-Japanese Friendship Hospital, Beijing, 100029, China
| | - Yuan Lin
- Department of Orthopedics, Beijing Chaoyang Hospital, Capital Medical University, Beijing, 100020, China
| | - Tie-Bing Qu
- Department of Orthopedics, China Rehabilitation Research Center Beijing Boai Hospital, Beijing, 100068, China
| | - Ai Guo
- Department of Orthopedics, Beijing Friendship Hospital, Capital Medical University, Beijing, 100050, China
| | - Yong-Ping Cao
- Department of Orthopedics, Peking University First Hospital, Beijing, 100034, China
| | - Xi-Sheng Weng
- Department of Orthopedics, Peking Union Medical College Hospital, CAMS & PUMC, No.1 Shuaifuyuan, Wangfujing, Dongcheng District, Beijing, 100730, China.
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25
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Yan CH, Arciola CR, Soriano A, Levin LS, Bauer TW, Parvizi J. Team Approach: The Management of Infection After Total Knee Replacement. JBJS Rev 2019; 6:e9. [PMID: 29664872 DOI: 10.2106/jbjs.rvw.17.00058] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
- Chun Hoi Yan
- Department of Orthopaedics & Traumatology, The University of Hong Kong, Hong Kong SAR, People's Republic of China
| | - Carla Renata Arciola
- Research Unit on Implant Infections, Rizzoli Orthopaedic Institute, Bologna, Italy.,Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Bologna, Italy
| | - Alex Soriano
- Department of Infectious Diseases, Hospital Clinic of Barcelona, IDIBAPS, University of Barcelona, Spain
| | - L Scott Levin
- Department of Orthopaedic Surgery, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - Thomas W Bauer
- Department of Pathology and Laboratory Medicine, Hospital for Special Surgery, New York, NY
| | - Javad Parvizi
- Department of Orthopaedic Surgery, Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
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26
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Vancomycin and its crystalline degradation products released from bone grafts and different types of bone cement. Folia Microbiol (Praha) 2019; 65:475-482. [PMID: 31654320 DOI: 10.1007/s12223-019-00752-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Accepted: 09/20/2019] [Indexed: 10/25/2022]
Abstract
Vancomycin is often used in orthopedic surgery as a local prophylaxis of bacterial infection. The aim of this work was to compare the release of vancomycin and its biologically inactive crystalline degradation products (CDP-1) during in vitro experiments from different types of local antibiotic delivery systems (bone grafts and bone cements). The concentrations of vancomycin and its crystalline degradation products were determined by high-performance liquid chromatography. Each experiment was performed in a phosphate buffer solution over 21 days. Morselized bone grafts, synthetic bone cements Palacos and Copal, and synthetic bone grafts were tested as local carriers of vancomycin. The highest concentration approximately 670 mg/L of vancomycin was released from synthetic bone grafts Actifuse. Even after 21 days, the concentration of vancomycin was still above the minimum inhibitory concentration (MIC). The maximum concentration of vancomycin released in two experiments with human bone grafts exceeded 600 mg/L during the first day and was still above MIC level 21 days later when the experiment was concluded. By comparing the synthetic bone cements Palacos and Copal, Copal had the average maximum concentration of only 32.4 mg/L and Palacos 35.7 mg/L. The concentration of vancomycin fell below the MIC for vancomycin-resistant Staphylococcus aureus (VRSA) on the seventh day with Palacos and the ninth day with Copal. This study showed the insufficient concentration of released vancomycin from synthetic bone cements at the end of the experiment. For improvement of local prophylaxis, it would be beneficial to increase the amount of vancomycin in bone cements.
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27
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Peeters A, Putzeys G, Thorrez L. Current Insights in the Application of Bone Grafts for Local Antibiotic Delivery in Bone Reconstruction Surgery. J Bone Jt Infect 2019; 4:245-253. [PMID: 31700774 PMCID: PMC6831806 DOI: 10.7150/jbji.38373] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Accepted: 08/27/2019] [Indexed: 12/15/2022] Open
Abstract
Introduction: Bone implant related infection is still one of the biggest challenges in bone and joint surgery. Antibiotic impregnated bone grafts seem to be promising in both treatment and prevention of these infections. However, great variance in methodology predominates this field of research. This paper gives an overview of the published literature. Methods: The PRISMA-flowchart was used as protocol for article selection. Medline was searched and articles were selected in accordance with predetermined exclusion criteria. Results: Forty-eight articles were included in the synthesis. Topics including bone graft type, manipulations of the graft, elution profile, bacterial inhibition, osteotoxicity, incorporation, special impregnation methods, clinical use and storage were investigated. Therapeutically, high initial levels seem appropriate for biofilm eradication. A single stage procedure in the treatment of bone implant related infection seems feasible. Prophylactically, the literature indicates a reduction of postoperative infections when using antibiotic impregnated bone grafts. Conclusion: Bone grafts are a suitable carrier for local antibiotic application both therapeutically and prophylactically.
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Affiliation(s)
| | - Guy Putzeys
- Orthopedic Centre, AZ Groeninge, Kortrijk, Belgium
| | - Lieven Thorrez
- Department of Development and Regeneration, KU Leuven, Kortrijk, Belgium
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28
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McDonald E. What Are the Predictors of Treatment Failure in Patients Who Have Undergone Two-Stage Exchange for Infected Total Ankle Arthroplasty (TAA)? Foot Ankle Int 2019; 40:60S-61S. [PMID: 31322953 DOI: 10.1177/1071100719861547] [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: 02/01/2023]
Abstract
RECOMMENDATION Predictors for treatment failure in patients undergoing 2-stage exchange for infected total ankle arthroplasty (TAA) include compromised soft tissues (eg, sinus tract and exposed hardware), significant bone involvement/osteomyelitis, and insufficient timing of antibiotic course before reimplantation. LEVEL OF EVIDENCE Moderate. DELEGATE VOTE Agree: 100%, Disagree: 0%, Abstain: 0% (Unanimous, Strongest Consensus).
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Affiliation(s)
- Elizabeth McDonald
- 1 Rothman Orthopaedics, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA
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29
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Ellington K, Bemenderfer TB. What Are the Indications for One-Stage Versus Two-Stage Exchange Arthroplasty in Management of the Infected Total Ankle Arthroplasty (TAA)? Foot Ankle Int 2019; 40:55S-58S. [PMID: 31322956 DOI: 10.1177/1071100719861104] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
RECOMMENDATION Two-stage exchange arthroplasty is recommended in the majority of cases following infected TAA. One-stage arthroplasty is only indicated in a limited patient population with acute infection, preoperatively identified low-virulence organisms, and low-risk patient factors. LEVEL OF EVIDENCE Consensus. DELEGATE VOTE Agree: 92%, Disagree: 8%, Abstain: 0% (Super Majority, Strong Consensus).
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Affiliation(s)
- Kent Ellington
- 1 OrthoCarolina, Foot and Ankle Institute, Charlotte, NC, USA
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30
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Ellington K, Hirose CB, Bemenderfer TB. What Is the Treatment "Algorithm" for Infection After Ankle or Hindfoot Arthrodesis? Foot Ankle Int 2019; 40:64S-70S. [PMID: 31322955 DOI: 10.1177/1071100719861643] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
RECOMMENDATION There is no universal algorithm for addressing the infected ankle or subtalar arthrodesis. A potential algorithm created by consensus is. LEVEL OF EVIDENCE Consensus. DELEGATE VOTE Agree: 100%, Disagree: 0%, Abstain: 0% (Unanimous, Strongest Consensus).
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Affiliation(s)
- Kent Ellington
- 1 OrthoCarolina, Foot and Ankle Institute, AtriumHealth, Charlotte, NC, USA
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31
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Enhancing biology and providing structural support for acetabular reconstruction in single-stage revision for infection. J Orthop Traumatol 2019; 20:23. [PMID: 31236707 PMCID: PMC6591340 DOI: 10.1186/s10195-019-0530-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2017] [Accepted: 08/29/2018] [Indexed: 11/26/2022] Open
Abstract
Background Reconstruction of combined segmental and cavitary defects of the acetabulum is a challenge to the hip surgeon. One question regards the efficacy of reconstruction of acetabular defects using a combination of tantalum metal augments (TMAs) and impaction graft in single-stage revision for periprosthetic infection. Materials and methods In the period between July 2009 and August 2014, 24 patients with combined segmental and cavitary acetabular defects and Paprosky classification grade IIB, IIC, and IIIA had hips reconstructed using the combination of TMAs and antibiotic-loaded impaction grafting. A similar group of 30 patients who received single-stage revision without metal augments were identified and taken as control. All patients received a polyethylene cemented cup and long cementless (Wagner SL) stem. Patients were prospectively evaluated using the modified Harris Hip Score (HHS) in addition to radiological evaluation at 3, 6, and 12 months then annually thereafter. Results At an average follow-up period of 4 years (range 2–7 years), all but one patient in the study group were free of infection, indicating a 96% success rate. This rate of eradicating infection was comparable to the 97% success rate in the control group. All metal augments were stable, and good incorporation of the impacted bone graft was observed. The HHS improved significantly from 27 preoperatively to 83 postoperatively (P < 0.001). Conclusion Metal augments can convert massive acetabular defects to a more contained defect suitable for grafting. The combination of tantalum augments that provide strong structural support and antibiotic-loaded allograft is successful in the mid-term in single-stage revisions for infection. Level of evidence Level IV (prospective case series).
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32
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Frommelt L. [Use of antibiotics in bones : Prophylaxis and current treatment standards]. DER ORTHOPADE 2019; 47:24-29. [PMID: 29222580 DOI: 10.1007/s00132-017-3508-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND Treatment of bone infection is difficult due the systemic administration of antibiotics, which means that only low concentrations reach the inflamed bone tissue. Loss of bone stock is common in osteomyelitis and device associated infection. Local antibiotics are administered in several ways for prophylactic purposes and also for treatment of bone infection. We intend to show the options and limitations of clinical use of antibiotic-loaded bone grafts. SUITABILITY Bone grafts are a suitable carrier system for antibiotics. Bone grafts may be loaded with a variety of antimicrobial agents so that individual therapies may be carried out. Critical systemic side effects are unlikely even though extreme high drug concentrations are obtained locally, if the thresholds for loading with antibiotics are respected. Thus, antibiotic-loaded bone grafts are appropriate for prophylaxis and therapy as well. If processing is done in the operating theatre compliance to the legal rules must be respected. RULES Due to a lack of standardised procedures for loading, application and performance of the application of antibiotic-loaded bone grafts medical societies are being asked to initiate consensus meetings in order to issue recommendations or guidelines with respect to antibiotic-loaded bone grafts to establish reliable rules for surgeons using these devices.
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Affiliation(s)
- L Frommelt
- Institut für Klinische Mikrobiologie, Infektiologie und Krankenhaushygiene, HELIOS ENDO-Klinik Hamburg, Holstenstr. 2, 22767, Hamburg, Deutschland.
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33
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Kamra P, Lamba AK, Faraz F, Tandon S. Effect of antibiotic impregnation time on the release of gentamicin from cryopreserved allograft bone chips: an in vitro study. Cell Tissue Bank 2019; 20:267-273. [PMID: 30989363 DOI: 10.1007/s10561-019-09765-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2018] [Accepted: 04/01/2019] [Indexed: 11/25/2022]
Abstract
Freezing is the most common method for storing bones until use in skeletal reconstruction. However, the effect of freezing at different temperatures on antibiotic delivery from antibiotic-coated bone chips has not been evaluated. In this study, we compared antibiotic delivery in vitro from gentamicin-coated human bone stored at different temperatures impregnated for different time periods. Bone chips obtained from human femur heads were chemically cleaned and mixed with gentamicin sulfate solution for 1 h and 10 h respectively. Samples of both groups were cryopreserved for 4 months at - 20 °C, 4 months at - 80 °C, or evaluated immediately without freezing. Antibiotic release from the bone chips was measured using Bacillus subtilis as an indicator strain. Zones of inhibition and rates of gentamicin were higher for the samples impregnated for 10 h as compared to 1 h. There was no significant difference between non-cryopreservation, cryopreservation at different temperatures of - 20 and - 80 °C on the release of gentamicin from bone chips even after storage for 4 months.
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Affiliation(s)
- Priyanka Kamra
- Department of Periodontics, Maulana Azad Institute of Dental Sciences, New Delhi, 110002, India.
| | - Arundeep Kaur Lamba
- Department of Periodontics, Maulana Azad Institute of Dental Sciences, New Delhi, 110002, India
| | - Farrukh Faraz
- Department of Periodontics, Maulana Azad Institute of Dental Sciences, New Delhi, 110002, India
| | - Shruti Tandon
- Department of Periodontics, Maulana Azad Institute of Dental Sciences, New Delhi, 110002, India
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34
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Sukeik M, Haddad FS. Periprosthetic joint infections after total hip replacement: an algorithmic approach. SICOT J 2019; 5:5. [PMID: 30816089 PMCID: PMC6394232 DOI: 10.1051/sicotj/2019004] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Accepted: 01/28/2019] [Indexed: 12/25/2022] Open
Abstract
An algorithm for managing periprosthetic joint infections (PJIs) after total hip replacement (THR) surgery using a multidisciplinary approach and a clearly defined protocol may improve infection eradication rates. In this article, we present an algorithm for the management of different types of PJIs including the acutely infected cemented and cementless THRs where the components are well-fixed postoperatively and when the infection is secondary to haematogenous spread in previously well-functioning and well-fixed implants. For chronic PJIs where the components are often loose, the standard treatment includes a two-stage revision procedure. However, in a highly selected subset of patients, a single-stage approach has been utilised with high rates of eradicating infections.
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Affiliation(s)
- Mohamed Sukeik
- Foothills Medical Centre, 1403 29 St NW Calgary, AB T2N 2T9, Canada
| | - Fares Sami Haddad
- University College London Hospital, 235 Euston Road, London NW1 2BU, UK
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35
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Bialecki J, Bucsi L, Fernando N, Foguet P, Guo S, Haddad F, Hansen E, Janvari K, Jones S, Keogh P, McHale S, Molloy R, Mont MA, Morgan-Jones R, Ohlmeier M, Saldaña A, Sodhi N, Toms A, Walker R, Zahar A. Hip and Knee Section, Treatment, One Stage Exchange: Proceedings of International Consensus on Orthopedic Infections. J Arthroplasty 2019; 34:S421-S426. [PMID: 30348563 DOI: 10.1016/j.arth.2018.09.026] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
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36
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General Assembly, Prevention, Local Antimicrobials: Proceedings of International Consensus on Orthopedic Infections. J Arthroplasty 2019; 34:S75-S84. [PMID: 30352772 DOI: 10.1016/j.arth.2018.09.056] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
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37
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Burke NG, Gibbons JP, Cassar-Gheiti AJ, Walsh FM, Cashman JP. Total hip replacement-the cause of failure in patients under 50 years old? Ir J Med Sci 2018; 188:879-883. [PMID: 30569374 DOI: 10.1007/s11845-018-01956-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Accepted: 12/13/2018] [Indexed: 10/27/2022]
Abstract
AIM To establish the mode of failure of primary total hip replacement in patients under 50 years old. METHODS A total of 1062 revision total hip arthroplasties were performed over a 5-year period, with 146 on patients under 50 years old. These were subdivided into early (< 5 years) and late (> 5 years) failures from the index procedure. RESULTS The commonest mechanism of failure was aseptic loosening (42.3%) followed by metal-on-metal failure (15.8%), infection (14.4%) and instability (9.6%). The commonest cause of early revision surgery was due to metal-on-metal failure (27.8%) followed by aseptic loosening (19.7%) and infection (18.4%). In the late revision group, the main cause of failure was aseptic loosening (64%) and infection (10.7%). CONCLUSION The changing trend of early revision due to metal-on-metal failure is important to recognise. Continuous review of the mechanism of primary total hip replacement failure is necessary to ensure the best patient outcome and maximise implant survivorship.
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Affiliation(s)
- Neil G Burke
- Department of Orthopaedic Surgery, Cappagh National Orthopaedic Hospital, Dublin, Ireland.
| | - John P Gibbons
- Department of Orthopaedic Surgery, Cappagh National Orthopaedic Hospital, Dublin, Ireland
| | - Adrian J Cassar-Gheiti
- Department of Orthopaedic Surgery, Cappagh National Orthopaedic Hospital, Dublin, Ireland
| | - Fionnuala M Walsh
- Department of Orthopaedic Surgery, Cappagh National Orthopaedic Hospital, Dublin, Ireland
| | - James P Cashman
- Department of Orthopaedic Surgery, Cappagh National Orthopaedic Hospital, Dublin, Ireland
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One-stage exchange with antibacterial hydrogel coated implants provides similar results to two-stage revision, without the coating, for the treatment of peri-prosthetic infection. Knee Surg Sports Traumatol Arthrosc 2018; 26:3362-3367. [PMID: 29549387 DOI: 10.1007/s00167-018-4896-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2017] [Accepted: 03/12/2018] [Indexed: 02/06/2023]
Abstract
PURPOSE Aim of this study was to verify the hypothesis that a one-stage exchange procedure, performed with an antibiotic-loaded, fast-resorbable hydrogel coating, provides similar infection recurrence rate than a two-stage procedure without the coating, in patients affected by peri-prosthetic joint infection (PJI). METHODS In this two-center case-control, study, 22 patients, treated with a one-stage procedure, using implants coated with an antibiotic-loaded hydrogel [defensive antibacterial coating (DAC)], were compared with 22 retrospective matched controls, treated with a two-stage revision procedure, without the coating. RESULTS At a mean follow-up of 29.3 ± 5.0 months, two patients (9.1%) in the DAC group showed an infection recurrence, compared to three patients (13.6%) in the two-stage group. Clinical scores were similar between groups, while average hospital stay and antibiotic treatment duration were significantly reduced after one-stage, compared to two-stage (18.9 ± 2.9 versus 35.8 ± 3.4 and 23.5 ± 3.3 versus 53.7 ± 5.6 days, respectively). CONCLUSIONS Although in a relatively limited series of patients, our data shows similar infection recurrence rate after one-stage exchange with DAC-coated implants, compared to two-stage revision without coating, with reduced overall hospitalization time and antibiotic treatment duration. These findings warrant further studies in the possible applications of antibacterial coating technologies to treat implant-related infections. LEVEL OF EVIDENCE III.
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Abstract
The treatment of superficial wound infections with local antibiotics is considered to be problematic as it is accompanied by an increased risk of resistance development and ineffectiveness in deeper regions. On the contrary, the local application of antibiotics is useful in arthroplasty and necessary if implants are utilized. The reason for this is the prevention of a rapid biofilm formation on foreign implants and a resulting infection may remain undiscovered until it becomes chronic. Apart from exogenous material, necrotic tissue (e. g. bone sequestra) provides suitable retreat areas for pathogens in the body. Because of the characteristics of bone and joint infections and an exceptional infection recurrence rate, a combined approach is required. Systemic antibiotic prophylaxis is able to reduce the number of pathogens acquired by perioperative contamination or hematogenic spread from another focus of infection; however, systemically applied antibiotics often fail to form an effective colonization barrier around the implant because their ability to penetrate the bone is relatively low. On the other hand, the high concentration of locally released antibiotics leads to an effective protection of the implant from bacteria in situ. Thus, for the treatment of implant-associated infections, systemic and local application of anti-infective agents is a reliable adjuvant measure that improves the therapeutic success. Polymethylmethacrylate (PMMA) bone cement is the most commonly used local drug carrier. Based on clinical and microbiological results, microbiologists and infectious disease experts together with the surgeon and pharmacist determine which anti-infective agents are indicated for systemic and local, PMMA cement-related application. Because there is no evident concept for the local application, unlike the recommendation for systemic use of anti-infective agents, this review article describes which aspects should be taken into account.
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Rowan FE, Donaldson MJ, Pietrzak JR, Haddad FS. The Role of One-Stage Exchange for Prosthetic Joint Infection. Curr Rev Musculoskelet Med 2018; 11:370-379. [PMID: 29987643 PMCID: PMC6105475 DOI: 10.1007/s12178-018-9499-7] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
PURPOSE OF REVIEW In an era of increasing numbers of hip and knee replacements, strategies to manage prosthetic joint infection (PJI) that are effective at infection control with good patient-reported outcomes and cost containment for health systems are needed. Interest in single-stage exchange for PJI is rising and we assess evidence from the last 5 years related to this treatment strategy. RECENT FINDINGS Only five series for total knee replacement and ten series for total hip replacement have been reported in the last five years. More review articles and opinion pieces have been written. Reinfection rates in these recent studies range from 0 to 65%, but a meta-analysis and systematic review of all studies showed a reinfection rate of 7.6% (95% CI 3.4-13.1) and 8.8% (95% CI 7.2-10.6) for single-stage and two-stage revisions respectively. There is emerging evidence to support single-stage revision in the setting of significant bony deficiency and atypical PJIs such as fungal infections. Prospective randomised studies are recruiting and are necessary to guide the direction of single-stage revision selection criteria. The onus of surgical excellence in mechanical removal of implants, necrotic tissue, and biofilms lies with the arthroplasty surgeon and must remain the cornerstone of treatment. Single-stage revision may be considered the first-line treatment for all PJIs unless the organism is unknown, the patient is systemically septic, or there is a poor tissue envelope.
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Affiliation(s)
- Fiachra E Rowan
- Department of Orthopaedic Surgery, University College London Hospital, 250 Euston Road, London, NW1 2PG, UK.
- The Princess Grace Hospital, 42-52 Nottingham Place, Marylebone, London, W1U 5NY, UK.
| | - Matthew J Donaldson
- Department of Orthopaedic Surgery, University College London Hospital, 250 Euston Road, London, NW1 2PG, UK
- The Princess Grace Hospital, 42-52 Nottingham Place, Marylebone, London, W1U 5NY, UK
| | - Jurek R Pietrzak
- Department of Orthopaedic Surgery, University College London Hospital, 250 Euston Road, London, NW1 2PG, UK
- The Princess Grace Hospital, 42-52 Nottingham Place, Marylebone, London, W1U 5NY, UK
| | - Fares S Haddad
- Department of Orthopaedic Surgery, University College London Hospital, 250 Euston Road, London, NW1 2PG, UK
- The Princess Grace Hospital, 42-52 Nottingham Place, Marylebone, London, W1U 5NY, UK
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Kuiper JW, Rustenburg CM, Willems JH, Verberne SJ, Peters EJ, Saouti R. Results and Patient Reported Outcome Measures (PROMs) after One-Stage Revision for Periprosthetic Joint Infection of the Hip: A Single-centre Retrospective Study. J Bone Jt Infect 2018; 3:143-149. [PMID: 30013896 PMCID: PMC6043468 DOI: 10.7150/jbji.24366] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2017] [Accepted: 06/13/2018] [Indexed: 12/21/2022] Open
Abstract
Background: Little is known about functional outcome and quality of life (QoL) after one-stage revision for periprosthetic joint infection (PJI) of the hip. Methods: a cohort of 30 subjects treated with one-stage revision between 2011 and 2015 was identified, and questionnaires on functional outcome and QoL were distributed. Results: 28 subjects were successfully treated (93%). Most subjects were referred from other hospitals. Coagulase-negative Staphylococcus was found in 50% of the cases, and 40% of all cultured bacteria were multidrug-resistant. 25% had subsequent revision surgery, unrelated to PJI. Functional outcome was good and QoL scores were high, comparable to prosthetic joint revision surgery in general. Conclusion: Although the cohort was small and statistical analysis was not performed, this study showed that excellent results can be obtained with one-stage revision for hip PJI. Functional outcome and QoL was comparable to prosthetic joint revision surgery in general.
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Affiliation(s)
- Jesse W.P. Kuiper
- Department of Orthopaedic Surgery, VU University Medical Centre, Amsterdam, the Netherlands
- Department of Orthopaedic Surgery, Noord-West Ziekenhuisgroep, Alkmaar, the Netherlands
| | | | - Jore H. Willems
- Department of Orthopaedic Surgery, Noord-West Ziekenhuisgroep, Alkmaar, the Netherlands
- Department of Orthopaedic Surgery, Spaarne Gasthuis, Hoofddorp, the Netherlands
| | - Steven J. Verberne
- Department of Orthopaedic Surgery, Noord-West Ziekenhuisgroep, Alkmaar, the Netherlands
| | - Edgar J.G. Peters
- Department of Internal Medicine, VU University Medical Centre, Amsterdam, the Netherlands
- Amsterdam Infection and Immunity Institute, Amsterdam, the Netherlands
| | - Rachid Saouti
- Department of Orthopaedic Surgery, VU University Medical Centre, Amsterdam, the Netherlands
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Casadidio C, Butini ME, Trampuz A, Di Luca M, Censi R, Di Martino P. Daptomycin-loaded biodegradable thermosensitive hydrogels enhance drug stability and foster bactericidal activity against Staphylococcus aureus. Eur J Pharm Biopharm 2018; 130:260-271. [PMID: 30064700 DOI: 10.1016/j.ejpb.2018.07.001] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Revised: 06/20/2018] [Accepted: 07/02/2018] [Indexed: 10/28/2022]
Abstract
A drug delivery system based on fully biodegradable thermosensitive hydrogels enabling controlled antibiotic release may support the management of implant-associated infections. In this work, the lipopeptide antibiotic daptomycin was encapsulated in hydrogel networks consisting of vinyl sulfonated triblock copolymers of PEG-p(HPMAm-lac1,2) and thiolated hyaluronic acid. High concentrations of active daptomycin exceeding the minimum biofilm eradicating concentration were sustainably eluted from the biodegradable carrier. The drug release profiles were tailored by varying the degree of substitution (DS) of thiol groups of hyaluronic acid, reaching a plateau level after 200 and 330 h for DS values of 53% and 31%, respectively. The hydrogel polymeric network preserved the structural stability of the loaded antibiotic and retained the calcium-dependent daptomycin activity, showing a noticeable biofilm bactericidal effect against a 24 h-old Staphylococcus aureus biofilm in vitro. The two-component thermosensitive hydrogels demonstrated to be an excellent antibiotic releasing scaffold with potential clinical applications in the management of implant-associated infections.
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Affiliation(s)
- Cristina Casadidio
- School of Pharmacy, University of Camerino, Via S. Agostino 1, 62032 Camerino, MC, Italy
| | - Maria Eugenia Butini
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Center for Musculoskeletal Surgery, Charitéplatz 1, 10117 Berlin, Germany; Berlin-Brandenburg Center for Regenerative Therapies, Charité - Universitätsmedizin Berlin, Augustenburger Platz 1, 13353 Berlin, Germany
| | - Andrej Trampuz
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Center for Musculoskeletal Surgery, Charitéplatz 1, 10117 Berlin, Germany; Berlin-Brandenburg Center for Regenerative Therapies, Charité - Universitätsmedizin Berlin, Augustenburger Platz 1, 13353 Berlin, Germany
| | - Mariagrazia Di Luca
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Center for Musculoskeletal Surgery, Charitéplatz 1, 10117 Berlin, Germany; Berlin-Brandenburg Center for Regenerative Therapies, Charité - Universitätsmedizin Berlin, Augustenburger Platz 1, 13353 Berlin, Germany; NEST, Istituto Nanoscienze - Consiglio Nazionale delle Ricerche, Piazza San Silvestro 12, 10027 Pisa, Italy
| | - Roberta Censi
- School of Pharmacy, University of Camerino, Via S. Agostino 1, 62032 Camerino, MC, Italy.
| | - Piera Di Martino
- School of Pharmacy, University of Camerino, Via S. Agostino 1, 62032 Camerino, MC, Italy
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Economic Evaluation of Antibacterial Coatings on Healthcare Costs in First Year Following Total Joint Arthroplasty. J Arthroplasty 2018. [PMID: 29530518 DOI: 10.1016/j.arth.2018.01.057] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Antibacterial coatings (ABCs) of implants have proven safe and effective to reduce postsurgical infection, but little is known about their possible economic impact on large-scale use. This study evaluated the point of economic balance, during the first year after surgery, and the potential overall annual healthcare cost savings of 3 different antibacterial technologies applied to joint arthroplasty: a dual-antibiotic-loaded bone cement (COPAL G + C), an antibacterial hydrogel coating (DAC), and a silver coating (Agluna). METHODS The variables included in the algorithm were average cost and number of primary joint arthroplasties; average cost per patient of the ABC; incidence of periprosthetic joint infections and expected reduction using the ABCs; average cost of infection treatment and expected number of cases. RESULTS The point of economic balance for COPAL G + C, DAC, and Agluna in the first year after surgery was reached in patient populations with an expected postsurgical infection rate of 1.5%, 2.6%, and 19.2%, respectively. If applied on a national scale, in a moderately high-risk population of patients with a 5% expected postsurgical infection rate, COPAL G + C and DAC hydrogel would provide annual direct cost savings of approximately €48,800,000 and €43,200,000 (€1220 and €1080 per patient), respectively, while the silver coating would be associated with an economic loss of approximately €136,000,000. CONCLUSION This economic evaluation shows that ABC technologies have the potential to decrease healthcare costs primarily by decreasing the incidence of surgical site infections, provided that the technology is used in the appropriate risk class of patients.
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Lange J, Troelsen A, Solgaard S, Otte KS, Jensen NK, Søballe K. Cementless One-Stage Revision in Chronic Periprosthetic Hip Joint Infection. Ninety-One Percent Infection Free Survival in 56 Patients at Minimum 2-Year Follow-Up. J Arthroplasty 2018; 33:1160-1165.e1. [PMID: 29221839 DOI: 10.1016/j.arth.2017.11.024] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2017] [Revised: 10/22/2017] [Accepted: 11/10/2017] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Cementless 1-stage revision in chronic periprosthetic hip joint infections is limited evaluated. The purpose of this study was to evaluate a specific treatment protocol in this patient group. METHODS The study was performed as a multicenter, proof-of-concept, observational study with prospective data collection. Patients were treated with a cementless 1-stage revision according to the CORIHA protocol between 2009 and 2014. Fifty-six patients, McPherson type III-A/B-1/2, were enrolled with a mean follow-up time from the CORIHA procedure of 4 years (minimum of 2 years). The primary outcome was re-revision performed due to infection and was evaluated by competing risk analysis, with death and aseptic revision as competing events. All-cause mortality was evaluated by Kaplan-Meier survival analysis. Oxford Hip Score (OHS) was used as disease-specific patient-reported outcome measure. RESULTS The cumulative incidence of re-revision due to infection was 8.9% (confidence interval [CI] 3.2%-18.1%). The 1-year and 5-year survival incidence was 96% (CI 86%-99%) and 89% (CI 75%-95%). OHS at baseline was 19.9 (CI 17.3-22.6) and at 24-month follow-up 35.1 (CI 31.7-38.5). The mean change in OHS from baseline to 24-month follow-up was 11.8 points (CI 7.3; 16.3). Three patients had aseptic revision performed: two suffered periprosthetic fractures and one had stem subsidence. Failure analysis of the 5 reinfections did not detect a clear pattern as to the cause of failure. CONCLUSION We found that cementless 1-stage revision in chronic periprosthetic hip joint infections has low reinfection rates in selected patients and may be applicable as a first-line treatment.
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Affiliation(s)
- Jeppe Lange
- Lundbeck Foundation Centre for Fast-track Hip and Knee Surgery, Aarhus, Denmark; Interdisciplinary Research Unit, Center for Planned Surgery, Silkeborg, Denmark; Department of Orthopaedic Surgery, Regional Hospital Horsens, Horsens, Denmark
| | - Anders Troelsen
- Department of Orthopaedic Surgery, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
| | - Søren Solgaard
- Department of Orthopaedic Surgery, Gentofte Hospital, Gentofte, Denmark
| | - Kristian S Otte
- Department of Orthopaedic Surgery, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
| | - Niels K Jensen
- Department of Orthopaedic Surgery, Regional Hospital Viborg, Viborg, Denmark
| | - Kjeld Søballe
- Lundbeck Foundation Centre for Fast-track Hip and Knee Surgery, Aarhus, Denmark; Department of Orthopaedic Surgery, Aarhus University Hospital, Aarhus, Denmark
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- Lundbeck Foundation Centre for Fast-track Hip and Knee Surgery, Aarhus, Denmark
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Sanz-Ruiz P, Calvo-Haro JA, Villanueva-Martinez M, Matas-Diez JA, Vaquero-Martín J. Biarticular total femur spacer for massive femoral bone loss: the mobile solution for a big problem. Arthroplast Today 2018; 4:58-64. [PMID: 29560397 PMCID: PMC5859195 DOI: 10.1016/j.artd.2017.02.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2016] [Revised: 02/14/2017] [Accepted: 02/17/2017] [Indexed: 11/30/2022] Open
Abstract
Bone cement spacers loaded with antibiotic are the gold standard in septic revision. However, the management of massive bone defects constitutes a surgical challenge, requiring the use of different nails, expensive long stems, or cement-coated tumor prostheses for preparing the spacer. In most cases, the knee joint must be sacrificed. We describe a novel technique for preparing a biarticular total femur spacer with the help of a trochanteric nail coated with antibiotic loaded cement, allowing mobility of the hip and knee joints and assisted partial loading until second step surgery. This technique is helpful to maintain the length of the leg, prevent soft tissue contracture, and help eradicate the infection preserving the patient comfort and autonomy while waiting to receive total femoral replacement.
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Affiliation(s)
- Pablo Sanz-Ruiz
- Department of Traumatology and Orthopaedic Surgery, General University Hospital Gregorio Marañón, Madrid, Spain.,Department of Surgery, School of Medicine, Medicine Faculty, Universidad Complutense of Madrid, Spain
| | - Jose Antonio Calvo-Haro
- Department of Traumatology and Orthopaedic Surgery, General University Hospital Gregorio Marañón, Madrid, Spain.,Department of Surgery, School of Medicine, Medicine Faculty, Universidad Complutense of Madrid, Spain
| | - Manuel Villanueva-Martinez
- Department of Traumatology and Orthopaedic Surgery, General University Hospital Gregorio Marañón, Madrid, Spain
| | - Jose Antonio Matas-Diez
- Department of Traumatology and Orthopaedic Surgery, General University Hospital Gregorio Marañón, Madrid, Spain
| | - Javier Vaquero-Martín
- Department of Traumatology and Orthopaedic Surgery, General University Hospital Gregorio Marañón, Madrid, Spain.,Department of Surgery, School of Medicine, Medicine Faculty, Universidad Complutense of Madrid, Spain
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Bori G, Navarro G, Morata L, Fernández-Valencia JA, Soriano A, Gallart X. Preliminary Results After Changing From Two-Stage to One-Stage Revision Arthroplasty Protocol Using Cementless Arthroplasty for Chronic Infected Hip Replacements. J Arthroplasty 2018; 33:527-532. [PMID: 28947373 DOI: 10.1016/j.arth.2017.08.033] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2017] [Revised: 08/14/2017] [Accepted: 08/24/2017] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND The objective of our study is to evaluate our preliminary results after changing from a 2-stage revision arthroplasty protocol to a 1-stage revision arthroplasty protocol using cementless arthroplasty for all patients with chronic infected hip replacements. METHODS Prospective study of all hip arthroplasties that were diagnosed with chronic infection and were treated using the 1-stage revision without taking into account the traditional criteria used to determine the use of a 1-stage revision was conducted. There were 2 main variables evaluated: infection control and costs. The definitive diagnosis of infection of the revision was determined using the criteria proposed by the Musculoskeletal Infection Society. The costs were calculated using average cost in USD, excluding social expenses, as described by Klouche (2010) for 1-stage or 2-stage revisions. RESULTS Nineteen patients were included in the study and the infection was controlled in 18 patients. The total economic savings for our hospital for these 19 patients was 391.609 USD. CONCLUSION This clinical success has led to an important change in our hospital in treating chronic infected hip replacements and an important cost reduction from an economic point of view.
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Affiliation(s)
- Guillem Bori
- Department of Orthopaedic and Trauma Surgery, Hospital Clinic of Barcelona, University of Barcelona, Barcelona, Spain; Bone and Joint Infectious Diseases Unit, Hospital Clinic of Barcelona, University of Barcelona, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Guillem Navarro
- Department of Orthopaedic and Trauma Surgery, Hospital Clinic of Barcelona, University of Barcelona, Barcelona, Spain; Bone and Joint Infectious Diseases Unit, Hospital Clinic of Barcelona, University of Barcelona, Barcelona, Spain
| | - Laura Morata
- Bone and Joint Infectious Diseases Unit, Hospital Clinic of Barcelona, University of Barcelona, Barcelona, Spain; Department of Infectious Diseases, Hospital Clinic of Barcelona, University of Barcelona, Barcelona, Spain
| | - Jenaro A Fernández-Valencia
- Department of Orthopaedic and Trauma Surgery, Hospital Clinic of Barcelona, University of Barcelona, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Alex Soriano
- Bone and Joint Infectious Diseases Unit, Hospital Clinic of Barcelona, University of Barcelona, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain; Department of Infectious Diseases, Hospital Clinic of Barcelona, University of Barcelona, Barcelona, Spain
| | - Xavier Gallart
- Department of Orthopaedic and Trauma Surgery, Hospital Clinic of Barcelona, University of Barcelona, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
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Butini ME, Cabric S, Trampuz A, Di Luca M. In vitro anti-biofilm activity of a biphasic gentamicin-loaded calcium sulfate/hydroxyapatite bone graft substitute. Colloids Surf B Biointerfaces 2018; 161:252-260. [DOI: 10.1016/j.colsurfb.2017.10.050] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2017] [Revised: 10/07/2017] [Accepted: 10/17/2017] [Indexed: 02/03/2023]
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Vancomycin and tobramycin impregnated mineralized allograft for the surgical regenerative treatment of peri-implantitis: a 1-year follow-up case series. Clin Oral Investig 2017; 22:2199-2207. [PMID: 29275491 DOI: 10.1007/s00784-017-2310-0] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2017] [Accepted: 12/12/2017] [Indexed: 10/18/2022]
Abstract
OBJECTIVES To assess the clinical and radiographic outcomes of the regenerative treatment of peri-implantitis using a vancomycin and tobramycin impregnated allograft (VTA) after a 12-month period. MATERIAL AND METHODS Thirteen consecutive patients who required a regenerative treatment of peri-implantitis were recruited. For the 17 implant sites, a flap was raised, and after mechanical and chemical implant decontamination, a vancomycin and tobramycin impregnated allograft was placed in the defect and then covered with a collagen membrane. Soft tissues were sutured allowing a non-submerged healing. Clinical and radiographic variables were evaluated at baseline and at 12 months after treatment. RESULTS No signs of continuous bone loss were observed and no implant was lost, yielding a 100% survival rate. All patient's clinical examination at 12 months revealed peri-implant health showing absence of suppuration and a statistically significant reduction in terms of bleeding on probing scores (70.6%, P = 0.001). Initial probing pocket depth (7.88 ± 1.22 mm) was significantly reduced at 12 months healing, a mean reduction of 4.23 ± 1.47 mm (P = 0.001) was achieved. The mean radiological infrabony defect at baseline reached 4.33 ± 1.62 mm, and was significantly reduced up to 0.56 ± 0.88 mm, which represents an 86.99 ± 18.2% bone fill from the original infrabony defect. CONCLUSIONS Within the limits of the study, the application of VTA with a collagen membrane yielded positive outcomes in terms of radiographic bone fill, pocket depth reduction, and attachment gain after a 12-month period. Thus, VTA plus a collagen membrane seem to be suitable for the regenerative treatment of peri-implantitis. CLINICAL RELEVANCE The use of locally delivered antibiotic together with the bone graft may reduce the undesirable effects related to the systemic administration and the risk of resistances. In the light of the results obtained, these grafting materials might offer new treatment strategies in the surgical regenerative treatment of peri-implantitis.
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Kucera T, Ryskova L, Soukup T, Malakova J, Cermakova E, Mericka P, Suchanek J, Sponer P. Elution kinetics of vancomycin and gentamicin from carriers and their effects on mesenchymal stem cell proliferation: an in vitro study. BMC Musculoskelet Disord 2017; 18:381. [PMID: 28865450 PMCID: PMC5581458 DOI: 10.1186/s12891-017-1737-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2017] [Accepted: 08/25/2017] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Musculoskeletal infections remain a major complication in orthopedic surgery. The local delivery of antibiotics provides the high levels required to treat an infection without systemic toxicity. However, the local toxicity of antibiotic carriers to the mesenchymal stem cells, as a result of both the peak concentrations and the type of carrier, may be significant. METHODS To address this concern, the elution kinetics of vancomycin and gentamicin from several commercially available antibiotic carriers and several carriers impregnated by a surgeon (10 ml of each sterile carrier were manually mixed with a 500 mg vancomycin and an 80 mg gentamicin solution, and the duration of impregnation was 30 min) were assessed. Moreover, the effects of these antibiotic carriers on stem cell proliferation were investigated. The following two types of stem cells were used: bone marrow and dental pulp stem cells. RESULTS The high eluted initial concentrations from antibiotic impregnated cancellous allogeneic bone grafts (which may be increased with the addition of fibrin glue) did not adversely affect stem cell proliferation. Moreover, an increased dental pulp stem cell proliferation rate in the presence of antibiotics was identified. In contrast to allogeneic bone grafts, a significant amount of antibiotics remained in the cement. Despite the favorable elution kinetics, the calcium carriers, bovine collagen carrier and freeze-dried bone exhibited decreased stem cell proliferation activity even in lower antibiotic concentrations compared with an allogeneic graft. CONCLUSIONS This study demonstrated the benefits of antibiotic impregnated cancellous allogeneic bone grafts versus other carriers.
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Affiliation(s)
- Tomas Kucera
- Department of Orthopaedic Surgery, University Hospital Hradec Kralove, Charles University in Prague, Faculty of Medicine in Hradec Kralove, Sokolska 581, 500 05, Hradec Kralove, Czech Republic.
| | - Lenka Ryskova
- Department of Clinical Microbiology, University Hospital Hradec Kralove, Charles University in Prague, Faculty of Medicine in Hradec Kralove, Sokolska 581, 500 05, Hradec Kralove, Czech Republic
| | - Tomas Soukup
- Department of Histology and Embryology, Charles University in Prague, Faculty of Medicine in Hradec Kralove, Sokolska 581, 500 05, Hradec Kralove, Czech Republic
| | - Jana Malakova
- Department of Clinical Biochemistry, University Hospital Hradec Kralove, Charles University in Prague, Faculty of Medicine in Hradec Kralove, Sokolska 581, 500 05, Hradec Kralove, Czech Republic
| | - Eva Cermakova
- Department of Medical Biophysics, Charles University in Prague, Faculty of Medicine in Hradec Kralove, Sokolska 581, 500 05, Hradec Kralove, Czech Republic
| | - Pavel Mericka
- Tissue Bank, University Hospital Hradec Kralove, Sokolska 581, 500 05, Hradec Kralove, Czech Republic
| | - Jakub Suchanek
- Department of Dentistry, University Hospital Hradec Kralove, Charles University in Prague, Faculty of Medicine in Hradec Kralove, Sokolska 581, 500 05, Hradec Kralove, Czech Republic
| | - Pavel Sponer
- Department of Orthopaedic Surgery, University Hospital Hradec Kralove, Charles University in Prague, Faculty of Medicine in Hradec Kralove, Sokolska 581, 500 05, Hradec Kralove, Czech Republic
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George DA, Haddad FS. One-Stage Exchange Arthroplasty: A Surgical Technique Update. J Arthroplasty 2017; 32:S59-S62. [PMID: 28302460 DOI: 10.1016/j.arth.2017.02.025] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2017] [Accepted: 02/09/2017] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Standard surgical treatment for a periprosthetic knee infection has been based on a staged surgical technique, in order to assure infection eradication prior to implantation of a new prosthesis. METHODS In this article, we discuss our surgical technique in undertaking a single-stage exchange of a chronic knee periprosthetic infection. RESULTS This technique, which is based on the fundamental principles of controlling infection, preventing recurrence, and restoring function, has been shown to deliver high success rates. CONCLUSION As demonstrated, when undertaken under appropriate circumstances, a single-stage exchange combined with local and systemic antibiotic delivery can result in infection eradication comparable to a 2-staged exchange.
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Affiliation(s)
- David A George
- Department of Trauma and Orthopaedics, University College London Hospitals, London, United Kingdom
| | - Fares S Haddad
- Department of Trauma and Orthopaedics, University College London Hospitals, London, United Kingdom
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