Defining peri-prosthetic infection: do we have a workable gold standard?

Debridement, Antibiotic Pearls, and Retention of the Implant (DAPRI) in the Treatment of Early Periprosthetic Knee Joint Infections: A Literature Review

(1) Background: Periprosthetic joint infections (PJIs) are severe and frightening complications in orthopaedic surgery, and they are generally divided into three categories: early infections (those occurring within the first 4-6 weeks), delayed infections (those occurring between 3 and 24 months), and late infections (those occurring more than 2 years after surgery). PJI treatment comprises "debridement, antibiotics, and implant retention" (DAIR), single-stage revision, and double-stage revision. Nowadays, to improve the chances of retaining an infected implant and to improve the traditional DAIR method, a modified surgical technique has been developed, named DAPRI (debridement, antibiotic pearls, and retention of the implant). Our study aims to present an up-to-date concept evaluation of the DAPRI technique and its success rate. (2) Methods: Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) standards were followed, applying a protocol defined by the authors: a total of 765 articles were identified, and at the end of the screening process only 7 studies were included. (3) Results: Currently, the DAPRI procedure can be performed only on patients who have had PJI symptoms for less than 4 weeks, and in order to achieve the highest success rate, indications are quite strict: it is appropriate in patients with acute, superficial infections without sinus tract presence, and well-fixed implants with known sensitive bacteria. The DAPRI surgical method follows a step-by-step process consisting of a first phase of biofilm identification with intra-articular injection of methylene blue, followed by biofilm removal (thermic, mechanical, and chemical aggression), and a last step consisting of prevention of PJI recurrence by using calcium sulphate antibiotic-added beads. (4) Conclusions: The DAPRI approach improves the traditional DAIR technique. It is a correct treatment for acute and early haematogenous PJI, and improves the DAIR success rate.

Debridement, antibiotics, and implant retention (DAIR) for the early prosthetic joint infection of total knee and hip arthroplasties: a systematic review

PURPOSE

Early periprosthetic joint infection (PJI) represents one of the most fearsome complications of joint replacement. No international consensus has been reached regarding the best approach for early prosthetic knee and hip infections. The aim of this updated systematic review is to assess whether debridement, antibiotics, and implant retention (DAIR) is an effective choice of treatment in early postoperative and acute hematogenous PJI.

METHODS

This systematic review was performed using the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. The diagnostic criteria defining a PJI, the most present pathogen, and the days between the index procedure and the onset of the PJI were extracted from the selected articles. Additionally, the mean follow-up, antibiotic regimen, and success rate of the treatment were also reported.

RESULTS

The articles included provided a cohort of 970 patients. Ten studies specified the joint of their cohort in PJIs regarding either hip prostheses or knee prostheses, resulting in 454 total knees and 460 total hips. The age of the patients ranged from 18 to 92 years old. Success rates for the DAIR treatments in the following cohort ranged from 55.5% up to a maximum of 90% (mean value of 71%).

CONCLUSION

Even though the DAIR procedure is quite limited, it is still considered an effective option for patients developing an early post-operative or acute hematogenous PJI. However, there is a lack of studies, in particular randomized control trials (RCTs), comparing DAIR with one-stage and two-stage revision protocols in the setting of early PJIs, reflecting the necessity to conduct further high-quality studies to face the burden of early PJI.

Comparison of Surgical Procedures in the Treatment of Hip Periprosthetic Infection

Objective The present study aimed to compare the cure rate recovery time and Merle d'Aubigné-Postel functional (MAPF) score after single-stage surgery (C1T) or two-stage surgery (C2T) to treat prosthetic infections of the hip considering sociodemographic and clinical features of the patients. Materials and Methods The present retrospective study occurred in a single center from 2011 to 2014 with 37 studied cases including 26 treated with C1T and 11 with C2T. We compared the cure rate recovery time and MAPF score in the two groups as well as the sociodemographic and clinical features of the patients. We also considered surgical complications and the most common infectious agents. Results The C1T group had a faster functional recovery than the C2T group but there were no significant differences in the cure rate surgical complications or MAPF score. However C1T group patients were significantly younger which may have influenced the outcomes. Staphylococcus spp. was the most common infectious agent (62%). Conclusion Although C2T appears superior regarding infection cure C1T may be preferable for faster functional recovery. However it is critical to consider individual patient characteristics when choosing treatment. Further research with a larger sample size is required to confirm these results.

Periprosthetic joint infection: what next?

Periprosthetic joint infection (PJI) remains an extremely challenging complication. We have focused on this issue more over the last decade than previously, but there are still many unanswered questions. We now have a workable definition that everyone should align to, but we need to continue to focus on identifying the organisms involved. Surgical strategies are evolving and care is becoming more patient-centred. There are some good studies under way. There are, however, still numerous problems to resolve, and the challenge of PJI remains a major one for the orthopaedic community. This annotation provides some up-to-date thoughts about where we are, and the way forward. There is still scope for plenty of research in this area.

Cite this article: Bone Joint J 2022;104-B(11):1193–1195.

Diagnosing periprosthetic joint infections : a comparison of infection definitions: EBJIS 2021, ICM 2018, and IDSA 2013

AIMS

This study evaluated the definitions developed by the European Bone and Joint Infection Society (EBJIS) 2021, the International Consensus Meeting (ICM) 2018, and the Infectious Diseases Society of America (IDSA) 2013, for the diagnosis of periprosthetic joint infection (PJI).

METHODS

In this single-centre, retrospective analysis of prospectively collected data, patients with an indicated revision surgery after a total hip or knee arthroplasty were included between 2015 and 2020. A standardized diagnostic workup was performed, identifying the components of the EBJIS, ICM, and IDSA criteria in each patient.

RESULTS

Of 206 included patients, 101 (49%) were diagnosed with PJI with the EBJIS definition. IDSA and ICM diagnosed 99 (48%) and 86 (42%) as infected, respectively. A total of 84 cases (41%) had an infection based on all three criteria. In 15 cases (n = 15/206; 7%), PJI was present when applying only the IDSA and EBJIS criteria. No infection was detected by one definition alone. Inconclusive diagnoses occurred more frequently with the ICM criteria (n = 30/206; 15%) compared to EBJIS (likely infections: n = 16/206; 8%) (p = 0.029). A better preoperative performance of the EBJIS definition was seen compared with the ICM and IDSA definitions (p < 0.001).

CONCLUSION

The novel EBJIS definition identified all PJIs diagnosed by any other criteria. Use of the EBJIS definition significantly reduced the number of uncertain diagnoses, allowing easier clinical decision-making.Cite this article: Bone Joint Res 2022;11(9):608-618.

[Diagnosis of periprosthetic joint infection : Development of an evidence-based algorithm by the work group of implant-associated infection of the AE-(German Society for Arthroplasty)]

Hintergrund

Die Behandlung periprothetischer Infektionen (PPI) ist eine der größten Herausforderungen im Bereich der Endoprothetik. Der möglichst sichere Ausschluss oder die Bestätigung einer periprothetischen Infektion ist die Voraussetzung für jede Revisionsoperation und kann für den behandelnden Orthopäden und Unfallchirurgen eine große Herausforderung darstellen. Eine sichere evidenzbasierte präoperative Diagnostik ist im Sinne des Patienten notwendig, um einerseits eine periprothetische Infektion zu erkennen sowie die entsprechende chirurgische und antibiotische Therapie zu planen und andererseits unnötige zweizeitige Wechsel zu vermeiden.

Ziel der Arbeit

Ziel ist es, ein evidenzbasiertes problem- und prioritätenbasiertes Vorgehen zu entwickeln und dies in einem transparenten und standardisierten Algorithmus zusammenzufassen.

Methode

Durch systematische Literaturrecherche wurden relevante Arbeiten identifiziert und im Rahmen von Expertenrunden bewertet. Nach Extraktion der Daten erfolgte die Berechnung von Sensitivität, Spezifität, positiver und negativer Likelihood-Ratio sowie positiver und negativer prädiktiver Werte. Im Rahmen von 4 Treffen wurden die entsprechenden Studien der Arbeitsgruppe für implantatassoziierte Infektionen präsentiert und analog zu Standard-Delphi-Runden durch die einzelnen Experten bearbeitet und bewertet. Gemäß der Prioritätenliste der Expertenrunde erfolgte die Entwicklung eines zur ISO (International Organization for Standardisation) konformen Algorithmus.

Ergebnisse

Der entwickelte Algorithmus ist eine Abfolge von evidenzbasierten Prozessen gemäß der verwendeten ISO-Norm. Gemäß der durch die Expertenrunde priorisierten Haupt- und Nebenkriterien erfolgte die Entwicklung logisch strukturiert und problemorientiert.

Schlussfolgerung

Der Ausschluss einer periprothetischen Infektion ist von enormer Bedeutung vor einer Revisionsoperation und entscheidet in vielen Fällen über den Erfolg und die Invasivität der Operation. Die Diagnose „periprothetische Infektion“ erfordert eine substanzielle Veränderung der therapeutischen Strategie. Der durch die Arbeitsgruppe entwickelte Algorithmus fasst Positionen aus der aktuellen Literatur und spezielle Expertenmeinungen zusammen, dies ermöglicht einen transparenten diagnostischen Ansatz im Sinne einer Standard Operation Procedure.

The introduction of day-case total knee arthroplasty in a national healthcare system: A review of the literature and development of a hospital pathway

INTRODUCTION

As we now drive to reinitiate our full capacity elective services in an attempt to tackle an ever-growing demand for lower limb arthroplasty, this pandemic has presented rare opportunities to revise and re-engage elective arthroplasty pathways aimed at improving patient care and healthcare efficiency.

AIMS

We present the development of an evidence-based multidisciplinary perioperative care pathway for day-case total knee arthroplasty (TKA) in a United Kingdom National Health Service (NHS) institution, in conjunction with a review of the literature upon which the protocol is founded.

METHODOLOGY

We performed a review of the literature reporting complication or readmission rates at ≥30 day postoperative following day-case TKA. Electronic searches were performed using four databases from the date of inception to November 2020. Relevant studies were identified, data extracted, and qualitative synthesis performed.

RESULTS

13 manuscripts with a total of 3370 day-case TKAs, defined as discharged on the same-calendar-day of surgery, were included in analysis. Mean 90-day complication rates (8.31% [range, 0-16.3%] vs 9.49% [range, 0-13.1%], respectively) and readmission rates (2.71% [range, 0-10.0%] vs 3.41% [range, 0-9.9%], respectively) were equivocal between day-case and inpatient TKA. The overall rate of successful same-calendar-day discharge was 95.8%. Our evaluation and critique of the evidence-based literature identifies day-case TKA to be safe, effective and economical, benefitting both patients and healthcare systems alike.

CONCLUSION

We further validate the introduction of our institutional Elective Day Surgery Arthroplasty Pathway (EDSAP) based on the evidence presented. Careful patient selection paralleled with well-defined care pathways are essential for successful introduction of day-case TKA into the NHS.

The EBJIS definition of periprosthetic joint infection

Aims

The diagnosis of periprosthetic joint infection (PJI) can be difficult. All current diagnostic tests have problems with accuracy and interpretation of results. Many new tests have been proposed, but there is no consensus on the place of many of these in the diagnostic pathway. Previous attempts to develop a definition of PJI have not been universally accepted and there remains no reference standard definition.

Methods

This paper reports the outcome of a project developed by the European Bone and Joint Infection Society (EBJIS), and supported by the Musculoskeletal Infection Society (MSIS) and the European Society of Clinical Microbiology and Infectious Diseases (ESCMID) Study Group for Implant-Associated Infections (ESGIAI). It comprised a comprehensive review of the literature, open discussion with Society members and conference delegates, and an expert panel assessment of the results to produce the final guidance.

Results

This process evolved a three-level approach to the diagnostic continuum, resulting in a definition set and guidance, which has been fully endorsed by EBJIS, MSIS, and ESGIAI.

Conclusion

The definition presents a novel three-level approach to diagnosis, based on the most robust evidence, which will be useful to clinicians in daily practice.

Cite this article: Bone Joint J 2021;103-B(1):18–25.

Antibacterial Effect of the Controlled Nanoscale Precipitates Obtained by Different Heat Treatment Schemes with a Ti-Based Nanomaterial, Ti-7.5Mo-5Cu Alloy

It is well known that copper is an excellent option for a Ti-based alloy component as a β-stabilizer that provides improved biocompatibility and antibacterial ability. The development of a Ti-based nanomaterial containing Cu is a promising strategy for addressing implant-associated infections (OII). However, the antibacterial mechanism of copper-related alloys is still unknown. There are two popular hypotheses: copper ion release sterilization and alloy contact sterilization. The main mechanism of contact sterilization may be Cu-related phase (Ti₂Cu) precipitation. Because excess copper can lead to cytotoxicity and reduce the β-Ti phase content, molybdenum needs to be added to the alloy given its well-known and widely researched β-stabilizer characteristics, which can provide satisfactory mechanical properties, wear resistance, and biocompatibility. Our study created a Ti-based nanomaterial, Ti-7.5Mo-5Cu, and performed two kinds of heat treatment schemes at different solution temperatures: 750 and 900 °C. The above schemes resulted in homogeneous and heterogeneous nucleation on the precipitation behavior of the Ti₂Cu crystal phase, which controlled its amount, distribution, and size. Finally, our results showed that Ti-7.5Mo-5Cu, especially at 900 °C, possessed excellent antibacterial ability, corrosion resistance, cytocompatibility, and induced osteogenic differentiation, indicating its potential for use as a biomedical antibacterial alloy in the future.

Sphingosine is able to prevent and eliminate Staphylococcus epidermidis biofilm formation on different orthopedic implant materials in vitro

Abstract

Periprosthetic infection (PPI) is a devastating complication in joint replacement surgery. On the background of an aging population, the number of joint replacements and associated complications is expected to increase. The capability for biofilm formation and the increasing resistance of different microbes to antibiotics have complicated the treatment of PPI, requiring the need for the development of alternative treatment options. The bactericidal effect of the naturally occurring amino alcohol sphingosine has already been reported. In our study, we demonstrate the antimicrobial efficacy of sphingosine on three different strains of biofilm producing Staphylococcus epidermidis, representing one of the most frequent microbes involved in PPI. In an in vitro analysis, sphingosine’s capability for prevention and treatment of biofilm-contamination on different common orthopedic implant surfaces was tested. Coating titanium implant samples with sphingosine not only prevented implant contamination but also revealed a significant reduction of biofilm formation on the implant surfaces by 99.942%. When testing the antimicrobial efficacy of sphingosine on sessile biofilm-grown Staphylococcus epidermidis, sphingosine solution was capable to eliminate 99.999% of the bacteria on the different implant surfaces, i.e., titanium, steel, and polymethylmethacrylate. This study provides evidence on the antimicrobial efficacy of sphingosine for both planktonic and sessile biofilm-grown Staphylococcus epidermidis on contaminated orthopedic implants. Sphingosine may provide an effective and cheap treatment option for prevention and reduction of infections in joint replacement surgery.

Key messages

• Here we established a novel technology for prevention of implant colonization by sphingosine-coating of orthopedic implant materials.

• Sphingosine-coating of orthopedic implants prevented bacterial colonization and significantly reduced biofilm formation on implant surfaces by 99.942%.

• Moreover, sphingosine solution was capable to eliminate 99.999% of sessile biofilm-grown Staphylococcus epidermidis on different orthopedic implant surfaces.

bbFISH-ing in the sonication fluid

By 2030, the annual number of combined total hip and knee arthroplasty is estimated to reach 3.5 to 4 million in the US alone. In the context of a constant increase of the number of primary and revision total hip and knee arthroplasty, an increased risk of complication is expected. Prosthetic joint infections (PJIs) represent major cause of healthcare expenditure and morbidity. PJI still remain the most common and feared arthroplasty complication. A rapid and correct diagnosis of infection is decisive for a correct therapeutical management. In this setting, the Academic Emergency Hospital Sibiu adopted and implemented, with the beginning of September 2016, a new strategy for the diagnosis of PJIs strategy that uses sonication and beacon-based fluorescent in situ hybridization (bbFISH) technology.Until November 2017, 40 patients (40 retrieved implants) were enrolled in the study. Sonication fluid (SF) was collected after sonication of the implants, and samples were harvested on aerobic and anaerobic culture media. A bbFISH was used as a rapid method of bacteria detection.16 patients were diagnosed with PJIs (all 16 patients presented a positive culture of the SF). Comparing bbFISH with culture, 11 samples tested true-positive. As the kit doesn't contain probes for Pseudomonas fluorescens or Ralstonia pickettii, 4 strains of R pickettii and 1 strain of P fluorescens that was associated with Staphylococcus epidermidis were not detected.Bacteria culture of SF remains the gold standard. bbFISH holds promise to be a diagnostic tool for rapid identifying of PJIs. The bbFISH assay needs to be optimized for the detection of bacterial strains that are relevant for the PJIs field.

Periprosthetic joint infections after total hip replacement: an algorithmic approach

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.

In Situ Growth of Mesoporous Silica with Drugs on Titanium Surface and Its Biomedical Applications

Mesoporous silica has been developed for the modification of titanium surfaces that are used as implant materials. Yet, the traditional modification methods failed to effectively construct mesoporous silica on the titanium surface evenly and firmly, in which the interaction between mesoporous silica and titanium was mainly physical. Here, in situ growth of mesoporous silica on a titanium surface was performed using a simple evaporation-induced self-assembly strategy. Meantime, in situ introduction of drugs (heparin and vancomycin) to mesoporous silica was also adopted to improve the drug-loading amount. Both the above-mentioned processes were completed at the same time. Transmission electron microscopy, N₂ adsorption-desorption isotherms, Fourier transform infrared spectroscopy, scanning electron microscopy, and water contact angle measurements were used to characterize the structure of the mesoporous silica film. Results indicated that the mesoporous silica film that in situ grew on the titanium surface was smooth, thin, transparent, and stable. Cytotoxicity, proliferation performance of osteoblast cells, and in vitro and in vivo studies of the antibacterial activity of the coating were tested. This is the first study to modify the titanium surface by the in situ growth of a mesoporous silica coating with two kinds of drugs. The stability of the mesoporous silica coating can be attributed to the chemical bonding between dopamine and silicon hydroxyl of the mesoporous silica coating, and the smooth surface of mesoporous silica is a result of the method of in situ growth. The large amount of drug-loading also could be ascribed to the in situ introduction of drugs during the synthetic process. The strategy proposed in this work will bring more possibilities for the preparation of advanced functional materials based on the combination of mesoporous structure and metallic materials.

Assessment of the automated multiplex-PCR Unyvero i60 ITI® cartridge system to diagnose prosthetic joint infection: a multicentre study

OBJECTIVES

Prosthetic joint infections (PJI) are responsible for significant morbidity and mortality and their number continues to rise. Their management remains complex, especially the microbiological diagnosis. Besides 'homemade' tests developed by several teams, new molecular biology methods are now available with different analytical performance and usability.

METHODS

We studied the performances of one of these tests: ITI^® multiplex PCR (mPCR) by the Curetis^® company and compared it to either 'optimized' culture or 16S rRNA PCR. We performed a retrospective multicentre study to assess the contributions of mPCR in the diagnosis of PJI. We randomly selected 484 intraoperative specimens among 1252 of various types (biopsy, bone, tissue around the prosthesis, synovial fluid) from 251 patients in seven different hospitals. Each sample was treated according to the recommendations of the manufacturer.

RESULTS

In all, 154 out of 164 (93.9%) samples negative in culture were negative with the mPCR. Among the 276 positive samples in culture, 251 (90.9%) were monomicrobial, of which 119 (47.4%) were positive with the mPCR, and 25 (9.1%) were polymicrobial, of which 12 (48%) were positive with the mPCR. The concordance rate of mPCR with culture was 58.1% (53.6%-62.7%) and the concordance rate with 16S rRNA PCR was 70.1% (65.5%-74.6%).

CONCLUSION

This new standardized molecular test showed a lack of detection when the bacterial inoculum was low (number of positive media per sample and number of colonies per media) but can be useful when patients have received antibiotic therapy previously.

Prosthetic joint infection development of an evidence-based diagnostic algorithm

BACKGROUND

Increasing rates of prosthetic joint infection (PJI) have presented challenges for general practitioners, orthopedic surgeons and the health care system in the recent years. The diagnosis of PJI is complex; multiple diagnostic tools are used in the attempt to correctly diagnose PJI. Evidence-based algorithms can help to identify PJI using standardized diagnostic steps.

METHODS

We reviewed relevant publications between 1990 and 2015 using a systematic literature search in MEDLINE and PUBMED. The selected search results were then classified into levels of evidence. The keywords were prosthetic joint infection, biofilm, diagnosis, sonication, antibiotic treatment, implant-associated infection, Staph. aureus, rifampicin, implant retention, pcr, maldi-tof, serology, synovial fluid, c-reactive protein level, total hip arthroplasty (THA), total knee arthroplasty (TKA) and combinations of these terms.

RESULTS

From an initial 768 publications, 156 publications were stringently reviewed. Publications with class I-III recommendations (EAST) were considered. We developed an algorithm for the diagnostic approach to display the complex diagnosis of PJI in a clear and logically structured process according to ISO 5807.

CONCLUSIONS

The evidence-based standardized algorithm combines modern clinical requirements and evidence-based treatment principles. The algorithm provides a detailed transparent standard operating procedure (SOP) for diagnosing PJI. Thus, consistently high, examiner-independent process quality is assured to meet the demands of modern quality management in PJI diagnosis.

[Not Available]

Zusammenfassung. Mit stetig steigender Häufigkeit endoprothetischer Eingriffe nimmt auch die Bedeutung der damit vergesellschafteten Revisionschirurgie zu. Die Gelenksprothesen-Infektion ist hierbei eine der schwerwiegendsten Komplikationen, die zur Erlangung eines bestmöglichen Behandlungsergebnisses eine differenzierte Diagnose- und Therapiestrategie erfordert. Anamnese, klinische Untersuchung, Laborkontrollen, Radiologie (konventionelle und spezialisierte), Gelenkspunktion sowie Mikrobiologie und Histologie liefern entscheidende Hinweise zur Diagnosestellung als unabdingbare Voraussetzung zur Erstellung und Einleitung des entsprechenden Therapiekonzeptes. Insbesondere die Abgrenzung zwischen aseptischen und septischen Prothesenlockerungen ist schwierig und erfordert ein differenziertes und interdisziplinäres Vorgehen. Die kurative Behandlungsstrategie ist abhängig von: Dauer der Symptome, Latenz seit Primärimplantation, Keimspektrum, Antibiogramm und Weichteilverhältnissen und umfasst prothesenerhaltende Strategien bei nicht gelockerter Prothese, reizlosen Weichteilen und Abwesenheit von Problemkeimen, bis hin zum kompletten ein- oder zweizeitigen Prothesenwechsel bei einer chronischen Infektion. In diesem Beitrag werden die aktuellen Management-Konzepte der Gelenksprothesen-Infektionen diskutiert.

Definition of Periprosthetic Hip and Knee Joint Infections and the Economic Burden

Periprosthetic Joint infection (PJI) following hip and knee replacements is an important complication causing major concern for patients, operating surgeons and healthcare systems. Therefore, a standardized definition of PJI is required to improve communication and allow for valid comparisons of various diagnostic and treatment strategies. This review summarizes the most commonly used definitions for PJI and the current consensus. It also highlights the economic burden related to PJIs and the importance of a multidisciplinary approach to managing those infections.

Multifunctional coatings to simultaneously promote osseointegration and prevent infection of orthopaedic implants

The two leading causes of failure for joint arthroplasty prostheses are aseptic loosening and periprosthetic joint infection. With the number of primary and revision joint replacement surgeries on the rise, strategies to mitigate these failure modes have become increasingly important. Much of the recent work in this field has focused on the design of coatings either to prevent infection while ignoring bone mineralization or vice versa, to promote osseointegration while ignoring microbial susceptibility. However, both coating functions are required to achieve long-term success of the implant; therefore, these two modalities must be evaluated in parallel during the development of new orthopaedic coating strategies. In this review, we discuss recent progress and future directions for the design of multifunctional orthopaedic coatings that can inhibit microbial cells while still promoting osseointegration.

Hypercalcaemia following the use of antibiotic-eluting absorbable calcium sulphate beads in revision arthroplasty for infection

Periprosthetic joint infection (PJI) is a devastating complication for patients and results in greatly increased costs of care for both healthcare providers and patients. More than 15 500 revision hip and knee procedures were recorded in England, Wales and Northern Ireland in 2013, with infection accounting for 13% of revision hip and 23% of revision knee procedures. We report our experience of using antibiotic eluting absorbable calcium sulphate beads in 15 patients (eight men and seven women with a mean age of 64.8 years; 41 to 83) as part of a treatment protocol for PJI in revision arthroplasty. The mean follow-up was 16 months (12 to 22). We report the outcomes and complications, highlighting the risk of hypercalcaemia which occurred in three patients. We recommend that serum levels of calcium be routinely sought following the implantation of absorbable calcium sulphate beads in orthopaedic surgery.

How accurate are orthopedic surgeons in diagnosing periprosthetic joint infection after total knee arthroplasty?: A multicenter study

BACKGROUND

The lack of standardized diagnostic criteria for periprosthetic joint infection (PJI) poses a challenge to accurate diagnosis of PJI. Recently, the Musculoskeletal Infection Society (MSIS) proposed diagnostic criteria for PJI. However, it is not known how well these proposed criteria accommodate real clinical scenarios. We determined what proportion of patients satisfied the MSIS criteria, and if MSIS criteria were not met, what other rationales were used to diagnose PJI.

METHODS

We retrospectively reviewed the records of 303 patients who underwent two-stage exchange arthroplasty for treatment of PJI of the knee at 17 institutions. The rationale for making the diagnosis of PJI was also recorded, if the case did not meet the MSIS criteria. In addition, detailed information about isolated microorganisms were gathered.

RESULTS

Among the 303 patients, 198 met the diagnostic criteria proposed by MSIS. Among the 105 patients who did not meet the MSIS criteria, 88% met two or three minor criteria; however joint fluid analysis or histologic analysis was not performed in 85% of these 105 patients. The most common rationale for the diagnosis of PJI was the presence of abnormal physical findings. Microorganisms were identified in only 52% of all patients; the most common organism was coagulase-negative Staphylococcus.

CONCLUSIONS

The diagnosis of PJI was based on clinical suspicion in approximately one-third of cases. In this series, joint aspiration or histological analysis was not performed in a large number of patients. Thus, surgeons should perform joint fluid and histologic analysis to assure the accuracy of PJI diagnosis.

Is single-stage revision according to a strict protocol effective in treatment of chronic knee arthroplasty infections?

BACKGROUND

The increasing number of patients experiencing periprosthetic total knee arthroplasty (TKA) infections and the cost of treating them suggest that we seek alternatives to two-stage revision. Single-stage revision is a potential alternative to the standard two-stage procedure because it involves only one surgical procedure, so if it is comparably effective, it would be associated with less patient morbidity and lower cost.

QUESTIONS/PURPOSES

We compared (1) the degree to which our protocol of a highly selective single-stage revision approach achieved infection control compared with a two-stage revision approach to TKA infections; and (2) Knee Society scores and radiographic evidence of implant fixation between the single-stage and two-stage patients who were treated for more complicated infections.

METHODS

Between 2004 and 2009, we treated 102 patients for chronic TKA infections, of whom 28 (27%) were treated using a single-stage approach and 74 (73%) were treated using a two-stage approach. All patients were available for followup at a minimum of 3 years (mean, 6.5 years; range, 3-9 years). The indications for using a single-stage approach were minimal/moderate bone loss, the absence of immunocompromise, healthy soft tissues, and a known organism with known sensitivities for which appropriate antibiotics are available. Participants included 38 men and 64 women with a mean age of 65 years (range, 45-87 years). We used the Musculoskeletal Infection Society definition of periprosthetic joint infection to confirm infection control at the last followup appointment. Radiographs were evaluated for signs of loosening, and patients completed Knee Society Scores for clinical evaluation.

RESULTS

None of the patients in the single-stage revision group developed recurrence of infection, and five patients (93%) in the two-stage revision group developed reinfection (p=0.16). Patients treated with a single-stage approach had higher Knee Society scores than did patients treated with the two-stage approach (88 versus 76, p<0.001). However, radiographic findings showed a well-fixed prosthesis in all patients with no evidence of loosening at last followup in either group.

CONCLUSIONS

Our data provide preliminary support to the use of a single-stage approach in highly selected patients with chronically infected TKAs as an alternative to a two-stage procedure. However, larger, multicenter, prospective trials are called for to validate our findings.

LEVEL OF EVIDENCE

Level III, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.

Deep infection after total hip replacement: a method for national incidence surveillance

OBJECTIVE

The purpose of this study was to estimate the incidence of deep periprosthetic joint infections (PJIs) after primary total hip replacement (THR) in Sweden prior to the introduction of a national initiative to reduce these infections.

DESIGN

Prospective open cohort study with 2 years follow-up of each subject.

SETTING

All THR-performing clinics in Sweden.

METHODS

All patients registered for a primary THR in the Swedish Hip Arthroplasty Register between July 1, 2005, and December 31, 2008, were selected for the study (45,531 patients with 49,219 THRs) and were matched with the Swedish Prescribed Drug Register. All patients with a minimum of 4 weeks of continuous outpatient antibiotic treatment within 2 years after their primary THR (1,989 patients with 2,219 THRs) were selected for a medical records review, and the number of cases with PJI was determined.

RESULTS

The cumulative incidence of PJI within 2 years after primary THR was 0.9% (95% confidence interval, 0.85-1.02; n = 443), and 405 of these had been reoperated. The incidence rate of PJI for the first 3 months was 5 per 10,000 THR-weeks and, thereafter, 0.3 per 10,000 THR-weeks. Staphylococcus aureus and coagulase-negative staphylococci were the most common bacteria isolated.

CONCLUSIONS

This study describes a new method of national postoperative infection surveillance. The incidence is similar to previous smaller reports and is useful for monitoring changes over time to evaluate the national initiative to reduce infections.

A multidisciplinary team approach to two-stage revision for the infected hip replacement

We report the five year outcomes of a two-stage approach for infected total hip replacement. This is a single-surgeon experience at a tertiary centre where the more straightforward cases are treated using single-stage exchange. This study highlights the vital role of the multidisciplinary team in managing these cases.

A total of 125 patients (51 male, 74 female) with a mean age of 68 years (42 to 78) were reviewed prospectively. Functional status was assessed using the Harris hip score (HHS). The mean HHS improved from 38 (6 to 78.5) pre-operatively to 81.2 (33 to 98) post-operatively. Staphylococcus species were isolated in 85 patients (68%).

The rate of control of infection was 96% at five years. In all, 19 patients died during the period of the study. This represented a one year mortality of 0.8% and an overall mortality of 15.2% at five years. No patients were lost to follow-up.

We report excellent control of infection in a series of complex patients and infections using a two-stage revision protocol supported by a multidisciplinary approach. The reason for the high rate of mortality in these patients is not known.

Cite this article: Bone Joint J 2014;96-B:1312–18

Prosthetic joint infection

Prosthetic joint infection (PJI) is a tremendous burden for individual patients as well as the global health care industry. While a small minority of joint arthroplasties will become infected, appropriate recognition and management are critical to preserve or restore adequate function and prevent excess morbidity. In this review, we describe the reported risk factors for and clinical manifestations of PJI. We discuss the pathogenesis of PJI and the numerous microorganisms that can cause this devastating infection. The recently proposed consensus definitions of PJI and approaches to accurate diagnosis are reviewed in detail. An overview of the treatment and prevention of this challenging condition is provided.

Periprosthetic joint infections: clinical and bench research

Prosthetic joint infection is a devastating complication with high morbidity and substantial cost. The incidence is low but probably underestimated. Despite a significant basic and clinical research in this field, many questions concerning the definition of prosthetic infection as well the diagnosis and the management of these infections remained unanswered. We review the current literature about the new diagnostic methods, the management and the prevention of prosthetic joint infections.