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Wagener N, Pumberger M, Hardt S. Impact of fixation method on femoral bone loss: a retrospective evaluation of stem loosening in first-time revision total hip arthroplasty among two hundred and fifty five patients. INTERNATIONAL ORTHOPAEDICS 2024:10.1007/s00264-024-06230-4. [PMID: 38822836 DOI: 10.1007/s00264-024-06230-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Accepted: 05/22/2024] [Indexed: 06/03/2024]
Abstract
PURPOSE Implant loosening represent the most common indication for stem revision in hip revision arthroplasty. This study compares femoral bone loss and the risk of initial revisions between cemented and uncemented loosened primary stems, investigating the impact of fixation method at primary implantation on femoral bone defects. METHODS This retrospective study reviewed 255 patients who underwent their first revision for stem loosening from 2010 to 2022, receiving either cemented or uncemented stem implants. Femoral bone loss was preoperatively measured using the Paprosky classification through radiographic evaluations. Kaplan-Meier analysis estimated the survival probability of the original stem, and the hazard ratio assessed the relative risk of revision for uncemented versus cemented stems in the first postoperative year and the following two to ten years. RESULTS Cemented stems showed a higher prevalence of significant bone loss (type 3b and 4 defects: 32.39% vs. 2.72%, p < .001) compared to uncemented stems, which more commonly had type 1 and 2 defects (82.07% vs. 47.89%, p < .001). In our analysis of revision cases, primary uncemented stems demonstrated a 20% lower incidence of stem loosening in the first year post-implantation compared to cemented stems (HR 0.8; 95%-CI 0.3-2.0). However, the incidence in uncemented stems increased by 20% during the subsequent years two to ten (HR 1.2; 95%-CI 0.7-1.8). Septic loosening was more common in cemented stems (28.17% vs. 10.87% in uncemented stems, p = .001). Kaplan-Meier analysis indicated a modestly longer revision-free period for cemented stems within the first ten years post-implantation (p < .022). CONCLUSION During first-time revision, cemented stems show significantly larger femoral bone defects than uncemented stems. Septic stem loosening occurred 17.30% more in cemented stems.
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Affiliation(s)
- Nele Wagener
- Center for Musculoskeletal Surgery, Department of Orthopaedic Surgery, Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Charitéplatz 1, 10117, Berlin, Germany.
| | - Matthias Pumberger
- Center for Musculoskeletal Surgery, Department of Orthopaedic Surgery, Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Sebastian Hardt
- Center for Musculoskeletal Surgery, Department of Orthopaedic Surgery, Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Charitéplatz 1, 10117, Berlin, Germany
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Janz V, Rakow A, Schröder L, Hofer A, Wiebe S, Schoon J, Weiss S, Bröker BM, Wassilew GI, Raafat D. Investigation of the pathogen-specific antibody response in periprosthetic joint infection. Infection 2024:10.1007/s15010-024-02285-y. [PMID: 38819638 DOI: 10.1007/s15010-024-02285-y] [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: 11/23/2023] [Accepted: 04/24/2024] [Indexed: 06/01/2024]
Abstract
PURPOSE Periprosthetic joint infections (PJIs) are a very demanding complication of arthroplasty. Diagnosis of PJI and pathogen identification pose considerable challenges in clinical practice. We hypothesized that the pathogen-specific immune response to PJI reflects the infection process, provides clinically relevant information on disease course, and has the potential to further optimize antimicrobial therapy. METHODS We conducted a prospective matched cohort pilot study with 13 patients undergoing two-stage septic revision arthroplasty (PJI patients) between 06/2020 and 06/2021, as well as 11 control patients undergoing one-stage aseptic revision arthroplasty (Non-PJI patients). Pre-, intra- and postoperative serum samples were collected at standardized time points. We developed a custom Luminex®-based quantitative bead-based suspension array (Infection Array; IA), and used it for simultaneous measurement of antibody specificities against 32 pathogens commonly associated with PJI in 267 serum samples. RESULTS The IA was able to trace the dynamics of the pathogen-specific humoral immune response in all patients against PJI-related pathogens, prominently coagulase-negative staphylococci and streptococci. Pathogen-specific serum antibody titers declined in 62% of PJI patients over the course of treatment, while no changes in antibody titers were observed in 82% of Non-PJI patients during this study. Our serological data strongly suggested that antibody signatures reflect an immune response to microbial invasion. CONCLUSION Our results provide insights into the pathophysiology of PJI and information on the individual disease courses. The IA is therefore a promising and novel serological tool of high resolution for monitoring the immunoproteomic footprints of infectious pathogens in the course of PJI.
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Affiliation(s)
- Viktor Janz
- Center for Orthopaedics, Trauma Surgery and Rehabilitation Medicine, University Medicine Greifswald, 17475, Greifswald, Germany
- Sporthopaedicum, 93053, Regensburg, Germany
| | - Anastasia Rakow
- Center for Orthopaedics, Trauma Surgery and Rehabilitation Medicine, University Medicine Greifswald, 17475, Greifswald, Germany
| | - Leonie Schröder
- Institute of Immunology, University Medicine Greifswald, 17475, Greifswald, Germany
| | - André Hofer
- Center for Orthopaedics, Trauma Surgery and Rehabilitation Medicine, University Medicine Greifswald, 17475, Greifswald, Germany
| | - Sergej Wiebe
- Center for Orthopaedics, Trauma Surgery and Rehabilitation Medicine, University Medicine Greifswald, 17475, Greifswald, Germany
| | - Janosch Schoon
- Center for Orthopaedics, Trauma Surgery and Rehabilitation Medicine, University Medicine Greifswald, 17475, Greifswald, Germany
| | - Stefan Weiss
- Interfaculty Institute for Genetics and Functional Genomics, University Medicine Greifswald, 17475, Greifswald, Germany
| | - Barbara M Bröker
- Institute of Immunology, University Medicine Greifswald, 17475, Greifswald, Germany
| | - Georgi I Wassilew
- Center for Orthopaedics, Trauma Surgery and Rehabilitation Medicine, University Medicine Greifswald, 17475, Greifswald, Germany
| | - Dina Raafat
- Institute of Immunology, University Medicine Greifswald, 17475, Greifswald, Germany.
- Department of Microbiology and Immunology, Faculty of Pharmacy, Alexandria University, 21521, Alexandria, Egypt.
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Lekkala S, Inverardi N, Yuh J, Wannomae KK, Tierney P, Sekar A, Muratoglu OK, Oral E. Antibiotic-Loaded Ultrahigh Molecular Weight Polyethylenes. Macromol Biosci 2024; 24:e2300389. [PMID: 38095273 PMCID: PMC11018474 DOI: 10.1002/mabi.202300389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Revised: 11/20/2023] [Indexed: 01/09/2024]
Abstract
The occurrence of periprosthetic joint infections (PJI) after total joint replacement constitutes a great burden for the patients and the healthcare system. Antibiotic-loaded polymethylmethacrylate (PMMA) bone cement is often used in temporary spacers during antibiotic treatment. PMMA is not a load-bearing solution and needs to be replaced by a functional implant. Elution from the ultrahigh molecular weight polyethylene (UHMWPE) bearing surface for drug delivery can combine functionality with the release of clinically relevant doses of antibiotics. In this study, the feasibility of incorporating a range of antibiotics into UHMWPE is investigated. Drug stability is assessed by thermo-gravimetric analysis and nuclear magnetic resonance spectroscopy. Drug-loaded UHMWPEs are prepared by compression molding, using eight antibiotics at different loading. The predicted intra-articular concentrations of drugs eluted from UHMWPE are above minimum inhibitory concentration for at least 3 weeks against Staphylococci, which are the major causative bacteria for PJI. The antibacterial efficacy is confirmed for samples covering 2% of a representative knee implant in vitro over 72 h, showing that a small fraction of the implant surface loaded with antibiotics may be sufficient against Staphylococci.
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Affiliation(s)
- Sashank Lekkala
- Harris Orthopaedic Laboratory, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Nicoletta Inverardi
- Harris Orthopaedic Laboratory, Massachusetts General Hospital, Boston, MA 02114, USA
- Department of Orthopaedic Surgery, Harvard Medical School, Boston, MA 02114, USA
| | - Jean Yuh
- Harris Orthopaedic Laboratory, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Keith K. Wannomae
- Harris Orthopaedic Laboratory, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Peyton Tierney
- Harris Orthopaedic Laboratory, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Amita Sekar
- Harris Orthopaedic Laboratory, Massachusetts General Hospital, Boston, MA 02114, USA
- Department of Orthopaedic Surgery, Harvard Medical School, Boston, MA 02114, USA
| | - Orhun K. Muratoglu
- Harris Orthopaedic Laboratory, Massachusetts General Hospital, Boston, MA 02114, USA
- Department of Orthopaedic Surgery, Harvard Medical School, Boston, MA 02114, USA
| | - Ebru Oral
- Harris Orthopaedic Laboratory, Massachusetts General Hospital, Boston, MA 02114, USA
- Department of Orthopaedic Surgery, Harvard Medical School, Boston, MA 02114, USA
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Zanna L, Lee M, Karlidag T, Luo TD, Gehrke T, Citak M. Intramedullary Positive Tissue Culture Increases the Risk of Reinfection Following One-Stage Septic Revision Total Knee Arthroplasty. J Arthroplasty 2024:S0883-5403(24)00173-6. [PMID: 38403076 DOI: 10.1016/j.arth.2024.02.053] [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: 09/09/2023] [Revised: 02/15/2024] [Accepted: 02/19/2024] [Indexed: 02/27/2024] Open
Abstract
BACKGROUND Intraoperative acquisition of representative tissue samples is essential during revision arthroplasty of the infected total knee arthroplasty (TKA). While the number of intraoperative tissue samples needed to identify the organism is well described in the literature, there is still a paucity of evidence regarding the location of positive intraoperative samples and their correlation to postoperative outcomes. METHODS There were forty-two patients who had septic failure following one-stage revision TKA for periprosthetic joint infection who were identified between January 2009 and December 2017. They were matched to a control group of patients who had successful one-stage revision TKA without septic failure. The location of positive intraoperative tissue samples was categorized as: 1) soft tissue; 2) interface between bone and prosthesis; and 3) intramedullary (IM). Chi-square, Student's t-, and Wilcoxon Mann-Whitney U-tests were used as appropriate. Univariate and multivariate logistic regression analyses were performed to evaluate predictors of septic failure. RESULTS Weight > 100 kilograms (P = .033), higher Charlson Comorbidity Index (P < .001), and positive IM cultures (P < .001) were associated with a higher risk of reinfection after one-stage revision TKA. A positive IM sample carried a nearly five-fold increase in odds of reinfection (odds ratio 4.86, 95% confidence interval 1.85 to 12.78, P = .001). CONCLUSIONS A positive IM culture sample is significantly associated with septic failure after one-stage exchange for periprosthetic joint infection of the knee. Patients who had positive IM cultures may benefit from longer postoperative antibiotic therapy for the treatment of one-stage exchange arthroplasty to minimize the risk of reinfection.
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Affiliation(s)
- Luigi Zanna
- Department of Orthopaedic Surgery, Helios ENDO-Klinik Hamburg, Hamburg, Germany; Department of Orthopaedic Surgery, Santa Maria Annunziata Hospital, Azienda USL Toscana Centro, Bagno A Ripoli (FI), Italy
| | - Minjae Lee
- Department of Orthopaedic Surgery, Helios ENDO-Klinik Hamburg, Hamburg, Germany
| | - Taner Karlidag
- Department of Orthopaedic Surgery, Helios ENDO-Klinik Hamburg, Hamburg, Germany
| | - T David Luo
- Department of Orthopaedic Surgery, Helios ENDO-Klinik Hamburg, Hamburg, Germany; Orthopaedics Northeast, Fort Wayne, Indiana
| | - Thorsten Gehrke
- Department of Orthopaedic Surgery, Helios ENDO-Klinik Hamburg, Hamburg, Germany
| | - Mustafa Citak
- Department of Orthopaedic Surgery, Helios ENDO-Klinik Hamburg, Hamburg, Germany
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Mirghaderi P, Eshraghi N, Sheikhbahaei E, Razzaghof M, Roustai-Geraylow K, Pouramini A, Eraghi MM, Kafi F, Javad Mortazavi SM. Does Using Highly Porous Tantalum in Revision Total Hip Arthroplasty Reduce the Rate of Periprosthetic Joint Infection? A Systematic Review and Meta-Analysis. Arthroplast Today 2024; 25:101293. [PMID: 38298809 PMCID: PMC10827600 DOI: 10.1016/j.artd.2023.101293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 10/15/2023] [Accepted: 11/05/2023] [Indexed: 02/02/2024] Open
Abstract
Background Studies suggest tantalum (Ta) implants may have inherent antibacterial properties. However, there is no consensus regarding the effectiveness of Ta in preventing periprosthetic joint infection (PJI) after revision total hip arthroplasty (rTHA). Methods We searched 5 main databases for articles reporting the rate of PJI following rTHA using Ta implants from inception to February 2022. The PJI rates of the Ta group were meta-analyzed, compared with the control group, and represented as relative risks (RRs) in forest plots. Results We identified 67 eligible studies (28,414 joints) for assessing the prevalence of PJI following rTHA using Ta implants. Among these studies, only 9 compared the Ta implant group with a control group. The overall PJI rate following rTHA using Ta implants was 2.9% (95% confidence interval [CI]: 2.2%-3.8%), while it was 5.7% (95% CI = 4.1%-7.8%) if only septic revisions were considered. Comparing the Ta and control groups showed a significantly lower PJI rate following all-cause rTHA with an RR = 0.80 (95% CI = 0.65-0.98, P < .05). There was a trend toward lower reinfection rates in the Ta group after rTHA in septic cases, although the difference was not statistically significant (RR = 0.75, 95% CI = 0.44-1.29, P = .30). Conclusions Ta implants are associated with a lower PJI rate following all-cause rTHA but not after septic causes. Despite positive results, the clinical significance of Ta still remains unclear since the PJI rate was only reduced by 20%. Level of Evidence IV.
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Affiliation(s)
- Peyman Mirghaderi
- Surgical Research Society (SRS), Students’ Scientific Research Center, Tehran University of Medical Sciences, Tehran, Iran
- Joint Reconstruction Research Center (JRRC), Tehran University of Medical Sciences, Tehran, Iran
| | - Nasim Eshraghi
- Surgical Research Society (SRS), Students’ Scientific Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Erfan Sheikhbahaei
- Surgical Research Society (SRS), Students’ Scientific Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammadreza Razzaghof
- Joint Reconstruction Research Center (JRRC), Tehran University of Medical Sciences, Tehran, Iran
| | - Kiarash Roustai-Geraylow
- Surgical Research Society (SRS), Students’ Scientific Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Alireza Pouramini
- Surgical Research Society (SRS), Students’ Scientific Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammad Mirahmadi Eraghi
- Surgical Research Society (SRS), Students’ Scientific Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Fatemeh Kafi
- Surgical Research Society (SRS), Students’ Scientific Research Center, Tehran University of Medical Sciences, Tehran, Iran
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Dale H, Fenstad AM, Hallan G, Overgaard S, Pedersen AB, Hailer NP, Kärrholm J, Rolfson O, Eskelinen A, Mäkelä KT, Furnes O. Increasing risk of revision due to infection after primary total hip arthroplasty: results from the Nordic Arthroplasty Register Association. Acta Orthop 2023; 94:307-315. [PMID: 37378447 DOI: 10.2340/17453674.2023.13648] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Indexed: 06/29/2023] Open
Abstract
BACKGROUND AND PURPOSE The incidence of periprosthetic joint infection after total hip arthroplasty (THA) may be increasing. We performed time-trend analyses of risk, rates, and timing of revision due to infection after primary THAs in the Nordic countries from the period 2004-2018. PATIENTS AND METHODS 569,463 primary THAs reported to the Nordic Arthroplasty Register Association from 2004 to 2018 were studied. Absolute risk estimates were calculated by Kaplan-Meier and cumulative incidence function methods, whereas adjusted hazard ratios (aHR) were assessed by Cox regression with the first revision due to infection after primary THA as primary endpoint. In addition, we explored changes in the time span from primary THA to revision due to infection. RESULTS 5,653 (1.0%) primary THAs were revised due to infection during a median follow-up time of 5.4 (IQR 2.5-8.9) years after surgery. Compared with the period 2004-2008, the aHRs for revision were 1.4 (95% confidence interval [CI] 1.3-1.5) for 2009-2013, and 1.9 (CI 1.7-2.0) for 2014-2018. The absolute 5-year rates of revision due to infection were 0.7% (CI 0.7-0.7), 1.0% (CI 0.9-1.0), and 1.2% (CI 1.2-1.3) for the 3 time periods respectively. We found changes in the time span from primary THA to revision due to infection. Compared with 2004-2008, the aHR for revision within 30 days after THA was 2.5 (CI 2.1-2.9) for 2009-2013, and 3.4 (CI 3.0-3.9) for 2013-2018. The aHR for revision within 31-90 days after THA was 1.5 (CI 1.3-1.9) for 2009-2013, and 2.5 (CI 2.1-3.0) for 2013-2018, compared with 2004-2008. CONCLUSION The risk of revision due to infection after primary THA almost doubled, both in absolute cumulative incidence and in relative risk, throughout the period 2004-2018. This increase was mainly due to an increased risk of revision within 90 days of THA. This may reflect a "true" increase (i.e., frailer patients or more use of uncemented implants) and/or an "apparent" increase (i.e., improved diagnostics, changed revision strategy, or completeness of reporting) in incidence of periprosthetic joint infection. It is not possible to disclose such changes in the present study, and this warrants further research.
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Affiliation(s)
- Håvard Dale
- The Norwegian Arthroplasty Register, Department of Orthopaedic Surgery, Haukeland University Hospital, Bergen, Norway; Department of Clinical Medicine, University of Bergen, Norway.
| | - Anne Marie Fenstad
- The Norwegian Arthroplasty Register, Department of Orthopaedic Surgery, Haukeland University Hospital, Bergen, Norway
| | - Geir Hallan
- The Norwegian Arthroplasty Register, Department of Orthopaedic Surgery, Haukeland University Hospital, Bergen, Norway; Department of Clinical Medicine, University of Bergen, Norway
| | - Søren Overgaard
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark; Department of Orthopaedic Surgery and Traumatology, Copenhagen University Hospital, Bispebjerg, Denmark; The Danish Hip Arthroplasty Register, Aarhus, Denmark
| | - Alma B Pedersen
- The Danish Hip Arthroplasty Register, Aarhus, Denmark; Department of Clinical Epidemiology, Aarhus University Hospital, Denmark; Department of Clinical Medicine, Aarhus University, Denmark
| | - Nils P Hailer
- Section of Orthopaedics, Department of Surgical Sciences, Uppsala University Hospital, Sweden; The Swedish Arthroplasty Register, Gothenburg, Sweden
| | - Johan Kärrholm
- The Swedish Arthroplasty Register, Gothenburg, Sweden; Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Sweden
| | - Ola Rolfson
- The Swedish Arthroplasty Register, Gothenburg, Sweden; Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Sweden
| | - Antti Eskelinen
- Coxa Hospital for Joint Replacement, and Faculty of Medicine and Health Technologies, University of Tampere, Tampere, Finland; The Finnish Arthroplasty Register, Helsinki, Finland
| | - Keijo T Mäkelä
- The Finnish Arthroplasty Register, Helsinki, Finland; Department of Orthopaedics and Traumatology, Turku University Hospital and University of Turku, Finland
| | - Ove Furnes
- The Norwegian Arthroplasty Register, Department of Orthopaedic Surgery, Haukeland University Hospital, Bergen, Norway; Department of Clinical Medicine, University of Bergen, Norway
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Lenguerrand E, Whitehouse MR, Beswick AD, Kunutsor SK, Webb JCJ, Mehendale S, Porter M, Blom AW. Mortality and re-revision following single-stage and two-stage revision surgery for the management of infected primary hip arthroplasty in England and Wales. Bone Joint Res 2023; 12:321-330. [PMID: 37158424 PMCID: PMC10167772 DOI: 10.1302/2046-3758.125.bjr-2022-0131.r1] [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: 05/10/2023] Open
Abstract
We compared the risks of re-revision and mortality between two-stage and single-stage revision surgeries among patients with infected primary hip arthroplasty. Patients with a periprosthetic joint infection (PJI) of their primary arthroplasty revised with single-stage or two-stage procedure in England and Wales between 2003 and 2014 were identified from the National Joint Registry. We used Poisson regression with restricted cubic splines to compute hazard ratios (HRs) at different postoperative periods. The total number of revisions and re-revisions undergone by patients was compared between the two strategies. In total, 535 primary hip arthroplasties were revised with single-stage procedure (1,525 person-years) and 1,605 with two-stage procedure (5,885 person-years). All-cause re-revision was higher following single-stage revision, especially in the first three months (HR at 3 months = 1.98 (95% confidence interval (CI) 1.14 to 3.43), p = 0.009). The risks were comparable thereafter. Re-revision for PJI was higher in the first three postoperative months for single-stage revision and waned with time (HR at 3 months = 1.81 (95% CI 1.22 to 2.68), p = 0.003; HR at 6 months = 1.25 (95% CI 0.71 to 2.21), p = 0.441; HR at 12 months = 0.94 (95% CI 0.54 to 1.63), p = 0.819). Patients initially managed with a single-stage revision received fewer revision operations (mean 1.3 (SD 0.7) vs 2.2 (SD 0.6), p < 0.001). Mortality rates were comparable between these two procedures (29/10,000 person-years vs 33/10,000). The risk of unplanned re-revision was lower following two-stage revision, but only in the early postoperative period. The lower overall number of revision procedures associated with a single-stage revision strategy and the equivalent mortality rates to two-stage revision are reassuring. With appropriate counselling, single-stage revision is a viable option for the treatment of hip PJI.
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Affiliation(s)
- Erik Lenguerrand
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Michael R Whitehouse
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol NHS Foundation Trust and University of Bristol, Bristol, UK
| | - Andrew D Beswick
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Setor K Kunutsor
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol NHS Foundation Trust and University of Bristol, Bristol, UK
| | - Jason C J Webb
- Avon Orthopaedic Centre, Southmead Hospital, North Bristol NHS Trust, Bristol, UK
| | - Sanchit Mehendale
- Department of Trauma and Orthopaedics, Bristol Royal Infirmary, Bristol, UK
| | - Martyn Porter
- Centre for Hip Surgery, Wrightington Hospital, Wrightington, UK
| | - Ashley W Blom
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol NHS Foundation Trust and University of Bristol, Bristol, UK
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Steadman W, Chapman PR, Schuetz M, Schmutz B, Trampuz A, Tetsworth K. Local Antibiotic Delivery Options in Prosthetic Joint Infection. Antibiotics (Basel) 2023; 12:antibiotics12040752. [PMID: 37107114 PMCID: PMC10134995 DOI: 10.3390/antibiotics12040752] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Revised: 04/03/2023] [Accepted: 04/07/2023] [Indexed: 04/29/2023] Open
Abstract
Prosthetic Joint Infection (PJI) causes significant morbidity and mortality for patients globally. Delivery of antibiotics to the site of infection has potential to improve the treatment outcomes and enhance biofilm eradication. These antibiotics can be delivered using an intra-articular catheter or combined with a carrier substance to enhance pharmacokinetic properties. Carrier options include non-resorbable polymethylmethacrylate (PMMA) bone cement and resorbable calcium sulphate, hydroxyapatite, bioactive glass, and hydrogels. PMMA allows for creation of structural spacers used in multi-stage revision procedures, however it requires subsequent removal and antibiotic compatibility and the levels delivered are variable. Calcium sulphate is the most researched resorbable carrier in PJI, but is associated with wound leakage and hypercalcaemia, and clinical evidence for its effectiveness remains at the early stage. Hydrogels provide a versatile combability with antibiotics and adjustable elution profiles, but clinical usage is currently limited. Novel anti-biofilm therapies include bacteriophages which have been used successfully in small case series.
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Affiliation(s)
- William Steadman
- Jamieson Trauma Institute, Royal Brisbane and Women's Hospital, Herston, Brisbane 4029, Australia
- Department of Orthopaedics, Royal Brisbane and Women's Hospital, Herston, Brisbane 4029, Australia
- Faculty of Health, Queensland University of Technology, Brisbane 4059, Australia
| | - Paul R Chapman
- Jamieson Trauma Institute, Royal Brisbane and Women's Hospital, Herston, Brisbane 4029, Australia
- Herston Infectious Disease Institute, Royal Brisbane and Women's Hospital, Herston, Brisbane 4029, Australia
- Department of Infectious Diseases, Royal Brisbane and Women's Hospital, Herston, Brisbane 4029, Australia
| | - Michael Schuetz
- Jamieson Trauma Institute, Royal Brisbane and Women's Hospital, Herston, Brisbane 4029, Australia
- Department of Orthopaedics, Royal Brisbane and Women's Hospital, Herston, Brisbane 4029, Australia
- Faculty of Health, Queensland University of Technology, Brisbane 4059, Australia
| | - Beat Schmutz
- Jamieson Trauma Institute, Royal Brisbane and Women's Hospital, Herston, Brisbane 4029, Australia
- School of Mechanical, Medical and Process Engineering, Faculty of Engineering, Queensland University of Technology, Brisbane 4000, Australia
- Centre for Biomedical Technologies, Queensland University of Technology, Brisbane 4059, Australia
- Australian Research Council Training Centre for Multiscale 3D Imaging, Modelling, and Manufacturing, Queensland University of Technology, Brisbane 4059, Australia
| | - Andrej Trampuz
- Center for Musculoskeletal Surgery, Septic Unit Charité-Universitätsmedizin, 10117 Berlin, Germany
| | - Kevin Tetsworth
- Department of Orthopaedics, Royal Brisbane and Women's Hospital, Herston, Brisbane 4029, Australia
- School of Medicine, University of Queensland, Brisbane 4029, Australia
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9
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Adl Amini D, Wu CH, Perka C, Bäcker HC. Cure rate of infections is not an argument for spacer in two-stage revision arthroplasty of the hip. Arch Orthop Trauma Surg 2023; 143:2199-2207. [PMID: 35534712 PMCID: PMC10030410 DOI: 10.1007/s00402-022-04463-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2021] [Accepted: 04/25/2022] [Indexed: 11/25/2022]
Abstract
INTRODUCTION A devastating complication after total hip arthroplasty (THA) is chronic periprosthetic joint infection (PJI). Most frequently spacers (Sp) with or without antibiotics are implanted in a two-stage procedure even though not always indicated due to unknown pathogen, femoral and acetabular defects or muscular insufficiency. MATERIALS AND METHODS A retrospective analysis of a prospectively collected database was conducted, analyzing the treatment of 44 consecutive cases with chronic PJI undergoing two-stage revision using a Girdlestone situation (GS) in the interim period between 01/2015 and 12/2018. Diagnostics included intraoperative microbiological cultures, histological analysis, sonication of the initial implant, analysis of hip aspiration, as well as laboratory diagnostics and blood cultures. We analyzed the general and age-group-specific success rate of treatment using GS. Furthermore, we compared our data with the current literature on spacer implantation regarding common complications. RESULTS In total, 21 female and 23 male patients at a mean age of 59.3 ± 9.6 years were included. Age groups were divided into young, mid-age, and elderly. In most patients, microbiology revealed Staphylococcus epidermidis in 39.1% of cases, following Staphylococcus lugdunensis and Staphylococcus aureus in 10.9% after THA explantation. For histology, Krenn and Morawietz type 2 (infectious type) was diagnosed in 40.9%, type 3 (infectious and abrade-induced type) in 25.0%. With GS, the total cure rate was 84.1% compared to 90.1% (range 61-100%) using Sp as described in the literature. Among age-groups, cure rate varied between 77.8 and 100%. Other complications, which only occurred in the mid-age and elderly group, included the necessity of transfusion in 31.1%, and in total, one periprosthetic fracture was identified (2.3%). CONCLUSION GS shows an acceptable cure rate at a minimum of 2 years when compared to the cure rate reported in the literature for Sp without major complications. For patients with increased risks for treatment failure using spacer, GS seems to be an alternative for chronic PJI when looking at the success rate of treatment. LEVEL OF EVIDENCE III, Retrospective trial.
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Affiliation(s)
- Dominik Adl Amini
- Department of Orthopedic Surgery and Traumatology, Charité, University Hospital Berlin, Charitéplatz 1, 10117, Berlin, Germany.
| | - Chia H Wu
- Department of Orthopedics & Sports Medicine, Baylor College of Medicine Medical Center, Houston, TX, USA
| | - Carsten Perka
- Department of Orthopedic Surgery and Traumatology, Charité, University Hospital Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Henrik C Bäcker
- Department of Orthopedic Surgery and Traumatology, Charité, University Hospital Berlin, Charitéplatz 1, 10117, Berlin, Germany
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10
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Moore AJ, Wylde V, Whitehouse MR, Beswick AD, Walsh NE, Jameson C, Blom AW. Development of evidence-based guidelines for the treatment and management of periprosthetic hip infection. Bone Jt Open 2023; 4:226-233. [PMID: 37051823 PMCID: PMC10065846 DOI: 10.1302/2633-1462.44.bjo-2022-0155.r1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/03/2023] Open
Abstract
Aims Periprosthetic hip-joint infection is a multifaceted and highly detrimental outcome for patients and clinicians. The incidence of prosthetic joint infection reported within two years of primary hip arthroplasty ranges from 0.8% to 2.1%. Costs of treatment are over five-times greater in people with periprosthetic hip joint infection than in those with no infection. Currently, there are no national evidence-based guidelines for treatment and management of this condition to guide clinical practice or to inform clinical study design. The aim of this study is to develop guidelines based on evidence from the six-year INFection and ORthopaedic Management (INFORM) research programme. Methods We used a consensus process consisting of an evidence review to generate items for the guidelines and online consensus questionnaire and virtual face-to-face consensus meeting to draft the guidelines. Results The consensus panel comprised 21 clinical experts in orthopaedics, primary care, rehabilitation, and healthcare commissioning. The final output from the consensus process was a 14-item guideline. The guidelines make recommendations regarding increased vigilance and monitoring of those at increased risk of infection; diagnosis including strategies to ensure the early recognition of prosthetic infection and referral to orthopaedic teams; treatment, including early use of DAIR and revision strategies; and postoperative management including appropriate physical and psychological support and antibiotic strategies. Conclusion We believe the implementation of the INFORM guidelines will inform treatment protocols and clinical pathways to improve the treatment and management of periprosthetic hip infection. Cite this article: Bone Jt Open 2023;4(4):226–233.
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Affiliation(s)
- Andrew J. Moore
- University of Bristol, Bristol, UK
- Correspondence should be sent to Andrew J. Moore. E-mail:
| | | | | | | | - Nicola E. Walsh
- HAS - Allied Health Professions, University of the West of England, Bristol, UK
| | | | - Ashley W. Blom
- University of Sheffield Faculty of Medicine Dentistry and Health, Sheffield, UK
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11
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Trends in Revision Hip Arthroplasty for Prosthetic Joint Infection: A Single-Center Study of 423 Hips at a High-Volume Center Between 2008 and 2021. J Arthroplasty 2023; 38:1151-1159. [PMID: 36863575 DOI: 10.1016/j.arth.2023.02.061] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Revised: 02/16/2023] [Accepted: 02/21/2023] [Indexed: 03/04/2023] Open
Abstract
BACKGROUND Prosthetic joint infection (PJI) is one of the most devastating complications after total hip arthroplasty (THA), and comorbidities increase the risk. We examined whether there was a temporal change in the demographics, especially regarding comorbidities, of patients who have PJIs and were treated over a 13-year study period at a high-volume academic joint arthroplasty center. In addition, the surgical methods used and the microbiology of the PJIs were assessed. METHODS Revisions (n = 423, 418 patients) due to PJI of the hip performed at our institution between 2008 and September 2021 were identified. All included PJIs fulfilled the 2013 International Consensus Meeting diagnostic criteria. The surgeries were categorized into one of the following categories: debridement, antibiotics, and implant retention, 1-stage revision, and 2-stage revision. Infections were classified as early, acute hematogenous, and chronic infections. RESULTS There was no change in the median age of the patients, but the proportion of ASA-class 4 patients increased from 10.5% to 20%. The incidence of early infections increased from 0.11 per 100 primary THAs in 2008 to 1.09 in 2021. The incidence of 1-stage revisions increased the most, rising from 0.10 per 100 primary THAs in 2010 to 0.91 per 100 primary THAs in 2021. Furthermore, the proportion of infections caused by Staphylococcus aureus increased from 26.3% in 2008 to 2009 to 40% in 2020 to 2021. CONCLUSION The comorbidity burden of PJI patients increased during the study period. This increase may present a treatment challenge, as comorbidities are known to have a negative effect on PJI treatment outcomes.
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12
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Blom AW, Beswick AD, Burston A, Carroll FE, Garfield K, Gooberman-Hill R, Harris S, Kunutsor SK, Lane A, Lenguerrand E, MacGowan A, Mallon C, Moore AJ, Noble S, Palmer CK, Rolfson O, Strange S, Whitehouse MR. Infection after total joint replacement of the hip and knee: research programme including the INFORM RCT. PROGRAMME GRANTS FOR APPLIED RESEARCH 2022. [DOI: 10.3310/hdwl9760] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Background
People with severe osteoarthritis, other joint conditions or injury may have joint replacement to reduce pain and disability. In the UK in 2019, over 200,000 hip and knee replacements were performed. About 1 in 100 replacements becomes infected, and most people with infected replacements require further surgery.
Objectives
To investigate why some patients are predisposed to joint infections and how this affects patients and the NHS, and to evaluate treatments.
Design
Systematic reviews, joint registry analyses, qualitative interviews, a randomised controlled trial, health economic analyses and a discrete choice questionnaire.
Setting
Our studies are relevant to the NHS, to the Swedish health system and internationally.
Participants
People with prosthetic joint infection after hip or knee replacement and surgeons.
Interventions
Revision of hip prosthetic joint infection with a single- or two-stage procedure.
Main outcome measures
Long-term patient-reported outcomes and reinfection. Cost-effectiveness of revision strategies over 18 months from two perspectives: health-care provider and Personal Social Services, and societal.
Data sources
National Joint Registry; literature databases; published cohort studies; interviews with 67 patients and 35 surgeons; a patient discrete choice questionnaire; and the INFORM (INFection ORthopaedic Management) randomised trial.
Review methods
Systematic reviews of studies reporting risk factors, diagnosis, treatment outcomes and cost comparisons. Individual patient data meta-analysis.
Results
In registry analyses, about 0.62% and 0.75% of patients with hip and knee replacement, respectively, had joint infection requiring surgery. Rates were four times greater after aseptic revision. The costs of inpatient and day-case admissions in people with hip prosthetic joint infection were about five times higher than those in people with no infection, an additional cost of > £30,000. People described devastating effects of hip and knee prosthetic joint infection and treatment. In the treatment of hip prosthetic joint infection, a two-stage procedure with or without a cement spacer had a greater negative impact on patient well-being than a single- or two-stage procedure with a custom-made articulating spacer. Surgeons described the significant emotional impact of hip and knee prosthetic joint infection and the importance of a supportive multidisciplinary team. In systematic reviews and registry analyses, the risk factors for hip and knee prosthetic joint infection included male sex, diagnoses other than osteoarthritis, high body mass index, poor physical status, diabetes, dementia and liver disease. Evidence linking health-care setting and surgeon experience with prosthetic joint infection was inconsistent. Uncemented fixation, posterior approach and ceramic bearings were associated with lower infection risk after hip replacement. In our systematic review, synovial fluid alpha-defensin and leucocyte esterase showed high diagnostic accuracy for prosthetic joint infection. Systematic reviews and individual patient data meta-analysis showed similar reinfection outcomes in patients with hip or knee prosthetic joint infection treated with single- and two-stage revision. In registry analysis, there was a higher rate of early rerevision after single-stage revision for hip prosthetic joint infection, but, overall, 40% fewer operations are required as part of a single-stage procedure than as part of a two-stage procedure. The treatment of hip or knee prosthetic joint infection with early debridement and implant retention may be effective in > 60% of cases. In the INFORM randomised controlled trial, 140 patients with hip prosthetic joint infection were randomised to single- or two-stage revision. Eighteen months after randomisation, pain, function and stiffness were similar between the randomised groups (p = 0.98), and there were no differences in reinfection rates. Patient outcomes improved earlier in the single-stage than in the two-stage group. Participants randomised to a single-stage procedure had lower costs (mean difference –£10,055, 95% confidence interval –£19,568 to –£542) and higher quality-adjusted life-years (mean difference 0.06, 95% confidence interval –0.07 to 0.18) than those randomised to a two-stage procedure. Single-stage was the more cost-effective option, with an incremental net monetary benefit at a threshold of £20,000 per quality-adjusted life-year of £11,167 (95% confidence interval £638 to £21,696). In a discrete choice questionnaire completed by 57 patients 18 months after surgery to treat hip prosthetic joint infection, the most valued characteristics in decisions about revision were the ability to engage in valued activities and a quick return to normal activity.
Limitations
Some research was specific to people with hip prosthetic joint infection. Study populations in meta-analyses and registry analyses may have been selected for joint replacement and specific treatments. The INFORM trial was not powered to study reinfection and was limited to 18 months’ follow-up. The qualitative study subgroups were small.
Conclusions
We identified risk factors, diagnostic biomarkers, effective treatments and patient preferences for the treatment of hip and knee prosthetic joint infection. The risk factors include male sex, diagnoses other than osteoarthritis, specific comorbidities and surgical factors. Synovial fluid alpha-defensin and leucocyte esterase showed high diagnostic accuracy. Infection is devastating for patients and surgeons, both of whom describe the need for support during treatment. Debridement and implant retention is effective, particularly if performed early. For infected hip replacements, single- and two-stage revision appear equally efficacious, but single-stage has better early results, is cost-effective at 18-month follow-up and is increasingly used. Patients prefer treatments that allow full functional return within 3–9 months.
Future work
For people with infection, develop information, counselling, peer support and care pathways. Develop supportive care and information for patients and health-care professionals to enable the early recognition of infections. Compare alternative and new treatment strategies in hip and knee prosthetic joint infection. Assess diagnostic methods and establish NHS diagnostic criteria.
Study registration
The INFORM randomised controlled trial is registered as ISRCTN10956306. All systematic reviews were registered in PROSPERO (as CRD42017069526, CRD42015023485, CRD42018106503, CRD42018114592, CRD42015023704, CRD42017057513, CRD42015016559, CRD42015017327 and CRD42015016664).
Funding
This project was funded by the National Institute for Health and Care Research (NIHR) Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 10, No. 10. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Ashley W Blom
- National Institute for Health and Care Research Bristol Biomedical Research Centre, University Hospitals Bristol and Weston NHS Foundation Trust and University of Bristol, Bristol, UK
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Andrew D Beswick
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Amanda Burston
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Fran E Carroll
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Kirsty Garfield
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- Bristol Randomised Trials Collaboration, University of Bristol, Bristol, UK
| | - Rachael Gooberman-Hill
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Shaun Harris
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- Bristol Randomised Trials Collaboration, University of Bristol, Bristol, UK
| | - Setor K Kunutsor
- National Institute for Health and Care Research Bristol Biomedical Research Centre, University Hospitals Bristol and Weston NHS Foundation Trust and University of Bristol, Bristol, UK
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Athene Lane
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- Bristol Randomised Trials Collaboration, University of Bristol, Bristol, UK
| | - Erik Lenguerrand
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | | | - Charlotte Mallon
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Andrew J Moore
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Sian Noble
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Cecily K Palmer
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- National Institute for Health and Care Research Applied Research Collaboration West (NIHR ARC West), University Hospitals Bristol NHS Foundation Trust and University of Bristol, Bristol, UK
| | - Ola Rolfson
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Simon Strange
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Michael R Whitehouse
- National Institute for Health and Care Research Bristol Biomedical Research Centre, University Hospitals Bristol and Weston NHS Foundation Trust and University of Bristol, Bristol, UK
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
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13
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Blom AW, Lenguerrand E, Strange S, Noble SM, Beswick AD, Burston A, Garfield K, Gooberman-Hill R, Harris SRS, Kunutsor SK, Lane JA, MacGowan A, Mehendale S, Moore AJ, Rolfson O, Webb JCJ, Wilson M, Whitehouse MR. Clinical and cost effectiveness of single stage compared with two stage revision for hip prosthetic joint infection (INFORM): pragmatic, parallel group, open label, randomised controlled trial. BMJ 2022; 379:e071281. [PMID: 36316046 PMCID: PMC9645409 DOI: 10.1136/bmj-2022-071281] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES To determine whether patient reported outcomes improve after single stage versus two stage revision surgery for prosthetic joint infection of the hip, and to determine the cost effectiveness of these procedures. DESIGN Pragmatic, parallel group, open label, randomised controlled trial. SETTING High volume tertiary referral centres or orthopaedic units in the UK (n=12) and in Sweden (n=3), recruiting from 1 March 2015 to 19 December 2018. PARTICIPANTS 140 adults (aged ≥18 years) with a prosthetic joint infection of the hip who required revision (65 randomly assigned to single stage and 75 to two stage revision). INTERVENTIONS A computer generated 1:1 randomisation list stratified by hospital was used to allocate participants with prosthetic joint infection of the hip to a single stage or a two stage revision procedure. MAIN OUTCOME MEASURES The primary intention-to-treat outcome was pain, stiffness, and functional limitations 18 months after randomisation, measured by the Western Ontario and McMasters Universities Osteoarthritis Index (WOMAC) score. Secondary outcomes included surgical complications and joint infection. The economic evaluation (only assessed in UK participants) compared quality adjusted life years and costs between the randomised groups. RESULTS The mean age of participants was 71 years (standard deviation 9) and 51 (36%) were women. WOMAC scores did not differ between groups at 18 months (mean difference 0.13 (95% confidence interval -8.20 to 8.46), P=0.98); however, the single stage procedure was better at three months (11.53 (3.89 to 19.17), P=0.003), but not from six months onwards. Intraoperative events occurred in five (8%) participants in the single stage group and 20 (27%) in the two stage group (P=0.01). At 18 months, nine (14%) participants in the single stage group and eight (11%) in the two stage group had at least one marker of possible ongoing infection (P=0.62). From the perspective of healthcare providers and personal social services, single stage revision was cost effective with an incremental net monetary benefit of £11 167 (95% confidence interval £638 to £21 696) at a £20 000 per quality adjusted life years threshold (£1.0; $1.1; €1.4). CONCLUSIONS At 18 months, single stage revision compared with two stage revision for prosthetic joint infection of the hip showed no superiority by patient reported outcome. Single stage revision had a better outcome at three months, fewer intraoperative complications, and was cost effective. Patients prefer early restoration of function, therefore, when deciding treatment, surgeons should consider patient preferences and the cost effectiveness of single stage surgery. TRIAL REGISTRATION ISRCTN registry ISRCTN10956306.
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Affiliation(s)
- Ashley W Blom
- University of Bristol Medical School, Translational Health Sciences, Musculoskeletal Research Unit, Level 1 Learning and Research Building, Southmead Hospital, Westbury-on-Trym, Bristol, UK
- National Institute for Health and Care Research Bristol Biomedical Research Centre, University Hospitals Bristol and Weston NHS Foundation Trust and University of Bristol, Bristol, UK
| | - Erik Lenguerrand
- University of Bristol Medical School, Translational Health Sciences, Musculoskeletal Research Unit, Level 1 Learning and Research Building, Southmead Hospital, Westbury-on-Trym, Bristol, UK
| | - Simon Strange
- University of Bristol Medical School, Translational Health Sciences, Musculoskeletal Research Unit, Level 1 Learning and Research Building, Southmead Hospital, Westbury-on-Trym, Bristol, UK
| | - Sian M Noble
- University of Bristol Medical School, Population Health Sciences, Canynge Hall, Bristol, UK
| | - Andrew D Beswick
- University of Bristol Medical School, Translational Health Sciences, Musculoskeletal Research Unit, Level 1 Learning and Research Building, Southmead Hospital, Westbury-on-Trym, Bristol, UK
| | - Amanda Burston
- University of Bristol Medical School, Translational Health Sciences, Musculoskeletal Research Unit, Level 1 Learning and Research Building, Southmead Hospital, Westbury-on-Trym, Bristol, UK
| | - Kirsty Garfield
- University of Bristol Medical School, Population Health Sciences, Canynge Hall, Bristol, UK
- University of Bristol Faculty of Health Sciences, Bristol Randomised Trials Collaboration, Canynge Hall, Bristol, UK
| | - Rachael Gooberman-Hill
- University of Bristol Medical School, Translational Health Sciences, Musculoskeletal Research Unit, Level 1 Learning and Research Building, Southmead Hospital, Westbury-on-Trym, Bristol, UK
- National Institute for Health and Care Research Bristol Biomedical Research Centre, University Hospitals Bristol and Weston NHS Foundation Trust and University of Bristol, Bristol, UK
| | - Shaun R S Harris
- University of Bristol Medical School, Population Health Sciences, Canynge Hall, Bristol, UK
- University of Bristol Faculty of Health Sciences, Bristol Randomised Trials Collaboration, Canynge Hall, Bristol, UK
| | - Setor K Kunutsor
- University of Bristol Medical School, Translational Health Sciences, Musculoskeletal Research Unit, Level 1 Learning and Research Building, Southmead Hospital, Westbury-on-Trym, Bristol, UK
- National Institute for Health and Care Research Bristol Biomedical Research Centre, University Hospitals Bristol and Weston NHS Foundation Trust and University of Bristol, Bristol, UK
| | - J Athene Lane
- University of Bristol Medical School, Population Health Sciences, Canynge Hall, Bristol, UK
- University of Bristol Faculty of Health Sciences, Bristol Randomised Trials Collaboration, Canynge Hall, Bristol, UK
| | - Alasdair MacGowan
- Department of Medical Microbiology, Southmead Hospital, North Bristol NHS Trust, Bristol, Westbury-on-Trym, UK
| | - Sanchit Mehendale
- Department of Trauma and Orthopaedics, Bristol Royal Infirmary, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Andrew J Moore
- University of Bristol Medical School, Translational Health Sciences, Musculoskeletal Research Unit, Level 1 Learning and Research Building, Southmead Hospital, Westbury-on-Trym, Bristol, UK
| | - Ola Rolfson
- Department of Orthopaedics at Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Mölndal, Sweden
| | - Jason C J Webb
- University of Bristol Medical School, Translational Health Sciences, Musculoskeletal Research Unit, Level 1 Learning and Research Building, Southmead Hospital, Westbury-on-Trym, Bristol, UK
| | - Matthew Wilson
- The Exeter Hip Unit, Princess Elizabeth Orthopaedic Hospital, Royal Devon and Exeter Hospital NHS Foundation Trust, Exeter, UK
| | - Michael R Whitehouse
- University of Bristol Medical School, Translational Health Sciences, Musculoskeletal Research Unit, Level 1 Learning and Research Building, Southmead Hospital, Westbury-on-Trym, Bristol, UK
- National Institute for Health and Care Research Bristol Biomedical Research Centre, University Hospitals Bristol and Weston NHS Foundation Trust and University of Bristol, Bristol, UK
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Comparison of Titanium and PEEK Medical Plastic Implant Materials for Their Bacterial Biofilm Formation Properties. Polymers (Basel) 2022; 14:polym14183862. [PMID: 36146003 PMCID: PMC9504047 DOI: 10.3390/polym14183862] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Revised: 07/27/2022] [Accepted: 09/08/2022] [Indexed: 11/16/2022] Open
Abstract
This study investigated two of the most commonly used CAD–CAM materials for patient-specific reconstruction in craniomaxillofacial surgery. The aim of this study was to access the biofilm formation of Staphylococcus aureus, Streptococcus mutans, Enterococcus faecalis, and Escherichia coli on titanium and PEEK medical implant materials. Two titanium specimens (titanium grade 2 tooled with a Planmeca CAD–CAM milling device and titanium grade 5 tooled with a computer-aided design direct metal laser sintering device (CAD-DMLS)) and one PEEK specimen tooled with a Planmeca CAD–CAM milling device were studied. Bacterial adhesion on implants was evaluated in two groups (saliva-treated group and non-saliva-treated group) to imitate intraoral and extraoral surgical routes for implant placement. The PEEK medical implant material showed higher bacterial adhesion by S. aureus, S. mutans, and E. coli than titanium grade 2 and titanium grade 5, whereas E. faecalis showed higher adhesion to titanium as compared to PEEK. Saliva contamination of implants also effected bacterial attachment. Salivary coating enhanced biofilm formation by S. aureus, S. mutans, and E. faecalis. In conclusion, our findings imply that regardless of the implant material type or tooling techniques used, salivary coating plays a vital role in bacterial adhesion. In addition, the majority of the bacterial strains showed higher adhesion to PEEK than titanium.
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Smith AH, Brassett C, Gooding C, Abood A, Norrish A. Vastus lateralis vs rectus femoris muscle flaps for recalcitrant hip joint infection: an anatomical study comparing the effectiveness of acetabular dead space control. Clin Anat 2022; 35:961-973. [PMID: 35736665 PMCID: PMC9544425 DOI: 10.1002/ca.23925] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 05/08/2022] [Accepted: 06/22/2022] [Indexed: 11/09/2022]
Abstract
Eliminating recalcitrant prosthetic hip joint infections remains one of the greatest challenges in orthopedic surgery. In such cases, the salvage procedure of femoral head excision (the Girdlestone procedure) is often performed. There has been emerging surgical interest in filling the resulting acetabular dead space with a pedicled muscle flap, to enable antibiotic delivery. Both vastus lateralis (VL) and rectus femoris (RF) muscle flaps have been described for this purpose with good success. This study is the first anatomical investigation comparing VL and RF as candidates for interposition myoplasty following hip joint excision. Following standard surgical technique, the Girdlestone procedure and interposition myoplasty of both RF and VL were performed on 10 cadavers. The primary aim was to determine which muscle flap eliminated a greater volume of acetabular dead space. Secondary aims were to characterize the blood supply to RF and assess additional metrics indicative of the likelihood of flap success. The VL flap eliminated more dead space than RF. However, the use of the RF flap was feasible in all cases and has several benefits, including ease of harvest, mobility, and aesthetics. The location of the inferior vascular pedicle into RF was relatively consistent and the most effective predictor of flap success. Both VL and RF are effective in reducing acetabular dead space. While VL can fill a greater volume, the RF flap has technical advantages, related to the predictability of the blood supply.
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Affiliation(s)
- Alexandria H Smith
- Human Anatomy Centre, Department of Physiology, Development and Neuroscience, University of Cambridge, Downing Street, Cambridge
| | - Cecilia Brassett
- Human Anatomy Centre, Department of Physiology, Development and Neuroscience, University of Cambridge, Downing Street, Cambridge
| | | | - Ahid Abood
- Cambridge University Hospitals NHS Foundation Trust, Hills Road, Cambridge
| | - Alan Norrish
- Academic Orthopaedics, Trauma and Sports Medicine, University of Nottingham, Queen's Medical Centre, Nottingham
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Wei J, Tong K, Wang H, Wen Y, Chen L. Intra-articular versus systemic vancomycin for the treatment of periprosthetic joint infection after debridement and spacer implantation in a rat model. Bone Joint Res 2022; 11:371-385. [PMID: 35708551 PMCID: PMC9233408 DOI: 10.1302/2046-3758.116.bjr-2021-0319.r3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Aims Treatment outcomes for methicillin-resistant Staphylococcus aureus (MRSA) periprosthetic joint infection (PJI) using systemic vancomycin and antibacterial cement spacers during two-stage revision arthroplasty remain unsatisfactory. This study explored the efficacy and safety of intra-articular vancomycin injections for PJI control after debridement and cement spacer implantation in a rat model. Methods Total knee arthroplasty (TKA), MRSA inoculation, debridement, and vancomycin-spacer implantation were performed successively in rats to mimic first-stage PJI during the two-stage revision arthroplasty procedure. Vancomycin was administered intraperitoneally or intra-articularly for two weeks to control the infection after debridement and spacer implantation. Results Rats receiving intra-articular vancomycin showed the best outcomes among the four treatment groups, with negative bacterial cultures, increased weight gain, increased capacity for weightbearing activities, increased residual bone volume preservation, and reduced inflammatory reactions in the joint tissues, indicating MRSA eradication in the knee. The vancomycin-spacer and/or systemic vancomycin failed to eliminate the MRSA infections following a two-week antibiotic course. Serum vancomycin levels did not reach nephrotoxic levels in any group. Mild renal histopathological changes, without changes in serum creatinine levels, were observed in the intraperitoneal vancomycin group compared with the intra-articular vancomycin group, but no changes in hepatic structure or serum alanine aminotransferase or aspartate aminotransferase levels were observed. No local complications were observed, such as sinus tract or non-healing surgical incisions. Conclusion Intra-articular vancomycin injection was effective and safe for PJI control following debridement and spacer implantation in a rat model during two-stage revision arthroplasties, with better outcomes than systemic vancomycin administration. Cite this article: Bone Joint Res 2022;11(6):371–385.
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Affiliation(s)
- Jian Wei
- Department of Joint Surgery and Sports Medicine, Zhongnan Hospital of Wuhan University, Wuhan, China.,Joint Disease Research Center of Wuhan University, Wuhan, China
| | - Kai Tong
- Department of Joint Surgery and Sports Medicine, Zhongnan Hospital of Wuhan University, Wuhan, China.,Joint Disease Research Center of Wuhan University, Wuhan, China
| | - Hui Wang
- Department of Pharmacology, Department of Basic Medicine, Wuhan University, Wuhan, China
| | - Yinxian Wen
- Department of Joint Surgery and Sports Medicine, Zhongnan Hospital of Wuhan University, Wuhan, China.,Joint Disease Research Center of Wuhan University, Wuhan, China
| | - Liaobin Chen
- Department of Joint Surgery and Sports Medicine, Zhongnan Hospital of Wuhan University, Wuhan, China.,Joint Disease Research Center of Wuhan University, Wuhan, China
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17
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Aquilina CO, Aquilina AL, Webb J, Albur M, Whitehouse MR. Are multiple-use bottles of chlorhexidine solutions at risk of contamination in joint replacement surgery? Ann R Coll Surg Engl 2022; 104:434-436. [PMID: 34939853 PMCID: PMC9158045 DOI: 10.1308/rcsann.2021.0217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION Chlorhexidine gluconate 2% w/v in isopropanol 70% solutions in multiple-use bottles is commonly used in surgery as a cost-effective method for skin disinfection. However, multiple-use bottles risk contamination. This study aims to test whether bacterial contamination of multiple-use bottles or their solutions occurs once open and on use between different patients. METHODS Consecutive samples were taken each time a chlorhexidine bottle was used over a 7-day study period. Samples were tested using blood culture, agar plate and mass spectrometry. RESULTS No growth was observed in 52 samples taken from 18 bottles inoculated into blood culture bottles. Four growths on agar plate culture were determined to be contaminants from the sampling process. CONCLUSIONS This study supports the use of multiple-use bottled chlorhexidine solutions as safe and cost-effective in surgical practice.
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Affiliation(s)
| | | | - J Webb
- University of Bristol, UK
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18
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Xu H, Liu L, Xie J, Wang D, Huang Z, Wang W, Zhou Z. The Screening of Fixation-Related Infection in Patients Undergoing Conversion Total Hip Arthroplasty after Failed Internal Fixation of Hip Fractures: A Single-Central Retrospective Study. Orthop Surg 2022; 14:1167-1174. [PMID: 35582895 PMCID: PMC9163979 DOI: 10.1111/os.13225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2021] [Revised: 12/09/2021] [Accepted: 01/19/2022] [Indexed: 02/05/2023] Open
Abstract
Objective To evaluate the diagnostic values of preoperative plasma fibrinogen and platelet count for screening fixation‐related infection (FRI) in patients undergoing conversion total hip arthroplasty (cTHA) after failed internal fixation of hip fractures. Method This was a single‐center retrospective study. Data were retrospectively analyzed for 435 patients who underwent cTHA in our hospital from January 2008 to September 2020. They were divided into infected (n = 30) and non‐infected groups (n = 405) according to the 2013 International Consensus Meeting (ICM) criteria. The diagnostic sensitivity and specificity of plasma fibrinogen and platelet count were determined using receiver operating characteristic (ROC) curves. Optimal predictive cutoffs of these two markers were determined based on the Youden index. In addition, the diagnostic value of preoperative serum C‐reactive protein (CRP) and erythrocyte sedimentation rate (ESR) for screening FRI were also evaluated based on the cutoffs recommended by the 2013 ICM Criteria. Finally, the diagnostic ability of various combinations of the plasma fibrinogen and platelet count as well as serum CRP and ESR was re‐assessed. Results The numbers of patients with and without FRI were 30 (6.9%) and 405 (93.1%), respectively. Areas under the ROC curves were 0.770 for fibrinogen, 0.606 for platelet, 0.844 for CRP and 0.749 for ESR. The optimal predictive cutoff of fibrinogen was 3.73 g/L, which gave sensitivity of 60.0% and specificity of 90.5%. The optimal predictive cutoff for platelet was 241.5 × 109/L, which gave sensitivity of 46.7% and specificity of 83.7%. The CRP gave sensitivity of 66.7% and specificity of 92.5% with the predetermined cutoff of 10 mg/L, while the ESR gave sensitivity of 67.5% and specificity of 72.4% % with the predetermined cutoff of 30 mm/h. The combination of CRP and ESR showed high specificity of 93.2% but low sensitivity of 66.7%, while the corresponding values for CRP with fibrinogen were satisfied both for sensitivity of 80.0% and specificity of 78.7%. The combination of these four biomarkers gave sensitivity of 73.3% and specificity of 85.7%. Conclusion Preoperative serum CRP, ESR, plasma fibrinogen and platelet count have low sensitivity on their own for screening FRI in patients, but the combination of CRP with fibrinogen shows promise for that.
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Affiliation(s)
- Hong Xu
- Department of Orthopaedic Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Li Liu
- Department of Orthopaedic Surgery, West China Hospital, Sichuan University/ West China Hospital of Nursing, Sichuan University, Chengdu, China
| | - Jinwei Xie
- Department of Orthopaedic Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Duan Wang
- Department of Orthopaedic Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Zeyu Huang
- Department of Orthopaedic Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Wenqi Wang
- West China School of Medicine, Sichuan University, Chengdu, China
| | - Zongke Zhou
- Department of Orthopaedic Surgery, West China Hospital, Sichuan University, Chengdu, China
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19
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20
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Vitiello R, Ziranu A, Oliva MS, Meluzio MC, Cauteruccio M, Maccauro G, Liuzza F, Saccomanno MF. The value of megaprostheses in non-oncological fractures in elderly patients: A short-term results. Injury 2022; 53:1241-1246. [PMID: 34602244 DOI: 10.1016/j.injury.2021.09.026] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2021] [Accepted: 09/13/2021] [Indexed: 02/02/2023]
Abstract
INTRODUCTION The management of both hip and distal femur fractures as well as periprosthetic fractures can be challenging for orthopaedic surgeons. The use of megaprosthetic implants could provide substantial advantages in elderly population affected by complex fractures. The aim of the study was to evaluate the effectiveness of megaprosthetic implants for treating hip and distal femur fractures as well as periprosthetic fractures in elderly. MATERIAL AND METHODS From January 1st 2015 to December 31st 2019, patients treated for proximal or distal femoral fractures with severe bone loss or failure of previous surgery were retrospectively reviewed. Patients were divided into two group based on diagnosis: proximal femur fractures (group A) and distal femur fractures (group B). Subsequently, patients underwent hip (group A) or knee (group B) megaprosthesis. Self-assessed questionnaires were administered to all patients pre and postoperatively. Primary outcome was the Activity Daily Living. Secondary outcomes were: Instrumental Activity Daily Living, Short Form-12, Oxford knee or hip score, complications. Charlson score, Harris classification for hip or Anderson Orthopaedic Research Institute score and complication were recorded. All patients underwent a radiological follow up to rule out implant loosening and mobilization. Pre and postoperative functional score comparisons in each group were undertaken. Significance was set p ≤ 0.05. RESULTS Twelve patients were finally included in the study. There were 6 male and 6 females, the mean age was 72,9 years old (± 7,4); the mean BMI was 29,8 points (± 4.5). The mean follow-up was 2.9 years (± 1.4). No differences could be found between pre and postoperative evaluation in each group. No aseptic loosening, dislocation, mobilization or radiolucency were recorded during the follow-up. In group A, two surgical site infections (2/6 patients) and one pneumonia (1/6 patients) were recorded. In group B, two surgical site infections occurred (2/6 patients). All patients were treated by antimicrobial oral therapy with complete regression. CONCLUSION The use of hip and knee megaprosthetic implants in traumatology is a safe and viable option in elderly patients.
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Affiliation(s)
- Raffaele Vitiello
- Fondazione Policlinico Universitario A. Gemelli IRCSS, Roma, Italia; Università Cattolica Del Sacro Cuore, Roma, Italia
| | - Antonio Ziranu
- Fondazione Policlinico Universitario A. Gemelli IRCSS, Roma, Italia; Università Cattolica Del Sacro Cuore, Roma, Italia
| | - Maria Serena Oliva
- Fondazione Policlinico Universitario A. Gemelli IRCSS, Roma, Italia; Università Cattolica Del Sacro Cuore, Roma, Italia.
| | - Maria Concetta Meluzio
- Fondazione Policlinico Universitario A. Gemelli IRCSS, Roma, Italia; Università Cattolica Del Sacro Cuore, Roma, Italia
| | - Michele Cauteruccio
- Fondazione Policlinico Universitario A. Gemelli IRCSS, Roma, Italia; Università Cattolica Del Sacro Cuore, Roma, Italia
| | - Giulio Maccauro
- Fondazione Policlinico Universitario A. Gemelli IRCSS, Roma, Italia; Università Cattolica Del Sacro Cuore, Roma, Italia
| | - Francesco Liuzza
- Fondazione Policlinico Universitario A. Gemelli IRCSS, Roma, Italia; Università Cattolica Del Sacro Cuore, Roma, Italia
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21
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Microbiology of hip and knee periprosthetic joint infections: a database study. Clin Microbiol Infect 2022; 28:255-259. [PMID: 34129907 PMCID: PMC8665939 DOI: 10.1016/j.cmi.2021.06.006] [Citation(s) in RCA: 43] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Revised: 06/03/2021] [Accepted: 06/05/2021] [Indexed: 02/03/2023]
Abstract
OBJECTIVES Knowledge of the microbiological aetiology of periprosthetic joint infection (PJI) is essential to its management. Contemporary literature from the United States on this topic is lacking. This study aimed to identify the most common microorganisms associated with types of arthroplasty, the timing of infection, and clues to polymicrobial infection. METHODS We performed an analytical cross-sectional study of patients 18 years of age or older with hip or knee PJI diagnosed at our institution between 2010 and 2019. PJI was defined using the criteria adapted from those of the Musculoskeletal Infection Society. Cases included PJI associated with primary or revision arthroplasty and arthroplasty performed at our institution or elsewhere. RESULTS A total of 2067 episodes of PJI in 1651 patients were included. Monomicrobial infections represented 70% of episodes (n = 1448), with 25% being polymicrobial (n = 508) and the rest (5%, n = 111) culture-negative. The most common group causing PJI was coagulase-negative Staphylococcus species (other than S. ludgunensis) (37%, n = 761). The distribution of most common organisms was similar regardless of arthroplasty type. The S. aureus complex, Gram-negative bacteria, and anaerobic bacteria (other than Cutibacterium species) were more likely to be isolated than other organisms in the first year following index arthroplasty (OR 1.7, 95%CI 1.4-2.2; OR 1.5, 95%CI 1.1-2.0; and OR 1.5, 95%CI 1.0-2.2, respectively). The proportion of culture-negative PJIs was higher in primary than revision arthroplasty (6.5% versus 3%, p 0.0005). The presence of a sinus tract increased the probability of the isolation of more than one microorganism by almost three-fold (OR 2.6, 95%CI 2.0-3.3). CONCLUSIONS Joint age, presence of a sinus tract, and revision arthroplasties influenced PJI microbiology.
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22
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Marston S, Mirick Mueller G, Sabin A, Hansen GT, Lindgren B, Aparicio C, Armstrong AR, Larsen OH, Schmidt A, Kyle R, Gustilo R, Tsukayama D, Bechtold J, Bue M. Systemic versus free antibiotic delivery in preventing acute exogenous implant related infection in a rat model. J Orthop Res 2022; 40:429-438. [PMID: 33913540 DOI: 10.1002/jor.25052] [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] [Received: 09/01/2020] [Revised: 12/15/2020] [Accepted: 04/12/2021] [Indexed: 02/04/2023]
Abstract
We studied systemic ceftriaxone, and free/local tobramycin and doxycycline in a controlled rat model representing a generic acute exogenous joint infection. We hypothesized that evidence of infection (quantitative colony forming units [CFU], qualitative scanning electron microscopy [SEM], histopathology) (1a) would be reduced with local versus systemic antibiotic, (1b) any antibiotic would be superior to control, (2) there would be a difference among antibiotics, and (3) antibiotic would not be detectable in serum at 4-week euthanasia. Study groups included infected and noninfected (1) control (no treatment), (2) systemic ceftriaxone (daily), (3) local tobramycin, and (4) local doxycycline (10 rats/group; power = 0.8). With IACUC approval, a reliable acute exogenous joint infection was created by slowly injecting 50-μl, 104 CFU Staphylococcus aureus, into the distal femoral medullary canal. The antibiotic formulation was introduced locally to the femoral canal and joint space. After 4 weeks, serum, pin, bone, and synovium were obtained. CFU/ml of bone and synovium were quantified using macrotiter method. SEM imaged biofilm on the surface of the pin, histopathology identified tissue response, liquid chromatography/mass spectrometry quantified plasma antibiotic. (1) Groups receiving any antibiotic reported lower CFU/ml in synovium compared with no treatment. (2) In the synovium, free/local tobramycin reduced CFU/ml to a greater extent than free/local doxycycline (p < 0.05). (3) Antibiotic in plasma after the local application was nondetectable in all groups after 4 weeks. SEM revealed no difference in biofilm on pin among all groups.
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Affiliation(s)
- Scott Marston
- University of Minnesota, Minneapolis, Minnesota, USA
| | | | - Arick Sabin
- Hennepin Healthcare Research Institute, Minneapolis, Minnesota, USA
| | - Glen T Hansen
- University of Minnesota, Minneapolis, Minnesota, USA.,Hennepin Healthcare Research Institute, Minneapolis, Minnesota, USA
| | | | | | | | - Ole H Larsen
- Department of Clinical Biochemistry, Aarhus University Hospital, Aarhus, Denmark
| | - Andrew Schmidt
- University of Minnesota, Minneapolis, Minnesota, USA.,Hennepin Healthcare Research Institute, Minneapolis, Minnesota, USA
| | - Richard Kyle
- University of Minnesota, Minneapolis, Minnesota, USA.,Hennepin Healthcare Research Institute, Minneapolis, Minnesota, USA
| | - Ramon Gustilo
- University of Minnesota, Minneapolis, Minnesota, USA.,Hennepin Healthcare Research Institute, Minneapolis, Minnesota, USA
| | - Dean Tsukayama
- University of Minnesota, Minneapolis, Minnesota, USA.,Hennepin Healthcare Research Institute, Minneapolis, Minnesota, USA
| | - Joan Bechtold
- University of Minnesota, Minneapolis, Minnesota, USA.,Hennepin Healthcare Research Institute, Minneapolis, Minnesota, USA
| | - Mats Bue
- Department of Orthopaedic Surgery, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
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23
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Kamp MC, Liu WY, Goosen JHM, Rijnen WHC, van Steenbergen LN, van der Weegen W. Mismatch in Capture of Periprosthetic Joint Infections Between the Dutch Arthroplasty Register (LROI) and a Detailed Regional Periprosthetic Joint Infection Registry. J Arthroplasty 2022; 37:126-131. [PMID: 34563434 DOI: 10.1016/j.arth.2021.09.001] [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] [Received: 07/12/2021] [Revised: 08/19/2021] [Accepted: 09/01/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND National arthroplasty registries are important sources for periprosthetic joint infection (PJI) data and report an average incidence ranging from 0.5% to 2.0%. However, studies have shown that PJI incidence in national arthroplasty registries may be underestimated. Therefore, the incidence of PJI in the Dutch Arthroplasty Register (LROI) was evaluated. METHODS We matched revisions due to infection within 90 days of index procedure in the LROI database (prospectively registered in 2014-2018) with acute PJI cases registered in a Regional Infection Cohort (RIC) and vice versa. The RIC comprised of 1 university hospital, 3 large orthopedic teaching hospitals and 4 general district hospitals, representing 11.3% of all Dutch arthroplasty procedures with a similar case mix. RESULTS From the 352 acute PJIs in the RIC, 166 (47%) were registered in the LROI. Of the 186 confirmed PJI cases not registered in the LROI, 51% (n = 95) were a unregistered Debridement, Antibiotics, and Implant Retention procedure without component exchange. The remaining missing PJI cases (n = 91, 49%) were of administrative origin. The acute PJI incidence in the RIC was 1%, compared to a 0.6% incidence of revision <90 days due to infection from LROI data. CONCLUSION Besides unregistered Debridement, Antibiotics, and Implant Retention procedures without component exchange, administrative errors are an important source of missing PJI data for the LROI, leading to underestimation of PJI incidence in the Netherlands. A national arthroplasty complication registry, linked to the LROI, might decrease the number of missing PJI cases. Although our study concerns Dutch data, it supports the scarce literature on PJI incidence obtained from national arthroplasty registries, which also reports an underestimation.
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Affiliation(s)
- Maud C Kamp
- Sports & Orthopedics Research Centre, St. Anna Hospital, Geldrop, the Netherlands; Department of Orthopaedic Surgery & Trauma, Catharina Hospital, Eindhoven, the Netherlands
| | - Wai-Yan Liu
- Department of Orthopaedic Surgery & Trauma, Catharina Hospital, Eindhoven, the Netherlands; Department of Orthopaedic Surgery & Trauma, Máxima MC, Eindhoven, the Netherlands
| | - Jon H M Goosen
- Department of Orthopedic Surgery, Sint Maartenskliniek, Nijmegen, the Netherlands
| | - Wim H C Rijnen
- Department of Orthopedic Surgery, Radboud University Medical Center, Nijmegen, the Netherlands
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24
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The use of antibiotic-loaded bone cement does not increase antibiotic resistance after primary total joint arthroplasty. Knee Surg Sports Traumatol Arthrosc 2022; 30:3208-3214. [PMID: 34244827 PMCID: PMC9418265 DOI: 10.1007/s00167-021-06649-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Accepted: 06/21/2021] [Indexed: 11/11/2022]
Abstract
PURPOSE One of the preventive strategies for periprosthetic joint infection (PJI) is the use of antibiotic-loaded bone cement (ALBC) in primary total joint arthroplasty (TJA). Even though it is widely used, there are concerns about the development of antibacterial resistance. The aim of the study was to investigate whether using ALBC in primary TJA increases the antibiotic-resistant PJI. The hypothesis was that the regular use of ALBC does not increase the rate of resistant PJI. METHODS Patients with confirmed PJI who had revision surgery from year 2010 to 2019 were included in this international multicenter study. The ALBC group was compared to the non-ALBC TJA group from the same time period. Medical records were used to collect clinical (age, gender, body mass index, comorbidities), TJA-related (type of operation, implant type and survival) and PJI-related (cultured microorganism, antibiogram) data. Resistance to gentamicin, clindamycin and vancomycin were recorded from the antibiograms. Multiple logistic regression model was used to identify risk factors and account for the potential confounders. RESULTS 218 patients with PJI were included in the study: 142 with gentamicin-loaded bone cement and 76 in the non-ALBC group. The average age in the ALBC group was 71 ± 10 years and 62 ± 12 years in the comparison group (p < 0.001). Coagulase negative Staphylococci (CONS) were the most common (49%) isolated pathogens. The use of ALBC did not increase the rate of any resistant bacteria significantly (OR = 0.79 (0.42-1.48), p = 0.469). The presence of CONS was associated with higher risk of antibiotic resistance. CONCLUSIONS The current study demonstrates no increase in antibiotic resistance due to ALBC after primary TJA. Thus, the use of ALBC during primary TJA should not be feared in the context of antimicrobial resistance. LEVEL OF EVIDENCE III.
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25
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Day CW, Costi K, Pannach S, Atkins GJ, Hofstaetter JG, Callary SA, Nelson R, Howie DW, Solomon LB. Long-Term Outcomes of Staged Revision Surgery for Chronic Periprosthetic Joint Infection of Total Hip Arthroplasty. J Clin Med 2021; 11:jcm11010122. [PMID: 35011863 PMCID: PMC8745559 DOI: 10.3390/jcm11010122] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Revised: 12/20/2021] [Accepted: 12/22/2021] [Indexed: 11/16/2022] Open
Abstract
Periprosthetic joint infection (PJI) is a serious complication of total hip arthroplasty. Staged revision surgery is considered effective in eradicating PJI. We aimed to determine the rate of infection resolution after each stage of staged revision surgery (first stage, repeat first stage, second stage, excision arthroplasty, and reimplantation) and to assess functional outcomes and the mortality rate at ten years in a consecutive series of 30 chronic PJI of total hip arthroplasties. Infection resolution was defined as no clinical nor laboratory evidence of infection at 24 months after the last surgery and after a minimum of 12 months following cessation of antimicrobial treatment. Four patients died within 24 months of their final surgery. Nineteen patients, 73% (worst-case analysis (wca) 63%), were infection free after 1 surgery; 22 patients, 85% (wca 73%), were infection free after 2 surgeries; and 26 patients, 100% (wca 87%), were infection free after three and four surgeries. The median Harris Hip Score was 41 prior to first revision surgery and improved to 74 at twelve months and 76 at ten years after the final surgery. Thirteen patients died at a mean of 64 months from first revision, giving a mortality rate of 43% at ten years, which is approximately 25% higher than that of an age-matched general population. The results show that with repeated aggressive surgical treatment, most PJIs of the hip are curable. Ten years after successful treatment of PJI, functional outcomes and pain are improved and maintained compared to before initial surgery, but this must be balanced against the high 10-year mortality. Level of evidence: cohort studies.
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Affiliation(s)
- Christopher W. Day
- Department of Orthopaedics and Trauma, Royal Adelaide Hospital, Adelaide, SA 5000, Australia; (C.W.D.); (S.P.); (S.A.C.); (D.W.H.); (L.B.S.)
| | - Kerry Costi
- Department of Orthopaedics and Trauma, Royal Adelaide Hospital, Adelaide, SA 5000, Australia; (C.W.D.); (S.P.); (S.A.C.); (D.W.H.); (L.B.S.)
- Centre for Orthopaedic and Trauma Research, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, SA 5005, Australia;
- Correspondence: ; Tel.: +618-707-42112
| | - Susan Pannach
- Department of Orthopaedics and Trauma, Royal Adelaide Hospital, Adelaide, SA 5000, Australia; (C.W.D.); (S.P.); (S.A.C.); (D.W.H.); (L.B.S.)
| | - Gerald J. Atkins
- Centre for Orthopaedic and Trauma Research, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, SA 5005, Australia;
| | - Jochen G. Hofstaetter
- Ludwig Boltzmann Institute of Osteology, Hanusch Hospital of OEGK and AUVA Trauma Centre Meidling, 1st Medical Department Hanusch Hospital, 1140 Vienna, Austria;
- Michael Ogon Laboratory, Orthopaedic Hospital Vienna-Speising, 1130 Vienna, Austria
| | - Stuart A. Callary
- Department of Orthopaedics and Trauma, Royal Adelaide Hospital, Adelaide, SA 5000, Australia; (C.W.D.); (S.P.); (S.A.C.); (D.W.H.); (L.B.S.)
- Centre for Orthopaedic and Trauma Research, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, SA 5005, Australia;
| | - Renjy Nelson
- Department of Infectious Diseases, Royal Adelaide Hospital, Adelaide, SA 5000, Australia;
| | - Donald W. Howie
- Department of Orthopaedics and Trauma, Royal Adelaide Hospital, Adelaide, SA 5000, Australia; (C.W.D.); (S.P.); (S.A.C.); (D.W.H.); (L.B.S.)
- Centre for Orthopaedic and Trauma Research, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, SA 5005, Australia;
| | - Lucian B. Solomon
- Department of Orthopaedics and Trauma, Royal Adelaide Hospital, Adelaide, SA 5000, Australia; (C.W.D.); (S.P.); (S.A.C.); (D.W.H.); (L.B.S.)
- Centre for Orthopaedic and Trauma Research, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, SA 5005, Australia;
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Bourget-Murray J, Bansal R, Soroceanu A, Piroozfar S, Railton P, Johnston K, Johnson A, Powell J. Assessment of risk factors for early-onset deep surgical site infection following primary total hip arthroplasty for osteoarthritis. J Bone Jt Infect 2021; 6:443-450. [PMID: 34926130 PMCID: PMC8672450 DOI: 10.5194/jbji-6-443-2021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Accepted: 12/05/2021] [Indexed: 12/29/2022] Open
Abstract
The aim of this study was to determine the incidence, annual trend, and
perioperative outcomes and identify risk factors of early-onset (≤90 d) deep surgical site infection (SSI) following primary total hip arthroplasty (THA) for osteoarthritis. We performed a retrospective study using prospectively collected patient-level data from January 2013 to March 2020. The diagnosis of deep SSI was based on the published Centre for Disease Control/National Healthcare Safety Network (CDC/NHSN) definition. The Mann–Kendall trend test was used to detect monotonic trends. Secondary outcomes were 90 d mortality and 90 d readmission. A total of 22 685 patients underwent primary THA for osteoarthritis. A total of 46 patients had a confirmed deep SSI within 90 d of surgery representing a cumulative incidence of 0.2 %. The annual infection rate decreased over the 7-year study period (p=0.026). Risk analysis was performed on 15 466 patients. Risk factors associated with early-onset deep SSI included a BMI > 30 kg m-2 (odds ratio (OR) 3.42 [95 % CI 1.75–7.20]; p<0.001), chronic renal disease (OR, 3.52 [95 % CI 1.17–8.59]; p=0.011), and cardiac illness (OR, 2.47 [1.30–4.69]; p=0.005), as classified by the Canadian Institute for Health Information. Early-onset deep SSI was not associated with 90 d mortality (p=0.167) but was associated with an increased chance of 90 d readmission (p<0.001). This study establishes a reliable baseline infection rate for early-onset deep SSI after THA for osteoarthritis through the use of a robust methodological process. Several risk factors for early-onset deep SSI are potentially modifiable, and therefore targeted preoperative interventions of patients with these risk factors is encouraged.
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Affiliation(s)
- Jonathan Bourget-Murray
- Department of Surgery, Division of Orthopaedic Surgery, University of Calgary, Calgary, Alberta, Canada
| | - Rohit Bansal
- Department of Surgery, Division of Orthopaedic Surgery, University of Calgary, Calgary, Alberta, Canada
| | - Alexandra Soroceanu
- Department of Surgery, Division of Orthopaedic Surgery, University of Calgary, Calgary, Alberta, Canada
| | - Sophie Piroozfar
- Alberta Bone and Joint Health Institute, Calgary, Alberta, Canada
| | - Pam Railton
- Department of Surgery, Division of Orthopaedic Surgery, University of Calgary, Calgary, Alberta, Canada
| | - Kelly Johnston
- Department of Surgery, Division of Orthopaedic Surgery, University of Calgary, Calgary, Alberta, Canada
| | - Andrew Johnson
- Department of Medicine, Division of Infectious Diseases, University of Calgary, Calgary, Alberta, Canada
| | - James Powell
- Department of Surgery, Division of Orthopaedic Surgery, University of Calgary, Calgary, Alberta, Canada
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27
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McCulloch R, Adlan A, Evans S, Parry M, Stevenson J, Jeys L. Outcomes of the gastrocnemius flap performed by orthopaedic surgeons in salvage revision knee arthroplasty. J Bone Jt Infect 2021; 6:425-432. [PMID: 36561206 PMCID: PMC9720735 DOI: 10.5194/jbji-6-425-2021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Accepted: 10/29/2021] [Indexed: 12/25/2022] Open
Abstract
Introduction: The gastrocnemius myofascial flap is used to manage soft-tissue defects over the anterior aspect of the knee in the context of a patient presenting with a sinus and periprosthetic joint infection (PJI) or extensor mechanism failure. The aim of this study was twofold: firstly, to evaluate the outcomes of gastrocnemius flaps performed by appropriately trained orthopaedic surgeons in the context of PJI and, secondly, to evaluate the infection-free survival of this patient group. Patients and methods: We retrospectively reviewed 30 patients who underwent gastrocnemius flap reconstruction during staged revision total knee arthroplasty for prosthetic joint infection (PJI). All flaps were performed by an orthopaedic surgeon with orthoplastics training. Patients had a mean age of 68.9 years (range 50-84) and were followed up for a mean of 50.4 months (range 2-128 months). A total of 29 patients (97 %) were categorized into Musculoskeletal Infection Society (MSIS) local extremity grade 3 (greater than two compromising factors), and 52 % of PJIs were polymicrobial. The primary outcome measure was flap failure, and the secondary outcome measure was recurrent infection. Results: Flap survival was 100 % with no failures or early returns to theatre for flap problems such as necrosis or haematoma. Overall infection-free survival during the study period was 48 % (13 of 27 infected cases). Using limb salvage as the outcome, 77 % (23 of 30 patients) retained the limb. Infection recurrence occurred in 48 % (10 patients) in the type B3 cohort and 67 % (4 patients) in the type C3 cohort ( p = 0.65 ). Conclusions: The surgical technique for a gastrocnemius myofascial flap is reliable and reproducible when performed by appropriately trained orthopaedic surgeons, even in high-risk groups. However, the risks of recurrent infection and amputation remain high within our series due to poor host and extremity factors.
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Affiliation(s)
| | - Amirul Adlan
- Royal Orthopaedic Hospital, Bristol Road South, Northfield,
Birmingham, B31 2AP, UK
| | - Scott Evans
- Royal Orthopaedic Hospital, Bristol Road South, Northfield,
Birmingham, B31 2AP, UK
| | - Michael Parry
- Royal Orthopaedic Hospital, Bristol Road South, Northfield,
Birmingham, B31 2AP, UK
| | - Jonathan Stevenson
- Royal Orthopaedic Hospital, Bristol Road South, Northfield,
Birmingham, B31 2AP, UK
| | - Lee Jeys
- Royal Orthopaedic Hospital, Bristol Road South, Northfield,
Birmingham, B31 2AP, UK,Aston Medical School, Aston University, Birmingham,
UK,School of Life and Health Sciences, Aston University, Birmingham,
UK
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Chan PK, Fung WC, Lam KH, Chan W, Chan VWK, Fu H, Cheung A, Cheung MH, Yan CH, Chiu KY. The application of close incisional negative pressure wound therapy in revision arthroplasty among asian patients: a comparative study. ARTHROPLASTY 2021; 3:38. [PMID: 35236484 PMCID: PMC8796595 DOI: 10.1186/s42836-021-00094-4] [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] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 08/16/2021] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION Peri-prosthetic joint infection (PJI) was one of the main causes of revision of arthroplasty. In order to reduce wound complications and surgical site infections, close incisional negative pressure wound therapy (ciNPWT) has been introduced into arthroplasty. This study was designed to review the clinical benefits of the application of ciNPWT in revision arthroplasty. METHODS This was a single-centre retrospective comparative study approved by the Institutional Review Board. Patients, who underwent revision total knee arthroplasty or revision total hip arthroplasty at the author's institution from January 2016 to October 2019, were included in this study. The ciNPWT cohort included all eligible patients, who underwent operations from January 2018 to October 2019, with the use of ciNPWT(n = 36). The control cohort included all eligible patients, who underwent operations from January 2016 to December 2017 with the use of conventional dressing(n = 48). The incidences of wound complications were compared to both cohorts. RESULTS There was a statistically significant difference in the rate of superficial surgical site infection (SSI) between control cohort and ciNPWT cohort (12.5% in control vs 0% in ciNPWT, p = 0.035). However, there was no statistically significance of the overall wound complication rate for both cohorts. (14.6% in control vs 8.3% in ciNPWT, p = 0.504). CONCLUSIONS The application of ciNPWT could result in a lower rate of superficial surgical site infection when compared with conventional dressing among the patients undergoing revision total knee and total hip arthroplasties. TRIAL REGISTRATION UW19-706.
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Affiliation(s)
- Ping Keung Chan
- Department of Orthopaedics and Traumatology, Queen Mary Hospital, Hong Kong SAR, China.
| | - Wing Chiu Fung
- Department of Orthopaedics and Traumatology, The University of Hong Kong, Hong Kong SAR, China
| | - Kar Hei Lam
- Department of Orthopaedics and Traumatology, The University of Hong Kong, Hong Kong SAR, China
| | - Winnie Chan
- Department of Nursing, Queen Mary Hospital, Operation Theatre Services, Hong Kong SAR, China
| | - Vincent Wai Kwan Chan
- Department of Orthopaedics and Traumatology, Queen Mary Hospital, Hong Kong SAR, China
| | - Henry Fu
- Department of Orthopaedics and Traumatology, Queen Mary Hospital, Hong Kong SAR, China
| | - Amy Cheung
- Department of Orthopaedics and Traumatology, Queen Mary Hospital, Hong Kong SAR, China
| | - Man Hong Cheung
- Department of Orthopaedics and Traumatology, The University of Hong Kong, Hong Kong SAR, China
| | - Chun Hoi Yan
- Department of Orthopaedics and Traumatology, The University of Hong Kong, Hong Kong SAR, China
| | - Kwong Yuen Chiu
- Department of Orthopaedics and Traumatology, The University of Hong Kong, Hong Kong SAR, China
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Walker LC, Clement ND, Hashmi M, Green S, Longstaff L, Deehan DJ. The alpha defensin lateral flow test is effective in predicting eradication of periprosthetic joint infection after surgical debridement. Acta Orthop Belg 2021. [DOI: 10.52628/87.3.25] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
The primary aim of this study was to assess the utility of the alpha defensin lateral flow (ADLF) test for predicting the eradication of PJI after surgical debridement. The secondary aim was to describe the reliability of ADLF test in diagnosis of PJI intra- operatively. A prospective observational study was conducted in three independent orthopaedic centres. Twenty-two patients undergoing revision surgery (debridement, antibiotics and implant retention (DAIR), single or two-stage revision) for PJI were recruited, 13 female and 9 male with an average age of 64 years. Samples were collected intra-operatively at the start of the first surgical procedure and then at the completion of debridement or prior to reimplantation depending on the operation performed. These samples were tested using ADLF and then sent for microbiological analysis. The ADLF result was then compared to the corresponding culture result in order to determine the diagnostic predictive accuracy. The reliability of ADLF test to predict eradication of infection after debridement of PJI was excellent for specificity and positive predictive value (PPV) of which both where 100%, but had a poor sensitivity (14.3%) and negative predictive value (NPV) (62.5%). The reliability of ADLF test to predict PJI was poor with only a 50% sensitivity and specificity. The ADLF test has a high specificity and PPV for diagnosing eradication of infection after debridement. In contrast the ADLF testing appears to have poor diagnostic accuracy for PJI when used on intra-operative samples, prior to surgical intervention. No benefits or funds were received in suppo
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30
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Khalifa AA, Bakr HM, Farouk OA. Biomaterials and technologies in the management of periprosthetic infection after total hip arthroplasty: An updated review. JOURNAL OF MUSCULOSKELETAL SURGERY AND RESEARCH 2021; 5:142-151. [DOI: 10.25259/jmsr_51_2021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
Abstract
Although total hip arthroplasty (THA) is considered one of the most efficacious procedures for managing various hip conditions, failures due to different mechanisms are still being reported. Periprosthetic joint infection (PJI) is one of the devastating causes of failure and revision of THA. PJI carries a burden on the patient, the surgeon, and the health-care system. The diagnosis and management of PJIs carry many morbidities and increased treatment costs. The development of PJI is multifactorial, including issues related to the patient’s general condition, the surgeon’s efficiency, surgical technique, and the implants used. Recent advances in the area of diagnosis and predicting PJI as well as introducing new technologies and biomaterials update for the prevention and treatment of PJI. Local implant coatings, advancement in the bearing surfaces technologies, and new technologies such as immunotherapy and bacteriophage therapy were introduced and suggested as contemporary PJI eradication solutions. In this review, we aimed at discussing some of the newly introduced materials and technologies for the sake of PJI control.
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Affiliation(s)
- Ahmed A. Khalifa
- Department of Orthopedics, Qena Faculty of Medicine and University Hospital, South Valley University, Qena, Egypt
| | - Hatem M. Bakr
- Department of Orthopedics and Traumatology, Assiut University Hospital, Assiut, Egypt,
| | - Osama A. Farouk
- Department of Orthopedics and Traumatology, Assiut University Hospital, Assiut, Egypt,
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31
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Abbott S, Naraen A, Rawaf D, Craik J. Should we be prepping the foot? Stockinette use and drape contamination during hip arthroplasty: An experimental study. ANZ J Surg 2021; 91:1898-1902. [PMID: 34268845 DOI: 10.1111/ans.17069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2021] [Revised: 06/23/2021] [Accepted: 07/03/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Meticulous prepping and draping of the surgical field is paramount to reduce the risk of infection. A consistent technique for draping for hip arthroplasty is not well established. One technique for preparing the operative field utilises a sterile stockinette over an unprepped foot. This study aims to assess surgical site contamination when draping for hip arthroplasty without disinfecting the foot. METHODS Ultraviolet (UV) fluorescent powder was used as a surrogate for microbial presence on the foot. Powder was applied to a volunteer's foot to a level where antibacterial prep would stop. The leg was then draped according to three methods; directly with stockinette only, wrapping the foot without using an adhesive seal followed by stockinette, and wrapping the foot with the adhesive seal followed by stockinette. Proximal spread of powder after draping was assessed with UV light. RESULTS Contamination of the sterile field was found with all draping methods. Spread was particularly noted in the groin, posterior to the thigh and distal to mid-thigh. Wrapping the foot in a small drape without the adhesive seal prior to stockinette application was associated with significantly greater contamination when compared with use of the seal (p = 0.004). CONCLUSION Routine formal prepping of the foot during hip arthroplasty is recommended to reduce the risk of surgical site contamination. Surgeons who select not to prep the foot should make use of a small drape with occlusive, adhesive seal prior to stockinette application and consider applying a further U drape to the hip.
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Affiliation(s)
- Sarah Abbott
- Department of Trauma and Orthopaedics, Croydon University Hospital, London, UK
| | - Akarshan Naraen
- Department of Trauma and Orthopaedics, Kingston Hospital, Kingston upon Thames, UK
| | - David Rawaf
- Department of Trauma and Orthopaedics, Kingston Hospital, Kingston upon Thames, UK
| | - Johnathan Craik
- Department of Trauma and Orthopaedics, Epsom and St Helier University Hospitals NHS Trust, Carshalton, UK
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D'Apolito R, Bandettini G, Rossi G, Jacquot FP, Zagra L. Low Reinfection Rates But a High Rate of Complications in THA for Infection Sequelae in Childhood: A Systematic Review. Clin Orthop Relat Res 2021; 479:1094-1108. [PMID: 33617159 PMCID: PMC8116005 DOI: 10.1097/corr.0000000000001607] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Accepted: 11/20/2020] [Indexed: 01/31/2023]
Abstract
BACKGROUND Childhood hip infections can result in serious sequelae during adulthood, including persistent pain, functional limitations, and premature THA. When THA is performed in patients who had hip joint infections during childhood, surgeons surmise these arthroplasties are at an increased risk of complications and incomplete recovery. However, the degree to which this is true is not well characterized and has varied across a large number of small, retrospective studies. QUESTIONS/PURPOSES (1) What proportion of THAs performed in patients who had pediatric septic arthritis result in periprosthetic joint infection? (2) What are the Harris hip scores associated with these reconstructions? (3) What proportion of these patients develop complications after THA? (4) What proportion of patients undergo revision after these THAs? METHODS For this systematic review, we searched the MEDLINE (PubMed), Scopus, and CINAHL (EbscoHost) electronic databases. We evaluated studies published in English between 1980 and 2020 that had a minimum of 10 patients (with a minimum of 2 years of follow-up) in whom sequelae of septic arthritis of the hip were treated with single-stage THA. We also evaluated studies reporting clinical outcomes by means of the Harris hip score, along with a radiographic assessment of the prosthesis. Updates of previous studies using the same database, case reports, surgical technique reports, systematic reviews, and expert opinions were excluded. No restrictions were applied regarding study design and loss to follow-up. A total of 430 studies were identified through the initial search, and 11 studies were included after applying the inclusion and exclusion criteria. All but two studies, which included a historical control group, were retrospective case series. A total of 691 patients with a mean age of 45 years were involved. A total of 599 patients underwent cementless THAs, 84 patients underwent hybrid THA (cemented stems), and the remaining eight patients received a cemented THA. A total of 287 additional procedures were performed on the acetabulum, including autografting, allografting, and medial wall osteotomies; in three hips, tantalum augments were used. Three hundred thirty-five additional procedures were performed on the femora, including 223 shortening osteotomies and 112 greater trochanter osteotomies. The mean follow-up duration ranged from 5.5 to 15.2 years (minimum follow-up range 2-13 years). To assess the quality of the studies, we used the Methodological Index for Non-randomized Studies and the Assessment of Quality in Lower-limb Arthroplasty, for which a higher score represents a better study quality. The mean Methodological Index for Non-randomized Studies score for case series was 9 of 16 (range 6-12), and 19 and 18 of 24 for the two comparative studies. The mean reporting quality of the Assessment of Quality in Lower Limb Arthroplasty score was 6 of 8 (range 3-8). RESULTS Because of loss to follow-up, which was not consistently reported in the source studies, we caution the reader that the estimates provided here likely underestimate the risks of adverse events and overestimate the mean hip scores. The pooled proportion of patients in whom infections developed was 1% (seven of 691 THAs). Considering only studies published in the past 10 years, the proportion was 0.7% (two of 276 THAs). The Harris hip score increased from a mean of 52 ± 6 points before THA to a mean of 88 ± 2 points after THA. The pooled proportion of complications, including sciatic nerve palsy, femoral nerve palsy, intraoperative periprosthetic fracture, deep venous thrombosis, and dislocation, was 11% (76 complications among 691 THAs). The pooled proportion of patients who underwent revision was 8% (53 revisions of any components for any reason among 691 THAs) at a mean follow-up interval of 9.1 ± 3 years. CONCLUSION In THAs for sequelae of childhood septic arthritis, reinfections were uncommon, whereas generally, infection rates were slightly higher than those reported for conventional primary THAs. However, the duration of follow-up might have been insufficient to identify all patients in whom infections later developed, and the available data were not adequate to precisely detect the minimum quiescent period to avoid reinfections. Moreover, the studies in this systematic review were retrospective, and selection bias, transfer bias, and assessment bias likely influenced our findings. The general effect of these biases is to cause an underestimation of the harms of the intervention. Complications, especially intraoperative fracture and nerve palsy, were common in patients with the most-severe infections. Further data on this topic are needed, ideally from multicenter or registry studies with even longer follow-up durations. LEVEL OF EVIDENCE Level IV, therapeutic study.
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Affiliation(s)
- Rocco D'Apolito
- R. D'Apolito, G. Bandettini, G. Rossi, F. P. Jacquot, L. Zagra, Hip Department, IRCCS Istituto Ortopedico Galeazzi, Milan, Italy
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33
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Nagy M, Jakaraddi C, Neal T, Jackson R, Navin A, Davidson JS, Santini AJA. In vitro elution characteristics of gentamicin- and teicoplanin-loaded CMW1 and Palacos R bone cement. J Orthop 2021; 25:75-81. [PMID: 33935435 DOI: 10.1016/j.jor.2021.03.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Accepted: 03/28/2021] [Indexed: 10/21/2022] Open
Abstract
Purpose To compare the in vitro elution characteristics of CMW1 and Palacos R bone cement loaded with gentamicin, teicoplanin, or in combination. Methods Four bone cement discs were prepared for each cement type. Disc 1 contained no antibiotics; disc 2 contained 0.5 g gentamicin; disc 3 contained 2 g teicoplanin; disc 4 contained 0.5 g gentamicin and 2 g teicoplanin. Elution studies were conducted using a fluorescence polarisation immunoassay technique and performed at intervals of 6 weeks. Results For CMW1, gentamicin and teicoplanin elution levels in combination discs were higher than those in the single antibiotic discs (p < 0.001 & p < 0.06). For Palacos R, gentamicin elution levels in combination discs were higher than those in the single antibiotic discs (p < 0.001), but teicoplanin elution levels in combination discs were lesser than that from the single antibiotic discs (p < 0.02). In single and combination discs, gentamicin elution levels in Palacos R were higher than those in CMW1 (p < 0.001 & p < 0.001). Palacos R eluted more teicoplanin than CMW1, except in combined disc with gentamicin, when less teicoplanin was eluted. Conclusion Antibiotic elution is higher in Palacos R than CMW1. Antibiotic combination in both cement types has the synergistic effect of increasing antibiotic elution, except for teicoplanin from Palacos R. When high elution of gentamicin is required, Palacos R is preferable. When high elution of teicoplanin is required, Palacos R with only teicoplanin is superior to CMW1.
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Affiliation(s)
- M Nagy
- Lower Limb Arthroplasty Unit, Department of Trauma and Orthopaedic Surgery, Liverpool University Hospitals, Liverpool, UK
| | - C Jakaraddi
- Lower Limb Arthroplasty Unit, Department of Trauma and Orthopaedic Surgery, Liverpool University Hospitals, Liverpool, UK
| | - T Neal
- Department of Microbiology, Liverpool University Hospitals, Liverpool, UK
| | - R Jackson
- Liverpool Cancer Trial Centre, Statistical Department, University of Liverpool, UK
| | - A Navin
- Lower Limb Arthroplasty Unit, Department of Trauma and Orthopaedic Surgery, Liverpool University Hospitals, Liverpool, UK
| | - J S Davidson
- Lower Limb Arthroplasty Unit, Department of Trauma and Orthopaedic Surgery, Liverpool University Hospitals, Liverpool, UK
| | - A J A Santini
- Lower Limb Arthroplasty Unit, Department of Trauma and Orthopaedic Surgery, Liverpool University Hospitals, Liverpool, UK.,Faculty of Health and Life Sciences, University of Liverpool, UK
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Dale H, Høvding P, Tveit SM, Graff JB, Lutro O, Schrama JC, Wik TS, Skråmm I, Westberg M, Fenstad AM, Hallan G, Engesaeter LB, Furnes O. Increasing but levelling out risk of revision due to infection after total hip arthroplasty: a study on 108,854 primary THAs in the Norwegian Arthroplasty Register from 2005 to 2019. Acta Orthop 2021; 92:208-214. [PMID: 33228428 PMCID: PMC8158216 DOI: 10.1080/17453674.2020.1851533] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Background and purpose - Focus on prevention, surveillance, and treatment of infection after total hip arthroplasty (THA) in the last decade has resulted in new knowledge and guidelines. Previous publications have suggested an increased incidence of surgical revisions due to infection after THA. We assessed whether there have been changes in the risk of revision due to deep infection after primary THAs reported to the Norwegian Arthroplasty Register (NAR) over the period 2005-2019.Patients and methods - Primary THAs reported to the NAR from January 1, 2005 to December 31, 2019 were included. Adjusted Cox regression analyses with the first revision due to deep infection after primary THA were performed. We investigated changes in the risk of revision as a function of time of primary THA. Time was stratified into 5-year periods. We studied the whole population of THAs, and the subgroups: all-cemented, all-uncemented, reverse hybrid (cemented cup), and hybrid THAs (cemented stem). In addition, we investigated factors that were associated with the risk of revision, and changes in the time span from primary THA to revision.Results - Of the 108,854 primary THAs that met the inclusion criteria, 1,365 (1.3%) were revised due to deep infection. The risk of revision due to infection, at any time after primary surgery, increased through the period studied. Compared with THAs implanted in 2005-2009, the relative risk of revision due to infection was 1.4 (95% CI 1.2-1.7) for 2010-2014, and 1.6 (1.1-1.9) for 2015-2019. We found an increased risk for all types of implant fixation. Compared to 2005-2009, for all THAs, the risk of revision due to infection 0-30 days postoperatively was 2.2 (1.8-2.8) for 2010-2014 and 2.3 (1.8-2.9) for 2015-2019, 31-90 days postoperatively 1.0 (0.7-1.6) for 2010-2014 and 1.6 (1.0-2.5) for 2015-2019, and finally 91 days-1 year postoperatively 1.1 (0.7-1.8) for 2010-2014 and 1.6 (1.0-2.6) for 2015-2019. From 1 to 5 years postoperatively, the risk of revision due to infection was similar to 2005-2009 for both the subsequent time periodsInterpretation - The risk of revision due to deep infection after THA increased throughout the period 2005-2019, but appears to have levelled out after 2010. The increase was mainly due to an increased risk of early revisions, and may partly have been caused by a change of practice rather than a change in the incidence of infection.
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Affiliation(s)
- Håvard Dale
- The Norwegian Arthroplasty Register, Department of Orthopaedic Surgery, Haukeland University Hospital, Bergen;
- Department of Clinical Medicine, University of Bergen, Bergen;
| | - Pål Høvding
- The Norwegian Arthroplasty Register, Department of Orthopaedic Surgery, Haukeland University Hospital, Bergen;
| | - Sindre M Tveit
- The Norwegian Arthroplasty Register, Department of Orthopaedic Surgery, Haukeland University Hospital, Bergen;
| | - Julie B Graff
- The Norwegian Arthroplasty Register, Department of Orthopaedic Surgery, Haukeland University Hospital, Bergen;
| | - Olav Lutro
- Department of Medicine, Stavanger University Hospital, Stavanger;
| | - Johannes C Schrama
- The Norwegian Arthroplasty Register, Department of Orthopaedic Surgery, Haukeland University Hospital, Bergen;
| | - Tina S Wik
- Department of Orthopaedic Surgery, St Olav University Hospital, Trondheim;
| | - Inge Skråmm
- Department of Orthopaedic Surgery, Akershus University Hospital, Lørenskog;
| | - Marianne Westberg
- Division of Orthopaedic Surgery, Oslo University Hospital, Oslo, Norway
| | - Anne Marie Fenstad
- The Norwegian Arthroplasty Register, Department of Orthopaedic Surgery, Haukeland University Hospital, Bergen;
| | - Geir Hallan
- The Norwegian Arthroplasty Register, Department of Orthopaedic Surgery, Haukeland University Hospital, Bergen;
- Department of Clinical Medicine, University of Bergen, Bergen;
| | - Lars B Engesaeter
- The Norwegian Arthroplasty Register, Department of Orthopaedic Surgery, Haukeland University Hospital, Bergen;
- Department of Clinical Medicine, University of Bergen, Bergen;
| | - Ove Furnes
- The Norwegian Arthroplasty Register, Department of Orthopaedic Surgery, Haukeland University Hospital, Bergen;
- Department of Clinical Medicine, University of Bergen, Bergen;
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Olsen Kipp J, Hanberg P, Slater J, Møller Nielsen L, Storgaard Jakobsen S, Stilling M, Bue M. Vancomycin bone and tissue concentrations following tibial intraosseous administration - evaluated in a porcine model. J Bone Jt Infect 2021; 6:99-106. [PMID: 34084697 PMCID: PMC8129907 DOI: 10.5194/jbji-6-99-2021] [Citation(s) in RCA: 3] [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: 07/18/2020] [Accepted: 02/03/2021] [Indexed: 11/11/2022] Open
Abstract
Introduction. Systemic perioperative vancomycin may not provide sufficient prophylactic target-site concentrations in the prevention of prosthetic joint infections. Intraosseous vancomycin potentially provides high target-site concentrations. The objective of the present study was to evaluate the local bone and tissue concentrations following tibial intraosseous vancomycin administration in a porcine model. Methods. Eight pigs received 500 mg diluted vancomycin (50 mg/mL) through an intraosseous cannula into the proximal tibial cancellous bone. No tourniquet was applied. Microdialysis was applied for sampling of vancomycin concentrations in adjacent tibial cancellous bone, in cortical bone, in the intramedullary canal of the diaphysis, in the synovial fluid of the knee joint, and in the subcutaneous tissue. Plasma samples were obtained as a systemic reference. Samples were collected for 12 h. Results. High vancomycin concentrations were found in the tibial cancellous bone with a mean peak drug concentration of 1236 (range 28-5295) µ g / mL , which remained high throughout the sampling period. The mean (standard deviation) peak drug concentration in plasma was 19 (2) µ g / mL , which was obtained immediately after administration. Peak drug concentration, time to peak drug concentration, and area under the concentration-time curve were within the same range in the intramedullary canal, the synovial fluid of the knee, and the subcutaneous tissue. Conclusion. Tibial intraosseous administration of vancomycin provided high concentrations in tibial cancellous bone throughout a 12 h period but with an unpredictable and wide range of peak concentration. The systemic absorption was high and immediate, thus mirroring an intravenous administration. Low mean concentrations were found in all the remaining compartments.
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Affiliation(s)
- Josephine Olsen Kipp
- Orthopaedic Research Unit, Aarhus University Hospital, Palle Juul-Jensens Blvd. 99, 8200 Aarhus N, Denmark
| | - Pelle Hanberg
- Orthopaedic Research Unit, Aarhus University Hospital, Palle Juul-Jensens Blvd. 99, 8200 Aarhus N, Denmark.,Department of Orthopaedic Surgery, Horsens Regional Hospital, Sundvej 30, 8700 Horsens, Denmark
| | - Josefine Slater
- Orthopaedic Research Unit, Aarhus University Hospital, Palle Juul-Jensens Blvd. 99, 8200 Aarhus N, Denmark
| | - Line Møller Nielsen
- Department of Clinical Biochemistry, Aarhus University Hospital, Palle Juul-Jensens Blvd. 99, 8200 Aarhus N, Denmark
| | - Stig Storgaard Jakobsen
- Orthopaedic Research Unit, Aarhus University Hospital, Palle Juul-Jensens Blvd. 99, 8200 Aarhus N, Denmark.,Department of Orthopaedic Surgery, Aarhus University Hospital, Palle Juul-Jensens Blvd. 99, 8200 Aarhus N, Denmark
| | - Maiken Stilling
- Orthopaedic Research Unit, Aarhus University Hospital, Palle Juul-Jensens Blvd. 99, 8200 Aarhus N, Denmark.,Department of Orthopaedic Surgery, Aarhus University Hospital, Palle Juul-Jensens Blvd. 99, 8200 Aarhus N, Denmark
| | - Mats Bue
- Orthopaedic Research Unit, Aarhus University Hospital, Palle Juul-Jensens Blvd. 99, 8200 Aarhus N, Denmark.,Department of Orthopaedic Surgery, Aarhus University Hospital, Palle Juul-Jensens Blvd. 99, 8200 Aarhus N, Denmark
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What is the most cost-effective strategy for nasal screening and Staphylococcus aureus decolonization in patients undergoing total hip arthroplasty? BMC Musculoskelet Disord 2021; 22:129. [PMID: 33522920 PMCID: PMC7849129 DOI: 10.1186/s12891-021-04008-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Accepted: 01/24/2021] [Indexed: 12/02/2022] Open
Abstract
Background To reduce periprosthetic joint infection after total hip arthroplasty (THA), several nasal screening and decolonization strategies for methicillin-resistant Staphylococcus aureus (MRSA) and methicillin-sensitive Staphylococcus aureus (MSSA) have been performed. These include universal decolonization (UD; i.e., no screening and decolonization for all patients), universal screening and target decolonization (US; i.e., screening for all patients and decolonization for bacterial positive patients), and target screening and decolonization (TS; i.e., screening and decolonization for high-risk populations only). Although TS is the most cost-effective strategy, useful risk factors must be identified. The purpose of this study was to evaluate the presence of predictive factors that enable the TS strategy to be successfully implemented and to compare the costs of each strategy. Methods A total of 1654 patients scheduled for primary or revision THA (1464 female, 190 male; mean age 64 years) were screened prior to surgery for bacterial colonization of the nasal mucosa. Risk factors for positive MRSA and S. aureus (including both MRSA and MSSA) tests were analyzed according to the following parameters: sex, age ≥ 80 years, body mass index ≥ 30 kg/m2, antibiotic use within 3 years, corticosteroid use, serum albumin < 3.5 g/dL, glomerular filtration rate < 50 mL/min, presence of brain, thyroid, cardiac, or pulmonary disease, diabetes, asthma, smoking status, and whether revision surgery was performed. The average cost of each strategy was calculated. Results In total, 29 patients (1.8 %) tested positive for MRSA and 445 (26.9 %) tested positive for S. aureus. No parameters were identified as independent risk factors for MRSA and only female sex was identified as a risk factor for S. aureus (p = 0.003; odds ratio: 1.790; 95 % confidence interval: 1.210–2.640). The average cost of each strategy was 1928.3 yen for UD, 717.6 yen for US, and 717.6 yen for TS (for eradicating MRSA), and 1928.3 yen for UD, 1201.6 yen for US, and 1160.4 yen for TS (for eradicating S. aureus). Conclusions No useful predictive parameters for implementing the TS strategy were identified. Based on cost implications, US is the most cost-effective strategy for THA patients.
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Farhan-Alanie MM, Burnand HG, Whitehouse MR. The effect of antibiotic-loaded bone cement on risk of revision following hip and knee arthroplasty. Bone Joint J 2021; 103-B:7-15. [PMID: 33380204 DOI: 10.1302/0301-620x.103b1.bjj-2020-0391.r1] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
AIMS This study aimed to compare the effect of antibiotic-loaded bone cement (ALBC) versus plain bone cement (PBC) on revision rates for periprosthetic joint infection (PJI) and all-cause revisions following primary elective total hip arthroplasty (THA) and total knee arthroplasty (TKA). METHODS MEDLINE, Embase, Web of Science, and Cochrane databases were systematically searched for studies comparing ALBC versus PBC, reporting on revision rates for PJI or all-cause revision following primary elective THA or TKA. A random-effects meta-analysis was performed. The study was registered in the International Prospective Register of Systematic Reviews (PROSPERO ID CRD42018107691). RESULTS Nine studies and one registry report were identified, enabling the inclusion of 371,977 THA and 671,246 TKA. Pooled analysis for THA demonstrated ALBC was protective against revision for PJI compared with PBC (relative risk (RR) 0.66, 95% confidence interval (CI) 0.56 to 0.77; p < 0.001), however, no differences were seen for all-cause revision rate (RR 0.62, 95% CI 0.35 to 1.09; p = 0.100). For TKA, there were no significant differences in revision rates for PJI or all causes between ALBC and PBC (RR 0.92, 95% CI 0.59 to 1.45; p = 0.730, and RR 0.73, 95% CI 0.53 to 1.02; p = 0.060, respectively). CONCLUSION ALBC demonstrated a protective effect against revision for PJI compared with PBC in THA with no difference in all-cause revisions. No differences in revision rates for PJI and all-cause revision between ALBC and PBC for TKA were observed. Cite this article: Bone Joint J 2021;103-B(1):7-15.
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Affiliation(s)
- Muhamed M Farhan-Alanie
- Medical School, University of Warwick, Coventry, UK.,Trauma & Orthopaedics, University Hospital Coventry & Warwickshire, Coventry, UK
| | - Henry G Burnand
- University of Bristol, Learning & Research Centre, Bristol, UK
| | - Michael R Whitehouse
- National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol, Bristol, UK
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Lemaignen A, Bernard L, Marmor S, Ferry T, Grammatico-Guillon L, Astagneau P. Epidemiology of complex bone and joint infections in France using a national registry: The CRIOAc network. J Infect 2020; 82:199-206. [PMID: 33352213 DOI: 10.1016/j.jinf.2020.12.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Revised: 11/29/2020] [Accepted: 12/16/2020] [Indexed: 02/01/2023]
Abstract
OBJECTIVES In France, a network of reference centers for bone and joint infections (BJI) was created in 2008, focused on the management of complex BJI (previous failure, difficult-to-treat microorganisms, heavy comorbidities or surgical procedures). A national registry was implemented from 2012, collecting decisions advised in periodic multidisciplinary meetings. We present here an epidemiological overview. METHODS All consecutive adult patients presented from 2014 to 2019 in 23/30 reference centers were included in this cohort. Characteristics of patients, BJI, and medico-surgical management advice were described. RESULTS 27,483 individual patients were included, corresponding to 28,365 distinct infectious episodes, which 17,328 were complex. Median age was 65 years, with 62% of men, 1/3 patients presented more than 2 comorbidities. Prosthetic joint infections (PJI) represented 42% of all BJIs (11,812 episodes). Staphylococcus aureus, coagulase-negative staphylococci and polymicrobial PJI represented 26%, 25% and 16% respectively. DAIR (debridement, antibiotics and implant retention) was proposed for 3,157 (27%), whereas one-stage and two-stage revision for 3,683 (31%) and 1,764 (15%). An antibiotic treatment was advised in 10,493 episodes (87%), with combination therapy in 88%. CONCLUSION This national network allows an optimized management of complex BJIs. Its cohort is a unique opportunity to draw up a detailed epidemiological picture and to follow the trends of these infrequent infections.
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Affiliation(s)
- Adrien Lemaignen
- Service de Médecine Interne et Maladies Infectieuses, Hôpital Bretonneau, CHRU de Tours, 2, Boulevard Tonnellé, 37044 Tours CEDEX 9, France; Sorbonne Université, INSERM, Institut Pierre Louis d'épidémiologie et de Santé Publique, IPLESP, Paris, France.
| | - Louis Bernard
- Service de Médecine Interne et Maladies Infectieuses, Hôpital Bretonneau, CHRU de Tours, 2, Boulevard Tonnellé, 37044 Tours CEDEX 9, France
| | - Simon Marmor
- Groupe Hospitalier Diaconesses-Croix Saint Simon, CRIOAc, Paris, France
| | - Tristan Ferry
- Hospices Civils de Lyon, Service de Maladies Infectieuses et Tropicales, Lyon, France
| | - Leslie Grammatico-Guillon
- CHRU de Tours, Unité d'Épidémiologie des données cliniques, EpiDcliC, Tours, France; Unité Inserm 1259, Université de tours, Tours, France
| | - Pascal Astagneau
- Sorbonne Université, INSERM, Institut Pierre Louis d'épidémiologie et de Santé Publique, IPLESP, Paris, France; Centre d'appui pour la prévention des infections associées aux soins (CPIAS), Paris, France
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Veltman ES, Lenguerrand E, Moojen DJF, Whitehouse MR, Nelissen RGHH, Blom AW, Poolman RW. Similar risk of complete revision for infection with single-dose versus multiple-dose antibiotic prophylaxis in primary arthroplasty of the hip and knee: results of an observational cohort study in the Dutch Arthroplasty Register in 242,179 patients. Acta Orthop 2020; 91:794-800. [PMID: 32698642 PMCID: PMC8023957 DOI: 10.1080/17453674.2020.1794096] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Background and purpose - The optimal type and duration of antibiotic prophylaxis for primary arthroplasty of the hip and knee are subject to debate. We compared the risk of complete revision (obtained by a 1- or 2-stage procedure) for periprosthetic joint infection (PJI) after primary total hip or knee arthroplasty between patients receiving a single dose of prophylactic antibiotics and patients receiving multiple doses of antibiotics for prevention of PJI. Patients and methods - A cohort of 130,712 primary total hip and 111,467 knee arthroplasties performed between 2011 and 2015 in the Netherlands was analyzed. We linked data from the Dutch arthroplasty register to a survey collected across all Dutch institutions on hospital-level antibiotic prophylaxis policy. We used restricted cubic spline Poisson models adjusted for hospital clustering to compare the risk of revision for infection according to type and duration of antibiotic prophylaxis received. Results - For total hip arthroplasties, the rates of revision for infection were 31/10,000 person-years (95% CI 28-35), 39 (25-59), and 23 (15-34) in the groups that received multiple doses of cefazolin, multiple doses of cefuroxime, and a single dose of cefazolin, respectively. The rates for knee arthroplasties were 27/10,000 person-years (95% CI 24-31), 40 (24-62), and 24 (16-36). Similar risk of complete revision for infection among antibiotic prophylaxis regimens was found when adjusting for confounders. Interpretation - In a large observational cohort we found no apparent association between the type or duration of antibiotic prophylaxis and the risk of complete revision for infection. This does question whether there is any advantage to the use of prolonged antibiotic prophylaxis beyond a single dose.
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MESH Headings
- Anti-Bacterial Agents/administration & dosage
- Antibiotic Prophylaxis/methods
- Arthroplasty, Replacement, Hip/adverse effects
- Arthroplasty, Replacement, Hip/methods
- Arthroplasty, Replacement, Knee/adverse effects
- Arthroplasty, Replacement, Knee/methods
- Cefazolin/administration & dosage
- Cefuroxime/administration & dosage
- Dose-Response Relationship, Drug
- Duration of Therapy
- Female
- Humans
- Male
- Middle Aged
- Netherlands/epidemiology
- Outcome and Process Assessment, Health Care
- Prosthesis-Related Infections/diagnosis
- Prosthesis-Related Infections/epidemiology
- Prosthesis-Related Infections/prevention & control
- Prosthesis-Related Infections/surgery
- Reoperation/methods
- Reoperation/statistics & numerical data
- Risk Adjustment/methods
- Risk Adjustment/statistics & numerical data
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Affiliation(s)
- Ewout S Veltman
- Department of Orthopaedic and Trauma Surgery, Joint Research, OLVG, Amsterdam, the Netherlands
- Department of Orthopaedics, Leiden University Medical Center, Leiden, the Netherlands
| | - Erik Lenguerrand
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Dirk Jan F Moojen
- Department of Orthopaedic and Trauma Surgery, Joint Research, OLVG, Amsterdam, the Netherlands
| | - Michael R Whitehouse
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- National Institute for Health Research Bristol Biomedical Research Centre, University Hospital Bristol NHS Foundation Trust and University of Bristol, UK
| | - Rob G H H Nelissen
- Department of Orthopaedics, Leiden University Medical Center, Leiden, the Netherlands
| | - Ashley W Blom
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- National Institute for Health Research Bristol Biomedical Research Centre, University Hospital Bristol NHS Foundation Trust and University of Bristol, UK
| | - Rudolf W Poolman
- Department of Orthopaedic and Trauma Surgery, Joint Research, OLVG, Amsterdam, the Netherlands
- Department of Orthopaedics, Leiden University Medical Center, Leiden, the Netherlands
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Nessler JM, Nessler JP. The Patient With Chronic Total Hip Arthroplasty Dislocations: A Case Series of Five Patients Who Underwent Revision THA Using Polypropylene Mesh for Capsular Reconstruction. Arthroplast Today 2020; 6:655-661. [PMID: 32875015 PMCID: PMC7451887 DOI: 10.1016/j.artd.2020.07.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 07/15/2020] [Accepted: 07/19/2020] [Indexed: 11/18/2022] Open
Abstract
We report a case series of 5 patients who underwent revision total hip arthroplasty (THA) using a polypropylene mesh for capsular reconstruction for chronic THA instability. The average follow-up is 16.6 months (range, 9-20 months). There were no postoperative dislocations in our series. Three patients had previous infections with two-stage revisions before final revision surgery and were infection free at their most recent follow-up. One patient developed a prosthetic joint infection 2 months postoperatively. The use of a polypropylene mesh appears to be another tool that surgeons can use when dealing with the difficult dilemma on how to treat the patient with chronic THA instability and severe abductor and capsular tissue loss.
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Affiliation(s)
- Joseph M. Nessler
- Department of Orthopedics and Rehabilitation, University of Wisconsin, Madison, WI, USA
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Garfield K, Noble S, Lenguerrand E, Whitehouse MR, Sayers A, Reed MR, Blom AW. What are the inpatient and day case costs following primary total hip replacement of patients treated for prosthetic joint infection: a matched cohort study using linked data from the National Joint Registry and Hospital Episode Statistics. BMC Med 2020; 18:335. [PMID: 33203455 PMCID: PMC7672908 DOI: 10.1186/s12916-020-01803-7] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Accepted: 09/30/2020] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Prosthetic joint infection (PJI) following total hip replacement (THR) surgery is a serious complication that negatively impacts patients' lives and is financially burdensome for healthcare providers. As the number of THRs increases, so does this financial burden. This research estimates the economic burden with respect to inpatient and day case hospital admissions for patients receiving revision surgery for PJI following primary THR. METHODS In this matched cohort study, the National Joint Registry for England, Wales, Northern Ireland and the Isle of Man (NJR) was used to identify patients. Patients revised for PJI with a one- or two-stage revision following THR and patients not revised for PJI were matched on several characteristics using exact and radius matching. Hospital inpatient and day case healthcare records from the English Hospital Episode Statistics database were obtained for 5 years following the identified patient's primary THR. UK national unit costs were applied to hospital admissions and the 5-year total cost was estimated. A two-part model (Probit and generalised linear model) was employed to estimate the incremental difference in costs between those revised and not revised for PJI. RESULTS Between 2006 and 2009, 1914 revisions for PJI were identified in the NJR. The matching resulted in 422 patients revised for PJI and 1923 matches not revised for PJI who were included in the analysis. The average cost of inpatient and day case admissions in the 5 years following primary THR was approximately £42,000 for patients revised for PJI and £8000 for patients not revised for PJI. The difference in costs over the 5 years was £33,452 (95% CI £30,828 to £36,077; p < 0.00). CONCLUSIONS In the 5 years following primary THR, patients who develop PJI and have revision surgery cost approximately £33,000 (over 5-fold) more than patients not revised for PJI based on their hospital inpatient and day case admissions alone. The total burden of PJI is likely to be much higher when also considering outpatient, primary and community care costs. This highlights the need to find both ways to reduce the incidence of PJI following THR and cost-effective treatment strategies if PJI occurs.
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Affiliation(s)
- Kirsty Garfield
- Health Economics at Bristol, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK. .,Bristol Trials Centre, Bristol Medical School, University of Bristol, Bristol, UK.
| | - Sian Noble
- Health Economics at Bristol, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Erik Lenguerrand
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Michael R Whitehouse
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK.,National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol NHS Foundation Trust and University of Bristol, Bristol, UK
| | - Adrian Sayers
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Mike R Reed
- Department of Trauma and Orthopaedics, Wansbeck General Hospital, Northumbria Healthcare NHS Foundation Trust, Ashington, UK
| | - Ashley W Blom
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK.,National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol NHS Foundation Trust and University of Bristol, Bristol, UK
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Xu H, Yang J, Xie J, Huang Z, Huang Q, Cao G, Pei F. Efficacy and safety of intrawound vancomycin in primary hip and knee arthroplasty. Bone Joint Res 2020; 9:778-788. [PMID: 33135425 PMCID: PMC7649508 DOI: 10.1302/2046-3758.911.bjr-2020-0190.r2] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Aims The efficacy and safety of intrawound vancomycin for preventing surgical site infection in primary hip and knee arthroplasty is uncertain. Methods A systematic review of the literature was conducted, indexed from inception to March 2020 in PubMed, Web of Science, Cochrane Library, Embase, and Google Scholar databases. All studies evaluating the efficacy and/or safety of intrawound vancomycin in patients who underwent primary hip and knee arthroplasty were included. Incidence of periprosthetic joint infection (PJI), superficial infection, aseptic wound complications, acute kidney injury, anaphylactic reaction, and ototoxicity were meta-analyzed. Results were reported as odds ratios (ORs) and 95% confidence intervals (CIs). The quality of included studies was assessed using the risk of bias in non-randomized studies of interventions (ROBINS-I) assessment tool. Results Nine studies involving 4,607 patients were included. Intrawound vancomycin was associated with lower incidence of PJI (30 patients (1.20%) vs 58 control patients (2.75%); OR 0.44, 95% CI 0.28 to 0.69) and simultaneous acute kidney injury (four patients (0.28%) vs four control patients (0.35%), OR 0.71, 95% CI 0.19 to 2.55). However, it did not reduce risk of superficial infection (four patients (0.67%) vs six control patients (1.60%), OR 0.60, 95% CI 0.17 to 2.12) and was associated with higher incidence of aseptic wound complications (23 patients (2.15%) vs eight in control patients (0.96%), OR 2.39, 95% CI 1.09 to 5.23). Four studies reported no anaphylactic reactions and three studies reported no ototoxicity in any patient group. Conclusion The current literature suggests that intrawound vancomycin used in primary hip and knee arthroplasty may reduce incidence of PJI, but it may also increase risk of aseptic wound complications. Cite this article: Bone Joint Res 2020;9(11):778–788.
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Affiliation(s)
- Hong Xu
- Department of Orthopaedic Surgery and National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, Chengdu, China
| | - Jingli Yang
- College of Earth and Environmental Sciences, and School of Public Health, Lanzhou University, Lanzhou, China
| | - Jinwei Xie
- Department of Orthopaedic Surgery and National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, Chengdu, China
| | - Zeyu Huang
- Department of Orthopaedic Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Qiang Huang
- Department of Orthopaedic Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Guorui Cao
- Department of Orthopaedic Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Fuxing Pei
- Department of Orthopaedic Surgery, West China Hospital, Sichuan University, Chengdu, China
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Theil C, Freudenberg SC, Gosheger G, Schmidt-Braekling T, Schwarze J, Moellenbeck B. Do Positive Cultures at Second Stage Re-Implantation Increase the Risk for Reinfection in Two-Stage Exchange for Periprosthetic Joint Infection? J Arthroplasty 2020; 35:2996-3001. [PMID: 32546394 DOI: 10.1016/j.arth.2020.05.029] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Revised: 04/24/2020] [Accepted: 05/15/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Intraoperative cultures are important in the diagnosis and targeted treatment of periprosthetic joint infection (PJI). Positive cultures at reimplantation during a two-stage exchange are discussed as a risk factor for reinfection. The aim of this study is the investigation of the incidence and risk factors for positive cultures during reimplantation. METHODS We retrospectively identified 204 patients (111 knees, 93 hips) who were treated between 2012 and 2016 for PJI using a two-stage exchange protocol at a median follow-up of 42 months. PJI was diagnosed using the criteria of the musculoskeletal infection society (MSIS) of 2011. All cultural findings from first and second stage surgery were recorded. The primary endpoint was revision for infection. Risk factors for positive cultures and reinfection were analyzed. RESULTS During reimplantation 25% (51/204) of patients had at least one positive culture, in 19.1% (39/204) only a single culture. Patients with culture-negative infections had a higher risk for positive cultures at reimplantation (HR 2.946 (95% CI 1.247-6.961), P = .014) and patients with infected total hip arthroplasty (THA) (HR 3.547 (95% CI 1.7-7.4), P = .001). Patients with positive cultures during reimplantation had a higher risk for reinfection (HR 2.27 (95% CI 1.181-4.363), P = .014) as well as patients with a single positive culture (HR 2.421 (95% CI 1.139-5.143), P = .021). CONCLUSION As positive cultures are common and increase reinfection risk irrespective of their numbers, longer antibiotic therapy following reimplantation can be an option. Single positive cultures in reimplantation surgery should not be considered contamination.
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Affiliation(s)
- C Theil
- Department of Orthopedics and Tumor Orthopedics, Muenster University Hospital, Muenster, Germany
| | - Sophie C Freudenberg
- Department of Orthopedics and Tumor Orthopedics, Muenster University Hospital, Muenster, Germany
| | - G Gosheger
- Department of Orthopedics and Tumor Orthopedics, Muenster University Hospital, Muenster, Germany
| | - T Schmidt-Braekling
- Department of Orthopedics and Tumor Orthopedics, Muenster University Hospital, Muenster, Germany
| | - J Schwarze
- Department of Orthopedics and Tumor Orthopedics, Muenster University Hospital, Muenster, Germany
| | - B Moellenbeck
- Department of Orthopedics and Tumor Orthopedics, Muenster University Hospital, Muenster, Germany
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Sandiford NA. Complication rates are low with the use of Stimulan calcium sulphate based antibiotic delivery system in the management of patients with hip-related PJI: early results of a consecutive case series. Hip Int 2020; 30:3-6. [PMID: 32907427 DOI: 10.1177/1120700020925093] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Effective management of prosthetic joint infection (PJI) requires prolonged, sustained delivery of antibiotics to the effective joint space. Calcium sulphate antibiotic delivery systems have been used in this setting, however, potentially serious complications including symptomatic hypercalcaemia have been described. There is relatively little prospective data on the results with the use of these compounds. METHODS A prospective study was performed between October 2016 and June 2018. 29 patients who underwent revision total hip arthroplasty (THA) for confirmed PJI were treated with Stimulan calcium sulphate antibiotic delivery system. Laboratory blood tests including serum calcium levels, C-reactive protein (CRP) and white cell count (WBC) were monitored for 6 weeks post-surgery. Wounds were assessed for discharge and radiographs for dissolution and for signs of heterotopic ossification. RESULTS The mean age was 67 years and mean ASA score III. There was no significant increase between the preoperative serum calcium and those at 2 and 6 weeks. The CRP and white cell count were significantly reduced at 6 weeks. Full dissolution occurred by 6 weeks post-op. 1 patient (3.4%) had a prolonged wound discharge. CONCLUSIONS Stimulan is a valid option for management of patients with PJI following total hip arthroplasty. Complication rates are low following its use.
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Affiliation(s)
- N Amir Sandiford
- Joint Reconstruction Unit, Southland Hospital, Invercargill, New Zealand.,Work carried out at St. George's Hospital, London, UK
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Franceschini M, Sandiford NA, Cerbone V, Araujo LCTD, Kendoff D. Defensive antibacterial coating in revision total hip arthroplasty: new concept and early experience. Hip Int 2020; 30:7-11. [PMID: 32907424 DOI: 10.1177/1120700020917125] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Infections remains the most feared complication in total hip arthroplasty (THA). New strategies of PJI prevention includes coating of conventional implants. Defensive Antibacterial Coating (DAC), an antibacterial hydrogel coating made of hyaluronan, poly-D and L-lactide can protect biomaterials as an effective barrier at the time of implantation. In addition, it can be used with topical antibiotics to prevent early colonisation of the implant. SCOPE This manuscript describes the detailed function of the DAC in general as well as an analysis of its use in revision THA in a series of 28 patients in a short-term follow-up.Its use in patients undergoing cementless re-implantation after 2-staged procedures in THA is described in detail within the manuscript. CONCLUSION DAC found to be effective in terms of infection control and safety in our patient cohort and has been expanded for cementless 1-staged revisions in PJI of the hip in our institution.
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Palmer CK, Gooberman-Hill R, Blom AW, Whitehouse MR, Moore AJ. Post-surgery and recovery experiences following one- and two-stage revision for prosthetic joint infection-A qualitative study of patients' experiences. PLoS One 2020; 15:e0237047. [PMID: 32745086 PMCID: PMC7398523 DOI: 10.1371/journal.pone.0237047] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Accepted: 07/17/2020] [Indexed: 12/12/2022] Open
Abstract
Deep prosthetic hip infection is a devastating complication of hip replacement surgery, and treatment often involves multiple revision surgeries with antibiotic chemotherapy to control the infection. The aim of this study was to explore patients’ experiences of early and longer-term recovery after one-stage or two-stage revision with an excised hip, a temporary cement spacer or a custom-made articulating spacer. We interviewed 32 participants taking part in a surgical trial at two time points (2–4 months and 18 months) following one- or two-stage revision surgery. The analytic approach was inductive using the constant comparative method to generate themes from the data. Participants’ early recovery after revision was characterised by a long hospital stay with burdensome antibiotics and limited physiotherapy provision. Participants undergoing two-stage revision with an excised hip or a cement spacer described severe mobility restrictions which affected all aspects of their lives, while those undergoing one-stage revision, or two-stage revision with an articulating spacer were more mobile and independent, with some limitations. Participants with a cement spacer also reported more pain than other treatment groups, while those with an articulating spacer appeared to perceive that their recovery was slow. At 18 months, participants in all groups described both improvements and losses in mobility and functional ability. Participants in all treatment groups expressed considerable emotional resilience during recovery from revision, which may be linked to opportunities to talk with the trial personnel. Participants identified the need for better information and psychological and physical support. Experience of recovery differs after one- and two-stage revision, and further in relation to the use of spacers. Mobility, function, independence and pain are important aspects of recovery which affect all aspects of day-to-day life. Increased information and more opportunities to talk and share experiences may provide psychological support during recovery.
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Affiliation(s)
- Cecily K. Palmer
- National Institute for Health Research, Applied Research Collaboration West (NIHR ARC West), University Hospitals Bristol NHS Foundation Trust and University of Bristol, Bristol, United Kingdom
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - Rachael Gooberman-Hill
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, United Kingdom
- National Institute for Health Research, Bristol Biomedical Research Centre, University Hospitals Bristol NHS Foundation Trust and University of Bristol, Bristol, United Kingdom
| | - Ashley W. Blom
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, United Kingdom
- National Institute for Health Research, Bristol Biomedical Research Centre, University Hospitals Bristol NHS Foundation Trust and University of Bristol, Bristol, United Kingdom
| | - Michael R. Whitehouse
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, United Kingdom
- National Institute for Health Research, Bristol Biomedical Research Centre, University Hospitals Bristol NHS Foundation Trust and University of Bristol, Bristol, United Kingdom
| | - Andrew J. Moore
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, United Kingdom
- * E-mail:
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47
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Boyle KK, Kapadia M, Landy DC, Henry MW, Miller AO, Westrich GH. Utilization of Debridement, Antibiotics, and Implant Retention for Infection After Total Joint Arthroplasty Over a Decade in the United States. J Arthroplasty 2020; 35:2210-2216. [PMID: 32279946 DOI: 10.1016/j.arth.2020.03.029] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2020] [Revised: 02/28/2020] [Accepted: 03/15/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Reported clinical outcomes have varied for debridement, antibiotics, and implant retention (DAIR) and little is known regarding trends in utilization. We sought to evaluate the rate of DAIR utilization for total knee arthroplasty (TKA) and total hip arthroplasty (THA) periprosthetic joint infection (PJI) over a decade and clinical factors associated with these trends. METHODS A retrospective study of primary TKAs and THAs was performed using Medicare data from 2005 to 2014 using the PearlDiver database platform. Current Procedural Technology and International Classification of Diseases Ninth Edition codes identified patients who underwent a surgical revision for PJI, whether revision was a DAIR, as well as associated clinical factors including timing from index arthroplasty. RESULTS The proportion of revision TKAs and THAs performed using DAIR was 27% and 12% across all years, respectively. This proportion varied by year for TKAs and THAs with a linear trend toward increasing relative use of DAIR estimated at 1.4% and 0.9% per year (P < .001; P < .001). DAIR for TKA and THA performed within 90 days increased at a faster rate, 3.4% and 2.1% per year (P < .001; P < .001). Trends over time in TKA DAIRs showed an association with Elixhauser Comorbidity Index (ECI), 0-5 group increasing at 2.0% per year (P = .03) and patients >85 years (P = .04). CONCLUSION The proportion of revision arthroplasty cases for PJI managed with DAIR has been increasing over time in the United States, with the most substantial increase seen <90 days from index arthroplasty. Age, gender, and ECI had a minimal association with this trend, except in the TKA population >85 years and in those with a very low ECI score.
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Affiliation(s)
- K Keely Boyle
- Department of Orthopedic Surgery, Adult Reconstruction and Joint Replacement, Hospital for Special Surgery, New York, NY
| | - Milan Kapadia
- Department of Medicine, Division of Infectious Disease, Hospital for Special Surgery, New York, NY
| | - David C Landy
- Department of Orthopedic Surgery, Adult Reconstruction and Joint Replacement, Hospital for Special Surgery, New York, NY
| | - Michael W Henry
- Department of Medicine, Division of Infectious Disease, Hospital for Special Surgery, New York, NY
| | - Andy O Miller
- Department of Medicine, Division of Infectious Disease, Hospital for Special Surgery, New York, NY
| | - Geoffrey H Westrich
- Department of Orthopedic Surgery, Adult Reconstruction and Joint Replacement, Hospital for Special Surgery, New York, NY
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48
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Long acting anti-infection constructs on titanium. J Control Release 2020; 326:91-105. [PMID: 32580044 DOI: 10.1016/j.jconrel.2020.06.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Revised: 05/23/2020] [Accepted: 06/14/2020] [Indexed: 01/12/2023]
Abstract
Peri-prosthetic joint infections (PJI) are a serious adverse event following joint replacement surgeries; antibiotics are usually added to bone cement to prevent infection offset. For uncemented prosthesis, alternative antimicrobial approaches are necessary in order to prevent PJI; however, despite elution of drug from the surface of the device being shown one of the most promising approach, no effective antimicrobial eluting uncemented device is currently available on the market. Consequently, there is a clinical need for non-antibiotic antimicrobial uncemented prosthesis as these devices present numerous benefits, particularly for young patients, over cemented artificial joints. Moreover, non-antibiotic approaches are driven by the need to address the growing threat posed by antibiotic resistance. We developed a multilayers functional coating on titanium surfaces releasing chlorhexidine, a well-known antimicrobial agent used in mouthwash products and antiseptic creams, embedding the drug between alginate and poly-beta-amino-esters. Chlorhexidine release was sustained for almost 2 months and the material efficacy and safety was proven both in vitro and in vivo. The coatings did not negatively impact osteoblast and fibroblast cells growth and were capable of reducing bacterial load and accelerating wound healing in an excisional wound model. As PJI can develop weeks and months after the initial surgery, these materials could provide a viable solution to prevent infections after arthroplasty in uncemented prosthetic devices and, simultaneously, help the fight against antibiotic resistance.
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49
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Gil D, Atici AE, Connolly RL, Hugard S, Shuvaev S, Wannomae KK, Oral E, Muratoglu OK. Addressing prosthetic joint infections via gentamicin-eluting UHMWPE spacer. Bone Joint J 2020; 102-B:151-157. [PMID: 32475290 DOI: 10.1302/0301-620x.102b6.bjj-2019-1593.r1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
AIMS We propose a state-of-the-art temporary spacer, consisting of a cobalt-chrome (CoCr) femoral component and a gentamicin-eluting ultra-high molecular weight polyethylene (UHMWPE) tibial insert, which can provide therapeutic delivery of gentamicin, while retaining excellent mechanical properties. The proposed implant is designed to replace conventional spacers made from bone cement. METHODS Gentamicin-loaded UHMWPE was prepared using phase-separated compression moulding, and its drug elution kinetics, antibacterial, mechanical, and wear properties were compared with those of conventional gentamicin-loaded bone cement. RESULTS Gentamicin-loaded UHMWPE tibial components not only eradicated planktonic Staphylococcus aureus, but also prevented colonization of both femoral and tibial components. The proposed spacer possesses far superior mechanical and wear properties when compared with conventional bone cement spacers. CONCLUSION The proposed gentamicin-eluting UHMWPE spacer can provide antibacterial efficacy comparable with currently used bone cement spacers, while overcoming their drawbacks. The novel spacer proposed here has the potential to drastically reduce complications associated with currently used bone cement spacers and substantially improve patients' quality of life during the treatment. Cite this article: Bone Joint J 2020;102-B(6 Supple A):151-157.
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Affiliation(s)
- Dmitry Gil
- Harris Orthopaedic Laboratory, Massachusetts General Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Harvard University, Boston, Massachusetts, USA
| | - Ali E Atici
- Harris Orthopaedic Laboratory, Massachusetts General Hospital, Boston, Massachusetts, USA.,Department of Chemistry, Hacettepe University, Ankara, Turkey
| | - Rachel L Connolly
- Harris Orthopaedic Laboratory, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Shannon Hugard
- Harris Orthopaedic Laboratory, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Sergey Shuvaev
- Harvard Medical School, Harvard University, Boston, Massachusetts, USA
| | - Keith K Wannomae
- Harris Orthopaedic Laboratory, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Ebru Oral
- Harris Orthopaedic Laboratory, Massachusetts General Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Harvard University, Boston, Massachusetts, USA
| | - Orhun K Muratoglu
- Harris Orthopaedic Laboratory, Massachusetts General Hospital.,Harvard Medical School, Harvard University
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50
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van Hengel I, Putra N, Tierolf M, Minneboo M, Fluit A, Fratila-Apachitei L, Apachitei I, Zadpoor A. Biofunctionalization of selective laser melted porous titanium using silver and zinc nanoparticles to prevent infections by antibiotic-resistant bacteria. Acta Biomater 2020; 107:325-337. [PMID: 32145392 DOI: 10.1016/j.actbio.2020.02.044] [Citation(s) in RCA: 49] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Revised: 02/24/2020] [Accepted: 02/28/2020] [Indexed: 12/20/2022]
Abstract
Antibiotic-resistant bacteria are frequently involved in implant-associated infections (IAIs), making the treatment of these infections even more challenging. Therefore, multifunctional implant surfaces that simultaneously possess antibacterial activity and induce osseointegration are highly desired in order to prevent IAIs. The incorporation of multiple inorganic antibacterial agents onto the implant surface may aid in generating synergistic antibacterial behavior against a wide microbial spectrum while reducing the occurrence of bacterial resistance. In this study, porous titanium implants synthesized by selective laser melting (SLM) were biofunctionalized with plasma electrolytic oxidation (PEO) using electrolytes based on Ca/P species as well as silver and zinc nanoparticles in ratios from 0 to 100% that were tightly embedded into the growing titanium oxide layer. After the surface bio-functionalization process, silver and zinc ions were released from the implant surfaces for at least 28 days resulting in antibacterial leaching activity against methicillin-resistant Staphylococcus aureus (MRSA). Furthermore, the biofunctionalized implants generated reactive oxygen species, thereby contributing to antibacterial contact-killing. While implant surfaces containing up to 75% silver and 25% zinc nanoparticles fully eradicated both adherent and planktonic bacteria in vitro as well as in an ex vivo experiment performed using murine femora, solely zinc-bearing surfaces did not. The minimum inhibitory and bactericidal concentrations determined for different combinations of both types of ions confirmed the presence of a strong synergistic antibacterial behavior, which could be exploited to reduce the amount of required silver ions by two orders of magnitude (i.e., 120 folds). At the same time, the zinc bearing surfaces enhanced the metabolic activity of pre-osteoblasts after 3, 7, and 11 days. Altogether, implant biofunctionalization by PEO with silver and zinc nanoparticles is a fruitful strategy for the synthesis of multifunctional surfaces on orthopedic implants and the prevention of IAIs caused by antibiotic-resistant bacteria. STATEMENT OF SIGNIFICANCE: Implant-associated infections are becoming increasingly challenging to treat due to growing antibiotic resistance against antibiotics. Here, we propose an alternative approach where silver and zinc nanoparticles are simultaneously used for the biofunctionalization of rationally designed additively manufactured porous titanium. This combination of porous design and tailored surface treatment allows us to reduce the amount of required silver nanoparticles by two orders of magnitude, fully eradicate antibiotic-resistant bacteria, and enhance the osteogenic behavior of pre-osteoblasts. We demonstrate that the resulting implants display antibacterial activity in vitro and ex vivo against methicillin-resistant Staphylococcus aureus.
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