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Jevnikar BE, Khan ST, Huffman N, Pasqualini I, Surace PA, Deren ME, Piuzzi NS. Advancements in treatment strategies for periprosthetic joint infections: A comprehensive review. J Clin Orthop Trauma 2024; 55:102496. [PMID: 39157704 PMCID: PMC11324841 DOI: 10.1016/j.jcot.2024.102496] [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: 03/26/2024] [Revised: 07/03/2024] [Accepted: 07/17/2024] [Indexed: 08/20/2024] Open
Abstract
Periprosthetic joint infection (PJI) presents a critical challenge in orthopedic care, contributing to significant patient morbidity and healthcare costs. This burden is expected to increase secondary to growing demand for total joint arthroplasty (TJA). Despite the profound significance of PJI, there is currently no universally accepted "gold standard" diagnostic criteria using serum biomarker thresholds; latest criteria fail to differentiate acute infections from chronic or consider time since initial surgery. Furthermore, contemporary PJI treatment, which conventionally requires 2-stage revision surgery in conjunction with rigorous antibiotic treatment, can be particularly taxing on patients. Fortunately, recent years have seen marked evolution in both PJI diagnosis and treatment methods. Contemporary research supports time-dependent serum biomarker thresholds with greater sensitivity and specificity than previously reported, as well as alternative surgical options which may be more suitable for certain patients. The following narrative review aims to describe the significance and pathogenesis of PJI before characterizing current challenges, novel innovations, and the future landscape of PJI diagnosis and management. Here, we spotlight the emerging utility of novel biomarkers and metagenomic next-generation sequencing for diagnosis, advancements in patient-centered surgical outcome prediction tools for PJI risk assessment and prevention, and evolving surgical techniques including 1-stage and a "hybrid" 1.5-stage revision surgeries. Additionally, we explore cutting-edge therapeutic modalities including peptide and bacteriophage-based treatments, intraoperative anti-biofilm gel, the VT-X7 antibiotic pump, and promising immune-based interventions. Ultimately, these advancements hold the potential to revolutionize PJI management, offering hope for improved outcomes and reduced burdens on healthcare systems.
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Affiliation(s)
| | | | - Nickelas Huffman
- Cleveland Clinic Foundation, Department of Orthopaedic Surgery, Cleveland, OH, 44195, USA
| | - Ignacio Pasqualini
- Cleveland Clinic Foundation, Department of Orthopaedic Surgery, Cleveland, OH, 44195, USA
| | - Peter A. Surace
- Cleveland Clinic Foundation, Department of Orthopaedic Surgery, Cleveland, OH, 44195, USA
| | - Matthew E. Deren
- Cleveland Clinic Foundation, Department of Orthopaedic Surgery, Cleveland, OH, 44195, USA
| | - Nicolas S. Piuzzi
- Cleveland Clinic Foundation, Department of Orthopaedic Surgery, Cleveland, OH, 44195, 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; 39:2094-2099. [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] [MESH Headings] [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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Giarritiello F, Romanò CL, Lob G, Benevenia J, Tsuchiya H, Zappia E, Drago L. Enhancing Pathogen Detection in Implant-Related Infections through Chemical Antibiofilm Strategies: A Comprehensive Review. Antibiotics (Basel) 2024; 13:678. [PMID: 39061360 PMCID: PMC11274042 DOI: 10.3390/antibiotics13070678] [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: 06/27/2024] [Revised: 07/11/2024] [Accepted: 07/16/2024] [Indexed: 07/28/2024] Open
Abstract
Implant-related infections (IRIs) represent a significant challenge to modern surgery. The occurrence of these infections is due to the ability of pathogens to aggregate and form biofilms, which presents a challenge to both the diagnosis and subsequent treatment of the infection. Biofilms provide pathogens with protection from the host immune response and antibiotics, making detection difficult and complicating both single-stage and two-stage revision procedures. This narrative review examines advanced chemical antibiofilm techniques with the aim of improving the detection and identification of pathogens in IRIs. The articles included in this review were selected from databases such as PubMed, Scopus, MDPI and SpringerLink, which focus on recent studies evaluating the efficacy and enhanced accuracy of microbiological sampling and culture following the use of chemical antibiofilm. Although promising results have been achieved with the successful application of some antibiofilm chemical pre-treatment methods, mainly in orthopedics and in cardiovascular surgery, further research is required to optimize and expand their routine use in the clinical setting. This is necessary to ensure their safety, efficacy and integration into diagnostic protocols. Future studies should focus on standardizing these techniques and evaluating their effectiveness in large-scale clinical trials. This review emphasizes the importance of interdisciplinary collaboration in developing reliable diagnostic tools and highlights the need for innovative approaches to improve outcomes for patients undergoing both single-stage and two-stage revision surgery for implant-related infections.
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Affiliation(s)
- Fabiana Giarritiello
- Department of Medicine and Health Sciences “V. Tiberio”, University of Molise, 86100 Campobasso, Italy; (F.G.); (E.Z.)
| | | | - Guenter Lob
- Section Injury Prevention, Deutsche Gesellschaft für Orthopädie und Unfallchirurgie (DGOU), 10117 Berlin, Germany;
| | - Joseph Benevenia
- Orthopaedics Department, Rutgers New Jersey Medical School, Newark, NJ 07103, USA;
| | - Hiroyuki Tsuchiya
- Department of Orthopaedic Surgery, Graduate School of Medical Science, Kanazawa University, Kanazawa 921-8641, Japan;
| | - Emanuele Zappia
- Department of Medicine and Health Sciences “V. Tiberio”, University of Molise, 86100 Campobasso, Italy; (F.G.); (E.Z.)
| | - Lorenzo Drago
- Clinical Microbiology and Microbiome Laboratory, Department of Biomedical Sciences for Health, University of Milan, 20133 Milan, Italy
- UOC Laboratory of Clinical Medicine with Specialized Areas, IRCCS MultiMedica, 20138 Milan, Italy
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Szymski D, Walter N, Hierl K, Rupp M, Alt V. Direct Hospital Costs per Case of Periprosthetic Hip and Knee Joint Infections in Europe - A Systematic Review. J Arthroplasty 2024; 39:1876-1881. [PMID: 38266688 DOI: 10.1016/j.arth.2024.01.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2023] [Revised: 12/22/2023] [Accepted: 01/12/2024] [Indexed: 01/26/2024] Open
Abstract
BACKGROUND The rise of periprosthetic joint infections (PJIs) due to aging populations is steadily increasing the number of arthroplasties and treatment costs. This study analyzed the direct health care costs of PJI for total hip arthroplasty and total knee arthroplasty (TKA) in Europe. METHODS The databases PubMed, Scopus, Embase, Cochrane, and Google Scholar were systematically screened for direct costs of PJI in Europe. Publications that defined the joint site and the procedure performed were further analyzed. Mean direct health care costs were calculated for debridement, antibiotics, and implant retention (DAIR), one-stage, and 2-stage revisions for hip and knee PJI, respectively. Costs were adjusted for inflation rates and reported in US-Dollar (USD). RESULTS Of 1,374 eligible publications, 12 manuscripts were included in the final analysis after an abstract and full-text review. Mean direct costs of $32,933 were identified for all types of revision procedures for knee PJI. The mean direct treatment cost including DAIR for TKA after PJI was $19,476. For 2-stage revisions of TKA, the mean total cost was $37,980. For all types of hip PJI procedures, mean direct hospital costs were $28,904. For hip DAIR, one-stage and 2-stage treatment average costs of $7,120, $44,594, and $42,166 were identified, respectively. CONCLUSIONS Periprosthetic joint infections are associated with substantial direct health care costs. As detailed reports on the cost of PJI are scarce and of limited quality, more detailed financial data on the cost of PJI treatment are urgently required.
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Affiliation(s)
- Dominik Szymski
- Department for Trauma Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Nike Walter
- Department for Trauma Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Katja Hierl
- Department for Trauma Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Markus Rupp
- Department for Trauma Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Volker Alt
- Department for Trauma Surgery, University Medical Center Regensburg, Regensburg, Germany
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Zhou H, Yang Y, Zhang Y, Li F, Shen Y, Qin L, Huang W. Current Status and Perspectives of Diagnosis and Treatment of Periprosthetic Joint Infection. Infect Drug Resist 2024; 17:2417-2429. [PMID: 38912221 PMCID: PMC11192293 DOI: 10.2147/idr.s457644] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2024] [Accepted: 06/05/2024] [Indexed: 06/25/2024] Open
Abstract
Periprosthetic joint infection (PJI) is a catastrophic complication following joint replacement surgery, posing significant challenges to orthopedic surgeons. Due to the lack of a definitive diagnostic gold standard, timely treatment initiation is problematic, resulting in substantial economic burdens on patients and society. In this review, we thoroughly analyze the complexities of PJI and emphasize the importance of accurate diagnosis and effective treatment. The article specifically focuses on the advancements in diagnostic techniques, ranging from traditional pathogen culture to advanced molecular diagnostics, and discusses their role in enhancing diagnostic accuracy. Additionally, we review the latest surgical management strategies, including everything from debridement to revision surgeries. Our summary aims to provide practical information for the diagnosis and treatment of PJI and encourages further research to improve diagnostic accuracy and treatment outcomes.
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Affiliation(s)
- Haotian Zhou
- Department of Orthopaedics, the First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, People’s Republic of China
- Orthopedic Laboratory of Chongqing Medical University, Chongqing, 400016, People’s Republic of China
| | - Yaji Yang
- Department of Orthopaedics, the First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, People’s Republic of China
- Orthopedic Laboratory of Chongqing Medical University, Chongqing, 400016, People’s Republic of China
| | - Yanhao Zhang
- College of Pharmacy, Army Military Medical University, Chongqing, 400038, People’s Republic of China
| | - Feilong Li
- Department of Orthopaedics, the First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, People’s Republic of China
- Orthopedic Laboratory of Chongqing Medical University, Chongqing, 400016, People’s Republic of China
| | - Yidong Shen
- Department of Orthopaedics, The First People’s Hospital of Yancheng, Yancheng, 224000, People’s Republic of China
| | - Leilei Qin
- Department of Orthopaedics, the First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, People’s Republic of China
- Orthopedic Laboratory of Chongqing Medical University, Chongqing, 400016, People’s Republic of China
| | - Wei Huang
- Department of Orthopaedics, the First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, People’s Republic of China
- Orthopedic Laboratory of Chongqing Medical University, Chongqing, 400016, People’s Republic of China
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Xie C, Pan W, Wang S, Yan X, Luo H. Systematic review and meta-analysis of single-stage versus two-stage revision for periprosthetic joint infection after knee arthroplasty: a call for a randomised trial. EFORT Open Rev 2024; 9:479-487. [PMID: 38828985 PMCID: PMC11195333 DOI: 10.1530/eor-23-0147] [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: 06/05/2024] Open
Abstract
Purpose Knee arthroplasty is an effective treatment for severe knee degeneration; however, periprosthetic joint infection (PJI) is one of its serious complications. Single- and two-stage revision are common treatments, but few studies have compared single- and two-stage revision for PJI after knee arthroplasty. This study aimed to compare the reinfection and reoperation rates of single- and two-stage revision through meta-analysis. Methods The review process was conducted according to the PRISMA guidelines. We searched the PubMed, Medline, Embase and Cochrane Central Register of Controlled Trials databases for trials comparing single- and two-stage revision for PJI after knee arthroplasty from the respective inception dates to April 2023. Two researchers individually screened the studies, performed the literature quality evaluation and data extraction and used Stata 17 software for data analysis. Results The meta-analysis showed that the reinfection rate was significantly lower in the single-stage revision group than in the two-stage revision group. While the reoperation rates demonstrated no statistically significant difference between the two groups. We presented descriptive results because the discrepancies in the knee function scores and data reported in the studies meant that these data could not be combined in the meta-analysis. Conclusion Based on the available research, single-stage revision is a reliable option for PJI after knee arthroplasty. However, when developing the best treatment strategy, it is still necessary to consider the individual circumstances and needs of the patient, as well as the risks of postoperative rehabilitation and complications.
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Affiliation(s)
- Chengxin Xie
- Department of Orthopedics, Taizhou Hospital of Zhejiang Province affiliated to Wenzhou Medical University, Taizhou, Zhejiang, China
| | - Wenjun Pan
- Department of Orthopedics, Taizhou Hospital of Zhejiang Province affiliated to Wenzhou Medical University, Taizhou, Zhejiang, China
| | - Shouli Wang
- Department of Orthopedics, Taizhou Hospital of Zhejiang Province affiliated to Wenzhou Medical University, Taizhou, Zhejiang, China
| | - Xueli Yan
- Department of Orthopedics, Taizhou Hospital of Zhejiang Province affiliated to Wenzhou Medical University, Taizhou, Zhejiang, China
| | - Hua Luo
- Department of Orthopedics, Taizhou Hospital of Zhejiang Province affiliated to Wenzhou Medical University, Taizhou, Zhejiang, China
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Sutton R, Lizcano JD, Fraval A, Wiafe B, Courtney PM, Brown S. Comparable Results of Single and Two-Stage Exchange for Select Periprosthetic Hip and Knee Infection. J Am Acad Orthop Surg 2024:00124635-990000000-01009. [PMID: 38833728 DOI: 10.5435/jaaos-d-24-00013] [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] [Received: 01/05/2024] [Accepted: 04/26/2024] [Indexed: 06/06/2024] Open
Abstract
INTRODUCTION Although two-stage exchange has been the standard of care for periprosthetic joint infection (PJI) in the United States, single-stage exchange is emerging as an option in select patients. The purpose of this study was to compare outcomes of patients undergoing single-stage and two-stage exchange using strict surgical indications. METHODS We reviewed a consecutive series of 196 patients with diagnosed PJI undergoing revision total knee and hip arthroplasty from 2017 to 2021. Patients were excluded if they had PJI history, plastic surgery coverage, or extensive bone loss requiring endoprosthesis. We compared the number of patients PJI-free at 1-year follow-up using MusculoSkeletal Infection Society criteria and patients requiring re-revision between the single-stage and two-stage groups. RESULTS In total, 126 patients met inclusion criteria. Of 61 knee patients (48.4%), 22 underwent single-stage (36%) and 39 underwent two-stage (63.9%). Of 65 hip patients (51.6%), 38 underwent single-stage (58.5%) and 27 underwent two-stage (41.5%). At a mean follow-up of 1.95 ± 0.88 years, a higher rate of knee patients were classified as having treatment success in the single-stage group (77.3% versus 69.2%, P = 0.501), however with comparable septic failure rates (18.1% single-stage versus 17.9% two-stage; P = 0.982). At a mean follow-up of 1.81 ± 0.9 years, a higher rate of hip patients were classified as having treatment success in the single-stage group (94.7% versus 81.5%, P = 0.089), and more patients had septic failures in the two-stage group (18.5% versus 5.3%; P = 0.089). No differences were observed in the microorganism profile. More total complications (P = 0.021) and mortalities were found in the single-stage knee cohort than in the two-stage cohort (22.7% versus 2.6%; P = 0.011). CONCLUSION Single-stage arthroplasty is a viable alternative to standard two-stage exchange in patients with PJI without a history of infection and with no bone or soft-tissue compromise. Additional studies with longer term follow-up are needed to evaluate its efficacy.
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Affiliation(s)
- Ryan Sutton
- From Rothman Orthopaedic Institute, Philadelphia, PA
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Hamrouni N, Højvig JH, Knudsen UK, Skovgaard KK, Jensen LT, Bonde CT, Odgaard A. Microvascular free flap coverage of complex soft tissue defects after revision total knee arthroplasty: a cross-sectional observation study. Acta Orthop 2024; 95:186-191. [PMID: 38630868 PMCID: PMC11024721 DOI: 10.2340/17453674.2024.40183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Accepted: 02/10/2024] [Indexed: 04/19/2024] Open
Abstract
BACKGROUND AND PURPOSE Soft tissue defects after total knee arthroplasties (TKA) represent a major orthopedic challenge with amputation as a feared outcome. Microvascular free flap coverage (FFC) can increase limb salvage rates, but complications related to the procedure are yet to be explored further. We aimed to review a single-center experience with FFC for soft tissue defects related to revision total knee arthroplasty. METHODS Through a retrospective chart review from 2006 to 2021, we identified all patients who had FFC of a knee with an existing TKA. Typically, patients underwent 2-stage revision arthroplasty. To identify areas of intervention, we divided the entire regimen into 2 phases divided by the free flap surgery (pre- and post-free flap). RESULTS We identified 18 patients with a median age at free flap surgery of 69 years (range 39-85), who were followed for a median of 5.1 years (range 2 months to 10.6 years). The median duration from primary TKA to their final operation was 17.5 months (range 19 days to 7 years). Patients underwent a mean of 7.6 surgical procedures on their knee with 3.6 orthopedic revisions prior to the FFC and 0.6 after. Soft tissue coverage was achieved in all patients and no patients underwent amputation. One-third of patients experienced early complications at recipient site after free flap surgery. There were no donor site complications. CONCLUSION Microvascular FFC of complex soft tissue defects after revision total knee arthroplasty proved achievable in all patients with successful limb salvage in all patients.
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Affiliation(s)
- Nizar Hamrouni
- Department of Plastic Surgery and Burns Treatment, Center of Head, Neck and Orthopedics, University Hospital of Copenhagen, Rigshospitalet, Copenhagen.
| | - Jens H Højvig
- Department of Plastic Surgery and Burns Treatment, Center of Head, Neck and Orthopedics, University Hospital of Copenhagen, Rigshospitalet, Copenhagen
| | - Ulrik K Knudsen
- Department of Orthopedic Surgery, Center of Head, Neck and Orthopedics, University Hospital of Copenhagen, Rigshospitalet, Copenhagen
| | - Kurt K Skovgaard
- Department of Orthopedic Surgery, Center of Head, Neck and Orthopedics, University Hospital of Copenhagen, Rigshospitalet, Copenhagen
| | - Lisa T Jensen
- Department of Plastic Surgery and Burns Treatment, Center of Head, Neck and Orthopedics, University Hospital of Copenhagen, Rigshospitalet, Copenhagen
| | - Christian T Bonde
- Department of Plastic Surgery and Burns Treatment, Center of Head, Neck and Orthopedics, University Hospital of Copenhagen, Rigshospitalet, Copenhagen
| | - Anders Odgaard
- Department of Orthopedic Surgery, Center of Head, Neck and Orthopedics, University Hospital of Copenhagen, Rigshospitalet, Copenhagen; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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Wu X, Chen W, Rong R, Pan B, Hu X, Zheng L, Alimu A, Chu C, Tu Y, Zhang Z, Ye Y, Gu M, Sheng P. Application of the New Irrigation Protocol to Reduce Recurrence Rate in the Management Of Periprosthetic Joint Infection. Orthop Surg 2024; 16:577-584. [PMID: 38238252 PMCID: PMC10925507 DOI: 10.1111/os.13948] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2023] [Revised: 10/24/2023] [Accepted: 10/24/2023] [Indexed: 02/15/2024] Open
Abstract
OBJECTIVE Irrigation is a conventional treatment for acute and chronic periprosthetic joint infections (PJI). However, there has been no unified standard for irrigation during surgery for PJI in the past, and the efficacy is uncertain. The purpose of this study is to create a new irrigation protocol to enhance the infection control rate and reduce the postoperative recurrence rate of PJI patients. METHODS We conducted a single-institution retrospective review with a total of 56 patients who underwent revision total hip or knee arthroplasties due to PJI from January 2011 to January 2022. Conventional irrigation (CI) was used in 32 cases, and standard operating procedure of irrigation (SOPI) was used in 24. The CI protocol carries out an empirical irrigation after debridement, which is quite random. Our SOPI protocol clearly stipulates the soaking concentration and time of hydrogen peroxide and povidone-iodine. The irrigation is carried out three times, and tissue samples are taken from multiple parts before and after irrigation, which are sent for microbial culture. The important statistical indicators were the rate of positive microbiological culture and postoperative recurrence rate with an average follow-up of 24 average months. RESULTS The drainage volume was lower in the SOPI group than in the CI group on postoperative day 3 (p < 0.01) and 7 (p = 0.016). In addition, the percentage of positive microbiological cultures after the third irrigation was less than that before (p < 0.01) and after (p < 0.01) the first irrigation. The most common causative organism was Staphylococcus aureus, which was detected in 25.0% and 12.5% of the SOPI and CI groups, respectively. The failure rate at the final follow-up was 8.3% and 31.3% (p = 0.039) for the SOPI and CI groups, respectively. CONCLUSION Compared with the traditional CI method, SOPI standardized the soaking time of hydrogen peroxide and povidone-iodine, increased the frequency of and irrigation, and proved that microorganisms were almost completely removed through the microbial culture of multiple tissues. SOPI has the potential to become a standardized irrigation process worthy of promotion, effectively reducing the postoperative recurrence rate of PJI patients.
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Affiliation(s)
- Xiaoyu Wu
- Department of Joint SurgeryThe First Affiliated Hospital of Sun Yat‐Sen UniversityGuangzhouChina
- Guangdong Provincial Key Laboratory of Orthopaedics and TraumatologyThe First Affiliated Hospital of Sun Yat‐sen UniversityGuangzhouChina
| | - Weishen Chen
- Department of Joint SurgeryThe First Affiliated Hospital of Sun Yat‐Sen UniversityGuangzhouChina
- Guangdong Provincial Key Laboratory of Orthopaedics and TraumatologyThe First Affiliated Hospital of Sun Yat‐sen UniversityGuangzhouChina
| | - Rong Rong
- Department of Nosocomial InfectionThe First Affiliated Hospital of Sun Yat‐Sen UniversityGuangzhouChina
| | - Baiqi Pan
- Department of Joint SurgeryThe First Affiliated Hospital of Sun Yat‐Sen UniversityGuangzhouChina
- Guangdong Provincial Key Laboratory of Orthopaedics and TraumatologyThe First Affiliated Hospital of Sun Yat‐sen UniversityGuangzhouChina
| | - Xuantao Hu
- Department of Joint SurgeryThe First Affiliated Hospital of Sun Yat‐Sen UniversityGuangzhouChina
- Guangdong Provincial Key Laboratory of Orthopaedics and TraumatologyThe First Affiliated Hospital of Sun Yat‐sen UniversityGuangzhouChina
| | - Linli Zheng
- Department of Joint SurgeryThe First Affiliated Hospital of Sun Yat‐Sen UniversityGuangzhouChina
- Guangdong Provincial Key Laboratory of Orthopaedics and TraumatologyThe First Affiliated Hospital of Sun Yat‐sen UniversityGuangzhouChina
| | - Aerman Alimu
- Department of Joint SurgeryThe First Affiliated Hospital of Sun Yat‐Sen UniversityGuangzhouChina
- Guangdong Provincial Key Laboratory of Orthopaedics and TraumatologyThe First Affiliated Hospital of Sun Yat‐sen UniversityGuangzhouChina
| | - Chenghan Chu
- Department of Joint SurgeryThe First Affiliated Hospital of Sun Yat‐Sen UniversityGuangzhouChina
- Guangdong Provincial Key Laboratory of Orthopaedics and TraumatologyThe First Affiliated Hospital of Sun Yat‐sen UniversityGuangzhouChina
| | - Yucheng Tu
- Department of Joint SurgeryThe First Affiliated Hospital of Sun Yat‐Sen UniversityGuangzhouChina
- Guangdong Provincial Key Laboratory of Orthopaedics and TraumatologyThe First Affiliated Hospital of Sun Yat‐sen UniversityGuangzhouChina
| | - Ziji Zhang
- Department of Joint SurgeryThe First Affiliated Hospital of Sun Yat‐Sen UniversityGuangzhouChina
- Guangdong Provincial Key Laboratory of Orthopaedics and TraumatologyThe First Affiliated Hospital of Sun Yat‐sen UniversityGuangzhouChina
| | - Yongyu Ye
- Department of Spinal SurgeryGuangdong Provincial People's HospitalGuangzhouChina
| | - Minghui Gu
- Department of Joint SurgeryThe First Affiliated Hospital of Sun Yat‐Sen UniversityGuangzhouChina
- Guangdong Provincial Key Laboratory of Orthopaedics and TraumatologyThe First Affiliated Hospital of Sun Yat‐sen UniversityGuangzhouChina
| | - Puyi Sheng
- Department of Joint SurgeryThe First Affiliated Hospital of Sun Yat‐Sen UniversityGuangzhouChina
- Guangdong Provincial Key Laboratory of Orthopaedics and TraumatologyThe First Affiliated Hospital of Sun Yat‐sen UniversityGuangzhouChina
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Adolf J, David Luo T, Gehrke T, Citak M. The top ten benefits of one-stage septic exchange in the management of periprosthetic joint infections. Arch Orthop Trauma Surg 2024:10.1007/s00402-024-05217-5. [PMID: 38393443 DOI: 10.1007/s00402-024-05217-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2023] [Accepted: 01/29/2024] [Indexed: 02/25/2024]
Affiliation(s)
- Jakob Adolf
- Helios ENDO-Klinik, Holstenstraße 2, 22767, Hamburg, Germany
| | - T David Luo
- Helios ENDO-Klinik, Holstenstraße 2, 22767, Hamburg, Germany
- Orthopaedics Northeast, 5050 N Clinton St, Fort Wayne, IN, 46825, USA
| | - Thorsten Gehrke
- Helios ENDO-Klinik, Holstenstraße 2, 22767, Hamburg, Germany
| | - Mustafa Citak
- Helios ENDO-Klinik, Holstenstraße 2, 22767, Hamburg, Germany.
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Lu H, Wang W, Xu H, Zhou K, Zhou Z. Efficacy and safety of two-stage revision for patients with culture-negative versus culture-positive periprosthetic joint infection: a single-center retrospective study. BMC Musculoskelet Disord 2024; 25:160. [PMID: 38378509 PMCID: PMC10877912 DOI: 10.1186/s12891-024-07259-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Accepted: 02/04/2024] [Indexed: 02/22/2024] Open
Abstract
BACKGROUND The safety and efficacy of two-stage revision for culture-negative PJI remain controversial. This study analyzed outcomes after two-stage revision in patients with culture-negative and culture-positive periprosthetic joint infection (PJI) during follow-up lasting at least two years. METHODS Data were retrospectively analysed patients who underwent hip or knee revision arthroplasty from January 2008 to October 2020 at our medical center. The primary outcome was the re-revision rate, while secondary outcomes were the rates of reinfection, readmission, and mortality. Patients with culture-negative or culture-positive PJI were compared in terms of these outcomes, as well as survival time without reinfection or revision surgery, based on Kaplan‒Meier analysis. RESULTS The final analysis included 87 patients who were followed up for a mean of 72.3 months (range, 24-123 months). The mean age was 58.1 years in the culture-negative group (n = 24) and 59.1 years in the culture-positive group (n = 63). The two groups (culture-negative versus culture-positive) did not differ significantly in rates of re-revision (0.0% vs. 3.2%, p > 0.05), reinfection (4.2% vs. 3.2%, p > 0.05), readmission (8.4% vs. 8.0%, p > 0.05), or mortality (8.3% vs. 7.9%, p > 0.05). They were also similar in survival rates without infection-related complications or revision surgery at 100 months (91.5% in the culture-negative group vs. 87.9% in the culture-positive group; Mantel‒Cox log-rank χ2 = 0.251, p = 0.616). CONCLUSION The two-stage revision proves to be a well-tolerated and effective procedure in both culture-negative and culture-positive PJI during mid to long-term follow-up.
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Affiliation(s)
- Hanpeng Lu
- Department of Orthopaedic Surgery, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Wenqi Wang
- West China School of Medicine, Sichuan University, Chengdu, China
| | - Hong Xu
- Department of Orthopaedic Surgery, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Kai Zhou
- Department of Orthopaedic Surgery, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Zongke Zhou
- Department of Orthopaedic Surgery, West China Hospital, Sichuan University, Chengdu, 610041, China.
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12
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Desai V, Farid AR, Liimakka AP, Lora-Tamayo J, Wouthuyzen-Bakker M, Kuiper JWP, Sandiford N, Chen AF. What Is the Most Effective Treatment for Periprosthetic Joint Infection After Total Joint Arthroplasty in Patients with Rheumatoid Arthritis?: A Systematic Review. JBJS Rev 2024; 12:01874474-202402000-00002. [PMID: 38359149 DOI: 10.2106/jbjs.rvw.23.00124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2024]
Abstract
BACKGROUND Rheumatoid arthritis (RA) is a risk factor for periprosthetic joint infection (PJI) after total joint arthroplasty (TJA). The purpose of this study was to perform a systematic review comparing the failure rates of debridement, antibiotics, and implant retention (DAIR), one-stage exchange arthroplasty/revision (OSR), and 2-stage exchange arthroplasty/revision (TSR) for RA patients with PJI and identify risk factors in the RA population associated with increased treatment failure rate. METHODS PubMed, Ovid MEDLINE, and Ovid Embase databases were screened with the terms "rheumatoid arthritis," "total joint arthroplasty," "prosthetic joint infection," and "treatment for PJI" on August 29, 2021. Four hundred ninety-one studies were screened, of which 86 were evaluated. The primary outcome evaluated was failure of surgical treatment for PJI. RESULTS Ten retrospective cohort studies were included after full-text screening, yielding 401 patients with RA. Additional demographic and PJI management data were obtained for 149 patients. Patients with RA who underwent TSR demonstrated a lower failure rate (26.8%) than both DAIR (60.1%) and OSR (39.2%) (χ2 = 37.463, p < 0.00001). Patients with RA who underwent DAIR had a 2.27 (95% CI, 1.66-3.10) times higher risk of experiencing treatment failure than those who underwent TSR. Among risk factors, there was a significant difference in the C-reactive protein of patients who did vs. did not experience treatment failure (p = 0.02). CONCLUSION TSR has a higher rate of success in the management of PJI patients with RA compared with DAIR and OSR. The complete removal of the infected prosthesis and delayed reimplantation may lower the treatment failure rate. LEVEL OF EVIDENCE Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Vineet Desai
- Harvard Medical School, Boston, Massachusetts
- Department of Orthopaedic Surgery, Brigham & Women's Hospital, Boston, Massachusetts
| | - Alexander R Farid
- Harvard Medical School, Boston, Massachusetts
- Department of Orthopaedic Surgery, Brigham & Women's Hospital, Boston, Massachusetts
| | - Adriana P Liimakka
- Harvard Medical School, Boston, Massachusetts
- Department of Orthopaedic Surgery, Brigham & Women's Hospital, Boston, Massachusetts
| | - Jaime Lora-Tamayo
- Department of Internal Medicine, Hospital Universitario 12 de Octubre, Instituto de Investigación Biomédica imás12, CIBER de Enfermedades Infecciosas (CIBERINFEC, Instituto de Salud Carlos III), Madrid, Spain
| | - Marjan Wouthuyzen-Bakker
- Department of Medical Microbiology and Infection Prevention, University of Groningen, University Medical Center Groningen, the Netherlands
| | - Jesse W P Kuiper
- Department of Orthopaedic Surgery, Martini Hospital, Groningen, the Netherlands
| | - Nemandra Sandiford
- Joint Reconstruction Unit, Department of Orthopaedics, Southland Hospital, Invercargill, New Zealand
| | - Antonia F Chen
- Harvard Medical School, Boston, Massachusetts
- Department of Orthopaedic Surgery, Brigham & Women's Hospital, Boston, Massachusetts
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13
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Tseng J, Oladipo V, Dandamudi S, Jones CM, Levine BR. Validation of a Classification System for Optimal Application of Debridement, Antibiotics, and Implant Retention in Prosthetic Joint Infections following Total Knee Arthroplasty: A Retrospective Review. Antibiotics (Basel) 2024; 13:48. [PMID: 38247607 PMCID: PMC10812511 DOI: 10.3390/antibiotics13010048] [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: 11/24/2023] [Revised: 12/26/2023] [Accepted: 01/02/2024] [Indexed: 01/23/2024] Open
Abstract
INTRODUCTION Periprosthetic joint infection (PJI) remains a serious complication after total knee arthroplasty (TKA). While debridement, antibiotics, and implant retention (DAIR) are considered for acute PJI, success rates vary. This study aims to assess a new scoring system's accuracy in predicting DAIR success. METHODS 119 TKA patients (2008-2019) diagnosed with PJI who underwent DAIR were included for analysis. Data were collected on demographics, laboratory values, and clinical outcomes. This was used for validation of the novel classification system consisting of PJI acuteness, microorganism classification, and host health for DAIR indication. Statistical analysis was carried out using SPSS programming. RESULTS Mean follow-up was 2.5 years with an average age of 65.5 ± 9.1 years, BMI of 31.9 ± 6.2 kg/m2, and CCI of 3.04 ± 1.8. Successful infection eradication occurred in 75.6% of patients. The classification system demonstrated 61.1% sensitivity, 72.4% specificity, and 87.3% positive predictive value (PPV) when the DAIR cutoff was a score less than 6. For a cutoff of less than 8, sensitivity was 100%, specificity was 37.9%, and PPV was 83.3%. CONCLUSIONS To date, no consensus exists on a classification system predicting DAIR success. This novel scoring system, with high PPV, shows promise. Further refinement is essential for enhanced predictive accuracy.
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Affiliation(s)
| | | | | | | | - Brett R. Levine
- Rush University Medical Center, Department of Orthopaedic Surgery, Chicago, IL 60612, USA; (J.T.); (V.O.); (S.D.); (C.M.J.)
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14
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Sanderson G, Olsen A, Nabet A, Goldman A. A simplified approach for the surgical treatment of hip and knee periprosthetic joint infections. J Orthop 2024; 47:58-62. [PMID: 38022845 PMCID: PMC10679533 DOI: 10.1016/j.jor.2023.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2023] [Accepted: 11/03/2023] [Indexed: 12/01/2023] Open
Affiliation(s)
- Galen Sanderson
- Bone and Joint Sports Medicine Institute, Naval Medical Center Portsmouth, VA, 620 John Paul Jones Circle, Portsmouth, VA, 23708, USA
- Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Aaron Olsen
- Bone and Joint Sports Medicine Institute, Naval Medical Center Portsmouth, VA, 620 John Paul Jones Circle, Portsmouth, VA, 23708, USA
- Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Austin Nabet
- Bone and Joint Sports Medicine Institute, Naval Medical Center Portsmouth, VA, 620 John Paul Jones Circle, Portsmouth, VA, 23708, USA
- Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Ashton Goldman
- Bone and Joint Sports Medicine Institute, Naval Medical Center Portsmouth, VA, 620 John Paul Jones Circle, Portsmouth, VA, 23708, USA
- Uniformed Services University of the Health Sciences, Bethesda, MD, USA
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15
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Gonzalez MR, Pretell-Mazzini J, Lozano-Calderon SA. Risk Factors and Management of Prosthetic Joint Infections in Megaprostheses-A Review of the Literature. Antibiotics (Basel) 2023; 13:25. [PMID: 38247584 PMCID: PMC10812472 DOI: 10.3390/antibiotics13010025] [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: 12/02/2023] [Revised: 12/22/2023] [Accepted: 12/23/2023] [Indexed: 01/23/2024] Open
Abstract
Prosthetic joint infection (PJI) is the most common mode of failure of megaprostheses, yet the literature on the topic is scarce, and studies report conflicting data regarding the optimal treatment strategy. Patients with megaprostheses PJI are often immunosuppressed, and surgeons must balance the trade-off between treatment efficacy and morbidity associated with the surgery aiming for infection eradication. Our review on megaprostheses PJI focuses on two axes: (1) risk factors and preventative strategies; and (2) surgical strategies to manage this condition. Risk factors were classified as either unmodifiable or modifiable. Attempts to decrease the risk of PJI should target the latter group. Strategies to prevent PJI include the use of silver-coated implants, timely discontinuation of perioperative antibiotic prophylaxis, and adequate soft tissue coverage to diminish the amount of dead space. Regarding surgical treatment, main strategies include debridement, antibiotics, implant retention (DAIR), DAIR with modular component exchange, stem retention (DAIR plus), one-stage, and two-stage revision. Two-stage revision is the "gold standard" for PJI in conventional implants; however, its success hinges on adequate soft tissue coverage and willingness of patients to tolerate a spacer for a minimum of 6 weeks. DAIR plus and one-stage revisions may be appropriate for a select group of patients who cannot endure the morbidity of two surgeries. Moreover, whenever DAIR is considered, exchange of the modular components should be performed (DAIR plus). Due to the low volume of megaprostheses implanted, studies assessing PJI should be conducted in a multi-institutional fashion. This would allow for more meaningful comparison of groups, with sufficient statistical power. Level of evidence: IV.
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Affiliation(s)
- Marcos R. Gonzalez
- Division of Orthopaedic Oncology, Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA; (M.R.G.); (S.A.L.-C.)
| | - Juan Pretell-Mazzini
- Miami Cancer Institute, Division of Orthopedic Oncology, Baptist Health System South Florida, Plantation, FL 33324, USA
| | - Santiago A. Lozano-Calderon
- Division of Orthopaedic Oncology, Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA; (M.R.G.); (S.A.L.-C.)
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16
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McCulloch RA, Martin A, Young BC, Kendrick BJ, Alvand A, Jeys L, Stevenson J, Palmer AJ. Frequent microbiological profile changes are seen in subsequent-revision hip and knee arthroplasty for prosthetic joint infection. J Bone Jt Infect 2023; 8:229-234. [PMID: 38127488 PMCID: PMC10726023 DOI: 10.5194/jbji-8-229-2023] [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] [Received: 06/25/2023] [Accepted: 09/22/2023] [Indexed: 12/23/2023] Open
Abstract
A proportion of patients with hip and knee prosthetic joint infection (PJI) undergo multiple revisions with the aim of eradicating infection and improving quality of life. The aim of this study was to describe the microbiology cultured from multiply revised hip and knee replacement procedures to guide antimicrobial therapy at the time of surgery. Patients and methods: Consecutive patients were retrospectively identified from databases at two specialist orthopaedic centres in the United Kingdom between 2011 and 2019. Patient were included who had undergone repeat-revision total knee replacement (TKR) or total hip replacement (THR) for infection, following an initial failed revision for infection. Results: A total of 106 patients were identified. Of these patients, 74 underwent revision TKR and 32 underwent revision THR. The mean age at first revision was 67 years (SD 10). The Charlson comorbidity index was ≤ 2 for 31 patients, 3-4 for 57 patients, and ≥ 5 for 18 patients. All patients underwent at least two revisions, 73 patients received three, 47 patients received four, 31 patients received five, and 21 patients received at least six. After six revisions, 90 % of patients had different organisms cultured compared with the initial revision, and 53 % of organisms were multidrug resistant. The most frequent organisms at each revision were coagulase-negative Staphylococcus (36 %) and Staphylococcus aureus (19 %). Fungus was cultured from 3 % of revisions, and 21 % of infections were polymicrobial. Conclusion: Patients undergoing multiple revisions for PJI are highly likely to experience a change in organism, with 90 % of patients having a different organism cultured by their sixth revision. It is therefore important to administer empirical antibiotics at each subsequent revision, taking into account known drug resistance from previous cultures. Our results do not support the routine use of empirical antifungals.
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Affiliation(s)
- Robert A McCulloch
- The Royal National Orthopaedic Hospital, Brockley Hill, Stanmore, Middlesex, HA7 4LP, UK
| | - Alex Martin
- The Nuffield Orthopaedic Centre, Windmill Road, Headington, Oxford, OX3 7HE, UK
| | - Bernadette C Young
- The Nuffield Orthopaedic Centre, Windmill Road, Headington, Oxford, OX3 7HE, UK
| | - Benjamin J Kendrick
- The Nuffield Orthopaedic Centre, Windmill Road, Headington, Oxford, OX3 7HE, UK
| | - Abtin Alvand
- The Nuffield Orthopaedic Centre, Windmill Road, Headington, Oxford, OX3 7HE, UK
| | - Lee Jeys
- The Royal Orthopaedic Hospital, Bristol Road, Northfield, Birmingham, B31 2AP, UK
| | - Jonathan Stevenson
- The Royal Orthopaedic Hospital, Bristol Road, Northfield, Birmingham, B31 2AP, UK
| | - Antony J Palmer
- The Nuffield Orthopaedic Centre, Windmill Road, Headington, Oxford, OX3 7HE, UK
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17
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Lee CR, Kim CW, Park DH, Kwon YU, Yoon JM. Risk of Infection After Septic and Aseptic Revision Total Knee Arthroplasty: A Systematic Review. J Bone Joint Surg Am 2023; 105:1630-1637. [PMID: 37616387 DOI: 10.2106/jbjs.23.00361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/26/2023]
Abstract
BACKGROUND The causes of primary total knee arthroplasty (TKA) failure can be divided into septic and aseptic etiologies. It is unclear whether the etiology affects the infection rate after revision TKA. This systematic review was conducted to evaluate whether there is a difference in infection rates between septic and aseptic revision TKA. We hypothesized that infection rates would be higher after septic revision TKA. METHODS The PubMed and Embase databases and the Cochrane Library were searched to find studies evaluating infection rates following septic and aseptic revision TKA. We included studies that compared the postoperative infection rates of a group that received revision TKA for aseptic failure and a group that received 1- or 2-stage revision TKA for septic failure. Studies on re-revision TKA and on revision surgery after partial knee arthroplasty were excluded, as were studies of debridement, antibiotics, and implant retention (DAIR). RESULTS Twelve studies were included in this systematic review. In studies in which 1- or 2-stage revision TKA was performed for septic failure, septic revision TKA had a significantly higher infection rate than aseptic revision TKA (odds ratio [OR], 6.83; 95% confidence interval [CI], 1.54 to 30.33; p = 0.01). Similarly, in studies in which 2-stage revision TKA was performed for septic failure, septic revision TKA had a significantly higher infection rate than aseptic revision TKA (OR, 4.14; 95% CI, 2.33 to 7.36; p < 0.00001). In the comparison of revision TKA for aseptic loosening and septic revision TKA, septic revision TKA had a higher infection rate than aseptic revision TKA (OR, 4.45; 95% CI, 2.28 to 8.70; p < 0.0001). CONCLUSIONS Overall, septic revision TKA had a higher infection rate than aseptic revision TKA. Even when 2-stage revision TKA was performed for septic failure, the infection rate was higher after septic revision TKA than after aseptic revision. Surgeons should explain the relatively high infection rates to patients undergoing revision TKA for septic failure of their primary joint replacement. LEVEL OF EVIDENCE Therapeutic Level IV . See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Chang-Rack Lee
- Department of Orthopedic Surgery, Inje University Busan Paik Hospital, Busan, Republic of Korea
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18
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Roof MA, Aggarwal VK, Schwarzkopf R. The Economics of Revision Arthroplasty for Periprosthetic Joint Infection. Arthroplast Today 2023; 23:101213. [PMID: 37745961 PMCID: PMC10511334 DOI: 10.1016/j.artd.2023.101213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2023] [Revised: 07/31/2023] [Accepted: 08/02/2023] [Indexed: 09/26/2023] Open
Affiliation(s)
- Mackenzie A. Roof
- Department of Orthopedic Surgery, NYU Langone Health, New York, NY, USA
| | - Vinay K. Aggarwal
- Department of Orthopedic Surgery, NYU Langone Health, New York, NY, USA
| | - Ran Schwarzkopf
- Department of Orthopedic Surgery, NYU Langone Health, New York, NY, USA
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19
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Shichman I, Ward SA, Lu L, Garceau S, Piuzzi NS, Seyler TM, Schwarzkopf R. Failed 2-Stage Revision Knee Arthroplasty for Periprosthetic Joint Infection-Patient Characteristics and Outcomes. J Arthroplasty 2023; 38:2177-2182. [PMID: 37179023 DOI: 10.1016/j.arth.2023.04.063] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2022] [Revised: 04/26/2023] [Accepted: 04/30/2023] [Indexed: 05/15/2023] Open
Abstract
BACKGROUND Chronic prosthetic joint infection (PJI) is most frequently treated with 2-stage revision in conjunction with antibiotic treatment. The aims of this study were 1) to investigate the characteristics of patients who have recurrent infection following 2-stage revision for PJI and 2) to identify risk factors associated with treatment failure. METHODS A multicenter retrospective review of 90 total knee arthroplasty (TKA) patients who underwent 2-stage revision for treatment of PJI from March 1, 2003 to July 31, 2019, and had recurrent PJI was conducted. The minimum follow-up was 12 months (median follow up of 2.4 years). Microorganisms, subsequent revision, PJI control status, and final joint status were collected. The infection-free survival after initial 2-stage revision was plotted utilizing the Kaplan-Meier method. RESULTS Mean survival time to reinfection was 21.3 months (range, 0.3 to 160.5). There were 14 recurrent infections that were acute PJIs treated with debridement, antibiotics, and implant retention (DAIR), while 76 were chronic and treated with repeat 2-stage revision. The most common pathogen identified for both index and recurrent PJI was coagulase-negative Staphylococci. Pathogen persistence was observed in 14 (22.2%) of recurrent PJIs. In total, 61 (67.8%) patients possessed a prosthetic reimplantation at their most recent follow-up, and 29 (35.6%) patients required intervention following repeat 2-stage. CONCLUSION Overall, 31.1% of the patients obtained infection control after treatment of a failed 2-stage revision due to PJI. The high rate of pathogen persistence and the relatively low survival time to recurrence suggests a need to more closely monitor PJIs cases within 2 years.
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Affiliation(s)
- Ittai Shichman
- Division of Adult Reconstruction, Department of Orthopedic Surgery, NYU Langone Health, New York, New York; Division of Orthopedic Surgery, Tel-Aviv Sourasky Medical Center, Sackler School of Medicine, Tel-Aviv, Israel
| | - Spencer A Ward
- Division of Adult Reconstruction, Department of Orthopedic Surgery, NYU Langone Health, New York, New York
| | - Laura Lu
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Simon Garceau
- Division of Orthopedics, Ottawa University Hospital, Ottawa, Ontario, Canada
| | - Nicolas S Piuzzi
- Department of Orthopedic Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Thorsten M Seyler
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina
| | - Ran Schwarzkopf
- Division of Adult Reconstruction, Department of Orthopedic Surgery, NYU Langone Health, New York, New York
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20
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Crowe M, Giacobazzi M, Griffin E, Storm S. Borrelia burgdorferi-A Bacterium Worthy of Consideration in Culture-Negative Prosthetic Joint Infection. J Am Acad Orthop Surg Glob Res Rev 2023; 7:01979360-202309000-00009. [PMID: 37707984 PMCID: PMC10503676 DOI: 10.5435/jaaosglobal-d-23-00068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 07/14/2023] [Accepted: 08/04/2023] [Indexed: 09/16/2023]
Abstract
A 68-year-old woman presented to the orthopaedic office with 2 weeks of atraumatic right prosthetic knee pain and swelling. She previously lived pain free and fully functional after a total knee arthroplasty 8 years ago. Initial radiographs showed a small joint effusion, and serum inflammatory markers were elevated. Arthrocentesis yielded 12ccs of culture-negative cloudy serous fluid containing 3,270 white blood cells, 92% polymorphonuclear neutrophils. The patient underwent prosthesis explant, antibiotic spacer placement, and began empiric IV antibiotic therapy as stage one of a planned two-stage revision. Intraoperative tissue cultures were negative, and the postoperative plan was to continue IV vancomycin for a total of 6 weeks. Two weeks post-op, serum Lyme antibody testing returned positive. The patient was switched to doxycycline and ceftriaxone for a total duration of 4 weeks, followed by a successful second-stage revision and remains asymptomatic after 1 year. Five cases of culture-negative prosthetic joint infections caused by the spirochete, Borrelia burgdorferi, have been reported in the orthopaedic literature.1-4 We present a sixth case, occurring in a 68-year-old woman in Northwestern Pennsylvania, 8 years after a primary right total knee arthroplasty.
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Affiliation(s)
- Mary Crowe
- From the Lake Erie College of Osteopathic Medicine, Erie, PA
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21
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Karczewski D, Schönnagel L, Hipfl C, Akgün D, Hardt S. Periprosthetic knee infection in octogenarians: a single institution experience at midterm outcome. Arch Orthop Trauma Surg 2023; 143:4317-4322. [PMID: 36750492 PMCID: PMC10293346 DOI: 10.1007/s00402-023-04796-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Accepted: 01/22/2023] [Indexed: 02/09/2023]
Abstract
PURPOSE Periprosthetic joint infections (PJI) of total knee arthroplasties (TKAs) in the elderly is among the clinically most challenging scenarios given multimorbidity combined with poor bone and soft tissue quality. Despite increasing prevalence, limited is known on PJI among this unique group of patients. As such, this study analyzed PJI characteristics, implant survivorship and non-surgical complications of octogenarians revised PJI for the knee. METHODS We identified 31 patients that were revised for PJIs of the knee between 2010 and 2019 using a single university-based registry. Mean age was 83 years (range 80-87), 48% were females, and mean BMI was 29 kg/m2. Mean age adjusted Charlson Comorbidity Index was 7, and mean ASA score was 3. Major causative pathogens included Coagulase-negative Staphylococci (26%), Staphylococcus aureus (13%), and Streptococci (13%). Two-stage exchange was performed in 30 patients, permanent resection arthroplasty in one joint. Kaplan-Meier survivorship analyses were performed. Mean follow-up was 4 years. RESULTS The 2-year survivorship free of any recurrent PJI was 96%, and there was one PJI relapse noted at 6 months. Moreover, there were three additional revisions for aseptic loosening, and one further revision for fracture. As such, the 2-year survivorship free of any revision was 87%. In addition to the aforementioned revisions, there was one additional plate osteosynthesis for a Vancouver C fracture, resulting in a 79% survivorship free of any reoperation at 2 years. Mean perioperative complication score according to the Clavien-Dindo classification was 2 out of 5. A total of three patients died: one patient 40 days after resection arthroplasty, two others 4 months and 8 months after reimplantation. CONCLUSIONS Octogenarians revised for PJI of the knee are at low risk of recurrent infection and overall revision at 2 years. However, moderate rates of perioperative complications and mortality at short term must acknowledge before deciding upon procedure. LEVEL OF EVIDENCE Therapeutic level IV.
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Affiliation(s)
- Daniel Karczewski
- Department of Orthopaedic Surgery, Musculoskeletal Oncology Service, Massachusetts General Hospital-Harvard Medical School, 55 Fruit Street, Boston, MA, 02114, USA.
- Department of Orthopaedic Surgery and Traumatology, Charité Berlin, University Hospital, Chariteplatz 1, 10117, Berlin, Germany.
| | - Lukas Schönnagel
- Department of Orthopaedic Surgery, Musculoskeletal Oncology Service, Massachusetts General Hospital-Harvard Medical School, 55 Fruit Street, Boston, MA, 02114, USA
| | - Christian Hipfl
- Department of Orthopaedic Surgery, Musculoskeletal Oncology Service, Massachusetts General Hospital-Harvard Medical School, 55 Fruit Street, Boston, MA, 02114, USA
| | - Doruk Akgün
- Department of Orthopaedic Surgery, Musculoskeletal Oncology Service, Massachusetts General Hospital-Harvard Medical School, 55 Fruit Street, Boston, MA, 02114, USA
| | - Sebastian Hardt
- Department of Orthopaedic Surgery, Musculoskeletal Oncology Service, Massachusetts General Hospital-Harvard Medical School, 55 Fruit Street, Boston, MA, 02114, USA
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22
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Şenel A, Öztürkmen Y, Eren M, Carkci E, Circi E, Kanay E, Açıkgöz İ. Factors Influencing the Clinical Outcomes of Two-Stage Re-Implantation in Patients With Periprosthetic Joint Infection After Total Knee Arthroplasty. Cureus 2023; 15:e42566. [PMID: 37637597 PMCID: PMC10460261 DOI: 10.7759/cureus.42566] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/27/2023] [Indexed: 08/29/2023] Open
Abstract
Introduction Infection is one of the most distressing complications of total knee arthroplasty (TKA), requiring a long treatment process and may negatively affect patient satisfaction. All surgeons aim to achieve infection-free survival, painless, functional, and stable knee after treatment of periprosthetic joint infection (PJI) with two-stage revision treatment. Many factors play a role in determining clinical outcomes. We aimed to evaluate the factors influencing the clinical outcomes of patients undergoing two-stage revision knee arthroplasty for PJI. Methods Forty-nine patients were retrospectively evaluated. Forty-four patients met the inclusion criteria. Spacer types, growth rates in culture, types and amount of antibiotics added to the cement, and intervals between stages were evaluated. Pre- and post-treatment infection parameters, changes in the range of motion (ROM), clinical and functional (C&F) Knee Society Score (KSS) results, and complications were also studied. Results After a mean follow-up of 48.8 ± 16.5 months, re-infection was detected in five out of 44 patients (10.4%). No significant difference was noted regarding C&F KSS when comparing time intervals between the two stages, whether they were shorter or longer than 10 weeks. However, better ROM results were obtained in patients with less than 10 weeks between stages. The relationship between spacer type, ROM, and C&F KSS was not found to be significant. Particularly, the addition of 4g of teicoplanin to the cement shortened the time between the two stages. Conclusion C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) levels can be considered safe parameters for diagnosis, reimplantation timing, and follow-up. The use of dynamic spacers or reimplantation performed within 10 weeks after the first stage is associated with better ROM outcomes. Additionally, the addition of teicoplanin to the cement shortened the duration of antibiotic therapy.
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Affiliation(s)
- Ahmet Şenel
- Orthopedics and Traumatology, Istanbul Training and Research Hospital, Istanbul, TUR
| | - Yusuf Öztürkmen
- Orthopedics and Traumatology, Istanbul Training and Research Hospital, Istanbul, TUR
| | - Murat Eren
- Orthopedics and Traumatology, Istanbul Training and Research Hospital, Istanbul, TUR
| | - Engin Carkci
- Orthopedics and Traumatology, Istanbul Training and Research Hospital, Istanbul, TUR
| | - Esra Circi
- Orthopedics and Traumatology, Istanbul Training and Research Hospital, Istanbul, TUR
| | - Enes Kanay
- Orthopedics and Traumatology, Istanbul Training and Research Hospital, Istanbul, TUR
| | - İlhan Açıkgöz
- Orthopedics and Traumatology, Istanbul Training and Research Hospital, Istanbul, TUR
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Danoff JR, Heimroth J, Willinger M, Trout S, Sodhi N. Surgical Technique: Robotic-Assisted 1.5-Stage Exchange Total Knee Arthroplasty for Periprosthetic Joint Infection. Arthroplast Today 2023; 21:101126. [PMID: 37234598 PMCID: PMC10205596 DOI: 10.1016/j.artd.2023.101126] [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: 06/27/2022] [Revised: 01/12/2023] [Accepted: 02/27/2023] [Indexed: 05/28/2023] Open
Abstract
A 1.5-stage exchange total knee arthroplasty for periprosthetic joint infection has been described; however, achieving a balanced and well-aligned construct can sometimes be difficult given the bony defects often encountered in these cases. The use of robotic navigation technologies allows for accurate and precise implant placement. This technique report details the utilization of robotic navigation in a 1.5-stage exchange total knee arthroplasty for periprosthetic joint infection and describes the outcome of 6 patients. This technique guide highlights how robotic technology can account for many commonly encountered bone voids, joint line identification, and component orientation, while achieving a balanced and well-aligned knee.
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Affiliation(s)
- Jonathan R. Danoff
- Corresponding author: Department of Orthopaedic Surgery, Northwell Health, North Shore University Hospital, 611 Northern Blvd, Suite 200 Great Neck, NY 11021, USA. Tel.: +1 516 325 7013.
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24
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Fraval A, Wang J, Tarabichi S, Parvizi J. Optimal timing for reimplantation in the setting of two stage revision for prosthetic joint infection. Rev Esp Cir Ortop Traumatol (Engl Ed) 2023; 67:246-252. [PMID: 36787833 DOI: 10.1016/j.recot.2023.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 02/10/2023] [Indexed: 02/14/2023] Open
Affiliation(s)
- A Fraval
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA, United States.
| | - J Wang
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA, United States
| | - S Tarabichi
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA, United States
| | - J Parvizi
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA, United States
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25
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Ryan SP, Warne CN, Osmon DR, Tande AJ, Ledford CK, Hyun M, Berry DJ, Abdel MP. Short Course of Oral Antibiotic Treatment After Two-Stage Exchange Arthroplasty Appears to Decrease Early Reinfection. J Arthroplasty 2023; 38:909-913. [PMID: 36496045 PMCID: PMC10430476 DOI: 10.1016/j.arth.2022.12.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Revised: 11/28/2022] [Accepted: 12/02/2022] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Recent evidence has suggested a benefit to extended postoperative prophylactic oral antibiotics after two-stage exchange arthroplasty for treatment of periprosthetic joint infections. We sought to determine reinfection rates with and without a short course of oral antibiotics after two-stage exchange procedures. METHODS A retrospective review identified patients undergoing two-stage exchange arthroplasty for periprosthetic joint infection of the hip or knee. Patients were excluded if they failed a prior two-stage exchange, had positive cultures at reimplantation, prolonged intravenous antibiotics postoperatively, and/or life-long suppression. This resulted in 444 reimplantations (210 hips and 234 knees). Patients were divided into three cohorts based on the duration of oral antibiotics after reimplantation: no antibiotics (102), ≤2 weeks (266), or >2 weeks (76). The primary endpoint was reinfection within 1 year of reimplantation. RESULTS Within 1 year of reimplantation, there were 34 reinfections. In the no-antibiotic, ≤ 2-week, and >2-week cohorts the reinfection rates were 14.1, 7.0, and 6.4%, respectively. Multivariate Cox regression showed a reduced reinfection rate in the ≤2-week cohort relative to no antibiotics (hazard ratio [HR]: 0.38, P = .01). While the smaller cohort with >2 weeks of antibiotics did not significantly reduce the reinfection rate (HR: 0.41, P = .12), when combined with the ≤2-week cohort, use of oral antibiotics had an overall reduction of the reinfection rate (HR: 0.39, P = .01). CONCLUSIONS These data support the hypothesis that a short course of oral antibiotics after reimplantation decreases the 1-year reinfection rate. Future randomized studies should seek to examine the efficacy of different durations of oral antibiotics to reduce reinfection. LEVEL OF EVIDENCE Prognostic Level IV.
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Affiliation(s)
- Sean P. Ryan
- Department of Orthopedic Surgery, Mayo Clinic, 200 First Street S.W., Rochester, MN 55905
| | - Christopher N. Warne
- Department of Orthopedic Surgery, Mayo Clinic, 200 First Street S.W., Rochester, MN 55905
| | - Douglas R. Osmon
- Division of Infectious Diseases, Department of Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905
| | - Aaron J. Tande
- Division of Infectious Diseases, Department of Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905
| | - Cameron K. Ledford
- Department of Orthopedic Surgery, Mayo Clinic, 200 First Street S.W., Rochester, MN 55905
| | - Meredith Hyun
- Department of Quantitative Health Sciences, Division of Clinical Trials and Biostatistics, Mayo Clinic, 200 First Street S.W., Rochester, MN 55905
| | - Daniel J. Berry
- Department of Orthopedic Surgery, Mayo Clinic, 200 First Street S.W., Rochester, MN 55905
| | - Matthew P. Abdel
- Department of Orthopedic Surgery, Mayo Clinic, 200 First Street S.W., Rochester, MN 55905
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26
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Fraval A, Wang J, Tarabichi S, Parvizi J. Optimal timing for reimplantation in the setting of two stage revision for prosthetic joint infection. Rev Esp Cir Ortop Traumatol (Engl Ed) 2023; 67:T246-T252. [PMID: 36940848 DOI: 10.1016/j.recot.2023.02.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 02/10/2023] [Indexed: 03/22/2023] Open
Affiliation(s)
- A Fraval
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pensilvania, Estados Unidos.
| | - J Wang
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pensilvania, Estados Unidos
| | - S Tarabichi
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pensilvania, Estados Unidos
| | - J Parvizi
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pensilvania, Estados Unidos
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27
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Steinicke AC, Schwarze J, Gosheger G, Moellenbeck B, Ackmann T, Theil C. Repeat two-stage exchange arthroplasty for recurrent periprosthetic hip or knee infection: what are the chances for success? Arch Orthop Trauma Surg 2023; 143:1731-1740. [PMID: 34982202 PMCID: PMC10030533 DOI: 10.1007/s00402-021-04330-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Accepted: 12/18/2021] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Two-stage revision is a frequently chosen approach to treat chronic periprosthetic joint infection (PJI). However, management of recurrent infection after a two-stage exchange remains debated and the outcome of a repeat two-stage procedure is unclear. This study investigates the success rates of repeat two-stage exchange arthroplasty and analyzes possible risk factors for failure. MATERIALS AND METHODS We retrospectively identified 55 patients (23 hips, 32 knees) who were treated with repeat resection arthroplasty and planned delayed reimplantation for recurrent periprosthetic joint infection between 2010 and 2019 after a prior two-stage revision at the same institution. The minimum follow-up was 12 months with a median follow-up time of 34 months (IQR 22-51). The infection-free survival, associated revision surgeries, and potential risk factors for further revision were analyzed using Kaplan-Meier survival curves and comparative non-parametric testing. RESULTS 78% (43/55) underwent reimplantation after a repeat implant removal. Of those who completed the second-stage surgery, 37% (16/43) underwent additional revision for infection and 14% (6/55) underwent amputation. The reinfection-free implant survivorship amounted to 77% (95% CI 64-89%) after 1 year and 38% (95% CI 18-57%) after 5 years. Patients with a higher comorbidity score were less likely to undergo second-stage reimplantation (median 5 vs. 3, p = 0.034). Furthermore, obese patients (p = 0.026, Fisher's exact test) and diabetics (p < 0.001, log-rank test) had a higher risk for further infection. Most commonly cultures yielded polymicrobial growth at the repeat two-stage exchange (27%, 15/55) and at re-reinfection (32%, 9/28). Pathogen persistence was observed in 21% (6/28) of re-reinfected patients. CONCLUSION The success rates after repeat two-stage exchange arthroplasty are low. Patients must be counseled accordingly and different modes of treatment should be considered.
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Affiliation(s)
- A C Steinicke
- Department of Orthopedics and Tumor Orthopedics, Muenster University Hospital, Muenster, Albert-Schweitzer-Campus 1, 48149, Muenster, Germany
| | - J Schwarze
- Department of Orthopedics and Tumor Orthopedics, Muenster University Hospital, Muenster, Albert-Schweitzer-Campus 1, 48149, Muenster, Germany
| | - G Gosheger
- Department of Orthopedics and Tumor Orthopedics, Muenster University Hospital, Muenster, Albert-Schweitzer-Campus 1, 48149, Muenster, Germany
| | - B Moellenbeck
- Department of Orthopedics and Tumor Orthopedics, Muenster University Hospital, Muenster, Albert-Schweitzer-Campus 1, 48149, Muenster, Germany
| | - T Ackmann
- Department of Orthopedics and Tumor Orthopedics, Muenster University Hospital, Muenster, Albert-Schweitzer-Campus 1, 48149, Muenster, Germany
| | - C Theil
- Department of Orthopedics and Tumor Orthopedics, Muenster University Hospital, Muenster, Albert-Schweitzer-Campus 1, 48149, Muenster, Germany.
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28
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Ciccullo C, Neri T, Farinelli L, Gigante A, Philippot R, Farizon F, Boyer B. Antibiotic Prophylaxis in One-Stage Revision of Septic Total Knee Arthroplasty: A Scoping Review. Antibiotics (Basel) 2023; 12:antibiotics12030606. [PMID: 36978473 PMCID: PMC10044675 DOI: 10.3390/antibiotics12030606] [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: 12/05/2022] [Revised: 02/28/2023] [Accepted: 03/15/2023] [Indexed: 03/30/2023] Open
Abstract
BACKGROUND Total knee replacement (TKA) is becoming a routine procedure in orthopedic surgery. One of the possible complications of this surgery is periprosthetic joint infection (PJI). The purpose of this study is to identify, through a literature review, which antibiotic is used as prophylaxis for septic one-stage revision TKA and what is the rationale for its use. METHODS We searched: MEDLINE, Embase, PsycINFO on Ovid, the Cochrane Library, and the Google Scholar Database. The searches were limited by date (January 2005 to September 2022) and to the English language. All types of original research were considered, including prospective or retrospective longitudinal studies, cross-sectional studies, and randomized trials. The specific search terms were ((antibiotic [MeSH]) AND (prophylaxis)) and (TKA OR TKR OR "Arthroplasty, Replacement, Knee" [MeSH] OR ((knee) adj2 (replace* OR arthroplasty* OR prosthe*))). RESULTS Despite our research efforts, we found no article capable of answering the question of which antibiotic to use as surgical prophylaxis for a septic revision one-stage TKA. CONCLUSIONS Although the research results are inconclusive, we would recommend using the same antibiotic prophylaxis as for primary joint replacement, i.e., cefazolin, as it was recommended for its low side effect rate and relative effectiveness.
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Affiliation(s)
- Carlo Ciccullo
- Clinical Ortopaedics, Department of Clinical and Molecular Sciences, Università Politecnica delle Marche, 60121 Ancona, Italy
| | - Thomas Neri
- Department of Orthopaedic Surgery, University Hospital of Saint Etienne, Hôpital Nord, 42055 Saint-Étienne, France
- Laboratoire Interuniversitaire de Biologie de la Motricité, Université de Lyon, 69361 Lyon, France
| | - Luca Farinelli
- Clinical Ortopaedics, Department of Clinical and Molecular Sciences, Università Politecnica delle Marche, 60121 Ancona, Italy
| | - Antonio Gigante
- Clinical Ortopaedics, Department of Clinical and Molecular Sciences, Università Politecnica delle Marche, 60121 Ancona, Italy
| | - Rémi Philippot
- Department of Orthopaedic Surgery, University Hospital of Saint Etienne, Hôpital Nord, 42055 Saint-Étienne, France
- Laboratoire Interuniversitaire de Biologie de la Motricité, Université de Lyon, 69361 Lyon, France
| | - Frederic Farizon
- Department of Orthopaedic Surgery, University Hospital of Saint Etienne, Hôpital Nord, 42055 Saint-Étienne, France
- U 1059 Sainbiose, Mines Saint-Étienne, Universitè Jean Monnet, INSERM, 42023 Saint-Étienne, France
| | - Bertrand Boyer
- Department of Orthopaedic Surgery, University Hospital of Saint Etienne, Hôpital Nord, 42055 Saint-Étienne, France
- U 1059 Sainbiose, Mines Saint-Étienne, Universitè Jean Monnet, INSERM, 42023 Saint-Étienne, France
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29
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Li F, Qiao Y, Zhang H, Cao G, Zhou S. Comparable clinical outcomes of culture-negative and culture-positive periprosthetic joint infections: a systematic review and meta-analysis. J Orthop Surg Res 2023; 18:210. [PMID: 36927390 PMCID: PMC10018887 DOI: 10.1186/s13018-023-03692-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Accepted: 03/08/2023] [Indexed: 03/18/2023] Open
Abstract
PURPOSE The aim of this study was to compare the clinical outcomes of culture-negative periprosthetic joint infection (CN PJI) with those of culture-positive periprosthetic joint infection (CP PJI). METHODS Data were obtained from Embase, Web of Science and EBSCO for all available studies comparing the clinical outcomes of CN PJI with those of CP PJI. The quality of the studies was scored using the Newcastle-Ottawa scale (NOS). Pooled odds ratios (ORs) and 95% confidence intervals (CIs) were used to assess clinical outcomes. Subgroup analyses were performed to explain heterogeneity among the included studies. Publication bias was estimated using Begg's funnel plot. Sensitivity analysis was performed to test the stability of pooled results. RESULTS Thirty studies with 1630 (38.7%) CN PJI and 2577 (61.3%) CP PJI were included in this meta-analysis. The pooled results of the included studies showed that overall failure rate in CN PJI group (19.0%, 309/1630) was significantly lower than that in CP PJI group (23.4%, 604/2577) (OR 0.63, 95% CI 0.47-0.84, P = 0.002). We performed the subgroup analysis based on the surgical strategies, the pooled results of nine studies for patients undergoing debridement, antibiotics and implant retention (DAIR) revealed that failure rate in CN PJI group (22.2%, 53/239) was significantly lower than that in CP PJI group (29.3%, 227/775) (OR 0.62, 95% CI 0.43-0.90, P = 0.01), the pooled results of four studies for patients undergoing one-stage revision revealed that failure rate between CN PJI group (11.5%, 11/96) and CP PJI group (7.6%, 27/355) had no significant difference (OR 1.57, 95% CI 0.75-3.26, P = 0.23), and the pooled results of 19 studies for patients undergoing two-stage revision revealed that failure rate in CN PJI group (16.1%, 171/1062) was significantly lower than that in CP PJI group (20.4%, 206/1010) (OR 0.52, 95% CI 0.34-0.79, P = 0.002). CONCLUSIONS CN PJI group had similar or better survival rate when compared with CP PJI group for patients who underwent DAIR, one-stage or two-stage revision. Negative culture was not a worse prognostic factor for PJI.
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Affiliation(s)
- Feng Li
- Department of Joint Surgery, The 940th Hospital of Joint Logistic Support Force of Chinese People's Liberation Army, Gansu, Lanzhou, China.,Department of Orthopaedics, The 943rd Hospital of Joint Logistic Support Force of Chinese People's Liberation Army, Gansu, Wuwei, China
| | - Yongjie Qiao
- Department of Joint Surgery, The 940th Hospital of Joint Logistic Support Force of Chinese People's Liberation Army, Gansu, Lanzhou, China
| | - Haoqiang Zhang
- Department of Joint Surgery, The 940th Hospital of Joint Logistic Support Force of Chinese People's Liberation Army, Gansu, Lanzhou, China
| | - Guoding Cao
- Department of Orthopaedics, Lanzhou University Second Hospital, Gansu, Lanzhou, China
| | - Shenghu Zhou
- Department of Joint Surgery, The 940th Hospital of Joint Logistic Support Force of Chinese People's Liberation Army, Gansu, Lanzhou, China.
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Maimaiti Z, Li Z, Xu C, Fu J, Hao LB, Chen JY, Chai W. Host Immune Regulation in Implant-Associated Infection (IAI): What Does the Current Evidence Provide Us to Prevent or Treat IAI? Bioengineering (Basel) 2023; 10:bioengineering10030356. [PMID: 36978747 PMCID: PMC10044746 DOI: 10.3390/bioengineering10030356] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Revised: 02/25/2023] [Accepted: 03/03/2023] [Indexed: 03/17/2023] Open
Abstract
The number of orthopedic implants for bone fixation and joint arthroplasty has been steadily increasing over the past few years. However, implant-associated infection (IAI), a major complication in orthopedic surgery, impacts the quality of life and causes a substantial economic burden on patients and societies. While research and study on IAI have received increasing attention in recent years, the failure rate of IAI has still not decreased significantly. This is related to microbial biofilms and their inherent antibiotic resistance, as well as the various mechanisms by which bacteria evade host immunity, resulting in difficulties in diagnosing and treating IAIs. Hence, a better understanding of the complex interactions between biofilms, implants, and host immunity is necessary to develop new strategies for preventing and controlling these infections. This review first discusses the challenges in diagnosing and treating IAI, followed by an extensive review of the direct effects of orthopedic implants, host immune function, pathogenic bacteria, and biofilms. Finally, several promising preventive or therapeutic alternatives are presented, with the hope of mitigating or eliminating the threat of antibiotic resistance and refractory biofilms in IAI.
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Affiliation(s)
- Zulipikaer Maimaiti
- Department of Orthopaedics, The Fourth Medical Centre, Chinese PLA General Hospital, Beijing 100048, China
- Department of Orthopaedics, The First Medical Centre, Chinese PLA General Hospital, Beijing 100853, China
| | - Zhuo Li
- Department of Orthopaedics, The First Medical Centre, Chinese PLA General Hospital, Beijing 100853, China
- School of Medicine, Nankai University, Tianjin 300071, China
| | - Chi Xu
- Department of Orthopaedics, The Fourth Medical Centre, Chinese PLA General Hospital, Beijing 100048, China
- Department of Orthopaedics, The First Medical Centre, Chinese PLA General Hospital, Beijing 100853, China
| | - Jun Fu
- Department of Orthopaedics, The Fourth Medical Centre, Chinese PLA General Hospital, Beijing 100048, China
- Department of Orthopaedics, The First Medical Centre, Chinese PLA General Hospital, Beijing 100853, China
| | - Li-Bo Hao
- Department of Orthopaedics, The Fourth Medical Centre, Chinese PLA General Hospital, Beijing 100048, China
- Department of Orthopaedics, The First Medical Centre, Chinese PLA General Hospital, Beijing 100853, China
| | - Ji-Ying Chen
- Department of Orthopaedics, The Fourth Medical Centre, Chinese PLA General Hospital, Beijing 100048, China
- Department of Orthopaedics, The First Medical Centre, Chinese PLA General Hospital, Beijing 100853, China
- Correspondence: (J.-Y.C.); (W.C.)
| | - Wei Chai
- Department of Orthopaedics, The Fourth Medical Centre, Chinese PLA General Hospital, Beijing 100048, China
- Department of Orthopaedics, The First Medical Centre, Chinese PLA General Hospital, Beijing 100853, China
- Correspondence: (J.-Y.C.); (W.C.)
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31
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Anoushiravani AA, Kalyanasundaram G, Feng JE, Congiusta F, Iorio R, DiCaprio M. Treating Hepatitis C Prior to Total Hip Arthroplasty is Cost Effective: A Markov Analysis. J Arthroplasty 2023:S0883-5403(23)00198-5. [PMID: 36878438 DOI: 10.1016/j.arth.2023.02.067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 02/21/2023] [Accepted: 02/26/2023] [Indexed: 03/08/2023] Open
Abstract
INTRODUCTION Patients infected with the hepatitis C virus (HCV) have high complication rates following total hip arthroplasty (THA). Advances in HCV therapy now enable clinicians to eradicate the disease, however, its cost effectiveness from an orthopaedic perspective remains to be demonstrated. We sought to conduct a cost effectiveness analysis comparing no therapy to direct acting antiviral therapy (DAA) prior to THA among HCV positive patients. METHODS A Markov model was utilized to evaluate the cost-effectiveness of treating HCV with DAA prior to THA. The model was powered with event probabilities, mortality, cost and quality adjusted life-year values for patients with and without HCV that were obtained from the published literature. This included treatment costs, successes of HCV eradication, incidences of superficial or periprosthetic joint infection (PJI), probabilities of utilizing various PJI treatment modalities, PJI treatment success/failures, and mortality rates. The incremental cost-effectiveness ratio (ICER) was compared to a willingness-to-pay threshold of $50,000/QALY. RESULTS Our Markov model indicates that in comparison to no therapy, DAA prior to THA is cost-effective for HCV positive patients. THA in the setting of no therapy and DAA added 8.06 and 14.39 QALYs at a mean cost of $28,800 and $115,800. The ICER associated with HCV DAA in comparison to no therapy was $13,800/QALY, below the willingness-to-pay threshold of $50,000/QALY. CONCLUSION Hepatitis-C treatment with DAA prior to THA is cost-effective at all current drug list prices. Given these findings, strong consideration should be given to treating patients for HCV prior to elective THA.
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Affiliation(s)
| | | | - James E Feng
- Department of Orthopaedic Surgery, Corewell Health William Beaumont University Hospital, Royal Oak, Michigan
| | | | - Richard Iorio
- Department of Orthopaedic Surgery, Brigham Women's Health, Boston, Massachusetts
| | - Matthew DiCaprio
- Department of Orthopaedic Surgery, Albany Medical Center, Albany, New York
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32
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Mu W, Ji B, Cao L. Single-stage revision for chronic periprosthetic joint infection after knee and hip arthroplasties: indications and treatments. ARTHROPLASTY 2023; 5:11. [PMID: 36864484 PMCID: PMC9979399 DOI: 10.1186/s42836-023-00168-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Accepted: 01/16/2023] [Indexed: 03/04/2023] Open
Abstract
Single-stage revision for chronic periprosthetic joint infection has been introduced 40 years ago. This option is gaining more and more attention as well as popularity. It is a reliable treatment for the chronic periprosthetic joint infection after knee and hip arthroplasties when implemented by an experienced multi-disciplinary team. However, its indications and corresponding treatments remain controversial. This review focused on the indications and specific treatments related to the option, with an attempt to help surgeons to use this method with more favorable outcomes.
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Affiliation(s)
- Wenbo Mu
- grid.412631.3Department of Orthopedics, the First Affiliated Hospital of Xinjiang Medical University, Urumqi, 830011 Xinjiang China ,grid.13394.3c0000 0004 1799 3993Department of Pharmacognosy, School of Pharmacy, Xinjiang Medical University, Urumqi, 830011 Xinjiang China
| | - Baochao Ji
- grid.412631.3Department of Orthopedics, the First Affiliated Hospital of Xinjiang Medical University, Urumqi, 830011 Xinjiang China
| | - Li Cao
- Department of Orthopedics, the First Affiliated Hospital of Xinjiang Medical University, Urumqi, 830011, Xinjiang, China.
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Spacer exchange in persistent periprosthetic joint infection: microbiological evaluation and survivorship analysis. Arch Orthop Trauma Surg 2023; 143:1361-1370. [PMID: 35028707 DOI: 10.1007/s00402-021-04300-5] [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: 02/19/2021] [Accepted: 12/02/2021] [Indexed: 12/23/2022]
Abstract
PURPOSE The purposes of this study were to determine demographics and characteristics of patients who underwent spacer exchange for persistent infection in the setting of two-stage arthroplasty for periprosthetic joint infection, to describe the microbiology of pathogens involved, to analyze survivorship free from infection in these patients. METHODS The institutional prospectively collected database was reviewed to enroll patients with minimum 2 years follow-up. Patients who underwent two-stage procedure for septic arthritis were excluded, as were patients who had spacer fracture or dislocation. RESULTS A total of 34 patients (41 procedures) were included. Mean age was 65.0 ± 12.8 years. Mean follow-up was 53.4 ± 24.8 months. Mean number of previous procedures was 3.6 ± 1.2. A total of 27 (79.4%) patients underwent final reimplantation. The most frequently isolated pathogen in spacer exchange was Staphylococcus epidermidis (10 cases, 28.6%). Polymicrobial cultures were obtained from 9 (25.71%) patients, 10 (28.6%) presented culture-negative infections. A total of 11 (32.4%) resistant pathogens were isolated, and 16 (47.0%) difficult to treat pathogens were detected. Eradication rate was 78.8%. Overall survivorship of implants after final reimplantation was 72.8% at 51.8 months. CONCLUSION Surgeons should be aware that subjects necessitating spacer exchange often present multiple comorbidities, previous staged revision failures, soft-tissue impairment and difficult to treat infection. In these patients, spacer exchange provides good clinical results and infection eradication, preventing arthrodesis or amputation.
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Magan AA, Radhakrishnan GT, Kayani B, Ronca F, Khanduja V, Meek RMD, Haddad FS. Time for return to sport following total hip arthroplasty: a meta-analysis. Hip Int 2023; 33:221-230. [PMID: 34538122 DOI: 10.1177/11207000211041975] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
INTRODUCTION Total Hip Arthroplasty (THA) is being increasingly undertaken in younger and more active patients, with many of these patients wanting to return to sport (RTS) after surgery. However, the percentage of patients RTS and time at which they are able to get back to sport following surgery remains unknown. The objective of this meta-analysis was to determine the time patients RTS after THA. METHODS A search was performed on PUBMED, MEDLINE, EMBASE, and the Cochrane Library for trials on THA and RTS, in the English language, published from the inception of the database to October 2020. All clinical trials reporting on to RTS following THA were included. Data relating to patient demographics, methodological quality, RTS, clinical outcomes and complications were recorded. The PRISMA guidelines were used to undertake this study. RESULTS The initial literature search identified 1720 studies. Of these, 11 studies with 2297 patients matched the inclusion criteria. 3 studies with 154 patients demonstrated an overall pooled proportion of 40.0% (95% CI, 32.5-47.9%) of patients RTS between 2 and 3 months after surgery. 4 studies with 242 patients demonstrated an overall pooled proportion of 76.9% (95% CI, 71.5-82.0) of patients RTS by 6 months after surgery. Pooled proportion analysis from 7 trials with 560 patients demonstrated 93.9% (95% CI, 82.7-99.5%) of patients RTS between 6 and 12 months after surgery. CONCLUSIONS Pooled proportion analysis showed increasingly more patients were able to RTS after THA over the first 1 year after surgery. There remains marked inter and intra-study variations in time for RTS but the pooled analysis shows that over 90% of patients were able to RTS at 6-12 months after THA. These finding will enable more informed discussions between patients and healthcare professionals about time for RTS following THA.
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Affiliation(s)
- Ahmed A Magan
- Department of Trauma and Orthopaedic Surgery, University College Hospital, London, UK.,Department of Orthopaedic Surgery, The Princess Grace Hospital, London, UK
| | - Ganan T Radhakrishnan
- Department of Trauma and Orthopaedic Surgery, University College Hospital, London, UK.,Department of Orthopaedic Surgery, The Princess Grace Hospital, London, UK
| | - Babar Kayani
- Department of Trauma and Orthopaedic Surgery, University College Hospital, London, UK.,Department of Orthopaedic Surgery, The Princess Grace Hospital, London, UK
| | - Flaminia Ronca
- Institute of Sports, Health and Exercise, University College Hospital, London, UK
| | - Vikas Khanduja
- Department of Trauma and Orthopaedic Surgery, Young Adult Hip Service, Addenbrooke's - Cambridge University Hospital, Cambridge, UK
| | - Robert M D Meek
- Department of Trauma and Orthopaedic surgery, Glasgow University, Glasgow, UK
| | - Fares S Haddad
- Department of Trauma and Orthopaedic Surgery, University College Hospital, London, UK.,Department of Orthopaedic Surgery, The Princess Grace Hospital, London, UK.,Institute of Sports, Health and Exercise, University College Hospital, London, UK
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Successful eradication rate following one-stage septic knee and hip exchange in selected pre-operative culture-negative periprosthetic joint infections. INTERNATIONAL ORTHOPAEDICS 2023; 47:659-666. [PMID: 36576518 DOI: 10.1007/s00264-022-05677-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Accepted: 12/17/2022] [Indexed: 12/29/2022]
Abstract
PURPOSE The main requirement for performing the one-stage septic exchange is the pre-operative identification of the pathogen and its susceptibility. The purpose of this study is to evaluate the success rate with special focus on reinfection in a cohort of patients who underwent one-stage septic knee or hip revision for pre-operative culture-negative PJI. METHODS We retrospectively analyzed 640 patients treated by one-stage revision for chronic knee or hip PJI between January 1, 2016, and December 31, 2018. Only cases with pre-operative culture-negative PJI, with culture-negative synovial aspirations and one negative open biopsy, were analyzed. We evaluated the septic and aseptic complication and the rate of complication-free survival defined as the time from the date of first operation and the date of complication events. RESULTS A total of 22 patients fulfilled the inclusion and were enrolled. The mean age of the group was 73.2 ± 9.8 years, with a median ASA score of 3 (range 3-4). After mean follow-up of 3.6 ± 2.6 years, 86.4% (19 out of 22) of patients reported no complications. Two patients (9.1%) after one-stage hip required revision arthroplasty due to septic failure, while one patient (4.5%) with one-stage knee had revision for femoral component aseptic loosening. CONCLUSION Our analysis suggests that the absence of pre-operative pathogen detection may not be contraindication to the one-stage revision in selected patients. The one-stage exchange might be considered in patients with pre-operative negative cultures in presence of ASA > 3 and multiple comorbidities that are not able to tolerate multiple surgeries.
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Cole M, Patel A, Collins L, Hawkins B, Sherman WF. Pseudogout After Total Knee Arthroplasty Meeting Minor Criteria for Infection Treated by Polyethylene Exchange. Orthop Rev (Pavia) 2023; 15:67912. [PMID: 36776277 PMCID: PMC9907320 DOI: 10.52965/001c.67912] [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: 01/30/2023] Open
Abstract
Case Pseudogout in a total joint arthroplasty is rare and can be difficult to distinguish from a prosthetic joint infection (PJI). In this unique case, we present a patient who developed her first episode of pseudogout 17 years after her primary total knee arthroplasty at age 75. Conclusion With similar clinical and laboratory findings, it is important to distinguish the presence of PJI and inflammatory arthropathy. The use of diagnostic tools available, consideration of patient co-morbidities, and timing of symptoms can help guide surgeons' treatment.
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Affiliation(s)
- Matthew Cole
- Orthopaedic SurgeryTulane University School of Medicine
| | - Akshar Patel
- Orthopaedic SurgeryTulane University School of Medicine
| | - Lacee Collins
- Orthopaedic SurgeryTulane University School of Medicine
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Ji B, Li G, Zhang X, Wang Y, Mu W, Cao L. Midterm Survival of a Varus-Valgus Constrained Implant following One-Stage Revision for Periprosthetic Joint Infection: A Single-Center Study. J Knee Surg 2023; 36:284-291. [PMID: 34520562 DOI: 10.1055/s-0041-1731739] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Revision total knee arthroplasty (TKA) is challenging to perform in patients with periprosthetic joint infection (PJI) due to the difficulty of eradicating the infection and potential for bone and ligamentous deficits. The current study aimed to evaluate the midterm survival of varus-valgus constrained (VVC) implants used in one-stage revision TKA for chronic PJI at our institution. This retrospective analysis included 132 patients with chronic PJI who underwent one-stage revision using a VVC implant. The average follow-up was 51.6 months (range: 24-85 months). Five-year survival analysis was performed to set recurrent infection and mechanical failure as the end point. Hospital for special surgery (HSS) as functional outcomes was evaluated preoperatively and at the latest follow-up. A total of 12 patients (9.1%) underwent retreatment for reinfection (nine patients) and mechanical failure (three patients). The overall 5-year revision-free survival was 82.7%, the infection-free survival was 91.1%, and the mechanical failure-free survival was 98.3%. The preoperative HSS knee score improved from 35.6 points (range: 24.3-47.7 points) preoperatively to 76.8 points (range: 57.2-87.6 points) at the latest follow-up. Complications were identified in 20 patients (15.2%) which included aseptic osteolysis in 4 cases, acceptable flexion instability in 3 cases, arthrofibrosis in 2 patients, hematomas in 2 cases, calf intermuscular venous thrombosis in 6 patients, and femoral stem tip pain in 3 cases. This is the first study to report the outcomes of one-stage revision using VVC implants for knee PJI. Improved functional outcomes and good midterm survival are demonstrated at an average follow-up of 51.6 months.
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Affiliation(s)
- Baochao Ji
- Department of Orthopaedics, First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang, China
| | - Guoqing Li
- Department of Orthopaedics, First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang, China
| | - Xiaogang Zhang
- Department of Orthopaedics, First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang, China
| | - Yang Wang
- Department of Orthopaedics, First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang, China
| | - Wenbo Mu
- Department of Orthopaedics, First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang, China
| | - Li Cao
- Department of Orthopaedics, First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang, China
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Okafor CE, Nghiem S, Byrnes J. Is 2-Stage Septic Revision Worth the Money? A Cost-Utility Analysis of a 1-Stage Versus 2-Stage Septic Revision of Total Knee Arthroplasty. J Arthroplasty 2023; 38:347-354. [PMID: 36154866 DOI: 10.1016/j.arth.2022.09.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Revised: 08/23/2022] [Accepted: 09/05/2022] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Two-stage exchange arthroplasty remains the gold standard for the management of prosthetic joint infection (PJI) of the knee, but several studies have demonstrated that 1-stage exchange is as effective as 2-stage exchange. This study aimed to support decision-making via an economic evaluation of 1-stage compared to 2-stage exchange for total knee arthroplasty septic revision in patients who did not have compelling indication PJI (ie, Methicillin-resistant Staphylococcus aureus, multiorganism, systemic sepsis, comorbidities, culture negative, resistant organism, and immunocompromised) to undergo a 2-stage exchange. METHODS A cost-utility analysis was performed using a Markov cohort model from the health care provider perspective using Australia data. One-stage septic knee revisions were compared with 2-stage exchange procedures for chronic PJI using a patient-lifetime horizon. Health outcomes were expressed as quality-adjusted life-years (QALY), whereas costs were presented in 2020 Australian dollars. Sensitivity analyses, population expected values of perfect information, and the perfect information for parameters (EVPPI) were assessed to estimate the opportunity costs surrounding the decision made at a willingness-to-pay threshold of $50,000 per QALY. RESULTS The incremental cost-effectiveness ratio of 2-stage exchange compared with 1-stage exchange was $231,000 per QALY, with 98.5% of the probabilistic sensitivity simulations above the willingness-to-pay threshold. The population expected value of perfect information was $882,000, whereas the expected value of perfect information for parameters for the "cost parameters" was $207,000. CONCLUSION The adoption of 1-stage septic knee revision is the optimal choice for patients who have a PJI and who do not have a compelling need for a 2-stage exchange arthroplasty. One-stage exchange for PJI should be advocated in patients who meet the eligibility criteria.
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Affiliation(s)
- Charles E Okafor
- Centre for Applied Health Economics, School of Medicine and Dentistry, Griffith University, Queensland, Australia; Menzies Health Institute, Griffith University, Queensland, Australia
| | - Son Nghiem
- Department of Health Services, Research and Policy, Australian National University, Canberra, Australia
| | - Joshua Byrnes
- Centre for Applied Health Economics, School of Medicine and Dentistry, Griffith University, Queensland, Australia; Menzies Health Institute, Griffith University, Queensland, Australia
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Wignadasan W, Ibrahim M, Haddad FS. One- or two-stage reimplantation for infected total knee prosthesis? Orthop Traumatol Surg Res 2023; 109:103453. [PMID: 36302451 DOI: 10.1016/j.otsr.2022.103453] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Revised: 02/08/2022] [Accepted: 03/02/2022] [Indexed: 11/07/2022]
Abstract
A prosthetic joint infection (PJI) is possibly the most significant potential complication of total knee arthroplasty (TKA) and is associated with substantial morbidity and socioeconomic burden. It is a devastating complication for both the patient and the surgeon alike. A two-stage revision approach for infected TKA has been the standard for surgical management; however, there is growing interest in single-stage revision surgery due to fewer procedures, reduced inpatient hospital stay and reduced costs to healthcare systems. A one-stage exchange is indicated when there is no sign of systemic sepsis and in cases where a microorganism has been isolated. It involves removal of the old prosthesis, debridement of all infected tissue, a copious washout and re-draping, and finally, re-implantation of a new prosthesis. The two-stage approach involves the use of an antibiotic spacer before the second stage is carried out. The length of time between the stages is discussed. Patients with a PJI should be managed by a multidisciplinary team. We recommend these patients are managed in specialist arthroplasty centres by high volume revision arthroplasty specialists.
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Affiliation(s)
- Warran Wignadasan
- University College London Hospitals, 250, Euston Road, London NW1 2 PG, United Kingdom.
| | - Mazin Ibrahim
- University College London Hospitals, 250, Euston Road, London NW1 2 PG, United Kingdom
| | - Fares S Haddad
- University College London Hospitals, 250, Euston Road, London NW1 2 PG, United Kingdom
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Kocaoğlu H, Hennes F, Abdelaziz H, Neufeld ME, Gehrke T, Citak M. Survival analysis of one-stage exchange of infected unicompartmental knee arthroplasty: a single-center study with minimum 3 years follow-up. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2023; 33:327-333. [PMID: 35066655 DOI: 10.1007/s00590-021-03187-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Accepted: 12/16/2021] [Indexed: 11/30/2022]
Abstract
PURPOSE The rates of unicompartmental knee arthroplasty (UKA) are increasing yet little data exists regarding management of periprosthetic joint infections (PJI) after UKA, particularly utilizing one-stage revision. The aim of this study was to determine the septic and all-cause revision-free survival of UKA PJIs treated with one-stage revision, as well as functional outcomes and risk factors for failure. METHODS A retrospective review of one-stage septic revisions with a hinged or rotating hinged implant between 2000 and 2015 at a single institution was performed. Results of 15 patients with a minimum of 3-year follow-up (mean = 93 months; range 37-217) were evaluated by means of infection control, survivorship, patient reported functional score and possible causal factors for a re-revision. Kaplan-Meier curves and Cox regression analysis were used. RESULTS After a mean of 8 years of follow-up infection control rate was 93.3%, the survivorship free of any reoperation, including both septic and aseptic causes, was 80% at 5 years and 64.2% at ten years and average Lysholm score was 72.7 ± 21.3 (33-100). CONCLUSION One-stage revision for PJI of UKA using a hinged knee design has excellent infection-free survival at mid to long-term follow-up. Likewise, patient reported functional outcomes are promising. However, one-third of patients required aseptic reoperation and aseptic loosening was the dominant etiology.
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Affiliation(s)
- Hakan Kocaoğlu
- Department of Orthopaedic Surgery, Helios ENDO-Klinik Hamburg, Holstenstr. 2, 22767, Hamburg, Germany. .,Department of Orthopaedics and Traumatology, Faculty of Medicine, Ankara University, Ibn-i Sina Hospital Talatpasa Blvd, 06100, Ankara, Turkey.
| | - Fabian Hennes
- Department of Orthopaedic Surgery, Helios ENDO-Klinik Hamburg, Holstenstr. 2, 22767, Hamburg, Germany.,Zentrum für Rehabilitationmedizin/Sportmedizin, BG Klinikum Hamburg, Bergerdorfer Strasse 10, 21033, Hamburg, Germany
| | - Hussein Abdelaziz
- Department of Orthopaedic Surgery, Helios ENDO-Klinik Hamburg, Holstenstr. 2, 22767, Hamburg, Germany
| | - Michael E Neufeld
- Department of Orthopaedic Surgery, Helios ENDO-Klinik Hamburg, Holstenstr. 2, 22767, Hamburg, Germany.,Division of Lower Limb Reconstruction, Department of Orthopaedics, University of British Columbia, Vancouver, BC, Canada
| | - Thorsten Gehrke
- Department of Orthopaedic Surgery, Helios ENDO-Klinik Hamburg, Holstenstr. 2, 22767, Hamburg, Germany
| | - Mustafa Citak
- Department of Orthopaedic Surgery, Helios ENDO-Klinik Hamburg, Holstenstr. 2, 22767, Hamburg, Germany
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A Permanent Articulating Spacer Versus Two-Stage Exchange for Chronic Periprosthetic Joint Infection: A Propensity Score-Matched Study. J Arthroplasty 2023:S0883-5403(23)00057-8. [PMID: 36720418 DOI: 10.1016/j.arth.2023.01.036] [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: 09/09/2022] [Revised: 01/21/2023] [Accepted: 01/23/2023] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Although 2-stage revision has been proposed as gold standard for periprosthetic joint infection treatment, limited evidence exists for the role of articulating spacers as definitive management. The purpose of this study was to compare clinical outcomes and costs associated with articulating spacers (1.5-stage) and a matched 2-stage cohort. METHODS A retrospective review was performed for patients who had chronic periprosthetic joint infections after total knee arthroplasty defined by Musculoskeletal Infection Society criteria and were matched via propensity score matching using cumulative Musculoskeletal Infection Society scores and a comorbidity index. Patients who maintained an articulating spacer (cemented cobalt-chrome femoral component and all-poly tibia) were included in the 1.5-stage cohort. Patients who underwent a 2-stage reimplantation procedure were included in the 2-stage cohort. Outcomes included visual analog scale pain scores, 90-day emergency department visits, 90-day readmission, unplanned reoperation, reinfection, as well as cost at 1 and 2-year intervals. A total of 116 patients were included for analyses. RESULTS The 90-day pain scores were lower in the 1.5-stage cohort compared to the 2-stage cohort (2.9 versus 4.6, P = .0001). There were no significant differences between readmission and reoperation rates. Infection clearance was equivalent at 79.3% for both groups. Two-stage exchange demonstrated an increased cost difference of $26,346 compared to 1.5-stage through 2 years (P = .0001). Regression analyses found 2 culture-positive results with the same organism decreased the risk for reinfection [odds ratio: 0.2, 95% confidence interval 0.04-0.8, P = .03]. CONCLUSION For high-risk candidates, articulating spacers can preserve knee function, reduce morbidity from second-stage surgery, and lower the costs with similar rates of infection clearance as 2-stage exchange. LEVEL OF EVIDENCE Level III, therapeutic study.
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Puetzler J, Schulze M, Gosheger G, Schwarze J, Moellenbeck B, Theil C. Is long time to reimplantation a risk factor for reinfection in two-stage revision for periprosthetic infection? A systematic review of the literature. Front Surg 2023; 10:1113006. [PMID: 36874470 PMCID: PMC9981955 DOI: 10.3389/fsurg.2023.1113006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 01/31/2023] [Indexed: 02/19/2023] Open
Abstract
The two-stage revision arthroplasty is a common treatment option for chronic periprosthetic infection (PJI). The time to reimplantation (TTR) reported in the literature varies substantially from a few days to several hundred days. It is hypothesized that longer TTR could be associated with worse infection control after second stage. A systematic literature search was performed according to Preferred Reporting items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, in Pubmed, Cochrane Library and Web of Science Core Collection in clinical studies published until January 2023. Eleven studies investigating TTR as a potential risk factor for reinfection met the inclusion criteria (ten retrospective and one prospective study, published 2012-2022). Study design and outcome measures differed notably. The cutoff points above which TTR was regarded as "long" ranged from 4 to 18 weeks. No study observed a benefit for long TTR. In all studies, similar or even better infection control was observed for short TTR. The optimal TTR, however, is not yet defined. Larger clinical studies with homogeneous patient populations and adjustment for confounding factors are needed.
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Affiliation(s)
- Jan Puetzler
- Department of Orthopaedics and Tumor Orthopaedics, University Hospital Muenster, Muenster, Germany
| | - Martin Schulze
- Department of Orthopaedics and Tumor Orthopaedics, University Hospital Muenster, Muenster, Germany
| | - Georg Gosheger
- Department of Orthopaedics and Tumor Orthopaedics, University Hospital Muenster, Muenster, Germany
| | - Jan Schwarze
- Department of Orthopaedics and Tumor Orthopaedics, University Hospital Muenster, Muenster, Germany
| | - Burkhard Moellenbeck
- Department of Orthopaedics and Tumor Orthopaedics, University Hospital Muenster, Muenster, Germany
| | - Christoph Theil
- Department of Orthopaedics and Tumor Orthopaedics, University Hospital Muenster, Muenster, Germany
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Dedeogullari ES, Caglar O, Danisman M, Tokgozoglu AM, Kamaci S, Atilla B. Low dose vancomycin-loaded spacers for two-stage revision knee arthroplasty: High success, low toxicity. Knee 2023; 40:63-70. [PMID: 36410252 DOI: 10.1016/j.knee.2022.11.008] [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: 03/02/2022] [Revised: 09/22/2022] [Accepted: 11/03/2022] [Indexed: 11/19/2022]
Abstract
BACKGROUND Two-stage revision arthroplasty is a widely used treatment method for infected knee arthroplasty. Loading high doses of antibiotics to spacer during the first stage is standard practice. However, there are reported systemic side effects attributed to antibiotic-loaded spacers. The aim of our study is to investigate the success rate and systemic toxicity following the first stage revision knee arthroplasty with low-dose vancomycin-loaded spacers. METHOD We included patients with infected knee arthroplasty eligible for two-stage revision arthroplasty from 2001 to 2020. One gram of vancomycin is added per pack of bone cement. Spacers were handmade in the operating theatre. Following the first stage, pre-operative and postoperative culture results, infection parameters, kidney and liver function tests, and functional scores were analyzed. Kaplan-Meier survival analysis was done to determine the success rate. RESULTS Fifty patients with a mean follow-up of 48 months (24-108) were included in the study. A five-year survival analysis showed an 88.5% success rate. Fourteen percent of the patients had acute kidney injury with creatinine levels between 1.12-2.80 mg/dl, and 8% had a mild drug-induced liver injury with elevated serum ALT levels between 223-540 U/L and total bilirubin levels between 0.59-1.23 mg/dl. None of the patients required dialysis. All of the systemic side effects were reversible. CONCLUSION Our results have suggested that low dose antibiotic-loaded spacers are comparable to the studies with high dose antibiotic loaded spacers regarding infection eradication and survival rates. They are less likely to cause severe systemic side effects. Therefore we suggest low dose antibiotic-loaded spacers should be considered when treating patients with vancomycin sensitive Staphylococcal species and culture negative infected knee arthroplasty.
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Affiliation(s)
- Emin Suha Dedeogullari
- Hacettepe University Hospital, Department of Orthopedics and Traumatology, Hacettepe Mh. 06230, Ankara, Turkey.
| | - Omur Caglar
- Hacettepe University Hospital, Department of Orthopedics and Traumatology, Hacettepe Mh. 06230, Ankara, Turkey
| | - Murat Danisman
- Giresun University School of Medicine, Department of Orthopedics and Traumatology, Aksu Mh. Mehmet İzmen Cd. No:145, Giresun, Turkey
| | - A Mazhar Tokgozoglu
- Hacettepe University Hospital, Department of Orthopedics and Traumatology, Hacettepe Mh. 06230, Ankara, Turkey
| | - Saygin Kamaci
- Hacettepe University Hospital, Department of Orthopedics and Traumatology, Hacettepe Mh. 06230, Ankara, Turkey
| | - Bulent Atilla
- Hacettepe University Hospital, Department of Orthopedics and Traumatology, Hacettepe Mh. 06230, Ankara, Turkey
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Jeon YS, Kim MK, Kwon DG, Lee SS, Park JW, Kang DS, Ryu DJ. Palliative arthroscopic debridement with continuous irrigation for infected total knee arthroplasty in high mortality risk patients. INTERNATIONAL ORTHOPAEDICS 2023; 47:175-186. [PMID: 36401020 DOI: 10.1007/s00264-022-05632-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Accepted: 11/04/2022] [Indexed: 11/20/2022]
Abstract
PURPOSE This study aimed to evaluate the infection control rate of palliative arthroscopic debridement, antibiotics, and implant retention (DAIR) for the high mortality risk or terminal cancer stage patients. METHODS From March 2018 to August 2021, 21 patients met the following inclusion criteria: old age of more than 80, diagnosed as a terminal stage of cancer, high risk of mortality and morbidity representing as Charlson comorbidity index (CCI) ≥ 5, low daily activity with disabled extremity, and re-infection after two-stage revision. Each patient underwent arthroscopic DAIR and additional continuous irrigation for 48 hours. The need for subsequent re-arthroscopic DAIR or two-stage revision was determined by the post-operative trends of C-reactive protein (CRP) levels. Infection control was defined as continuing controlled status of infection based on clinical and laboratory results by one or two times of arthroscopic DAIR within initial two months. Treatment failure was defined as more than three times arthroscopic debridement, two-stage revision surgery, or expired due to uncontrolled infection. RESULTS Arthroscopic DAIR controlled the infection in 19 (90.5%) of the 21 cases. The other knee underwent a total of three times of re-arthroscopic DAIR and the other one underwent two-stage revision. Although five patients expired during the follow-up period due to worsening medical problems or terminal cancer, there were no deaths from uncontrolled infection, sepsis, or surgery-related complications. CONCLUSIONS Arthroscopic debridement with continuous irrigation for the infection TKA with high mortality risk or terminal cancer patients showed a 90.5% infection control rate. For high-risk patients, arthroscopic debridement with continuous irrigation can be an alternative treatment to improve the quality of life during survival.
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Affiliation(s)
- Yoon Sang Jeon
- Department of Orthopaedic Surgery, Inha University Hospital, Inha University School of Medicine, Inhang-Ro 27, Jung-Gu, Incheon, 22322, South Korea
| | - Myung Ku Kim
- Department of Orthopaedic Surgery, Inha University Hospital, Inha University School of Medicine, Inhang-Ro 27, Jung-Gu, Incheon, 22322, South Korea
| | - Dae Gyu Kwon
- Department of Orthopaedic Surgery, Inha University Hospital, Inha University School of Medicine, Inhang-Ro 27, Jung-Gu, Incheon, 22322, South Korea
| | - Sung-Sahn Lee
- Department of Orthopaedic Surgery, Ilsan Paik Hospital, Inje University School of Medicine, Goyang-Si, Korea
| | - Joo Won Park
- Department of Orthopaedic Surgery, Inha University Hospital, Inha University School of Medicine, Inhang-Ro 27, Jung-Gu, Incheon, 22322, South Korea
| | - Dong Seok Kang
- Department of Orthopaedic Surgery, Inha University Hospital, Inha University School of Medicine, Inhang-Ro 27, Jung-Gu, Incheon, 22322, South Korea
| | - Dong Jin Ryu
- Department of Orthopaedic Surgery, Inha University Hospital, Inha University School of Medicine, Inhang-Ro 27, Jung-Gu, Incheon, 22322, South Korea.
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Hecker A, Pütz HJA, Wangler S, Klenke FM. Survival, functional outcome and satisfaction of first revision total knee arthroplasty at a mean eleven-year follow-up. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2023; 33:415-424. [PMID: 35041071 PMCID: PMC9928929 DOI: 10.1007/s00590-022-03206-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Accepted: 01/05/2022] [Indexed: 10/19/2022]
Abstract
PURPOSE Providing long-term outcome data after rTKA and compare one- versus two-stage and septic versus aseptic revisions. METHODS This study represents a single-center retrospective study of first rTKAs performed for any reason with a final follow-up of a minimum of five years. Outcome parameters included stability assessment ROM, radiologic assessment, HSS score, KSS score, OKS score, EQ-5D-3L and VAS. 44 patients were included in the study. Subgroups analysis of one- versus two-stage revision and septic versus aseptic revision was performed. RESULTS The leading causes of rTKA in this mean 11 year follow-up study were aseptic loosening (36%) and periprosthetic joint infection (27%). At the final follow-up, there was a 89% survivorship of the implants. Patients showed a ROM of 114 ± 13°, HSS score of 78 ± 12, KKS objective score of 77 ± 16, KSS expectation and satisfaction score of 32 ± 11, KSS functional activity score of 50 ± 20, OKS of 30 ± 9, VAS of 53 ± 25 and EQ-5D index of 0.649. Functional outcome scores were not significantly altered in the analyzed subgroups. CONCLUSIONS In our 11 years follow-up, we obtained 89% implant survivorship. Measurements regarding functional outcome and pain showed results in the medium range of the respective scores, while patient satisfaction lay in the upper third. No significant differences in outcome scores between one- and two-stage revisions and septic versus aseptic revisions were observed. Level of Evidence Level III, retrospective cohort study.
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Affiliation(s)
- Andreas Hecker
- Department of Orthopaedic Surgery and Traumatology, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 4, 3010, Bern, Switzerland.
| | - Hans-Jürg A. Pütz
- grid.5734.50000 0001 0726 5157Department of Orthopaedic Surgery and Traumatology, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 4, 3010 Bern, Switzerland
| | - Sebastian Wangler
- grid.5734.50000 0001 0726 5157Department of Orthopaedic Surgery and Traumatology, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 4, 3010 Bern, Switzerland
| | - Frank M. Klenke
- grid.5734.50000 0001 0726 5157Department of Orthopaedic Surgery and Traumatology, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 4, 3010 Bern, Switzerland
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Dhillon MS, Hooda A, Moriarty TF, Sharma S. Biofilms-What Should the Orthopedic Surgeon know? Indian J Orthop 2023; 57:44-51. [PMID: 36660477 PMCID: PMC9789254 DOI: 10.1007/s43465-022-00782-6] [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: 11/07/2022] [Accepted: 11/18/2022] [Indexed: 12/24/2022]
Abstract
Background Musculoskeletal infections are a major source of morbidity for orthopedic and trauma patients, are associated with prolonged treatment times, and, unfortunately, suffer from poor functional outcomes. Further complicating the issue, antimicrobial resistance (AMR) is increasingly impacting the treatment of musculoskeletal infections with a diminishing repertoire of effective antibiotic agents for some highly resistant pathogens. Most orthopedic surgical procedures involve implants, and the formation of bacterial biofilms on these implants is now recognized as a major factor contributing to the failure of antibiotic therapy in orthopedic surgery. Methods This review presents an overview of the types, structure, formation, and pathogenesis of biofilms as they pertain to musculoskeletal infections. Furthermore, it describes the key concepts in the management of biofilms and future perspectives for the better treatment of patients with biofilm-related musculoskeletal infections. Results A bacterial biofilm is a dynamic, living conglomerate of bacteria encased in an extracapsular polysaccharide matrix (EPS). Biofilms are a natural mode of survival for virtually all bacterial species, including both Grampositive and Gram-negative bacteria, as well as fungi. The biofilm model of growth confers resistance by several well-defined mechanisms regardless of the species of the microorganism. In most cases, biofilm management often necessitates radical measures to ensure eradication including both surgical and medical interventions. Conclusions Orthopedic surgeons should be aware of the key concepts pertaining to biofilms, and the impact that these can have on clinical practice.
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Affiliation(s)
- Mandeep Singh Dhillon
- Foot & Ankle Biomechanics, Experimentation and Research Laboratory, Department of Orthopedics, Postgraduate Institute of Medical Education & Research, Chandigarh, India
| | - Aman Hooda
- Department of Emergency Medicine (Orthopedics), Ambedkar Institute of Medical Sciences, Mohali, Punjab India
| | | | - Siddhartha Sharma
- Foot & Ankle Biomechanics, Experimentation and Research Laboratory, Department of Orthopedics, Postgraduate Institute of Medical Education & Research, Chandigarh, India
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Qiao YJ, Li F, Zhang LD, Yu XY, Zhang HQ, Yang WB, Song XY, Xu RL, Zhou SH. Analysis of the clinical efficacy of two-stage revision surgery in the treatment of periprosthetic joint infection in the knee: A retrospective study. World J Clin Cases 2022; 10:13239-13249. [PMID: 36683646 PMCID: PMC9851019 DOI: 10.12998/wjcc.v10.i36.13239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Revised: 11/15/2022] [Accepted: 12/05/2022] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Periprosthetic joint infection (PJI) is a catastrophic complication that can occur following total knee arthroplasty (TKA). Currently, the treatment for PJI mainly includes the use of antibiotics alone, prosthetic debridement lavage, primary revision, secondary revision, joint fusion, amputation, etc.
AIM To explore the clinical effect of two-stage revision surgery for the treatment of PJI after TKA.
METHODS The clinical data of 27 patients (3 males and 24 females; age range, 47–80 years; mean age, 66.7 ± 8.0 years; 27 knees) with PJI treated with two-stage revision surgery in our hospital between January 1, 2010 and December 31, 2020 were analyzed retrospectively. The following outcomes were compared for changes between preoperative and last follow-up results: Erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), visual analogue scale (VAS) scores, Hospital for Special Surgery (HSS) scores, knee range of motion (ROM), and infection cure rates.
RESULTS All 27 patients were followed up (range, 13–112 mo). The ESR (14.5 ± 6.3 mm/h) and CRP (0.6 ± 0.4 mg/dL) of the patients at the last follow-up were significantly lower than those at admission; the difference was statistically significant (P < 0.001). The postoperative VAS score (1.1 ± 0.7), HSS score (82.3 ± 7.1), and knee ROM (108.0° ± 19.7°) were significantly improved compared with those before the surgery; the difference was statistically significant (P < 0.001). Of the 27 patients, 26 were cured of the infection, whereas 1 case had an infection recurrence; the infection control rate was 96.3%.
CONCLUSION Two-stage revision surgery can effectively relieve pain, control infection, and retain good joint function in the treatment of PJI after TKA.
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Affiliation(s)
- Yong-Jie Qiao
- Department of Joint Surgery, The 940th Hospital of Joint Logistic Support Force of Chinese People’s Liberation Army, Lanzhou 730050, Gansu Province, China
| | - Feng Li
- Department of Orthopedics, The 943rd Hospital of Joint Logistic Support Force of Chinese People’s Liberation Army, Wuwei 733000, Gansu Province, China
| | - Lv-Dan Zhang
- Department of Respiratory Medicine, The 940th Hospital of Joint Logistic Support Force of Chinese People’s Liberation Army, Lanzhou 730050, Gansu Province, China
| | - Xin-Yuan Yu
- Department of Joint Surgery, The 940th Hospital of Joint Logistic Support Force of Chinese People’s Liberation Army, Lanzhou 730050, Gansu Province, China
| | - Hao-Qiang Zhang
- Department of Joint Surgery, The 940th Hospital of Joint Logistic Support Force of Chinese People’s Liberation Army, Lanzhou 730050, Gansu Province, China
| | - Wen-Bin Yang
- Department of Joint Surgery, The 940th Hospital of Joint Logistic Support Force of Chinese People’s Liberation Army, Lanzhou 730050, Gansu Province, China
| | - Xiao-Yang Song
- Department of Joint Surgery, The 940th Hospital of Joint Logistic Support Force of Chinese People’s Liberation Army, Lanzhou 730050, Gansu Province, China
| | - Rui-Ling Xu
- Department of Joint Surgery, The 940th Hospital of Joint Logistic Support Force of Chinese People’s Liberation Army, Lanzhou 730050, Gansu Province, China
| | - Sheng-Hu Zhou
- Department of Joint Surgery, The 940th Hospital of Joint Logistic Support Force of Chinese People’s Liberation Army, Lanzhou 730050, Gansu Province, China
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One and a Half-Stage Revision With Prosthetic Articulating Spacer for Definitive Management of Knee Periprosthetic Joint Infection. Arthroplast Today 2022; 19:100993. [PMID: 36507285 PMCID: PMC9727150 DOI: 10.1016/j.artd.2022.07.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2022] [Revised: 06/26/2022] [Accepted: 07/08/2022] [Indexed: 12/12/2022] Open
Abstract
This paper is a comprehensive review that describes indications, contraindications, clinical outcomes, and pearls and pitfalls of 1.5-stage revision total knee arthroplasty (TKA) utilizing a primary TKA femoral component, all-polyethylene tibial component, and hand-crafted antibiotic cement for the management of chronic periprosthetic joint infection. The 1.5-stage exchange TKA details placement of an articulating spacer for an indefinite period, prolonging revision until reinfection, deterioration of functional status, or construct failure. A 1.5-stage revision TKA technique is a viable option for treatment of chronic periprosthetic knee infections. The inherent advantages of decreased health-care costs, decreased morbidity and mortality, and improved emotional ease from having a single procedure is attractive, especially if reinfection rates are determined to be equivocal to 2-stage revision.
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Lunz A, Omlor GW, Schmidt G, Moradi B, Lehner B, Streit MR. Quality of life, infection control, and complication rates using a novel custom-made articulating hip spacer during two-stage revision for periprosthetic joint infection. Arch Orthop Trauma Surg 2022; 142:4041-4054. [PMID: 34853867 PMCID: PMC9596578 DOI: 10.1007/s00402-021-04274-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2021] [Accepted: 11/19/2021] [Indexed: 01/04/2023]
Abstract
INTRODUCTION Two-stage revision remains the gold standard treatment for most chronically infected and complex total hip arthroplasty infections. To improve patient outcome and reduce complication rates, we have developed a novel custom-made articulating hip spacer technique and present our short-term results. MATERIALS AND METHODS Between November 2017 and November 2019, 27 patients (mean age 70 years) underwent two-stage revision for periprosthetic joint infection of the hip using the articulating spacer design described here. We retrospectively analyzed spacer-related complications as well as rates for complication, infection control, and implant survivorship after final reimplantation. Furthermore, we prospectively collected patient-reported health-related quality of life (HRQoL) scores prior to spacer implantation, with the spacer and after reimplantation of the new prosthesis. RESULTS An additional round of spacer exchange was performed in two patients (8.3%), persistent wound discharge was the reason in both cases. We had one (4.2%) spacer-related mechanical complication, a dislocation that was treated with closed reduction. After reimplantation, infection control was achieved in 96% with an implant survivorship of 92% after a mean follow-up time of 19 (range 7-32, SD 7.2) months. While the scores for VR-12 MCS, VAS hip pain and patient-reported overall satisfaction significantly improved after first stage surgery, the scores for WOMAC, UCLA and VR-12 PCS significantly improved after second stage surgery. CONCLUSIONS Our two-stage approach for periprosthetic joint infection shows high infection eradication and implant survivorship rates at short-term follow-up. Spacer-related complication rates were low, and we achieved high patient satisfaction rates and low pain levels already during the spacer period. To further simplify comparison between different spacer designs, we propose a new hip spacer classification system.
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Affiliation(s)
- Andre Lunz
- Clinic for Orthopedics and Trauma Surgery, Center for Orthopedics, Trauma Surgery and Spinal Cord Injury, Heidelberg University Hospital, Schlierbacher Landstrasse 200a, 69118, Heidelberg, Germany.
| | - Georg W Omlor
- Clinic for Orthopedics and Trauma Surgery, Center for Orthopedics, Trauma Surgery and Spinal Cord Injury, Heidelberg University Hospital, Schlierbacher Landstrasse 200a, 69118, Heidelberg, Germany
| | - Gunter Schmidt
- Clinic for Orthopedics and Trauma Surgery, Center for Orthopedics, Trauma Surgery and Spinal Cord Injury, Heidelberg University Hospital, Schlierbacher Landstrasse 200a, 69118, Heidelberg, Germany
| | - Babak Moradi
- Clinic for Orthopedics and Traumatology, University Medical Center Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Burkhard Lehner
- Clinic for Orthopedics and Trauma Surgery, Center for Orthopedics, Trauma Surgery and Spinal Cord Injury, Heidelberg University Hospital, Schlierbacher Landstrasse 200a, 69118, Heidelberg, Germany
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Comparison of Patient-Reported Outcomes Measures and Quality-Adjusted Life Years Following One- and Two-Stage Septic Knee Exchange. Antibiotics (Basel) 2022; 11:antibiotics11111602. [PMID: 36421246 PMCID: PMC9686804 DOI: 10.3390/antibiotics11111602] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2022] [Revised: 11/03/2022] [Accepted: 11/09/2022] [Indexed: 11/16/2022] Open
Abstract
(1) Background: Periprosthetic joint infection (PJI) can be managed with one- or two-stage revision surgery protocol. Despite several studies analyzing the eradication rates between both procedures, there are no comparative studies that analyze patient-reported outcome measures (PROMs) and quality-adjusted life years (QALYs) in both treatment strategies. (2) Methods: All patients who underwent a two-stage knee revision between January 2017 to December 2018, due to a periprosthetic joint infection were included in the study. From the time interval, we selected a comparative group with the one-stage septic procedure. All patients received the following questionnaires: Oxford Knee Score, EQ-5D-5L, SSQ-8, and the SF-36. Additionally, demographic patient data were collected. The quality-adjusted life years (QALY) were calculated using the EQ-5D-5L. (3) Results: A total of 35 patients with a mean age of 67.7 years (SD = 8.9) were included in the final evaluation. The mean follow-up period was 54.5 months (SD = 5.5). There was no statistically significant difference regarding the Charlson Comorbidity Index (CCI), postoperative complications, or all evaluated questionnaires. There was no statistically significant difference in QALYs between the one- and two-stage revision. (4) Conclusion: Our study results show that the one-stage revision for PJI achieves similar PROMs compared to two-stage revision.
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