1
|
Lewis DC, Blackburn BE, Archibeck J, Archibeck MJ, Anderson LA, Gililland JM, Certain LK, Pelt CE. Similar Efficacy and Lower Cost Associated With Ceftazidime Compared to Tobramycin Coupled With Vancomycin in Antibiotic Spacers in the Treatment of Periprosthetic Joint Infection. J Arthroplasty 2024; 39:S323-S327. [PMID: 38631513 DOI: 10.1016/j.arth.2024.04.018] [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: 11/12/2023] [Revised: 04/04/2024] [Accepted: 04/05/2024] [Indexed: 04/19/2024] Open
Abstract
BACKGROUND Vancomycin and tobramycin have traditionally been used in antibiotic spacers. In 2020, our institution replaced tobramycin with ceftazidime. We hypothesized that the use of ceftazidime/vancomycin (CV) in antibiotic spacers would not lead to an increase in treatment failure compared to tobramycin/vancomycin (TV). METHODS From 2014 to 2022, we identified 243 patients who underwent a stage I revision for periprosthetic joint infection. The primary outcome was a recurrent infection requiring antibiotic spacer exchange. We were adequately powered to detect a 10% difference in recurrent infection. Patients who had a prior failed stage I or two-stage revision for infection, acute kidney injury prior to surgery, or end-stage renal disease were excluded. Given no other changes to our spacer constructs, we estimated cost differences attributable to the antibiotic change. Chi-square and t-tests were used to compare the two groups. Multivariable logistic regressions were utilized for the outcomes. RESULTS The combination of TV was used in 127 patients; CV was used in 116 patients. Within one year of stage I, 9.8% of the TV group had a recurrence of infection versus 7.8% of the CV group (P = .60). By final follow-up, results were similar (12.6 versus 8.6%, respectively, P = .32). Adjusting for potential risk factors did not alter the results. Cost savings for ceftazidime versus tobramycin are estimated to be $68,550 per one hundred patients treated. CONCLUSIONS Replacing tobramycin with ceftazidime in antibiotic spacers yielded similar periprosthetic joint infection eradication success at a lower cost. While larger studies are warranted to confirm these efficacy and cost-saving results, our data justifies the continued investigation and use of ceftazidime as an alternative to tobramycin in antibiotic spacers.
Collapse
Affiliation(s)
- Daniel C Lewis
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, Utah
| | - Brenna E Blackburn
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, Utah
| | - Jane Archibeck
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, Utah
| | | | - Lucas A Anderson
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, Utah
| | - Jeremy M Gililland
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, Utah
| | - Laura K Certain
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, Utah; Department of Internal Medicine, Division of Infectious Diseases, University of Utah, Salt Lake City, Utah
| | - Christopher E Pelt
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, Utah
| |
Collapse
|
2
|
Prats-Peinado L, Fernández-Fernández T, Márquez-Gómez M, Matas-Diaz JA, Sánchez-Somolinos M, de la Villa-Martínez S, Vaquero-Martín J, Sanz-Ruiz P. Do High Doses of Multiple Antibiotics Loaded into Bone Cement Spacers Improve the Success Rate in Staphylococcal Periprosthetic Joint Infection When Rifampicin Cannot Be Employed? Antibiotics (Basel) 2024; 13:538. [PMID: 38927204 PMCID: PMC11200406 DOI: 10.3390/antibiotics13060538] [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: 04/07/2024] [Revised: 05/21/2024] [Accepted: 06/05/2024] [Indexed: 06/28/2024] Open
Abstract
Rifampicin is one of the mainstays in treating staphylococcal prosthetic joint infection (PJI). However, discontinuation due to intolerance, drug interactions, and adverse events is common. Two-stage revision surgery remains the gold standard, with the number of revision arthroplasties steadily increasing. This study aims to evaluate the effectiveness and safety of a novel two-stage revision protocol for staphylococcal prosthetic joint infection (PJI) utilizing bone cement spacers loaded with multiple high doses of antibiotics. Additionally, it seeks to analyze outcomes in patients ineligible for rifampicin treatment. A retrospective review of 43 cases of staphylococcal hip and knee prosthetic joint infections (PJIs) from 2012 to 2020 was conducted. In all instances, a commercial cement containing 1 g of gentamicin and 1 g of clindamycin, augmented with 4 g of vancomycin and 2 g of ceftazidime, was employed to cast a spacer manually after thorough surgical debridement. We report an eradication rate of 82%, with no significant differences observed (p = 0.673) between patients treated with (84%, n = 19) and without rifampicin (79%, n = 24). There were no disparities in positive culture rates (7%), spacer replacement (18%), or survival analysis (p = 0.514) after an average follow-up of 68 months (range 10-147) in the absence of systemic toxicity and surgical complications superimposable to those previously reported. In conclusion, two-stage revision with local high doses of ceftazidime, vancomycin, gentamicin, and clindamycin demonstrates high effectiveness in treating staphylococcal PJIs. Notably, systemic rifampicin does not influence the outcomes. This protocol, with multiple high doses of antibiotics loaded into the bone cement spacer, is presented as a viable and safe alternative for patients unsuitable for rifampicin treatment.
Collapse
Affiliation(s)
- Lourdes Prats-Peinado
- Department of Orthopedic Surgery, General University Hospital Gregorio Marañón, 28007 Madrid, Spain; (L.P.-P.); (T.F.-F.); (M.M.-G.); (J.A.M.-D.); (J.V.-M.)
| | - Tanya Fernández-Fernández
- Department of Orthopedic Surgery, General University Hospital Gregorio Marañón, 28007 Madrid, Spain; (L.P.-P.); (T.F.-F.); (M.M.-G.); (J.A.M.-D.); (J.V.-M.)
| | - Miguel Márquez-Gómez
- Department of Orthopedic Surgery, General University Hospital Gregorio Marañón, 28007 Madrid, Spain; (L.P.-P.); (T.F.-F.); (M.M.-G.); (J.A.M.-D.); (J.V.-M.)
| | - José Antonio Matas-Diaz
- Department of Orthopedic Surgery, General University Hospital Gregorio Marañón, 28007 Madrid, Spain; (L.P.-P.); (T.F.-F.); (M.M.-G.); (J.A.M.-D.); (J.V.-M.)
| | - Mar Sánchez-Somolinos
- Department of Microbiology, General University Hospital Gregorio Marañón, 28007 Madrid, Spain; (M.S.-S.); (S.d.l.V.-M.)
| | - Sofía de la Villa-Martínez
- Department of Microbiology, General University Hospital Gregorio Marañón, 28007 Madrid, Spain; (M.S.-S.); (S.d.l.V.-M.)
| | - Javier Vaquero-Martín
- Department of Orthopedic Surgery, General University Hospital Gregorio Marañón, 28007 Madrid, Spain; (L.P.-P.); (T.F.-F.); (M.M.-G.); (J.A.M.-D.); (J.V.-M.)
- Surgery Department, School of Medicine, Complutense University of Madrid, 28040 Madrid, Spain
| | - Pablo Sanz-Ruiz
- Department of Orthopedic Surgery, General University Hospital Gregorio Marañón, 28007 Madrid, Spain; (L.P.-P.); (T.F.-F.); (M.M.-G.); (J.A.M.-D.); (J.V.-M.)
- Surgery Department, School of Medicine, Complutense University of Madrid, 28040 Madrid, Spain
| |
Collapse
|
3
|
Ko CY, Tsai CH, Fong YC, Chen HY, Chen HT, Lin TL. Effect of Surgeon Volume on Mechanical Complications after Resection Arthroplasty with Articulating Spacer. J Pers Med 2024; 14:490. [PMID: 38793072 PMCID: PMC11122508 DOI: 10.3390/jpm14050490] [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: 03/23/2024] [Revised: 04/20/2024] [Accepted: 05/01/2024] [Indexed: 05/26/2024] Open
Abstract
Two-stage revision with an antibiotic-loaded cement articulating spacer is a standard treatment for chronic prosthetic knee infection (PKI); however, mechanical complications can occur during the spacer period. There is limited evidence on the association between surgeon volume and mechanical complications after resection arthroplasty (RA) using an articulating spacer. This study aimed to compare the rates of mechanical complications and reoperation after RA with articulating spacers by surgeons with high volumes (HV) and low volumes (LV) of RA performed and analyzed the risk factors for mechanical failure. The retrospective study investigated 203 patients treated with PKIs who underwent RA with articulating spacers and were divided according to the number of RAs performed by the surgeons: HV (≥14 RAs/year) or LV (<14 RAs/year). Rates of mechanical complications and reoperations were compared. Risk factors for mechanical complications were analyzed. Of the 203 patients, 105 and 98 were treated by two HV and six LV surgeons, respectively. The mechanical complication rate was lower in HV surgeons (3.8%) than in LV surgeons (36.7%) (p < 0.001). The reoperation rate for mechanical complications was lower in HV surgeons (0.9%) than in LV surgeons (24.5%) (p < 0.001). Additionally, 47.2% of patients required hinge knees after mechanical spacer failure. Medial proximal tibial angle < 87°, recurvatum angle > 5°, and the use of a tibial spacer without a cement stem extension were risk factors for mechanical complications. Based on these findings, we made the following three conclusions: (1) HV surgeons had a lower rate of mechanical complications and reoperation than LV surgeons; (2) mechanical complications increased the level of constraint in final revision knee arthroplasty; and (3) all surgeons should avoid tibial spacer varus malalignment and recurvatum deformity and always use a cement stem extension with a tibial spacer.
Collapse
Affiliation(s)
- Chih-Yuan Ko
- Department of Orthopedics, China Medical University Hospital, Taichung 40447, Taiwan; (C.-Y.K.); (C.-H.T.); (Y.-C.F.); (H.-T.C.)
- Graduate Institute of Biomedical Sciences, China Medical University, Taichung 40402, Taiwan
| | - Chun-Hao Tsai
- Department of Orthopedics, China Medical University Hospital, Taichung 40447, Taiwan; (C.-Y.K.); (C.-H.T.); (Y.-C.F.); (H.-T.C.)
- Department of Sports Medicine, College of Health Care, China Medical University, Taichung 40604, Taiwan
| | - Yi-Chin Fong
- Department of Orthopedics, China Medical University Hospital, Taichung 40447, Taiwan; (C.-Y.K.); (C.-H.T.); (Y.-C.F.); (H.-T.C.)
- Department of Sports Medicine, College of Health Care, China Medical University, Taichung 40604, Taiwan
| | - Hui-Yi Chen
- Department of Radiology, China Medical University Hospital, Taichung 40447, Taiwan;
| | - Hsien-Te Chen
- Department of Orthopedics, China Medical University Hospital, Taichung 40447, Taiwan; (C.-Y.K.); (C.-H.T.); (Y.-C.F.); (H.-T.C.)
- Department of Sports Medicine, College of Health Care, China Medical University, Taichung 40604, Taiwan
| | - Tsung-Li Lin
- Department of Orthopedics, China Medical University Hospital, Taichung 40447, Taiwan; (C.-Y.K.); (C.-H.T.); (Y.-C.F.); (H.-T.C.)
- Graduate Institute of Biomedical Sciences, China Medical University, Taichung 40402, Taiwan
- Department of Sports Medicine, College of Health Care, China Medical University, Taichung 40604, Taiwan
| |
Collapse
|
4
|
Hsu YH, Chou YC, Chen CL, Yu YH, Lu CJ, Liu SJ. Development of novel hybrid 3D-printed degradable artificial joints incorporating electrospun pharmaceutical- and growth factor-loaded nanofibers for small joint reconstruction. BIOMATERIALS ADVANCES 2024; 159:213821. [PMID: 38428121 DOI: 10.1016/j.bioadv.2024.213821] [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: 08/24/2023] [Revised: 02/04/2024] [Accepted: 02/27/2024] [Indexed: 03/03/2024]
Abstract
Small joint reconstruction remains challenging and can lead to prosthesis-related complications, mainly due to the suboptimal performance of the silicone materials used and adverse host reactions. In this study, we developed hybrid artificial joints using three-dimensional printing (3D printing) for polycaprolactone (PCL) and incorporated electrospun nanofibers loaded with drugs and biomolecules for small joint reconstruction. We evaluated the mechanical properties of the degradable joints and the drug discharge patterns of the nanofibers. Empirical data revealed that the 3D-printed PCL joints exhibited good mechanical and fatigue properties. The drug-eluting nanofibers sustainedly released teicoplanin, ceftazidime, and ketorolac in vitro for over 30, 19, and 30 days, respectively. Furthermore, the nanofibers released high levels of bone morphogenetic protein-2 and connective tissue growth factors for over 30 days. An in vivo animal test demonstrated that nanofiber-loaded joints released high concentrations of antibiotics and analgesics in a rabbit model for 28 days. The animals in the drug-loaded degradable joint group showed greater activity counts than those in the surgery-only group. The experimental data suggest that degradable joints with sustained release of drugs and biomolecules may be utilized in small joint arthroplasty.
Collapse
Affiliation(s)
- Yung-Heng Hsu
- Bone and Joint Research Center, Department of Orthopedic Surgery, Chang Gung Memorial Hospital-Linkou, Taoyuan 33305, Taiwan
| | - Ying-Chao Chou
- Bone and Joint Research Center, Department of Orthopedic Surgery, Chang Gung Memorial Hospital-Linkou, Taoyuan 33305, Taiwan
| | - Chao-Lin Chen
- Department of Mechanical Engineering, Chang Gung University, Taoyuan 33302, Taiwan
| | - Yi-Hsun Yu
- Bone and Joint Research Center, Department of Orthopedic Surgery, Chang Gung Memorial Hospital-Linkou, Taoyuan 33305, Taiwan
| | - Chia-Jung Lu
- Bone and Joint Research Center, Department of Orthopedic Surgery, Chang Gung Memorial Hospital-Linkou, Taoyuan 33305, Taiwan; Department of Mechanical Engineering, Chang Gung University, Taoyuan 33302, Taiwan
| | - Shih-Jung Liu
- Bone and Joint Research Center, Department of Orthopedic Surgery, Chang Gung Memorial Hospital-Linkou, Taoyuan 33305, Taiwan; Department of Mechanical Engineering, Chang Gung University, Taoyuan 33302, Taiwan.
| |
Collapse
|
5
|
Chiu YC, Yang SC, Kao YH, Tu YK. Interim Use of Antibiotic-Loaded Cement Spacer for Patients with Infected Cervical Fusion. World Neurosurg 2024; 184:e511-e517. [PMID: 38316175 DOI: 10.1016/j.wneu.2024.01.158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Revised: 01/27/2024] [Accepted: 01/29/2024] [Indexed: 02/07/2024]
Abstract
OBJECTIVE The management of postoperative deep infection after anterior cervical discectomy and fusion (ACDF) remains challenging for spine surgeons. Our institution uses handmade antibiotic-loaded cement spacers to treat these complex cases. This study aimed to determine the efficacy and feasibility of this treatment. METHODS This study included 4 patients with deep cervical spine infections after ACDF who underwent our treatment between March 2012 and January 2022. Patients' laboratory data, visual analog scale scores, comorbidities, complications, and neurological status were recorded. Their clinical conditions were also evaluated based on the Neck Disability Index, Japanese Orthopaedic Association score, and Odom criteria. RESULTS Infection eradication was achieved in all patients after treatment. The average preoperative visual analog scale score was 7.5 (range: 7-8); this decreased to 1.25 (range: 1-2) at 1 year postoperatively. None of the patients experienced severe complications, such as neurological deterioration or bone graft dislodgement. The Neck Disability Index improved from a preoperative value of 54% (range: 48-60%) to 6% (range: 4-8%) at 1 year postoperatively. The Japanese Orthopaedic Association score improved from a preoperative score of 10.25 (range: 10-11)-14.75 (range: 14-16) at 1 year postoperatively. All patients achieved excellent outcomes based on Odom criteria at 1 year postoperatively. CONCLUSIONS Good clinical outcomes were achieved in this study. Although 2-stage surgery is required, this technique could be an alternative for patients with postoperative deep infection after ACDF.
Collapse
Affiliation(s)
- Yen-Chun Chiu
- Department of Orthopaedic Surgery, E-Da Hospital, I-Shou University, Kaohsiung, Taiwan; School of Chinese Medicine for Post Baccalaureate, College of Medicine, I-Shou University, Kaohsiung, Taiwan
| | - Shih-Chieh Yang
- Department of Orthopaedic Surgery, E-Da Hospital, I-Shou University, Kaohsiung, Taiwan.
| | - Yu-Hsien Kao
- Department of Orthopaedic Surgery, E-Da Hospital, I-Shou University, Kaohsiung, Taiwan
| | - Yuan-Kun Tu
- Department of Orthopaedic Surgery, E-Da Hospital, I-Shou University, Kaohsiung, Taiwan
| |
Collapse
|
6
|
Umbel BD, Haghverdian BA, Schweitzer KM, Adams SB. Diagnosis and Management of Infected Total Ankle Replacements. Orthop Clin North Am 2024; 55:285-297. [PMID: 38403374 DOI: 10.1016/j.ocl.2023.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/27/2024]
Abstract
As the number of primary total ankle replacements increases for treatment of end-stage ankle arthritis, failures are also expected to rise. Periprosthetic joint infection is among the causes of failures and has been reported to be as high as 5%. Diagnosis is usually made by a combination of clinical examination findings, imaging, laboratory, and microbiological workup. Management is generally separated into limb salvage or amputation. Limb salvage can be challenging and may involve a single versus staged approach. Options include revision arthroplasty or arthrodesis procedures (ankle versus tibiotalocalcaneal), and a multidisciplinary approach is sought to eradicate infection before definitive management.
Collapse
Affiliation(s)
- Benjamin D Umbel
- Department of Orthopedic Surgery, Duke University Medical Center, 200 Trent Drive, Durham, NC 27710, USA.
| | - Brandon A Haghverdian
- Department of Orthopedic Surgery, Duke University Medical Center, 200 Trent Drive, Durham, NC 27710, USA
| | - Karl M Schweitzer
- Duke Orthopaedics of Raleigh, 3480 Wake Forest Road, Suite 204, Raleigh, NC 27609, USA
| | - Samuel B Adams
- Department of Orthopedic Surgery, Duke University Medical Center, 200 Trent Drive, Durham, NC 27710, USA
| |
Collapse
|
7
|
Chen CY, Lin CP, Tsai CH, Chen HY, Chen HT, Lin TL. Medullary-Sparing Antibiotic Cement Articulating Spacer Reduces the Rate of Mechanical Complications in Advanced Septic Hip Arthritis: A Retrospective Cohort Study. J Pers Med 2024; 14:162. [PMID: 38392594 PMCID: PMC10890418 DOI: 10.3390/jpm14020162] [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: 12/03/2023] [Revised: 01/06/2024] [Accepted: 01/29/2024] [Indexed: 02/24/2024] Open
Abstract
Antibiotic cement articulating spacers eradicate infection during a two-stage revision for advanced septic hip arthritis (ASHA); however, mechanical complications have been reported. We hypothesized that the rate of mechanical complications would be lower in medullary-sparing (MS) than in non-medullary-sparing (n-MS) articulating spacers. A retrospective study of ASHA using n-MS or MS spacers was conducted between 1999 and 2019. The rate of mechanical complications and reoperation and risk factors for mechanical complications were analyzed. The cohort included 71 n-MS and 36 MS spacers. All patients were followed up for 2 years. The rate of spacer dislocation was lower in MS (0%) than in n-MS spacers (14.1%; p = 0.014). The reoperation rate for mechanical complications was lower in MS (0%) than in n-MS spacers (12.7%; p = 0.019). The rate of a diaphyseal stem during reimplantation was lower in MS (0%) than in n-MS spacers (19.4%; p = 0.002). The identified risk factors for n-MS spacer dislocation were postoperative under-restored femoral head diameter ≥3 mm, femoral offset ≥3 mm, and surgical volume (≤6 resection arthroplasties per year). Both spacers controlled infection. However, MS spacers had a lower spacer dislocation and reoperation rate and avoided the diaphyseal stem during reimplantation. We recommend using MS spacers to restore native femoral head diameter and femoral offset when ASHA is treated by surgeons with lower surgical volumes.
Collapse
Affiliation(s)
- Chun-Yen Chen
- Department of Orthopedics, China Medical University Hospital, Taichung 40447, Taiwan
| | - Chin-Ping Lin
- Department of Orthopedics, China Medical University Hospital, Taichung 40447, Taiwan
| | - Chun-Hao Tsai
- Department of Orthopedics, China Medical University Hospital, Taichung 40447, Taiwan
- Department of Sports Medicine, College of Health Care, China Medical University, Taichung 406040, Taiwan
| | - Hui-Yi Chen
- Department of Radiology, China Medical University Hospital, Taichung 40447, Taiwan
| | - Hsien-Te Chen
- Department of Orthopedics, China Medical University Hospital, Taichung 40447, Taiwan
- Department of Sports Medicine, College of Health Care, China Medical University, Taichung 406040, Taiwan
| | - Tsung-Li Lin
- Department of Orthopedics, China Medical University Hospital, Taichung 40447, Taiwan
- Department of Sports Medicine, College of Health Care, China Medical University, Taichung 406040, Taiwan
- Graduate Institute of Biomedical Sciences, China Medical University, Taichung 40402, Taiwan
| |
Collapse
|
8
|
Wong R, Abbas AA, Ayob KA, Nasuruddin H, Selvaratnam V. Custom-Made Articulating Spacer (CUMARS): The Resolution of Periosteal Reaction and Femur Remodelling in Periprosthetic Hip Infection. Cureus 2023; 15:e41669. [PMID: 37575748 PMCID: PMC10412744 DOI: 10.7759/cureus.41669] [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] [Accepted: 07/09/2023] [Indexed: 08/15/2023] Open
Abstract
Periprosthetic joint infection (PJI) is one of the most common complications after total hip arthroplasty (THA). Two-stage revision surgery is one of the treatment options for PJI, however, it has been associated with poor patient tolerance, reduced patient mobility, and periarticular tissue contracture leading to difficulty during second-stage reconstruction. The custom-made articulating spacer (CUMARS) was developed to provide an alternative that is better tolerated and to reduce the complexity of second-stage reconstruction. This study details the treatment of a patient with PJI post-THA with significant periosteal reaction using a CUMARS construct, which enabled immediate post-operative weight bearing, eventual eradication of infection, restoration of femoral bone stock, and avoidance of second-stage reconstruction.
Collapse
Affiliation(s)
- Rosalind Wong
- Joint Reconstruction Unit (JRU) National Orthopedic Centre of Excellence for Research and Learning (NOCERAL) Department of Orthopedic Surgery, Faculty of Medicine, Universiti Malaya, Kuala Lumpur, MYS
| | - Azlina A Abbas
- Joint Reconstruction Unit (JRU) National Orthopedic Centre of Excellence for Research and Learning (NOCERAL) Department of Orthopedic Surgery, Faculty of Medicine, Universiti Malaya, Kuala Lumpur, MYS
| | - Khairul A Ayob
- Joint Reconstruction Unit (JRU) National Orthopedic Centre of Excellence for Research and Learning (NOCERAL) Department of Orthopedic Surgery, Faculty of Medicine, Universiti Malaya, Kuala Lumpur, MYS
| | - Haidar Nasuruddin
- Joint Reconstruction Unit (JRU) National Orthopedic Centre of Excellence for Research and Learning (NOCERAL) Department of Orthopedic Surgery, Faculty of Medicine, Universiti Malaya, Kuala Lumpur, MYS
| | - Veenesh Selvaratnam
- Joint Reconstruction Unit (JRU) National Orthopedic Centre of Excellence for Research and Learning (NOCERAL) Department of Orthopedic Surgery, Faculty of Medicine, Universiti Malaya, Kuala Lumpur, MYS
| |
Collapse
|
9
|
Cochrane N, Kim B, Kelly P, Seidelman J, Seyler T, Klifto C, Jiranek W. Cutibacterium positive cultures in total joint arthroplasty: a comparison of the hip, knee, and shoulder. INTERNATIONAL ORTHOPAEDICS 2023:10.1007/s00264-023-05804-y. [PMID: 37059870 DOI: 10.1007/s00264-023-05804-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Accepted: 04/01/2023] [Indexed: 04/16/2023]
Abstract
PURPOSE Cutibacterium spp. (formerly Propionibacterium) is a slow growing, Gram-positive, anaerobic bacteria and is an emerging clinical entity in prosthetic joint infection (PJI). This study compares the presentation, surgical management, and post-operative antibiotic therapy of patients with positive intraoperative cultures during revision total joint arthroplasty (TJA) of the hip, knee, and shoulder. METHODS This was a retrospective cohort study of patients from 2014 to 2020 of 57 revision TJAs (27 total hip arthroplasty (THA), 17 total shoulder arthroplasty (TSA), and 13 total knee arthroplasty (TKA)) with intraoperative cultures positive for Cutibacterium at a tertiary academic centre. Patient demographics, pre-operative labs, radiographs, and aspirate results were collected. Intraoperative data was reviewed. Post-operative antibiotic therapy and repeat infections were recorded. Data was compared with univariate analyses. RESULTS There was no significant difference in pre-operative lab values between the cohorts. All cohorts had > 58% radiographic lucency. Revision TSA patients had significantly fewer pre-operative aspirates. Six patients undergoing revision THA, three TKA and one TSA had a repeat infection requiring further surgery. Four in the THA cohort and one in the TKA cohort with repeat infections did not receive prolonged antibiotic therapy. CONCLUSION Cutibacterium is an infectious agent that can present in an indolent fashion after TJA. It commonly causes progressive radiographic lucency. The workup and post-operative management differs in the hip, knee, and shoulder, which is likely due to existing literature guiding physician practice. In all joints, Cutibacterium is a virulent pathogen that can cause repeat infections requiring surgical treatment.
Collapse
Affiliation(s)
- Niall Cochrane
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Billy Kim
- School of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Patrick Kelly
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA.
| | - Jessica Seidelman
- Department of Infectious Diseases, Duke University Medical Center, Durham, NC, USA
| | - Thorsten Seyler
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Christopher Klifto
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
| | - William Jiranek
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
| |
Collapse
|
10
|
Hsu YH, Yu YH, Chou YC, Lu CJ, Lin YT, Ueng SWN, Liu SJ. Sustained Release of Antifungal and Antibacterial Agents from Novel Hybrid Degradable Nanofibers for the Treatment of Polymicrobial Osteomyelitis. Int J Mol Sci 2023; 24:ijms24043254. [PMID: 36834663 PMCID: PMC9966905 DOI: 10.3390/ijms24043254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Revised: 01/31/2023] [Accepted: 02/04/2023] [Indexed: 02/10/2023] Open
Abstract
This study aimed to develop a drug delivery system with hybrid biodegradable antifungal and antibacterial agents incorporated into poly lactic-co-glycolic acid (PLGA) nanofibers, facilitating an extended release of fluconazole, vancomycin, and ceftazidime to treat polymicrobial osteomyelitis. The nanofibers were assessed using scanning electron microscopy, tensile testing, water contact angle analysis, differential scanning calorimetry, and Fourier-transform infrared spectroscopy. The in vitro release of the antimicrobial agents was assessed using an elution method and a high-performance liquid chromatography assay. The in vivo elution pattern of nanofibrous mats was assessed using a rat femoral model. The experimental results demonstrated that the antimicrobial agent-loaded nanofibers released high levels of fluconazole, vancomycin, and ceftazidime for 30 and 56 days in vitro and in vivo, respectively. Histological assays revealed no notable tissue inflammation. Therefore, hybrid biodegradable PLGA nanofibers with a sustainable release of antifungal and antibacterial agents may be employed for the treatment of polymicrobial osteomyelitis.
Collapse
Affiliation(s)
- Yung-Heng Hsu
- Department of Orthopedic Surgery, Bone and Joint Research Center, Chang Gung Memorial Hospital, Tao-Yuan 33305, Taiwan
| | - Yi-Hsun Yu
- Department of Orthopedic Surgery, Bone and Joint Research Center, Chang Gung Memorial Hospital, Tao-Yuan 33305, Taiwan
| | - Ying-Chao Chou
- Department of Orthopedic Surgery, Bone and Joint Research Center, Chang Gung Memorial Hospital, Tao-Yuan 33305, Taiwan
| | - Chia-Jung Lu
- Department of Mechanical Engineering, Chang Gung University, Tao-Yuan 33302, Taiwan
| | - Yu-Ting Lin
- Department of Mechanical Engineering, Chang Gung University, Tao-Yuan 33302, Taiwan
| | - Steve Wen-Neng Ueng
- Department of Orthopedic Surgery, Bone and Joint Research Center, Chang Gung Memorial Hospital, Tao-Yuan 33305, Taiwan
- Correspondence: (S.W.-N.U.); (S.-J.L.)
| | - Shih-Jung Liu
- Department of Orthopedic Surgery, Bone and Joint Research Center, Chang Gung Memorial Hospital, Tao-Yuan 33305, Taiwan
- Department of Mechanical Engineering, Chang Gung University, Tao-Yuan 33302, Taiwan
- Correspondence: (S.W.-N.U.); (S.-J.L.)
| |
Collapse
|
11
|
Lynch JP, Zhanel GG. Escalation of antimicrobial resistance among MRSA part 2: focus on infections and treatment. Expert Rev Anti Infect Ther 2023; 21:115-126. [PMID: 36469648 DOI: 10.1080/14787210.2023.2154654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
INTRODUCTION MRSA is associated with causing a variety of infections including skin and skin structure infections, catheter and device-related (e.g. central venous catheter, prosthetic heart valve) infections, infectious endocarditis, blood stream infections, bone, and joint infections (e.g. osteomyelitis, prosthetic joint, surgical site), central nervous system infections (e.g. meningitis, brain/spinal cord abscess, ventriculitis, hydrocephalus), respiratory tract infections (e.g. hospital-acquired pneumonia, ventilator-associated pneumonia), urinary tract infections, and gastrointestinal infections. The emergence and spread of multidrug resistant (MDR) MRSA clones has limited therapeutic options. Older agents such as vancomycin, linezolid and daptomycin and a variety of newer MRSA antimicrobials and combination therapy are available to treat serious MRSA infections. AREAS COVERED The authors discuss infections caused by MRSA as well as common older and newer antimicrobials and combination therapy for MRSA infections. A literature search of MRSA was performed via PubMed (up to September 2022), using the keywords: antimicrobial resistance; β-lactams; multidrug resistance, Staphylococcus aureus, vancomycin; glycolipopeptides. EXPERT OPINION Innovation, discovery, and development of new and novel classes of antimicrobial agents are critical to expand effective therapeutic options. The authors encourage the judicious use of antimicrobials in accordance with antimicrobial stewardship programs along with infection-control measures to minimize the spread of MRSA.
Collapse
Affiliation(s)
- Joseph P Lynch
- Division of Pulmonary, Critical Care Medicine, Allergy, and Clinical Immunology, Department of Internal Medicine, the David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - George G Zhanel
- Department of Medical Microbiology/Infectious Diseases, Max Rady College of Medicine, University of Manitoba, Professor-Department of Medical Microbiology and Infectious Diseases, Winnipeg, Manitoba, Canada
| |
Collapse
|
12
|
Subramanyam KN, Mundargi AV, Prabhu MV, Gopakumar KU, Gowda DSA, Reddy DR. Surgical management of chronic osteomyelitis: Organisms, recurrence and treatment outcome. Chin J Traumatol 2023:S1008-1275(23)00003-2. [PMID: 36828768 PMCID: PMC10388580 DOI: 10.1016/j.cjtee.2023.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 12/20/2022] [Accepted: 01/25/2023] [Indexed: 02/01/2023] Open
Abstract
PURPOSE The study aimed to identify the risk factors of recurrence in chronic osteomyelitis (COM) and to document the microbiological patterns pre- and intra-operatively and at recurrence, if any. METHODS We performed retrospective review on COM patients treated with surgical debridement and a six-week course of antibiotics. The patients with symptoms of osteomyelitis for at least six weeks, present or past episodes of discharging sinus, documentation of bone sequestration in operative notes or preoperative images were included in the study. Patients with symptoms of osteomyelitis < 6 weeks, lack of history of discharging sinus or lack of evidence of sequestration in preoperative images or intraoperative notes were excluded. Logistic regression models were used to assess the impact of risk factors of recurrence. Cohen-Kappa scores were derived to see the concordance between pre-operative and intra-operative isolates and at recurrence. RESULTS Totally, 147 COM patients (115 males and 32 females, mean age (33 ± 19) years) were included in this study. Recurrence was noted in 28 patients (19.0%). Polymicrobial growth and extended spectrum beta-lactamase producing Enterobacteriaceae increased the chance of recurrence. Cierny-Mader stage-1, hematogenous aetiology and negative intraoperative culture reduced the chance of recurrence. Concordance between pre-operative and intra-operative cultures was 59.85% (Kappa score 0.526, p < 0.001) and between index surgery and at recurrence was 23.81% (Kappa score 0.155, p < 0.001). Lack of knowledge of causative organism preoperatively did not affect outcome. At mean follow-up (42 ± 15) months, all patients were apparently infection free for at least one year. CONCLUSION Polymicrobial growth and multi-drug resistant organisms increase the risk of recurrence in COM. Patients' age, gender, diabetes mellitus, previous failed treatment, duration of symptoms, haemoglobin, white cell count, C-reactive protein and erythrocyte sedimentation rate at presentation did not have any impact on the recurrence of infection. Preoperative isolation of organism is of questionable value. Recurrences of infections do occur and are more of re-infections than relapses. Diligent isolation of organism must be attempted even in re-debridements. Even patients with recurrences do well with appropriate debridement and antibiotic therapy.
Collapse
Affiliation(s)
- Koushik Narayan Subramanyam
- Department of Orthopaedics, Sri Sathya Sai Institute of Higher Medical Sciences - Prasanthigram, Puttaparthi, Andhra Pradesh, 515134, India.
| | - Abhishek Vasant Mundargi
- Department of Orthopaedics, Sri Sathya Sai Institute of Higher Medical Sciences - Prasanthigram, Puttaparthi, Andhra Pradesh, 515134, India
| | - Milind Vittal Prabhu
- Department of Orthopaedics, Sri Sathya Sai Institute of Higher Medical Sciences - Prasanthigram, Puttaparthi, Andhra Pradesh, 515134, India
| | - K U Gopakumar
- School of Liberal Arts, Indian Institute of Technology, Jodhpur, Rajasthan, 342001, India
| | - D S Ankush Gowda
- Department of Orthopaedics, Sri Sathya Sai Institute of Higher Medical Sciences - Prasanthigram, Puttaparthi, Andhra Pradesh, 515134, India
| | - Devagiri Raviteja Reddy
- Department of Orthopaedics, Sri Sathya Sai Institute of Higher Medical Sciences - Prasanthigram, Puttaparthi, Andhra Pradesh, 515134, India
| |
Collapse
|
13
|
Influence of the Type of Bone Cement Used in Two-Stage Exchange Arthroplasty for Chronic Periarticular Joint Infection on the Spacer Replacement and Reinfection Rate. J Clin Med 2023; 12:jcm12020600. [PMID: 36675529 PMCID: PMC9866783 DOI: 10.3390/jcm12020600] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2022] [Revised: 12/22/2022] [Accepted: 01/08/2023] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND Antibiotic-loaded bone cement (ALBC) spacers are used in the first stage when treating periprosthetic joint infection (PJI). This study aimed to investigate whether a spacer made from commercial ALBC or plain bone cement with additional antibiotics could affect the spacer exchange rate before reimplantation. METHODS Patients undergoing two-stage exchange arthroplasty due to chronic PJI from January 2014 to August 2021 were retrospectively reviewed. The exclusion criteria included arthroplasty in the setting of septic arthritis, megaprosthesis, atypical pathogen infection, spacer placement unrelated to PJI, and spacer exchange due to mechanical complications. The patient demographics, brand of cement, and microbiology were recorded manually. The primary outcome was the incidence of spacer exchange due to persistent infection and the secondary outcome was the incidence of reinfection after reimplantation. A multivariate logistic regression analysis and Chi-square test were conducted to identify the effect of cement type on the spacer exchange. RESULTS A total of 334 patients underwent two-stage exchange arthroplasty for PJI. The spacer exchange rates in the commercial and non-commercial ALBC groups were 6.4% and 25.1%, respectively (p = 0.004). After controlling for confounding factors, there were significant differences between the commercial group and non-commercial groups in the spacer exchange rate (adjusted OR = 0.25; 95% CI = 0.72-0.87, p = 0.029). The use of commercial ALBC was not associated with a lower reinfection rate after reimplantation (p = 0.160). CONCLUSIONS In a two-stage exchange arthroplasty scenario, the spacer comprised of commercial ALBC resulted in a lower spacer exchange rate than the plain bone cement, both of which had additional antibiotics. However, the use of commercial ALBC was not associated with a lower incidence of reinfection following reimplantation.
Collapse
|
14
|
Wei J, Zhou S, Gu H, Tong K. Meropenem-loaded Cement Is Effective in Preventing Gram-negative Osteomyelitis in an Animal Model. Clin Orthop Relat Res 2023; 481:177-189. [PMID: 36135966 PMCID: PMC9750670 DOI: 10.1097/corr.0000000000002364] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Accepted: 07/27/2022] [Indexed: 01/31/2023]
Abstract
BACKGROUND Low-dose antibiotic-loaded acrylic cement is routinely used for preventing skeletal infection or reimplantation in patients with periprosthetic joint infections. However, few reports about the selection of antibiotics in acrylic cement for antigram-negative bacteria have been proposed. QUESTIONS/PURPOSES (1) Does the addition of antibiotics (tobramycin, meropenem, piperacillin, ceftazidime, ciprofloxacin, and aztreonam) to acrylic cement adversely affect compressive strength before and after elution? (2) Which antibiotics have the highest cumulative release within 28 days? (3) Which antibiotics showed antimicrobial activity within 28 days? (4) Does meropenem-loaded cement improve body weight, temperature, and other inflammatory markers compared with control unloaded cement? METHODS This is an in vitro study that assessed the mechanical strength, antibiotic elution, and antibacterial properties of antibiotic-loaded cement, combined with an animal study in a rat model that evaluated key endpoints from the animal study. In the in vitro study, we added 2 g of tobramycin (TOB), meropenem (MEM), piperacillin (PIP), ceftazidime (CAZ), ciprofloxacin (CIP), and aztreonam (ATM) to 40 g of acrylic cement. The compressive strength, elution, and in vitro antibacterial properties of the antibiotic-loaded cement were detected. Thirty male rats were randomly divided into two groups: CON (antibiotic-unloaded cement) and MEM (meropenem-loaded cement, which had the most stable antibacterial properties of the six tested antibiotic-loaded cements in vitro within 28 days). The right tibia of all rats underwent arthroplasty and was implanted with the cement, followed by inoculation with Pseudomonas aeruginosa in the knee. General status, serum biomarkers, radiology, microbiological assay, and histopathological tests were assessed over 14 days postoperatively. RESULTS The compressive strength of all tested antibiotic cement combinations exceeded the 70 MPa threshold (the requirement established in ISO 5833). The cumulative release proportions of the raw antibiotic in cement were 1182.8 ± 37.9 µg (TOB), 355.6 ± 16.2 µg (MEM), 721.2 ± 40.3 µg (PIP), 477.4 ± 37.1 µg (CAZ), 146.5 ± 11.3 µg (CIP), and 372.1 ± 14.5 µg (ATM) within 28 days. Over a 28-day period, meropenem cement demonstrated antimicrobial activities against the four tested gram-negative bacteria ( Escherichia coli , P. aeruginosa , Klebsiella pneumoniae , and Proteus vulgaris ). Ciprofloxacin cement inhibited E. coli growth, ceftazidime and aztreonam cement inhibited K. pneumonia growth, and tobramycin cement inhibited P. aeruginosa . Only meropenem demonstrated antimicrobial activity against all gram-negative bacteria on agar diffusion bioassay. Rats treated with meropenem cement showed improved body weight (control: 280.1 ± 4.2 g, MEM: 288.5 ± 6.6 g, mean difference 8.4 [95% CI 4.3 to 12.6]; p < 0.001), improved knee width (control: 13.5 ± 0.3 mm, MEM: 11.8± 0.4 mm, mean difference 1.7 [95% CI 1.4 to 2.0]; p < 0.001), decreased inflammatory marker (control: 316.7 ± 45.0 mm, MEM: 116.5 ± 21.8 mm, mean difference 200.2 [95% CI 162.3 to 238.2]; p < 0.001), decreased radiographic scores (control: 17.7 ± 2.0 mm, MEM: 10.7± 1.3 mm, mean difference 7.0 [95% CI 5.4 to 8.6]; p < 0.001), improved bone volume/total volume (control: 8.7 ± 3.0 mm, MEM: 28.5 ± 5 .5 mm, mean difference 19.8 [95% CI 13.3 to 26.2]; p < 0.001), decreased Rissing scale scores of the knee gross pathology (control: 3.3 ± 0.5, MEM: 1.1 ± 0.7, mean difference 2.2 [95% CI 1.7 to 2.7]; p < 0.001), decreased Petty scale scores of knee synovium (control: 2.9 ± 0.4 mm, MEM: 0.7 ± 0.7 mm, mean difference 2.1 [95% CI 1.7 to 2.5]; p < 0.001), and decreased bacterial counts of the bone and soft tissues and negative bacterial cultures of cement (p < 0.001, p < 0.001, p < 0.001, p < 0.001, respectively). CONCLUSION In this current study, MEM cement had the most stable in vitro antimicrobial activities, effective in vivo activity while having acceptable mechanical and elution characteristics, and it may be an effective prophylaxis against skeletal infection caused by gram-negative bacteria. CLINICAL RELEVANCE Meropenem-loaded acrylic cement is a potentially effective prevention measure for skeletal infection caused by gram-negative bacteria; however, more related clinical research is needed to further evaluate the safety and efficacy.
Collapse
Affiliation(s)
- Jian Wei
- Department of Joint Orthopedics, Liuzhou People's Hospital, Liuzhou, China
| | - Siqi Zhou
- Department of Joint Orthopedics, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Hanwen Gu
- Department of Joint Orthopedics, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Kai Tong
- Department of Joint Orthopedics, Zhongnan Hospital of Wuhan University, Wuhan, China
| |
Collapse
|
15
|
Peng SH, Lee SH, Chen CC, Lin YC, Chang Y, Hsieh PH, Shih HN, Ueng SWN, Chang CH. Nontuberculous mycobacteria peri-prosthetic joint infection: An outcome analysis for two stage revision arthroplasty. J Orthop Surg (Hong Kong) 2022; 30:10225536221140610. [PMID: 36396130 DOI: 10.1177/10225536221140610] [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: 11/19/2022] Open
Abstract
PURPOSE Nontuberculous mycobacteria periprosthetic joint infection (NTMPJI) is a rare complication of hip or knee joint arthroplasty. The experience for outcomes of NTMPJI treatment is still limited. The objective of this study was to investigate the outcome of hip or knee nontuberculous mycobacteria periprosthetic joint infection following treatment with two-stage exchange arthroplasty. MATERIAL AND METHODS From 1995 to 2020, 12 patients with NTMPJI were treated with two-stage exchange arthroplasty at our institution. We collected and analyzed variables including demographic data, comorbidity, microbiological data, treatment outcome and antibiotic formula in bone cement. RESULTS Mycobacterium abcessus (n = 6) and Mycobacterium chelonae (n = 2) constitute the majority of the cases. Five patients had early-onset PJIs and the other seven patients were late onset. The success rate of two-stage exchange arthroplasty was 66.7% (8 of 12). Three patients experienced infection relapse, and one patient had soft tissue compromise complication. Post-operative antibiotic therapy may not improve the success rate (4 of 6 cases, 66.7%). Based on in vitro study, the most commonly used effective antibiotic in bone cement spacer for nontuberculous mycobacteria was amikacin. CONCLUSIONS nontuberculous mycobacteria is a rare cause of PJIs and should be suspected especially in relatively immunocompromised patients. Resection arthroplasty with staged reimplantation is the preferred approach. Prolonged post-operative antibiotic therapy before reimplantation may not improve the success rate. Delayed revision surgery may not be needed and can be performed once C-reactive protein level is normal after a drug holiday.
Collapse
Affiliation(s)
- Shih-Hui Peng
- Department of Orthopedic Surgery, 38014Chang Gung Memorial Hospital, Linkou, Taiwan.,College of Medicine, 38014Chang Gung University, Taoyuan, Taiwan.,Bone and Joint Research Center, 38014Chang Gung Memorial Hospital, Linkou, Taiwan
| | - Sheng-Hsun Lee
- Department of Orthopedic Surgery, 38014Chang Gung Memorial Hospital, Linkou, Taiwan.,College of Medicine, 38014Chang Gung University, Taoyuan, Taiwan.,Bone and Joint Research Center, 38014Chang Gung Memorial Hospital, Linkou, Taiwan
| | - Chun-Chieh Chen
- Department of Orthopedic Surgery, 38014Chang Gung Memorial Hospital, Linkou, Taiwan.,College of Medicine, 38014Chang Gung University, Taoyuan, Taiwan.,Bone and Joint Research Center, 38014Chang Gung Memorial Hospital, Linkou, Taiwan
| | - Yu-Chih Lin
- Department of Orthopedic Surgery, 38014Chang Gung Memorial Hospital, Linkou, Taiwan.,College of Medicine, 38014Chang Gung University, Taoyuan, Taiwan.,Bone and Joint Research Center, 38014Chang Gung Memorial Hospital, Linkou, Taiwan
| | - Yuhan Chang
- Department of Orthopedic Surgery, 38014Chang Gung Memorial Hospital, Linkou, Taiwan.,College of Medicine, 38014Chang Gung University, Taoyuan, Taiwan.,Bone and Joint Research Center, 38014Chang Gung Memorial Hospital, Linkou, Taiwan
| | - Pang-Hsin Hsieh
- Department of Orthopedic Surgery, 38014Chang Gung Memorial Hospital, Linkou, Taiwan.,College of Medicine, 38014Chang Gung University, Taoyuan, Taiwan.,Bone and Joint Research Center, 38014Chang Gung Memorial Hospital, Linkou, Taiwan
| | - Hsin-Nung Shih
- Department of Orthopedic Surgery, 38014Chang Gung Memorial Hospital, Linkou, Taiwan.,College of Medicine, 38014Chang Gung University, Taoyuan, Taiwan.,Bone and Joint Research Center, 38014Chang Gung Memorial Hospital, Linkou, Taiwan
| | - Steve W N Ueng
- Department of Orthopedic Surgery, 38014Chang Gung Memorial Hospital, Linkou, Taiwan.,College of Medicine, 38014Chang Gung University, Taoyuan, Taiwan.,Bone and Joint Research Center, 38014Chang Gung Memorial Hospital, Linkou, Taiwan
| | - Chih-Hsiang Chang
- Department of Orthopedic Surgery, 38014Chang Gung Memorial Hospital, Linkou, Taiwan.,College of Medicine, 38014Chang Gung University, Taoyuan, Taiwan.,Bone and Joint Research Center, 38014Chang Gung Memorial Hospital, Linkou, Taiwan.,Graduate Institute of Clinical Medical Sciences, College of Medicine, 38014Chang Gung University, Taoyuan, Taiwan
| |
Collapse
|
16
|
Tseng TH, Chang CH, Chen CL, Chiang H, Hsieh HY, Wang JH, Young TH. A simple method to improve the antibiotic elution profiles from polymethylmethacrylate bone cement spacers by using rapid absorbable sutures. BMC Musculoskelet Disord 2022; 23:916. [PMID: 36242041 PMCID: PMC9563514 DOI: 10.1186/s12891-022-05870-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Accepted: 10/05/2022] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVE Antibiotic-loaded bone cement beads and spacers have been widely used for orthopaedic infection. Poor antibiotic elution is not capable of eradicating microbial pathogens and could lead to treatment failure. The elution profiles differ among different cement formulations. Although Simplex P cement has the least release amount, it is widely used due to its ready availability. Previous methods aiming to improve the elution profiles were not translated well to clinical practice. We sought to address this by using easily available materials to improve the elution profile of antibiotics from PMMA, which allows clinicians to implement the method intraoperatively. METHODS Vancomycin was mixed with Simplex P cement. We used Vicryl Rapide sutures to fabricate sustained-release cement beads by repetitively passing the sutures through the beads and/or mixing suture segments into the cement formulation. Vancomycin elution was measured for 49 days. The mechanism of antibiotic release was observed with gross appearance and scanning electron microscopic images. The antimicrobial activities against MRSA were tested using an agar disk diffusion bioassay. RESULTS Passing Vicryl Rapide sutures through cement beads significantly improved the elution profiles in the 7-week period. The increased ratios were 9.0% on the first day and 118.0% from the 2nd day to the 49th day. Addition of suture segments did not increase release amount. The Vicryl Rapide sutures completely degraded at the periphery and partially degraded at the center. The antibiotic particles were released around the suture, while antibiotic particles kept densely entrapped in the control group. The antimicrobial activities were stronger in passing suture groups. CONCLUSION Passing fast absorbable sutures through PMMA cement is a feasible method to fabricate sustained-release antibiotic bone cement. Intra-cement tunnels can be formed, and the effect can last for at least 7 weeks. It is suitable for a temporary spacer between two stages of a revision surgery.
Collapse
Affiliation(s)
- Tzu-Hao Tseng
- Department of Biomedical Engineering, National Taiwan University, No.1 Jen Ai road section 1, 10002, Taipei, Taiwan.,Department of Orthopaedic Surgery, National Taiwan University Hospital, 7 Chungsan South Road, 10002, Taipei, Taiwan
| | - Chih-Hao Chang
- Department of Orthopaedic Surgery, National Taiwan University Hospital, 7 Chungsan South Road, 10002, Taipei, Taiwan.,Department of Orthopaedic Surgery, National Taiwan University Hospital Jin-Shan Branch, New Taipei City, Taiwan
| | - Chien-Lin Chen
- Department of Biomedical Engineering, National Taiwan University, No.1 Jen Ai road section 1, 10002, Taipei, Taiwan
| | - Hongsen Chiang
- Department of Orthopaedic Surgery, National Taiwan University Hospital, 7 Chungsan South Road, 10002, Taipei, Taiwan.,Department of Biomedical Engineering, National Taiwan University Hospital, Taipei City, Taiwan
| | - Hao-Ying Hsieh
- Department of Biomedical Engineering, National Taiwan University, No.1 Jen Ai road section 1, 10002, Taipei, Taiwan
| | - Jyh-Horng Wang
- Department of Orthopaedic Surgery, National Taiwan University Hospital, 7 Chungsan South Road, 10002, Taipei, Taiwan.
| | - Tai-Horng Young
- Department of Biomedical Engineering, National Taiwan University, No.1 Jen Ai road section 1, 10002, Taipei, Taiwan.
| |
Collapse
|
17
|
Determination of the Elution Capacity of Dalbavancin in Bone Cements: New Alternative for the Treatment of Biofilm-Related Peri-Prosthetic Joint Infections Based on an In Vitro Study. Antibiotics (Basel) 2022; 11:antibiotics11101300. [PMID: 36289958 PMCID: PMC9598415 DOI: 10.3390/antibiotics11101300] [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: 09/12/2022] [Revised: 09/21/2022] [Accepted: 09/21/2022] [Indexed: 11/17/2022] Open
Abstract
Antibiotic-loaded bone cement is the most widely used approach for the treatment of biofilm-induced septic sequelae in orthopedic surgery. Dalbavancin is a lipoglycopeptide that acts against Gram-positive bacteria and has a long half-life, so we aimed to assess whether it could be a new alternative drug in antibiotic-loaded bone cement for the treatment of periprosthetic joint infections. We assessed the elution capacity of dalbavancin and compared it with that of vancomycin in bone cement. Palacos®R (Heraeus Medical GmbH, Wehrheim, Germany) bone cement was manually mixed with each of the antibiotics studied at 2.5% and 5%. Three cylinders were obtained from each of the mixtures; these were weighed and incubated in 5 mL phosphate-buffered saline at 37°C under shaking for 1 h, 2 h, 4 h, 8 h, 24 h, 48 h, 168 h, and 336 h. PBS was replenished at each time point. The samples were analyzed using high-performance liquid chromatography (vancomycin) and mass cytometry (dalbavancin). Elution was higher than the minimum inhibitory concentration (MIC)90 for both antibiotics after 14 days of study. The release of vancomycin at 14 days was higher than of dalbavancin at each concentration tested (p = 0.05, both). However, the cumulative release of 5% dalbavancin was similar to that of 2.5% vancomycin (p = 0.513). The elution capacity of dalbavancin reached a cumulative concentration similar to that of vancomycin. Moreover, considering that the MIC90 of dalbavancin is one third that of vancomycin (0.06 mg/L and 2 mg/L, respectively) and given the long half-life of dalbavancin, it may be a new alternative for the treatment of biofilm-related periprosthetic infections when loaded in bone cement.
Collapse
|
18
|
Yang C, Luo Y, Shen H, Ge M, Tang J, Wang Q, Lin H, Shi J, Zhang X. Inorganic nanosheets facilitate humoral immunity against medical implant infections by modulating immune co-stimulatory pathways. Nat Commun 2022; 13:4866. [PMID: 35982036 PMCID: PMC9388665 DOI: 10.1038/s41467-022-32405-x] [Citation(s) in RCA: 36] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Accepted: 07/28/2022] [Indexed: 11/09/2022] Open
Abstract
Strategies to manipulate immune cell co-inhibitory or co-activating signals have revolutionized immunotherapy. However, certain immunologically cold diseases, such as bacterial biofilm infections of medical implants are hard to target due to the complexity of the immune co-stimulatory pathways involved. Here we show that two-dimensional manganese chalcogenophosphates MnPSe3 (MPS) nanosheets modified with polyvinylpyrrolidone (PVP) are capable of triggering a strong anti-bacterial biofilm humoral immunity in a mouse model of surgical implant infection via modulating antigen presentation and costimulatory molecule expression in the infectious microenvironment (IME). Mechanistically, the PVP-modified MPS (MPS-PVP) damages the structure of the biofilm which results in antigen exposure by generating reactive oxidative species, while changing the balance of immune-inhibitory (IL4I1 and CD206) and co-activator signals (CD40, CD80 and CD69). This leads to amplified APC priming and antigen presentation, resulting in biofilm-specific humoral immune and memory responses. In our work, we demonstrate that pre-surgical neoadjuvant immunotherapy utilizing MPS-PVP successfully mitigates residual and recurrent infections following removal of the infected implants. This study thus offers an alternative to replace antibiotics against hard-to-treat biofilm infections.
Collapse
Affiliation(s)
- Chuang Yang
- Department of Orthopaedics, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai Jiao Tong University, Shanghai, 200233, P. R. China
| | - Yao Luo
- Department of Orthopaedics, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai Jiao Tong University, Shanghai, 200233, P. R. China
| | - Hao Shen
- Department of Orthopaedics, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai Jiao Tong University, Shanghai, 200233, P. R. China
| | - Min Ge
- State Key Laboratory of High Performance Ceramics and Superfine Microstructures, Shanghai Institute of Ceramics Chinese Academy of Sciences, Research Unit of Nanocatalytic Medicine in Specific Therapy for Serious Disease, Chinese Academy of Medical Sciences, Shanghai, 200050, P. R. China
| | - Jin Tang
- Department of Clinical Laboratory, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, 200233, P. R. China
| | - Qiaojie Wang
- Department of Orthopaedics, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai Jiao Tong University, Shanghai, 200233, P. R. China
| | - Han Lin
- State Key Laboratory of High Performance Ceramics and Superfine Microstructures, Shanghai Institute of Ceramics Chinese Academy of Sciences, Research Unit of Nanocatalytic Medicine in Specific Therapy for Serious Disease, Chinese Academy of Medical Sciences, Shanghai, 200050, P. R. China.
| | - Jianlin Shi
- State Key Laboratory of High Performance Ceramics and Superfine Microstructures, Shanghai Institute of Ceramics Chinese Academy of Sciences, Research Unit of Nanocatalytic Medicine in Specific Therapy for Serious Disease, Chinese Academy of Medical Sciences, Shanghai, 200050, P. R. China.
| | - Xianlong Zhang
- Department of Orthopaedics, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai Jiao Tong University, Shanghai, 200233, P. R. China.
| |
Collapse
|
19
|
Cochrane NH, Kim BI, Wu M, O'Donnell JA, Seidelman JL, Jiranek WA. Cutibacterium Positive Cultures in Total Hip Arthroplasty: Contaminant or Pathogen? J Arthroplasty 2022; 37:S642-S646. [PMID: 35660199 DOI: 10.1016/j.arth.2022.01.015] [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: 09/21/2021] [Revised: 12/16/2021] [Accepted: 01/06/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Cutibacterium spp. is an emerging pathogen in total hip arthroplasty (THA) that is not well evaluated in the literature. This study reported on the presentation and management of THA complicated by positive intraoperative Cutibacterium cultures. METHODS This is a retrospective review of 27 revision THAs with positive monomicrobial intraoperative Cutibacterium cultures from 2014 to 2020 at one academic center. These patients were divided into two cohorts based on meeting Musculoskeletal Infection Society (MSIS) criteria for prosthetic joint infections (PJI). Patient demographics, preoperative labs, and hip aspirate results were collected. Procedure performed, postoperative antibiotic regimens, and repeat infections were recorded. Data were compared with univariate analysis. RESULTS Nine of the 27 patients preoperatively met MSIS criteria for PJI. Patients with positive MSIS criteria had significantly higher median synovial cell count (P = .048) and neutrophil percentage in a preoperative aspirate (P = .050). Eight patients with positive MSIS criteria received six weeks of postoperative antibiotics compared to two patients with negative criteria. Two patients with positive MSIS criteria had a postoperative infection that required further surgical intervention. Four patients with negative criteria who required further surgical intervention did not receive postoperative antibiotics after initial revision. CONCLUSION While often categorized as a contaminant, Cutibacterium is an increasingly recognized pathogen in THA. Cutibacterium can often present with normal serology, which may result in misdiagnosis as aseptic THA failure. Without the administration of postoperative antibiotics after positive cultures, there is a risk for persistent infection requiring further surgical intervention.
Collapse
Affiliation(s)
- Niall H Cochrane
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC
| | - Billy I Kim
- School of Medicine, Duke University Medical Center, Durham, NC
| | - Mark Wu
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC
| | - Jeffrey A O'Donnell
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC
| | - Jessica L Seidelman
- Department of Infectious Diseases, Duke University Medical Center, Durham, NC
| | - William A Jiranek
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC
| |
Collapse
|
20
|
Wei J, Tong K, Wang H, Wen Y, Chen L. Intra-articular versus systemic vancomycin for the treatment of periprosthetic joint infection after debridement and spacer implantation in a rat model. Bone Joint Res 2022; 11:371-385. [PMID: 35708551 PMCID: PMC9233408 DOI: 10.1302/2046-3758.116.bjr-2021-0319.r3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Aims Treatment outcomes for methicillin-resistant Staphylococcus aureus (MRSA) periprosthetic joint infection (PJI) using systemic vancomycin and antibacterial cement spacers during two-stage revision arthroplasty remain unsatisfactory. This study explored the efficacy and safety of intra-articular vancomycin injections for PJI control after debridement and cement spacer implantation in a rat model. Methods Total knee arthroplasty (TKA), MRSA inoculation, debridement, and vancomycin-spacer implantation were performed successively in rats to mimic first-stage PJI during the two-stage revision arthroplasty procedure. Vancomycin was administered intraperitoneally or intra-articularly for two weeks to control the infection after debridement and spacer implantation. Results Rats receiving intra-articular vancomycin showed the best outcomes among the four treatment groups, with negative bacterial cultures, increased weight gain, increased capacity for weightbearing activities, increased residual bone volume preservation, and reduced inflammatory reactions in the joint tissues, indicating MRSA eradication in the knee. The vancomycin-spacer and/or systemic vancomycin failed to eliminate the MRSA infections following a two-week antibiotic course. Serum vancomycin levels did not reach nephrotoxic levels in any group. Mild renal histopathological changes, without changes in serum creatinine levels, were observed in the intraperitoneal vancomycin group compared with the intra-articular vancomycin group, but no changes in hepatic structure or serum alanine aminotransferase or aspartate aminotransferase levels were observed. No local complications were observed, such as sinus tract or non-healing surgical incisions. Conclusion Intra-articular vancomycin injection was effective and safe for PJI control following debridement and spacer implantation in a rat model during two-stage revision arthroplasties, with better outcomes than systemic vancomycin administration. Cite this article: Bone Joint Res 2022;11(6):371–385.
Collapse
Affiliation(s)
- Jian Wei
- Department of Joint Surgery and Sports Medicine, Zhongnan Hospital of Wuhan University, Wuhan, China.,Joint Disease Research Center of Wuhan University, Wuhan, China
| | - Kai Tong
- Department of Joint Surgery and Sports Medicine, Zhongnan Hospital of Wuhan University, Wuhan, China.,Joint Disease Research Center of Wuhan University, Wuhan, China
| | - Hui Wang
- Department of Pharmacology, Department of Basic Medicine, Wuhan University, Wuhan, China
| | - Yinxian Wen
- Department of Joint Surgery and Sports Medicine, Zhongnan Hospital of Wuhan University, Wuhan, China.,Joint Disease Research Center of Wuhan University, Wuhan, China
| | - Liaobin Chen
- Department of Joint Surgery and Sports Medicine, Zhongnan Hospital of Wuhan University, Wuhan, China.,Joint Disease Research Center of Wuhan University, Wuhan, China
| |
Collapse
|
21
|
Lin TL, Tsai CH, Fong YC, Shie MY, Chen HY, Chen YW. Posterior-Stabilized Antibiotic Cement Articulating Spacer With Endoskeleton-Reinforced Cam Reduces Rate of Post-Cam Mechanical Complications in Prosthetic Knee Infection: A Preliminary Study. J Arthroplasty 2022; 37:1180-1188.e2. [PMID: 35131390 DOI: 10.1016/j.arth.2022.01.094] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Revised: 01/28/2022] [Accepted: 01/31/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Posterior-stabilized antibiotic cement articulating spacers (PS spacers) reduce spacer mechanical complications in prosthetic knee infections (PKIs); however, joint dislocation after femoral cam fracture has been reported. We hypothesized that the rate of post-cam mechanical complications is lower in PS spacers with an endoskeleton-reinforced cam. METHOD A retrospective study of PKIs using PS spacers with or without a Kirschner wire-reinforced cam (K-PS or nK-PS spacers, respectively) was conducted between 2015 and 2019. The rates of post-cam mechanical complications and reoperation, as well as risk factors for post or cam failure, were analyzed. RESULTS The cohort included 118 nK-PS and 49 K-PS spacers. All patients were followed up for 2 years. The rate of joint subluxation/dislocation after femoral cam fracture was lower in K-PS (0%) than in nK-PS spacers (17.8%; P = .002). The reoperation rate for spacer mechanical complications was lower in K-PS (0%) than in nK-PS spacers (11.9%; P = .008). The identified risk factors for femoral cam fractures were body mass index ≥25 kg/m2, femoral spacer size ≤2, and surgical volume ≤12 resection arthroplasties per year. CONCLUSION This preliminary study highlights that K-PS spacers have a lower rate of post-cam mechanical complications than nK-PS spacers. We recommend the use of PS spacers with endoskeleton-reinforced cam when treating PKIs performed by surgeons with lower surgical volumes, especially in patients with higher body mass index and smaller femoral spacer sizes.
Collapse
Affiliation(s)
- Tsung-Li Lin
- Department of Orthopedics, China Medical University Hospital, Taichung, Taiwan; Department of Sports Medicine, College of Health Care, China Medical University, Taichung, Taiwan; Graduate Institute of Biomedical Sciences, China Medical University, Taichung, Taiwan
| | - Chun-Hao Tsai
- Department of Orthopedics, China Medical University Hospital, Taichung, Taiwan; Department of Sports Medicine, College of Health Care, China Medical University, Taichung, Taiwan
| | - Yi-Chin Fong
- Department of Orthopedics, China Medical University Hospital, Taichung, Taiwan; Department of Sports Medicine, College of Health Care, China Medical University, Taichung, Taiwan; Department of Orthopedics, China Medical University Beigang Hospital, Yunlin, Taiwan
| | - Ming-You Shie
- X-Dimension Center for Medical Research and Translation, China Medical University Hospital, Taichung, Taiwan; School of Dentistry, China Medical University, Taichung, Taiwan; Department of Bioinformatics and Medical Engineering, Asia University, Taichung, Taiwan
| | - Hui-Yi Chen
- Department of Radiology, China Medical University Hospital, Taichung, Taiwan
| | - Yi-Wen Chen
- Graduate Institute of Biomedical Sciences, China Medical University, Taichung, Taiwan; X-Dimension Center for Medical Research and Translation, China Medical University Hospital, Taichung, Taiwan; Department of Bioinformatics and Medical Engineering, Asia University, Taichung, Taiwan
| |
Collapse
|
22
|
Hsu YH, Yu YH, Lee D, Chou YC, Wu CK, Lu CJ, Liu SJ. Pharmaceutical-eluting hybrid degradable hydrogel/microparticle loaded sacs for finger joint interpositional arthroplasty. BIOMATERIALS ADVANCES 2022; 137:212846. [PMID: 35929275 DOI: 10.1016/j.bioadv.2022.212846] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Revised: 05/02/2022] [Accepted: 05/04/2022] [Indexed: 06/15/2023]
Abstract
Despite recent advances in medical technology, treatment of chronic osteomyelitis in the small joint of the hand remains challenging. Here, we exploited hybrid biodegradable hydrogel/microparticle/polycaprolactone (PCL) sacs for finger joint interpositional arthroplasty via electrospraying and rotational molding techniques. Degradable Pluronic F127, poly(lactic-co-glycolic acid) (PLGA), and PCL were starting materials for the hydrogels, microparticles, and sac, respectively. Vancomycin, ceftazidime, and lidocaine were the embedded pharmaceuticals. The in vitro and in vivo drug release behaviors of hybrid drug-eluting sacs were assessed. The empirical outcomes show that the size distribution of the electrosprayed vancomycin/ceftazidime/lidocaine PLGA microparticles was 8.25 ± 3.35 μm. Biodegradable PCL sacs offered sustainable and effective release of vancomycin, ceftazidime, and lidocaine, respectively, after 30, 16, and 11 days in vitro. The sacs also discharged high levels of anti-microbial agents for 56 days and analgesics for 14 days in a rabbit knee joint model. The blood urea nitrogen (creatinine) levels remained normal at various time points: 16.5 ± 2.5 mg/dL (0.85 ± 0.24 mg/dL), 20.0 ± 1.4 mg/dL (1.0 ± 0.16 mg/dL), 19.3 ± 2.4 mg/dL (1.13 ± 0.15 mg/dL), and 20.0 ± 2.16 mg/dL (1.0 ± 0.16 mg/dL) at days 7, 14, 21, and 35, respectively. The empirical outcomes of this study suggested that the hybrid biodegradable drug-eluting sacs with extended liberation of pharmaceuticals may find applications in the small joints for post-operative pain relief and infection control.
Collapse
Affiliation(s)
- Yung-Heng Hsu
- Department of Orthopedic Surgery, Bone and Joint Research Center, Chang Gung Memorial Hospital-Linkou, Taoyuan 33305, Taiwan
| | - Yi-Hsun Yu
- Department of Orthopedic Surgery, Bone and Joint Research Center, Chang Gung Memorial Hospital-Linkou, Taoyuan 33305, Taiwan
| | - Demei Lee
- Department of Mechanical Engineering, Chang Gung University, Taoyuan 33302, Taiwan
| | - Ying-Chao Chou
- Department of Orthopedic Surgery, Bone and Joint Research Center, Chang Gung Memorial Hospital-Linkou, Taoyuan 33305, Taiwan
| | - Chen-Kai Wu
- Department of Mechanical Engineering, Chang Gung University, Taoyuan 33302, Taiwan
| | - Chia-Jung Lu
- Department of Mechanical Engineering, Chang Gung University, Taoyuan 33302, Taiwan
| | - Shih-Jung Liu
- Department of Orthopedic Surgery, Bone and Joint Research Center, Chang Gung Memorial Hospital-Linkou, Taoyuan 33305, Taiwan; Department of Mechanical Engineering, Chang Gung University, Taoyuan 33302, Taiwan.
| |
Collapse
|
23
|
Li ZY, Lin YC, Chang CH, Chen SY, Lu TW, Lee SH. Trend of serum C-reactive protein is associated with treatment outcome of hip Periprosthetic joint infection undergoing two-stage exchange arthroplasty: a case control study. BMC Musculoskelet Disord 2021; 22:1007. [PMID: 34856956 PMCID: PMC8641244 DOI: 10.1186/s12891-021-04893-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Accepted: 11/17/2021] [Indexed: 01/09/2023] Open
Abstract
Background Serum C-reactive protein (CRP) trends are critical for monitoring patients’ treatment response following a two-stage exchange arthroplasty for periprosthetic joint infection (PJI) of the hip. However, CRP trends are poorly described in the literature. The primary aim of this study was to identify the relationships between PJI treatment outcomes and our proposed CRP trend definitions, parameters, and microbiological data. The secondary aim was to investigate CRP trends after the occurrence of spacer-related complications. Methods We conducted a retrospective review of 74 patients treated with a two-stage exchange protocol for PJI in a tertiary referral joint center between 2014 and 2016. Patients with factors that may affect CRP levels (inflammatory arthritis, concomitant infections, liver and kidney diseases, and intensive care admissions) were excluded. CRP trends were categorized into five types and PJI treatment outcome was defined as “success” or “failure” according to the Delphi criteria. Results Treatment was successful in 67 patients and failed in 7 patients. Multivariate logistic regression analysis showed that type 5 CRP, defined as serum CRP fluctuation without normalization after first stage surgery (odds ratio [OR]: 17.4; 95% confidence interval [CI]: 2.3–129.7; p = 0.005), and methicillin-resistant Staphylococcus aureus (MRSA; OR: 14.5; 95% CI: 1.6–131.7; p = 0.018) were associated with treatment failure. Spacer-related complications occurred in 18 patients. Of these, 12 had elevated CRP levels at later follow-up, while six had no elevation in CRP levels. Conclusions We found that MRSA infection and type 5 CRP were associated with PJI treatment failure.
Collapse
Affiliation(s)
- Zhong-Yan Li
- Department of Biomedical Engineering, National Taiwan University, No. 1, Sec. 4, Roosevelt Rd., Taipei, 10617, Taiwan, Republic of China
| | - Yu-Chih Lin
- Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, Linkou, No.5, Fuxing St., Guishan Dist., Taoyuan, 33305, Taiwan, Republic of China.,Bone and Joint Research Center, Chang Gung Memorial Hospital, Linkou, No.5, Fuxing St., Guishan Dist., Taoyuan, 33305, Taiwan, Republic of China
| | - Chih-Hsiang Chang
- Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, Linkou, No.5, Fuxing St., Guishan Dist., Taoyuan, 33305, Taiwan, Republic of China.,Bone and Joint Research Center, Chang Gung Memorial Hospital, Linkou, No.5, Fuxing St., Guishan Dist., Taoyuan, 33305, Taiwan, Republic of China
| | - Szu-Yuan Chen
- Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, Linkou, No.5, Fuxing St., Guishan Dist., Taoyuan, 33305, Taiwan, Republic of China.,Bone and Joint Research Center, Chang Gung Memorial Hospital, Linkou, No.5, Fuxing St., Guishan Dist., Taoyuan, 33305, Taiwan, Republic of China
| | - Tung-Wu Lu
- Department of Medicine, Chang Gung University, No.259, Wenhua 1st Rd., Guishan Dist., Taoyuan, 33302, Taiwan, Republic of China
| | - Sheng-Hsun Lee
- Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, Linkou, No.5, Fuxing St., Guishan Dist., Taoyuan, 33305, Taiwan, Republic of China. .,Bone and Joint Research Center, Chang Gung Memorial Hospital, Linkou, No.5, Fuxing St., Guishan Dist., Taoyuan, 33305, Taiwan, Republic of China. .,Department of Medicine, Chang Gung University, No.259, Wenhua 1st Rd., Guishan Dist., Taoyuan, 33302, Taiwan, Republic of China. .,Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, Linkou, No.5, Fuxing St., Guishan Dist., Taoyuan, 333, Taiwan, Republic of China.
| |
Collapse
|
24
|
Lin TL, Tsai CH, Fong YC, Shie MY, Chen HY, Chen YW. Cruciate-Retaining vs Posterior-Stabilized Antibiotic Cement Articulating Spacers for Two-Stage Revision of Prosthetic Knee Infection: A Retrospective Cohort Study. J Arthroplasty 2021; 36:3750-3759.e2. [PMID: 34284935 DOI: 10.1016/j.arth.2021.06.023] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Revised: 05/17/2021] [Accepted: 06/21/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Antibiotic cement articulating spacers are recommended during 2-stage revision for prosthetic knee infection because of increased range of motion (ROM) and improved function; however, spacer mechanical complications have been reported. We aimed to determine the association between different constraints of articulating spacers and the rate of complications and infection eradication, functional outcomes, and ROM. METHODS A retrospective study of prosthetic knee infection using cruciate-retaining (CR) or posterior-stabilized (PS) spacers was conducted between 2011 and 2018. The rate of spacer mechanical complications, infection eradication after reimplantation and reoperation, Hospital of Special Surgery (HSS) knee score, and ROM during the interim stage were analyzed. All patients were regularly followed up for 2 years. RESULTS One hundred forty-one patients were included, with 66 CR and 75 PS spacers. Overall mechanical complication rate was lower in PS (9.3%) than in CR spacers (45.5%) (P < .001), especially in joint dislocation (1.3% vs 30.3%, respectively, P < .001). Overall reoperation rate was lower in PS (16.0%) than in CR spacers (36.4%) (P < .001), especially for mechanical complications (1.3% vs 24.2%, respectively, P < .001). HSS knee score was higher in PS (72.3) than in CR spacers (63.8) (P < .001). ROM was greater in PS (90.3°) than in CR spacers (80.6°) (P = .005), especially at maximum flexion (102.4° vs 89.6°, respectively, P = .003). Infection eradication was comparable between the spacers. CONCLUSION Both spacers can control infection; however, PS spacers had a lower rate of mechanical complications and reoperation, better HSS knee scores, and greater ROM than CR spacers.
Collapse
Affiliation(s)
- Tsung-Li Lin
- Department of Orthopedics, China Medical University Hospital, Taichung, Taiwan; Department of Sports Medicine, College of Health Care, China Medical University, Taichung, Taiwan; Graduate Institute of Biomedical Sciences, China Medical University, Taichung, Taiwan
| | - Chun-Hao Tsai
- Department of Orthopedics, China Medical University Hospital, Taichung, Taiwan; Department of Sports Medicine, College of Health Care, China Medical University, Taichung, Taiwan
| | - Yi-Chin Fong
- Department of Orthopedics, China Medical University Hospital, Taichung, Taiwan; Department of Sports Medicine, College of Health Care, China Medical University, Taichung, Taiwan; Department of Orthopedics, China Medical University Beigang Hospital, Yunlin, Taiwan
| | - Ming-You Shie
- X-Dimension Center for Medical Research and Translation, China Medical University Hospital, Taichung, Taiwan; School of Dentistry, China Medical University, Taichung, Taiwan; Department of Bioinformatics and Medical Engineering, Asia University, Taichung, Taiwan
| | - Hui-Yi Chen
- Department of Radiology, China Medical University Hospital, Taichung, Taiwan
| | - Yi-Wen Chen
- Graduate Institute of Biomedical Sciences, China Medical University, Taichung, Taiwan; X-Dimension Center for Medical Research and Translation, China Medical University Hospital, Taichung, Taiwan; Department of Bioinformatics and Medical Engineering, Asia University, Taichung, Taiwan
| |
Collapse
|
25
|
Yu YH, Lin YT, Hsu YH, Chou YC, Ueng SWN, Liu SJ. Biodegradable Antimicrobial Agent/Analgesic/Bone Morphogenetic Protein-Loaded Nanofibrous Fixators for Bone Fracture Repair. Int J Nanomedicine 2021; 16:5357-5370. [PMID: 34408414 PMCID: PMC8364851 DOI: 10.2147/ijn.s325885] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Accepted: 08/03/2021] [Indexed: 12/28/2022] Open
Abstract
Purpose Postoperative infection and pain management are of great concern to orthopedic surgeons. Although there are several protocols available to deal with these aspects, they are fraught with complications, such as cartilage damage, cardiovascular and neurological intoxication, and systemic adverse responses. Therefore, it is necessary to develop safe and effective perioperative protocols. In the current study, antimicrobial agents/analgesics/growth factor-embedded biodegradable hybrid fixators (polycaprolactone fixator + poly[lactide-co-glycolide] sheath-core structured nanofibers) for bone fracture repair were designed. Methods The biodegradable hybrid fixators were fabricated using solution-extrusion three-dimensional printing and electrospinning. In vitro, the characteristics of the hybrid fixators were examined. Additionally, the release of the incorporated vancomycin, ceftazidime, lidocaine, and bone morphogenetic protein-2 (BMP-2) was evaluated. The in vivo efficacy including drug-eluting properties, fracture repair, and pain management of the biomolecule-loaded nanofibrous fixators was investigated in rabbit rib-fracture models. Results The nanofibrous fixators released vancomycin, ceftazidime, and lidocaine in a sustained manner under both in vitro and in vivo conditions and protected BMP-2 from burst release. The implantation of these hybrid fixators around the fractured rib significantly improved animal activities and bone union, indicating that the inclusion of analgesic in the fixator effectively reduced postsurgical pain and thereby helped in recovery. Conclusion The novel biomolecule-loaded nanofibrous hybrid fixators resulted in excellent therapeutic outcomes. These fixators may be effective in the repair of rib fractures in clinical settings and may help mitigate surgical complications, such as infection, nonunion, and intolerable postoperative pain.
Collapse
Affiliation(s)
- Yi-Hsun Yu
- Department of Orthopedic Surgery, Bone and Joint Research Center, Chang Gung Memorial Hospital, Tao-Yuan, 33305, Taiwan
| | - Yu-Ting Lin
- Department of Mechanical Engineering, Chang Gung University, Tao-Yuan, 33302, Taiwan
| | - Yung-Heng Hsu
- Department of Orthopedic Surgery, Bone and Joint Research Center, Chang Gung Memorial Hospital, Tao-Yuan, 33305, Taiwan
| | - Ying-Chao Chou
- Department of Orthopedic Surgery, Bone and Joint Research Center, Chang Gung Memorial Hospital, Tao-Yuan, 33305, Taiwan
| | - Steve W N Ueng
- Department of Orthopedic Surgery, Bone and Joint Research Center, Chang Gung Memorial Hospital, Tao-Yuan, 33305, Taiwan
| | - Shih-Jung Liu
- Department of Orthopedic Surgery, Bone and Joint Research Center, Chang Gung Memorial Hospital, Tao-Yuan, 33305, Taiwan.,Department of Mechanical Engineering, Chang Gung University, Tao-Yuan, 33302, Taiwan
| |
Collapse
|
26
|
Local Application of Vancomycin in One-Stage Revision of Prosthetic Joint Infection Caused by Methicillin-Resistant Staphylococcus aureus. Antimicrob Agents Chemother 2021; 65:e0030321. [PMID: 34181479 DOI: 10.1128/aac.00303-21] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
The rate of eradication of periprosthetic joint infection (PJI) caused by methicillin-resistant Staphylococcus aureus (MRSA) is still not satisfactory with systemic vancomycin administration after one-stage revision arthroplasty. This study aimed to explore the effectiveness and safety of intraarticular (IA) injection of vancomycin in the control of MRSA PJI after one-stage revision surgery in a rat model. Two weeks of intraperitoneal (IP) and/or IA injection of vancomycin was used to control the infection after one-stage revision surgery. The MRSA PJI rats treated with IA injection of vancomycin showed better outcomes in skin temperature, bacterial counts, biofilm on the prosthesis, serum α1-acid glycoprotein levels, residual bone volume, and inflammatory reaction in the joint tissue, compared with those treated with IP vancomycin, while the rats treated with IP and IA administration showed the best outcomes. However, only the IP and IA administration of vancomycin could eradicate MRSA. Minimal changes in renal pathology were observed in the IP and IP plus IA groups but not in the IA group, while no obvious changes were observed in the liver or in levels of serum markers, including creatinine, alanine aminotransferase, and aspartate aminotransferase. Therefore, IA use of vancomycin is effective and safe in the MRSA PJI rat model and is better than systemic administration, while IA and systemic vancomycin treatment could eradicate the infection with a 2-week treatment course.
Collapse
|
27
|
Köse N, Asfuroğlu ZM, Köse A, Şahintürk V, Gürbüz M, Doğan A. Silver ion-doped calcium phosphate-based bone-graft substitute eliminates chronic osteomyelitis: An experimental study in animals. J Orthop Res 2021; 39:1390-1401. [PMID: 33295663 DOI: 10.1002/jor.24946] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2020] [Revised: 11/30/2020] [Accepted: 12/07/2020] [Indexed: 02/04/2023]
Abstract
Despite the latest technologies and advances in microbiology and orthopedic surgery, chronic osteomyelitis is still a challenging disorder. Antibiotic resistance and bacterially induced bone destruction can have very serious consequences. We hypothesized that calcium phosphate-based bone graft substitution with silver ion doping would simultaneously treat bone infection and the bony defect in the chronic osteomyelitis. An unicortical 10-mm-diameter bone was harvested in the proximal tibial metaphysis of 24 rabbits. After contaminating the wounds with an infective dose of methicillin-resistant Staphylococcus aureus (MRSA), osteomyelitis was proven radiographically and microbiologically in all rabbits. Animals were than divided into three groups. The first group received vancomycin-impregnated bone cement beads (comparative control group), the second/experimental group received silver ion-doped calcium phosphate beads and the third group received pure calcium phosphate beads (negative controls). Radiographs, intraosseous cultures, and histopathological examinations were performed on postoperative Week 10. The cultures showed no evidence of intramedullary infection in the silver ion-doped calcium phosphate beads group, but they were positive for MRSA in four of the six rabbits in the vancomycin- impregnated bone cement beads group and in all of the eight rabbits in the pure calcium phosphate beads group. Quantitative assessment of histopathological examination showed lowest total damage score in silver ion-doped calcium phosphate beads group (p < .001). Percentage of osteoid tissue + bony tissue was also higher in this group compared with other groups. In the final radiological examinations, it was observed that the changes caused by osteomyelitis in the bone tissue in the silver ion-doped calcium phosphate beads group were much improved compared with the vancomycin-impregnated bone cement beads group. Silver ion doped calcium phosphate-based bone-graft substitute offer the ability to stimulate bone growth, combat infection, and, ultimately, treat experimental chronic osteomyelitis in an animal model.
Collapse
Affiliation(s)
- Nusret Köse
- Department of Orthopedics and Traumatology, Eskişehir Osmangazi University, Eskişehir, Turkey
| | - Zeynel M Asfuroğlu
- Division of Hand Surgery, Department of Orthopedics and Traumatology, Mersin University, Mersin, Turkey
| | - Aydan Köse
- Department of Plastic and Reconstructive Surgery, Eskişehir Osmangazi University, Eskişehir, Turkey
| | - Varol Şahintürk
- Department of Histology, Eskişehir Osmangazi University, Eskişehir, Turkey
| | - Mevlüt Gürbüz
- Department of Mechanical Engineering, Faculty of Engineering, Ondokuz Mayıs University, Samsun, Turkey
| | - Aydın Doğan
- Department of Materials Science and Engineering, Eskişehir Technical University, Eskişehir, Turkey
| |
Collapse
|
28
|
Chen JP, Chang CH, Lin YC, Lee SH, Shih HN, Chang Y. Two-stage exchange Arthroplasty for knee Periprosthetic joint infection exhibit high infection recurrence rate in patients with chronic viral hepatitis. BMC Musculoskelet Disord 2021; 22:538. [PMID: 34118906 PMCID: PMC8199816 DOI: 10.1186/s12891-021-04416-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Accepted: 05/31/2021] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Currently, there is little evidence about the outcome of two-stage exchange arthroplasty for the treatment of knee periprosthetic joint infection (PJI) in patients with chronic viral hepatitis. To evaluate it, we set the primary outcome as infection recurrence, and the secondary outcome as the difference between patients diagnosed with hepatitis B virus or hepatitis C virus. PATIENTS AND METHODS Between June, 2010 and December, 2016, 172 patients with knee PJIs were treated with two-stage exchange arthroplasty at our institute. Treatment success was defined using Delphi-based consensus. These patients were further divided into groups with or without chronic hepatitis. Variables were analyzed, including age, sex, comorbidities, microbiology, and operative methods. Minimum follow-up was 12 months (mean, 35 months; range, 12-85 months). RESULTS Of the 172 knee PJI patients, 25 were identified with chronic hepatitis. The infection recurrence rate in the hepatitis group (28%, 7 in 25) was significantly higher than that in the non-hepatitis group (9.5%, 14 in 147), p = 0.017. However, there was no significant difference in the infection recurrence rates between patients with HBV (24%, 4 in 16) and HCV (33.3%, 3 in 9). Regarding the outcomes of patients with infection recurrence, 4 of the non-hepatitis patients were treated with the debridement, antibiotic treatment, irrigation, and retention of prosthesis (DAIR) procedure, with a success rate of 75%. The other 17 patients (7 with hepatitis and 10 without) were treated with repeated two-stage exchange arthroplasty with 100% infection elimination rate until the final follow-up. CONCLUSIONS Knee PJI patients with chronic hepatitis have higher infection recurrence rate after two-stage exchange arthroplasty (28%).
Collapse
Affiliation(s)
- Jui-Ping Chen
- Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, Linkou, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Chih-Hsiang Chang
- Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, Linkou, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan.,Bone and Joint Research Center, Chang Gung Memorial Hospital, Linkou, Taiwan
| | - Yu-Chih Lin
- Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, Linkou, Taiwan.,Bone and Joint Research Center, Chang Gung Memorial Hospital, Linkou, Taiwan
| | - Sheng-Hsun Lee
- Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, Linkou, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan.,Bone and Joint Research Center, Chang Gung Memorial Hospital, Linkou, Taiwan
| | - Hsin-Nung Shih
- Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, Linkou, Taiwan.,Bone and Joint Research Center, Chang Gung Memorial Hospital, Linkou, Taiwan
| | - Yuhan Chang
- Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, Linkou, Taiwan. .,College of Medicine, Chang Gung University, Taoyuan, Taiwan. .,Bone and Joint Research Center, Chang Gung Memorial Hospital, Linkou, Taiwan. .,Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, 5, Fu-Hsin St., Kweishan, Taoyuan, Taiwan.
| |
Collapse
|
29
|
Frank BJH, Aichmair A, Simon S, Schwarz GM, Dominkus M, Hofstaetter JG. Analysis of Culture Positive First and Second Stage Procedures in Periprosthetic Knee and Hip Joint Infections. J Arthroplasty 2021; 36:2158-2164. [PMID: 33608181 DOI: 10.1016/j.arth.2021.01.074] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Revised: 01/24/2021] [Accepted: 01/27/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND A positive microbiological result at reimplantation may lead to a failed 2-stage revision arthroplasty in the treatment of periprosthetic joint infections. Little is known about changes in microbiological spectrum and resistance pattern between culture positive first and second stage procedures in revision knee and hip arthroplasty. METHODS Between January 2011 and December 2019, we performed 327 two-stage revision arthroplasties on 312 patients. There were 37 of 312 (11.9%) patients (20 hips/17 knees) who had a positive microbiological culture during the first and second stage procedure. We analyzed the microbiological spectrum, antimicrobial resistance pattern, and clinical outcome of culture positive first and second stage procedures as well as subsequent re-revisions. RESULTS Re-revision was necessary in 40.5% (15/37) of patients with culture positive first and second stage procedure at a median follow-up of 3.5 years. We found microbiological changes in 83.8% (31/37) of patients between the first and second stage and in 88.9% (8/9) between the second stage and subsequent culture positive re-revision. Polymicrobial infections were found in 21.6% (8/37) of first and in 16.2% (6/37) of second stage procedures. In 27% (10/37) of patients, microorganisms persisted between the first and second stage procedure. The antimicrobial resistance pattern changed in 60% of persistent microorganisms between the first and second stage procedure. CONCLUSION Changes in microbiological spectrum and resistance pattern are common between culture positive first and second stage procedures as well as subsequent re-revisions. This has to be considered in the antimicrobial treatment of periprosthetic joint infections.
Collapse
Affiliation(s)
- Bernhard J H Frank
- Michael Ogon Laboratory for Orthopaedic Research, Orthopaedic Hospital Vienna-Speising, Vienna, Austria
| | - Alexander Aichmair
- Michael Ogon Laboratory for Orthopaedic Research, Orthopaedic Hospital Vienna-Speising, Vienna, Austria; 2nd Department, Orthopaedic Hospital Vienna-Speising, Vienna, Austria
| | - Sebastian Simon
- Michael Ogon Laboratory for Orthopaedic Research, Orthopaedic Hospital Vienna-Speising, Vienna, Austria; 2nd Department, Orthopaedic Hospital Vienna-Speising, Vienna, Austria
| | - Gilbert M Schwarz
- Michael Ogon Laboratory for Orthopaedic Research, Orthopaedic Hospital Vienna-Speising, Vienna, Austria; Department of Orthopaedics and Trauma-Surgery, Medical University of Vienna, Vienna, Austria
| | - Martin Dominkus
- 2nd Department, Orthopaedic Hospital Vienna-Speising, Vienna, Austria; School of Medicine, Sigmund Freud University Vienna, Vienna, Austria
| | - Jochen G Hofstaetter
- Michael Ogon Laboratory for Orthopaedic Research, Orthopaedic Hospital Vienna-Speising, Vienna, Austria; 2nd Department, Orthopaedic Hospital Vienna-Speising, Vienna, Austria
| |
Collapse
|
30
|
Xu YM, Peng HM, Feng B, Weng XS. Progress of antibiotic-loaded bone cement in joint arthroplasty. Chin Med J (Engl) 2020; 133:2486-2494. [PMID: 32960839 PMCID: PMC7575178 DOI: 10.1097/cm9.0000000000001093] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Indexed: 11/26/2022] Open
Abstract
Bone cement, consisting of polymethyl methacrylate, is a bioinert material used for prothesis fixation in joint arthroplasty. To treat orthopedic infections, such as periprosthetic joint infection, antibiotic-loaded bone cement (ALBC) was introduced into clinical practice. Recent studies have revealed the limitations of the antibacterial effect of ALBC. Moreover, with the increase in high infection risk patients and highly resistant microbes, more researches and modification of ALBC are required. This paper reviewed latest findings about ALBC for most popular and destructive pathogens, summarized the influence of antibiotic kind, drug dosage, application method, and environment towards characteristic of ALBC. Subsequently, new cement additives and clinical applications of ALBC in joint arthroplasty were also discussed.
Collapse
Affiliation(s)
- Yi-Ming Xu
- Department of Orthopedics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100730, China
| | | | | | | |
Collapse
|
31
|
Polyethylene-Based Knee Spacer for Infection Control: Design Concept and Pre-Clinical In Vitro Validations. Polymers (Basel) 2020; 12:polym12102334. [PMID: 33066104 PMCID: PMC7601983 DOI: 10.3390/polym12102334] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Revised: 10/05/2020] [Accepted: 10/09/2020] [Indexed: 12/30/2022] Open
Abstract
Antibiotic-loaded polymethyl methacrylate (PMMA) has been widely applied in the treatment of knee periprosthetic joint infections. However, problems with antibiotic-loaded PMMA-based spacers, such as structural fracture and implant dislocation, remain unresolved. A novel polyethylene-based spacer, designed with an ultra-congruent articulating surface and multiple fenestrations, was introduced in the current study. Validation tests for biomechanical safety, wear performance, and efficacy of antibiotic cement were reported. During cycle fatigue testing, no tibial spacer failures were observed, and less wear debris generation was reported compared to commercial PMMA-based spacers. The volumetric wear of the novel spacer was within the safety threshold for osteolysis-free volumetric wear. An effective infection control was demonstrated despite the application of lesser antibiotic cement in the 30-day antibiotic elution test. The tube dilution test confirmed adequate inhibitory capabilities against pathogens with the loaded antibiotic option utilized in the current study. The novel polyethylene-based knee spacer may offer sufficient biomechanical safety and serve as an adequate carrier of antibiotic-loaded cement for infection control. Further clinical trials shall be conducted for more comprehensive validation of the novel spacer for practical application.
Collapse
|
32
|
Chen MJW, Hung JF, Chang CH, Lee SH, Shih HN, Chang YH. Periprosthetic knee infection reconstruction with a hinged prosthesis: Implant survival and risk factors for treatment failure. Knee 2020; 27:1035-1042. [PMID: 32317140 DOI: 10.1016/j.knee.2020.03.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2019] [Revised: 01/29/2020] [Accepted: 03/18/2020] [Indexed: 02/02/2023]
Abstract
BACKGROUND Severe bone and soft tissue defects are common after failed two-stage exchange arthroplasty for periprosthetic joint infection (PJI). There is a paucity of evidence on the outcomes of using a hinged prosthesis for knee PJI reconstruction during second-stage re-implantation, especially regarding implant survivorship, reinfection risk factors, and functionality after successful reconstruction. METHODS A total of 58 knee PJI patients with Anderson Orthopaedic Research Institute (AORI) type II/III defect and soft tissue insufficiency underwent reconstruction with hinged prosthesis. Enrolled patients adhered to a two-stage exchange arthroplasty protocol and were evaluated for a mean follow up of 65.1 months. Kaplan-Meier analysis was conducted for implant survivorship and infection-free survival. Multivariate analysis was used to determine independent risk factors for recurrent infections. Knee Society Score (KSS) was used to evaluate functional outcomes. RESULTS The survivorship of hinged prosthesis was 86.2% at 2 years and 70.2% at 5 years. Infection-free analysis revealed an estimation of 68.9% at 2 years and 60.6% at 5 years. Of the 58 patients, 13 (22.4%) developed recurrent PJI, three (5.2%) aseptic loosening, and one (1.7%) periprosthetic fracture. Multivariate analysis revealed that obesity (hazard ratio (HR), 3.11), high-virulent pathogen (HR, 3.44), and polymicrobial infection (HR, 3.59) were independent risk factors for reinfection. Patients showed a mean improvement of 32.8 ± 7.7 in Knee Society Clinical Score (KSCS) and 30.8 ± 11.0 in Knee Society Function Score (KSFS) after successful reconstruction (P<0.001). CONCLUSIONS Using hinged knee prosthesis for PJI reconstruction provided an overall implant survival of 70.2% and an infection-free survival of 60.6% at mid-term follow up. Obesity, virulent pathogens, and polymicrobial infections were independent risk factors for infection recurrence.
Collapse
Affiliation(s)
- Michael Jian-Wen Chen
- Division of Joint Reconstruction, Department of Orthopedic Surgery, Bone and Joint Research Center, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan, Taiwan
| | - Jui-Fu Hung
- College of Medicine, Chang Gung University, Taoyuan City, Taiwan
| | - Chih-Hsiang Chang
- Division of Joint Reconstruction, Department of Orthopedic Surgery, Bone and Joint Research Center, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan, Taiwan; College of Medicine, Chang Gung University, Taoyuan City, Taiwan
| | - Sheng-Hsun Lee
- Division of Joint Reconstruction, Department of Orthopedic Surgery, Bone and Joint Research Center, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan, Taiwan; College of Medicine, Chang Gung University, Taoyuan City, Taiwan
| | - Hsin-Nung Shih
- Division of Joint Reconstruction, Department of Orthopedic Surgery, Bone and Joint Research Center, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan, Taiwan; College of Medicine, Chang Gung University, Taoyuan City, Taiwan
| | - Yu-Han Chang
- Division of Joint Reconstruction, Department of Orthopedic Surgery, Bone and Joint Research Center, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan, Taiwan; College of Medicine, Chang Gung University, Taoyuan City, Taiwan.
| |
Collapse
|
33
|
Xu C, Goswami K, Li WT, Tan TL, Yayac M, Wang SH, Parvizi J. Is Treatment of Periprosthetic Joint Infection Improving Over Time? J Arthroplasty 2020; 35:1696-1702.e1. [PMID: 32192834 DOI: 10.1016/j.arth.2020.01.080] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Accepted: 01/30/2020] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND It is unknown whether the outcomes of treatment for periprosthetic joint infection (PJI) are improving with time. This study evaluated trends in PJI treatment outcomes in the hip and knee following 2-stage exchange arthroplasty and irrigation and debridement (I&D) over the last 17 years. METHODS We reviewed 550 two-stage exchange arthroplasties and 194 I&Ds between 2000 and 2016 at our institution. Treatment success was defined according to the Delphi consensus criteria and Kaplan-Meier survivorship curves were generated. A multivariate Cox proportional hazards regression model was generated to determine time trends in the outcome of PJI treatment with the year of surgery included as both a continuous covariate (per 1-year increase) and a categorical covariate (2000-2010 or 2011-2016). RESULTS The survivorship of I&D, 2-stage revision, and the total combined cohort were comparable between 2000-2010 and 2011-2016 groups. Multivariate Cox regression analysis showed that the year of surgery was not associated with treatment failure following an I&D or 2-stage exchange arthroplasty, and neither did it increase the risk of non-reimplantation. When year of surgery was considered as a categorical variable, there remained no significant difference in treatment failure following an I&D or 2-stage exchange arthroplasty between the 2000-2010 cohort and 2011-2016 cohort. CONCLUSION Despite the increasing clinical focus, research advances, and growing literature relating to PJI, we were unable to detect any substantial improvement in the treatment success rates of PJI at our institution over the 17 years examined in this study. Novel treatments and techniques are certainly needed as current and prior strategies remain far from optimal.
Collapse
Affiliation(s)
- Chi Xu
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA; Department of Orthopaedic Surgery, General Hospital of People's Liberation Army, Beijing, China
| | - Karan Goswami
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA
| | - William T Li
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA
| | - Timothy L Tan
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA
| | - Michael Yayac
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA
| | - Sheng-Hao Wang
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA; Department of Orthopaedics, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Javad Parvizi
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA
| |
Collapse
|
34
|
Kim S, Bishop AR, Squire MW, Rose WE, Ploeg HL. Mechanical, elution, and antibacterial properties of simplex bone cement loaded with vancomycin. J Mech Behav Biomed Mater 2020; 103:103588. [DOI: 10.1016/j.jmbbm.2019.103588] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Revised: 12/06/2019] [Accepted: 12/07/2019] [Indexed: 02/08/2023]
|
35
|
Wang X, Wang S, Fu J, Sun D, Shen J, Xie Z. Risk factors associated with recurrence of extremity osteomyelitis treated with the induced membrane technique. Injury 2020; 51:307-311. [PMID: 31771787 DOI: 10.1016/j.injury.2019.11.026] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Revised: 11/10/2019] [Accepted: 11/20/2019] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Our aim was to observe the efficacy of the induced membrane technique in the treatment of extremity osteomyelitis and to analyse the causes of infection recurrence and its risk factors. METHODS We retrospectively analysed 424 cases of extremity osteomyelitis treated with the induced membrane technique in our department between May 2013 and June 2017. Infection recurrence time, recurrence sites and other relevant information were collected, summarized, and analysed. RESULTS A total of 424 patients were considered as "cured" of osteomyelitis after the first stage and the induced membrane technique was performed to rebuild the bone defects. After a mean follow-up of 31.6 (16-63) months, 52 patients had recurrence of infection, including 42 tibias and 10 femurs. The recurrence rate was 12.26%. Symptoms were relieved in 16 patients after intravenous antibiotic treatment. In the remaining 36 cases (8.49%), the infection was uncontrolled by intravenous antibiotics and surgical debridement was performed. The recurrence rate of infection of the tibia (16.22%) was higher than that of the femur (8.70%). The recurrence rate of post-traumatic osteomyelitis (14.66%) was significantly higher than that of hematogenous osteomyelitis (2.41%). Patients in whom Pseudomonas aeruginosa was isolated at the first stage had a recurrence rate of 28% (7/25), which was higher than that with the other isolated bacteria. Logistic regression analysis showed that repeated operations (≥3), post-traumatic osteomyelitis, and internal fixation at the first stage were risk factors for recurrence of infection, with odds ratios (ORs) of 2.30, 5.53 and 5.28 respectively. CONCLUSIONS The induced membrane technique is an effective method in the treatment of extremity osteomyelitis, although infection recurs in some cases. Repeated operations, post-traumatic osteomyelitis, and internal fixation at the first stage were risk factors for recurrence of infection. P. aeruginosa isolated at the first stage, tibia osteomyelitis, the presence of sinus, or flaps may also be associated with recurrence of infection.
Collapse
Affiliation(s)
- Xiaohua Wang
- National & Regional United Engineering Laboratory of Tissue Engineering, Department of Orthopaedics, First Affiliated Hospital, Third Military Medical University (Army Medical University), Chongqing 400038, PR China
| | - Shulin Wang
- National & Regional United Engineering Laboratory of Tissue Engineering, Department of Orthopaedics, First Affiliated Hospital, Third Military Medical University (Army Medical University), Chongqing 400038, PR China
| | - Jingshu Fu
- National & Regional United Engineering Laboratory of Tissue Engineering, Department of Orthopaedics, First Affiliated Hospital, Third Military Medical University (Army Medical University), Chongqing 400038, PR China
| | - Dong Sun
- National & Regional United Engineering Laboratory of Tissue Engineering, Department of Orthopaedics, First Affiliated Hospital, Third Military Medical University (Army Medical University), Chongqing 400038, PR China
| | - Jie Shen
- National & Regional United Engineering Laboratory of Tissue Engineering, Department of Orthopaedics, First Affiliated Hospital, Third Military Medical University (Army Medical University), Chongqing 400038, PR China
| | - Zhao Xie
- National & Regional United Engineering Laboratory of Tissue Engineering, Department of Orthopaedics, First Affiliated Hospital, Third Military Medical University (Army Medical University), Chongqing 400038, PR China.
| |
Collapse
|
36
|
Xu C, Jia CQ, Kuo FC, Chai W, Zhang MH, Chen JY. Does the use of a closed-suction drain reduce the effectiveness of an antibiotic-loaded spacer in two-stage exchange Arthroplasty for Periprosthetic hip infection? A prospective, randomized, controlled study. BMC Musculoskelet Disord 2019; 20:583. [PMID: 31801510 PMCID: PMC6894212 DOI: 10.1186/s12891-019-2974-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Accepted: 11/27/2019] [Indexed: 12/04/2022] Open
Abstract
Background There is a concern regarding the use of a closed-suction drain (CSD) in two-stage exchange arthroplasty for periprosthetic joint infection as it may decrease the antibiotic concentrations in the joint fluids. The purpose of this study was to identify whether the use of a CSD could reduce local antibiotic concentrations following spacer implantation. Methods A prospective, randomized, controlled trial was conducted at our institution between January 2018 and November 2018. We enrolled 32 patients undergoing two-stage exchange arthroplasty for periprosthetic hip infection with an interim cement spacer containing 4-g vancomycin and 2-g meropenem per 40-g methyl-methacrylate cement polymer. Patients were randomized and evenly divided into the study group (non-CSD) and control group (CSD group) by sealed envelopes. Drainage samples of joint fluids (n = 160) were collected every 24 h for the first five days following spacer implantation. The antibiotic concentrations of drainage samples were measured by high-performance liquid chromatography, and the bioactivities of the drainage samples against methicillin-sensitive and methicillin-resistant Staphylococcus aureus (MSSA and MRSA) and E. coli were assessed. Results There was no significant difference in the decrease of vancomycin (study group vs. control group: 163.20 ± 77.05 vs. 162.39 ± 36.31; p = 0.917) and meropenem concentration (123.78 ± 21.04 vs. 117.27 ± 19.38; P = 0.548) between the two groups during the first five days following spacer implantation. All joint drainage samples in each group exhibited antibacterial activity against MSSA, MRSA and E. coli. Conclusions The use of CSD following the implantation of an antibiotic-loaded cement spacer does not reduce the effectiveness of such a spacer in two-stage exchange arthroplasty. (Chinese Clinical Trial Registry, ChiCTR-INR-17014162. Registered 26 December 2017.)
Collapse
Affiliation(s)
- Chi Xu
- Department of Orthopaedic Surgery, General Hospital of Peoples Liberation Army, No. 28 Fuxing Road, Beijing, 100853, Haidian District, China
| | - Cheng-Qi Jia
- Department of Orthopaedic Surgery, General Hospital of Peoples Liberation Army, No. 28 Fuxing Road, Beijing, 100853, Haidian District, China
| | - Feng-Chih Kuo
- Department of Orthopaedic Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University, College of Medicine, Kaohsiung, Taiwan
| | - Wei Chai
- Department of Orthopaedic Surgery, General Hospital of Peoples Liberation Army, No. 28 Fuxing Road, Beijing, 100853, Haidian District, China
| | - Ming-Hua Zhang
- Department of Clinical Pharmacy Laboratory, General Hospital of Peoples Liberation Army, No. 28 Fuxing Road, Beijing, 100853, Haidian District, China
| | - Ji-Ying Chen
- Department of Orthopaedic Surgery, General Hospital of Peoples Liberation Army, No. 28 Fuxing Road, Beijing, 100853, Haidian District, China.
| |
Collapse
|
37
|
Li T, Fu L, Wang J, Shi Z. High dose of vancomycin plus gentamicin incorporated acrylic bone cement decreased the elution of vancomycin. Infect Drug Resist 2019; 12:2191-2199. [PMID: 31410038 PMCID: PMC6645360 DOI: 10.2147/idr.s203740] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Accepted: 07/03/2019] [Indexed: 12/23/2022] Open
Abstract
Purpose Low doses of vancomycin and gentamicin were commonly incorporated into acrylic bone cement (antibiotic-impregnated bone cement, AIBC) during revision arthroplasty. Previous studies showed that only a very small amount of antibiotics could be eluted from AIBC. Given the fact that a high dose of antibiotic would elute high concentration of antibiotic, this study investigated the influence of a high dose of dual-antibiotic loading on the properties of cement. Methods A total of 8 groups of AIBC containing either gentamicin or vancomycin or both with different amounts of antibiotics (1 g, 2 g and 4 g) were tested on material properties, elution profiles, antibacterial activity and cytological toxicity. Results A high dose of gentamicin and vancomycin AIBC (with 2 g gentamicin and 2 g vancomycin loaded) regiment showed acceptable compressive strength of 74.25±0.72 MPa. No cytotoxicity or antibacterial activity reduction was observed in any group tested in this study. The elution profiles indicated that incorporating 2 g vancomycin resulted in 4.77% (1049.57±3.74 μg) released after 28 days. However, after 2 g gentamicin was added, the vancomycin released was significantly reduced to 2.42% (532.24±1.77 μg) (p<0.001), approximately 50% reduction. No significant influence of vancomycin on gentamicin was observed. Conclusion These findings suggest that the addition of 2 g vancomycin and 2 g gentamicin into acrylic bone cement was preferred while considering this dual-antibiotic AIBC regiment with acceptably material properties and effective antibacterial activity. However, special attention should be drawn to the reduction of vancomycin elution when incorporated with gentamicin.
Collapse
Affiliation(s)
- Tao Li
- Department of Orthopedics, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, People's Republic of China
| | - Lilan Fu
- Nanfang PET Center, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, People's Republic of China
| | - Jian Wang
- Department of Orthopedics, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, People's Republic of China
| | - Zhanjun Shi
- Department of Orthopedics, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, People's Republic of China
| |
Collapse
|
38
|
Shakked R, Da Rin de Lorenzo F. What Determines the Type and Dose of Antibiotic That Is Needed to Be Added to the Cement Spacer in Patients With Infected Total Ankle Arthroplasty (TAA)? Foot Ankle Int 2019; 40:48S-52S. [PMID: 31322933 DOI: 10.1177/1071100719861098] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
RECOMMENDATION We recommend tailoring the antibiotic in cement spacers to the infecting organism if it has been identified, as is typically done in total knee and hip arthroplasty. Otherwise, broad-spectrum antibiotics may be utilized. Medical comorbidities should always be considered, especially with regard to renal function and allergy profile. A thermostable antibiotic should be added to cement. LEVEL OF EVIDENCE Consensus. DELEGATE VOTE Agree: 100%, Disagree: 0%, Abstain: 0% (Unanimous, Strongest Consensus).
Collapse
|
39
|
A preliminary study of the novel antibiotic-loaded cement computer-aided design-articulating spacer for the treatment of periprosthetic knee infection. J Orthop Surg Res 2019; 14:136. [PMID: 31096988 PMCID: PMC6521453 DOI: 10.1186/s13018-019-1175-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Accepted: 04/29/2019] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND In comparison to static spacers, articulating spacers have been shown to result in a similar infection eradication rate in two-stage revision of periprosthetic knee infections. However, the optimal construct for articulating spacers has not been identified yet. The aim of this study was to present a preliminary result of treatment for periprosthetic knee infection using a novel computer-aided design (CAD)-articulating spacer. METHODS We retrospectively reviewed 32 consecutive cases of chronic periprosthetic knee infection occurring from January 2015 to December 2015. In these cases, we used an antibiotic-loaded, optimized CAD-articulating spacer based on the retrieved knee prosthesis. Evaluation included infection eradication rate, the Hospital of Special Surgery (HSS) knee score, range of motion (ROM), and spacer-related mechanical complications. All cases were regularly followed-up for 2 years minimum. RESULTS Twenty-eight of 32 patients (87.5%) had infection eradication; 18 patients (56.3%) received reimplantation successfully. The mean interval between spacer insertion and reimplantation was 8.8 months (range 4.0-12.5 months). The mean HSS knee score and ROM significantly increased during each interval (p < 0.0001 for both). The mean HSS knee scores were 31.2 (range 20-48) at initial visit, 65.4 (range 60-78.8) at 1 month after spacer insertion, and 84.2 (range 78-90) at 3 months after reimplantation (p < 0.0001). The mean ROM were 72.0° (range 15-100°), 85.6° (range 35-110°), and 102.0° (range 80-122°), respectively (p = 0.002). Two (6.3%) spacer-related mechanical complications occurred. CONCLUSIONS The CAD-articulating spacer in two-staged revision of periprosthetic knee infection significantly controlled infection, improved clinical outcomes, increased ROM, and decreased mechanical complications in the preliminary study. Further larger clinical studies are needed to confirm the findings presented here.
Collapse
|
40
|
Chen MF, Chang CH, Yang LY, Hsieh PH, Shih HN, Ueng SWN, Chang Y. Synovial fluid interleukin-16, interleukin-18, and CRELD2 as novel biomarkers of prosthetic joint infections. Bone Joint Res 2019; 8:179-188. [PMID: 31069072 PMCID: PMC6498892 DOI: 10.1302/2046-3758.84.bjr-2018-0291.r1] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
Objectives Prosthetic joint infection (PJI) diagnosis is a major challenge in orthopaedics, and no reliable parameters have been established for accurate, preoperative predictions in the differential diagnosis of aseptic loosening or PJI. This study surveyed factors in synovial fluid (SF) for improving PJI diagnosis. Methods We enrolled 48 patients (including 39 PJI and nine aseptic loosening cases) who required knee/hip revision surgery between January 2016 and December 2017. The PJI diagnosis was established according to the Musculoskeletal Infection Society (MSIS) criteria. SF was used to survey factors by protein array and enzyme-linked immunosorbent assay to compare protein expression patterns in SF among three groups (aseptic loosening and first- and second-stage surgery). We compared routine clinical test data, such as C-reactive protein level and leucocyte number, with potential biomarker data to assess the diagnostic ability for PJI within the same patient groups. Results Cut-off values of 1473 pg/ml, 359 pg/ml, and 8.45 pg/ml were established for interleukin (IL)-16, IL-18, and cysteine-rich with EGF-like domains 2 (CRELD2), respectively. Receiver operating characteristic curve analysis showed that these factors exhibited an accuracy of 1 as predictors of PJI. These factors represent potential biomarkers for decisions associated with prosthesis reimplantation based on their ability to return to baseline values following the completion of debridement. Conclusion IL-16, IL-18, and CRELD2 were found to be potential biomarkers for PJI diagnosis, with SF tests outperforming blood tests in accuracy. These factors could be useful for assessing successful debridement based on their ability to return to baseline values following the completion of debridement.Cite this article: M-F. Chen, C-H. Chang, L-Y. Yang, P-H. Hsieh, H-N. Shih, S. W. N. Ueng, Y. Chang. Synovial fluid interleukin-16, interleukin-18, and CRELD2 as novel biomarkers of prosthetic joint infections. Bone Joint Res 2019;8:179-188. DOI: 10.1302/2046-3758.84.BJR-2018-0291.R1.
Collapse
Affiliation(s)
- M-F Chen
- Bone and Joint Research Center, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - C-H Chang
- Bone and Joint Research Center, Chang Gung Memorial Hospital, Taoyuan, Taiwan; Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan; Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - L-Y Yang
- Biostatistics Unit, Clinical Trial Center, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - P-H Hsieh
- Bone and Joint Research Center, Chang Gung Memorial Hospital, Taoyuan, Taiwan; Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - H-N Shih
- Bone and Joint Research Center, Chang Gung Memorial Hospital, Taoyuan, Taiwan; Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - S W N Ueng
- Bone and Joint Research Center, Chang Gung Memorial Hospital, Taoyuan, Taiwan; Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Y Chang
- Bone and Joint Research Center, Chang Gung Memorial Hospital, Taoyuan, Taiwan; Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| |
Collapse
|
41
|
Hsu YH, Chen DWC, Li MJ, Yu YH, Chou YC, Liu SJ. Sustained Delivery of Analgesic and Antimicrobial Agents to Knee Joint by Direct Injections of Electrosprayed Multipharmaceutical-Loaded Nano/Microparticles. Polymers (Basel) 2018; 10:polym10080890. [PMID: 30960815 PMCID: PMC6403761 DOI: 10.3390/polym10080890] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Revised: 08/04/2018] [Accepted: 08/07/2018] [Indexed: 11/23/2022] Open
Abstract
In this study, we developed biodegradable lidocaine–/vancomycin–/ceftazidime–eluting poly(d,l–lactide–co–glycolide) (PLGA) nano/microparticulate carriers using an electrospraying process, and we evaluated the release behaviors of the carriers in knee joints. To prepare the particles, predetermined weight percentages of PLGA, vancomycin, ceftazidime, and lidocaine were dissolved in solvents. The PLGA/antibiotic/lidocaine solutions were then fed into a syringe for electrospraying. After electrospraying, the morphology of the sprayed nano/microparticles was elucidated by scanning electron microscopy (SEM). The in vitro antibiotic/analgesic release characteristics of the nano/microparticles were studied using high-performance liquid chromatography (HPLC). In addition, drug release to the synovial tissues and fluids was studied in vivo by injecting drug-loaded nano/microparticles into the knee joints of rabbits. The biodegradable electrosprayed nano/microparticles released high concentrations of vancomycin/ceftazidime (well above the minimum inhibition concentration) and lidocaine into the knee joints for more than 2 weeks and for over 3 days, respectively. Such results suggest that electrosprayed biodegradable nano/microcarriers could be used for the long-term local delivery of various pharmaceuticals.
Collapse
Affiliation(s)
- Yung-Heng Hsu
- Department of Orthopedic Surgery, Chang Gung Memorial Hospital-Linkou, Tao-Yuan 33305, Taiwan.
- Department of Mechanical Engineering, Chang Gung University, Tao-Yuan 33302, Taiwan.
| | - Dave Wei-Chih Chen
- Department of Orthopedic Surgery, Chang Gung Memorial Hospital-Keelung, Keelung 20401, Taiwan.
| | - Min-Jhan Li
- Department of Mechanical Engineering, Chang Gung University, Tao-Yuan 33302, Taiwan.
| | - Yi-Hsun Yu
- Department of Orthopedic Surgery, Chang Gung Memorial Hospital-Linkou, Tao-Yuan 33305, Taiwan.
- Department of Mechanical Engineering, Chang Gung University, Tao-Yuan 33302, Taiwan.
| | - Ying-Chao Chou
- Department of Orthopedic Surgery, Chang Gung Memorial Hospital-Linkou, Tao-Yuan 33305, Taiwan.
- Department of Mechanical Engineering, Chang Gung University, Tao-Yuan 33302, Taiwan.
| | - Shih-Jung Liu
- Department of Orthopedic Surgery, Chang Gung Memorial Hospital-Linkou, Tao-Yuan 33305, Taiwan.
- Department of Mechanical Engineering, Chang Gung University, Tao-Yuan 33302, Taiwan.
| |
Collapse
|
42
|
Chang MJ, Song MK, Shin JH, Yoon C, Chang CB, Kang SB. Two-stage approach to total knee arthroplasty using colistin-loaded articulating cement spacer for vancomycin-resistant Pseudomonas aeruginosa infection in an arthritic knee. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2018; 29:227-230. [PMID: 29915953 DOI: 10.1007/s00590-018-2268-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Accepted: 06/09/2018] [Indexed: 10/14/2022]
Abstract
BACKGROUND A two-stage approach to total knee arthroplasty (TKA) using an antibiotic-impregnated articulating cement spacer is an option for an infected arthritic knee. Vancomycin combined with broad-spectrum antibiotics can be used to make an antibiotic-impregnated articulating cement spacer. Causative organisms are sometimes not confirmed before surgery. Joint infections of multidrug-resistant organisms are increasing. Therefore, routine combinations of antibiotics may not be effective. METHODS AND RESULTS We present a case of a patient who developed vancomycin-resistant Pseudomonas aeruginosa infection in an arthritic knee. A 71-year-old man was initially diagnosed with pyogenic arthritis caused by Staphylococcus aureus. He underwent arthroscopic debridement elsewhere. However, the infection persisted. He was referred to our hospital, and we performed a two-stage TKA using a vancomycin-based antibiotic-impregnated articulating cement spacer. Vancomycin-resistant P. aeruginosa was identified after surgery. Intravenous colistin was added. However, this failed, either because vancomycin was not effective against P. aeruginosa, or because insufficient systemic colistin due to colistin-induced acute kidney injury. Therefore, debridement was repeated, and colistin-loaded cement spacer was inserted. The spacer delivered high concentrations of colistin to the infected joint with decreased systemic effects. Thus, less systemic colistin was used. The infection was controlled without recurrent acute kidney injury. One year after surgery, conversion to TKA was successfully performed. CONCLUSION A two-stage approach to TKA using a colistin-loaded articulating cement spacer can be used for an arthritic knee infected by vancomycin-resistant P. aeruginosa. Furthermore, local administration of colistin using a cement spacer can reduce the systemic side effects of colistin.
Collapse
Affiliation(s)
- Moon Jong Chang
- Department of Orthopaedic Surgery, SMG-SNU Boramae Medical Center, Seoul National University College of Medicine, 20, Boramae-ro 5-gil, Dongjak-gu, Seoul, 156-707, South Korea
| | - Min Kyu Song
- Department of Orthopaedic Surgery, SMG-SNU Boramae Medical Center, Seoul National University College of Medicine, 20, Boramae-ro 5-gil, Dongjak-gu, Seoul, 156-707, South Korea
| | - Jae Hoon Shin
- Department of Orthopaedic Surgery, SMG-SNU Boramae Medical Center, Seoul National University College of Medicine, 20, Boramae-ro 5-gil, Dongjak-gu, Seoul, 156-707, South Korea
| | - Chan Yoon
- Department of Orthopaedic Surgery, SMG-SNU Boramae Medical Center, Seoul National University College of Medicine, 20, Boramae-ro 5-gil, Dongjak-gu, Seoul, 156-707, South Korea
| | - Chong Bum Chang
- Department of Orthopaedic Surgery, SMG-SNU Boramae Medical Center, Seoul National University College of Medicine, 20, Boramae-ro 5-gil, Dongjak-gu, Seoul, 156-707, South Korea
| | - Seung-Baik Kang
- Department of Orthopaedic Surgery, SMG-SNU Boramae Medical Center, Seoul National University College of Medicine, 20, Boramae-ro 5-gil, Dongjak-gu, Seoul, 156-707, South Korea.
| |
Collapse
|
43
|
Carli AV, Sethuraman AS, Bhimani SJ, Ross FP, Bostrom MPG. Selected Heat-Sensitive Antibiotics Are Not Inactivated During Polymethylmethacrylate Curing and Can Be Used in Cement Spacers for Periprosthetic Joint Infection. J Arthroplasty 2018; 33:1930-1935. [PMID: 29610009 DOI: 10.1016/j.arth.2018.01.034] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2017] [Revised: 12/29/2017] [Accepted: 01/19/2018] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Antibiotic use in polymethylmethacrylate (PMMA) spacers has historically been limited to those which are "heat-stable" and thus retain their antimicrobial properties after exposure to the high temperatures which occur during PMMA curing. METHODS This study examines the requirement of "heat stability" by measuring temperatures of Palacos and Simplex PMMA as they cure inside commercial silicone molds of the distal femur and proximal tibia. Temperature probes attached to thermocouples were placed at various depths inside the molds and temperatures were recorded for 20 minutes after PMMA introduced and a temperature curve for each PMMA product was determined. A "heat-stable" antibiotic, vancomycin, and a "heat-sensitive" antibiotic, ceftazidime, were placed in a programmable thermocycler and exposed to the same profile of PMMA curing temperatures. Antimicrobial activity against Staphylococcus aureus was compared for heat-treated antibiotics vs room temperature controls. RESULTS Peak PMMA temperatures were significantly higher in tibial (115.2°C) vs femoral (85.1°C; P < .001) spacers. In the hottest spacers, temperatures exceeded 100°C for 3 minutes. Simplex PMMA produced significantly higher temperatures (P < .05) compared with Palacos. Vancomycin bioactivity did not change against S aureus with heat exposure. Ceftazidime bioactivity did not change when exposed to femoral temperature profiles and was reduced only 2-fold with tibial profiles. CONCLUSION The curing temperatures of PMMA in knee spacers are not high enough or maintained long enough to significantly affect the antimicrobial efficacy of ceftazidime, a known "heat-sensitive" antibiotic. Future studies should investigate if more "heat-sensitive" antibiotics could be used clinically in PMMA spacers.
Collapse
Affiliation(s)
- Alberto V Carli
- Hospital for Special Surgery, New York, NY; The Ottawa Hospital, Ottawa, Canada
| | | | | | | | | |
Collapse
|
44
|
Levack AE, Cyphert EL, Bostrom MP, Hernandez CJ, von Recum HA, Carli AV. Current Options and Emerging Biomaterials for Periprosthetic Joint Infection. Curr Rheumatol Rep 2018; 20:33. [PMID: 29713837 DOI: 10.1007/s11926-018-0742-4] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE OF REVIEW Infection in the setting of total joint arthroplasty, referred to as periprosthetic joint infection (PJI), is a devastating complication requiring prolonged and costly treatment. The unique environment around an artificial joint and ability of surrounding tissues to sequester bacteria collectively make prevention, diagnosis, and treatment of this condition challenging. In light of the unique pathogenesis of PJI, this review explores the limitations of contemporary treatments and discusses novel treatment options. RECENT FINDINGS Recent advancements in local antibiotic delivery platforms for preventing and treating PJI include titanium nanotube arrays, synthetic polymers, resorbable hydrogels, and cyclodextrin-based drug delivery options. In particular, cyclodextrins have facilitated great advancements in other clinical disorders and have demonstrated early promise as a future option in the arena of PJI. Novel treatment modalities for PJI optimize the implant surfaces to prevent bacterial biofilm formation or provide prolonged intra-articular antibiotic dosing to eradicate bacteria.
Collapse
Affiliation(s)
| | - Erika L Cyphert
- Department of Biomedical Engineering, Case Western Reserve University, Room 220 Wickenden Building, 10900 Euclid Avenue, Cleveland, OH, 44106, USA
| | | | - Christopher J Hernandez
- Hospital for Special Surgery, New York, NY, USA
- Sibley School of Mechanical and Aerospace Engineering, Cornell University, Ithaca, NY, USA
- Meinig School of Biomedical Engineering, Cornell University, Ithaca, NY, USA
| | - Horst A von Recum
- Department of Biomedical Engineering, Case Western Reserve University, Room 220 Wickenden Building, 10900 Euclid Avenue, Cleveland, OH, 44106, USA.
| | - Alberto V Carli
- Hospital for Special Surgery, New York, NY, USA
- Surgery, The Ottawa Hospital, Ottawa, ON, Canada
| |
Collapse
|
45
|
Souery WN, Bishop CJ. Clinically advancing and promising polymer-based therapeutics. Acta Biomater 2018; 67:1-20. [PMID: 29246651 DOI: 10.1016/j.actbio.2017.11.044] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2017] [Revised: 11/11/2017] [Accepted: 11/27/2017] [Indexed: 12/11/2022]
Abstract
In this review article, we will examine the history of polymers and their evolution from provisional World War II materials to medical therapeutics. To provide a comprehensive look at the current state of polymer-based therapeutics, we will classify technologies according to targeted areas of interest, including central nervous system-based and intraocular-, gastrointestinal-, cardiovascular-, dermal-, reproductive-, skeletal-, and neoplastic-based systems. Within each of these areas, we will consider several examples of novel, clinically available polymer-based therapeutics; in addition, this review will also include a discussion of developing therapies, ranging from the in vivo to clinical trial stage, for each targeted area of treatment. Finally, we will emphasize areas of patient care in need of more effective, accessible, and targeted treatment approaches where polymer-based therapeutics may offer potential solutions.
Collapse
Affiliation(s)
- Whitney N Souery
- Department of Biomedical Engineering, Texas A&M University, Emerging Technologies Building, 101 Bizzell St., College Station, TX 77843, USA
| | - Corey J Bishop
- Department of Biomedical Engineering, Texas A&M University, Emerging Technologies Building, 101 Bizzell St., College Station, TX 77843, USA.
| |
Collapse
|
46
|
Athans V, Veve MP, Davis SL. Trowels and Tribulations: Review of Antimicrobial-Impregnated Bone Cements in Prosthetic Joint Surgery. Pharmacotherapy 2017; 37:1565-1577. [DOI: 10.1002/phar.2040] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- Vasilios Athans
- Department of Pharmacy Services; Cleveland Clinic; Cleveland Ohio
| | - Michael P. Veve
- Eugene Applebaum College of Pharmacy and Health Sciences; Wayne State University; Detroit Michigan
- Department of Pharmacy Services; Henry Ford Hospital; Detroit Michigan
| | - Susan L. Davis
- Eugene Applebaum College of Pharmacy and Health Sciences; Wayne State University; Detroit Michigan
- Department of Pharmacy Services; Henry Ford Hospital; Detroit Michigan
| |
Collapse
|
47
|
Zhang Y, Shen L, Mao Z, Wang N, Wang X, Huang X, Hu Y, Shou D, Wen C. Icariin Enhances Bone Repair in Rabbits with Bone Infection during Post-infection Treatment and Prevents Inhibition of Osteoblasts by Vancomycin. Front Pharmacol 2017; 8:784. [PMID: 29163169 PMCID: PMC5671559 DOI: 10.3389/fphar.2017.00784] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2017] [Accepted: 10/16/2017] [Indexed: 12/13/2022] Open
Abstract
Vancomycin is an effective antibiotic for treatment of bone infection caused by Staphylococcus aureus, however, a high local concentration of vancomycin might induce a delay in bone union. Icariin has been reported to suppress osteoclastogenes and promote osteogenesis. Our study aimed to investigate the effect of icariin on bone repair after anti-infection treatment in vivo and to explore the resisting effect of icariin on rat calvarial osteoblasts (ROBs) inhibited with high doses of vancomycin. Rabbits with bone infection of S. aureus were treated with implanted vancomycin-calcium sulfate (VCS) and icariin at 10.86 mg/kg/day for consecutive 8 weeks. Micro-CT, morphology, blood biochemistry were evaluated. In addition, ROBs were treated with vancomycin and icariin at different doses. Cell proliferation and differentiation capabilities, BMP2, Runx2, OPG, RANKL mRNA levels and protein expression were assessed. The results indicated that high dose of vancomycin significantly decreased bone mass and inhibited osteocalcin secretion; icariin increased these indicators compared with the single vancomycin treatment. Over 0.1 mg/mL of vancomycin inhibited the proliferation and differentiation of ROBs, while icariin resisted the inhibition of vancomycin by regulating cell cycle and promoting the Alkaline phosphatase (ALP) activity. Moreover, icariin promote bone formation by up-regulating BMP2/Runx2 and OPG/RANKL pathways. Icariin exhibited osteoplastic properties on osteoblasts that had been inhibited with high doses of vancomycin. Therefore, icariin is helpful for post-infection treatment of bone infection.
Collapse
Affiliation(s)
- Yang Zhang
- Department of Medicine, Zhejiang Academy of Traditional Chinese Medicine, Hangzhou, China
| | - Lifeng Shen
- Department of Orthopaedic Surgery, Zhejiang Provincial Tongde Hospital, Hangzhou, China
| | - Zhujun Mao
- Department of Medicine, Zhejiang Academy of Traditional Chinese Medicine, Hangzhou, China
| | - Nani Wang
- Department of Medicine, Zhejiang Academy of Traditional Chinese Medicine, Hangzhou, China
| | - Xuping Wang
- Department of Medicine, Zhejiang Academy of Traditional Chinese Medicine, Hangzhou, China
| | - Xiaowen Huang
- Department of Medicine, Zhejiang Academy of Traditional Chinese Medicine, Hangzhou, China
| | - Ying Hu
- Zhejiang Pharmaceutical College, Ningbo, China
| | - Dan Shou
- Department of Medicine, Zhejiang Academy of Traditional Chinese Medicine, Hangzhou, China
| | - Chengping Wen
- College of Basic Medicine, Zhejiang Chinese Medical University, Hangzhou, China
| |
Collapse
|