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Ersoy A, Say F, Tokur O, Karaca E, Aksoy A, Çiftçi A. High-dose vancomycin spacers provided early recovery without nephrotoxicity compared with standard-dose in MRSA-induced periprosthetic joint infection model of rats. Knee 2024; 49:125-134. [PMID: 38909590 DOI: 10.1016/j.knee.2024.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Revised: 05/01/2024] [Accepted: 06/03/2024] [Indexed: 06/25/2024]
Abstract
BACKGROUND Periprosthetic joint infections (PJIs) are commonly treated with two-stage revision surgery utilising antibiotic-loaded spacers; however, antibiotic release from spacers is limited and usually drops below effective levels a few days after placement. This study compared high-dose and standard-dose vancomycin-loaded spacers in terms of efficacy, safety, and overall treatment duration in a rat periprosthetic joint infection model. METHODS Thirty male Wistar albino rats (8-10 weeks old, 300-320 g) were housed individually at standard conditions. A periprosthetic infection model was established in the right knee of the rats using methicillin-resistant Staphylococcus aureus (MRSA) -contaminated Kirschner wires. Two weeks later, the infection was verified, and the Kirschner wires were removed. Rats were randomly divided into three groups (n = 10): standard-dose (SVanc) and high-dose (HVanc) vancomycin groups had 2.5 and 7.5% vancomycin in their spacers, respectively, while the control group had no spacers. All groups received intramuscular (IM) vancomycin and gentamicin for 4 weeks after spacer implantation. Microbiological counts and vancomycin levels in the blood and joint flush samples were measured, and histopathological assessments were conducted on the femur and kidneys. RESULTS After spacer implantation, MRSA was eliminated in the HVanc group with 4 weeks of treatment, while the SVanc group required 6 weeks of treatment (P < 0.001). Histopathological findings of the femoral medulla and cortical samples were better in the HVanc group compared with other groups (P = 0.007). Vancomycin levels in serum remained within safe limits in all groups, and kidney damage was not observed. CONCLUSION The use of high-dose vancomycin spacers might accelerate the transition period, which in turn reduces the duration of systemic antibiotic use and mitigates the risk of nephrotoxicity. Thus, this method may decrease the medical costs associated with PJI treatment.
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Affiliation(s)
- Ahmet Ersoy
- Department of Orthopaedics and Traumatology, Faculty of Medicine, Ondokuz Mayıs University, Türkiye.
| | - Ferhat Say
- Department of Orthopaedics and Traumatology, Faculty of Medicine, Ondokuz Mayıs University, Türkiye
| | - Orhan Tokur
- Department of Pharmacology and Toxicology, Faculty of Veterinary Medicine, Ondokuz Mayıs University, Türkiye
| | - Efe Karaca
- Department of Pathology, Faculty of Veterinary Medicine, Ondokuz Mayıs University, Türkiye
| | - Abdurrahman Aksoy
- Department of Pharmacology and Toxicology, Faculty of Veterinary Medicine, Ondokuz Mayıs University, Türkiye
| | - Alper Çiftçi
- Department of Microbiology, Faculty of Veterinary Medicine, Ondokuz Mayıs University, Türkiye
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Fraval A, Zhou Y, Parvizi J. Antibiotic-loaded cement in total joint arthroplasty: a comprehensive review. Arch Orthop Trauma Surg 2024:10.1007/s00402-024-05328-z. [PMID: 38687383 DOI: 10.1007/s00402-024-05328-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2024] [Accepted: 04/14/2024] [Indexed: 05/02/2024]
Abstract
This review evaluates the decision-making framework for using antibiotic-loaded cement (ALC) in the management of prosthetic joint infection (PJI). Drawing on available literature, we offer orthopaedic surgeons a guided discussion on several critical considerations. First, we explore the impact of antibiotic-loading on the mechanical properties of polymethylmethacrylate (PMMA) cement, assessing both strength and durability. We then explore the optimal antibiotic dosage to load into cement, aiming to achieve effective local concentrations for infection control without compromising mechanical stability. Furthermore, we explore how cement and antibiotic properties affect the overall antibiotic elution characteristics of ALC. Finally, we discuss risks of systemic toxicity, particularly acute kidney injury, when using ALC. The principal goal in this review is to provide a balanced approach based on best available evidence that optimises antibiotic elution from ALC whilst minimising potential harms associated with its use.
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Affiliation(s)
- Andrew Fraval
- Department of Orthopaedic Surgery, St. Vincent's Hospital Melbourne, 41 Victoria Parade, Fitzroy, VIC, 3065, Australia.
- Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, PA, USA.
| | - Yushy Zhou
- Department of Orthopaedic Surgery, St. Vincent's Hospital Melbourne, 41 Victoria Parade, Fitzroy, VIC, 3065, Australia
| | - Javad Parvizi
- Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, PA, USA
- International Joint Center, Acibadem University Hospital, Istanbul, Turkey
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3
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Springer BD, Higuera-Rueda CA, de Beaubien BC, Warner KD, Glassman AH, Parvataneni HK, Piuzzi NS. Safety Profile of Seven-Day Intra-articular Antibiotic Irrigation for the Treatment of Chronic Periprosthetic Joint Infection: A Prospective Randomized Phase II Comparative Study. J Arthroplasty 2024:S0883-5403(24)00313-9. [PMID: 38604274 DOI: 10.1016/j.arth.2024.03.069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Revised: 03/20/2024] [Accepted: 03/21/2024] [Indexed: 04/13/2024] Open
Abstract
BACKGROUND Systemic intravenous antimicrobials yield poor outcomes during treatment of periprosthetic joint infection due to the inability to obtain minimum biofilm eradication concentrations. This study evaluated the safety of a novel method of optimized local delivery of intra-articular antibiotics (IAAs). METHODS This was a Phase II, multicenter, prospective randomized trial evaluating safety of a rapid (seven-day) two-stage exchange arthroplasty with IAA irrigation compared to standard two-stage exchange. The Experimental Group received irrigation using 80 mg tobramycin daily with a 2-hour soak, followed by hourly irrigation using 125 mg vancomycin with a 30-minute soak via an intramedullary irrigation device. The Control Group received an antibiotic-loaded cement spacer with vancomycin (average 8.4 g) and tobramycin (average 7.1 g, total 16 g antibiotics). Both groups received 12 weeks of systemic antibiotics following Stage 2. Safety measures included adverse events, peak vancomycin/tobramycin serum concentrations (Experimental Group), blood transfusion, and mortality. There were thirty-seven patients randomized to the Experimental Group and 39 to control. There was no difference in baseline demographics or comorbidities. RESULTS There were no antibiotic medication-related adverse events and 2 serious adverse events related to antibiotic instillation. Of 188 vancomycin peak measurements, 69% had detectable serum level concentrations, with all concentrations well below the maximum acceptable trough threshold of 20 μg/mL. Of the 103 tobramycin peak measurements, 45% had detectable levels, with all below the maximum acceptable peak threshold of 18 to 24 μg/mL. There was no difference in blood transfused per subject (Experimental: 655 mL versus Control: 792 mL; P = .4188). There were two (2) deaths in the Experimental Group and four (4) in the control. CONCLUSIONS The use of IAA is safe with minimal systemic antibiotic exposure. There was no difference in the rates or severity of serious adverse events between groups. Further research is being conducted to examine treatment efficacy.
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Affiliation(s)
| | | | | | | | - Andrew H Glassman
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | | | - Nicolas S Piuzzi
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, Ohio
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4
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Adolf J, David Luo T, Gehrke T, Citak M. The top ten benefits of one-stage septic exchange in the management of periprosthetic joint infections. Arch Orthop Trauma Surg 2024:10.1007/s00402-024-05217-5. [PMID: 38393443 DOI: 10.1007/s00402-024-05217-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2023] [Accepted: 01/29/2024] [Indexed: 02/25/2024]
Affiliation(s)
- Jakob Adolf
- Helios ENDO-Klinik, Holstenstraße 2, 22767, Hamburg, Germany
| | - T David Luo
- Helios ENDO-Klinik, Holstenstraße 2, 22767, Hamburg, Germany
- Orthopaedics Northeast, 5050 N Clinton St, Fort Wayne, IN, 46825, USA
| | - Thorsten Gehrke
- Helios ENDO-Klinik, Holstenstraße 2, 22767, Hamburg, Germany
| | - Mustafa Citak
- Helios ENDO-Klinik, Holstenstraße 2, 22767, Hamburg, Germany.
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5
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Warwick HS, Tan TL, Rangwalla K, Shau DN, Barry JJ, Hansen EN. Effect of Antibiotic Spacer Dosing on Treatment Success in Two-Stage Exchange for Periprosthetic Joint Infection. J Am Acad Orthop Surg Glob Res Rev 2024; 8:01979360-202402000-00014. [PMID: 38385716 PMCID: PMC10883627 DOI: 10.5435/jaaosglobal-d-23-00103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Accepted: 01/10/2024] [Indexed: 02/23/2024]
Abstract
INTRODUCTION In two-stage exchange for periprosthetic joint infection (PJI), adding antibiotics to cement spacers is the standard of care; however, little is known about optimal dosage. There is emphasis on using >3.6 g of total antibiotic, including ≥2.0 g of vancomycin, per 40 g of cement, but these recommendations lack clinical evidence. We examined whether recommended antibiotic spacer doses affect treatment success. METHODS This was a retrospective review of 202 patients who underwent two-stage exchange for PJI from 2004 to 2020 with at least 1-year follow-up. Patients were separated into high (>3.6 g of total antibiotic per 40 g of cement) and low-dose spacer groups. Primary outcomes were overall and infectious failure. RESULTS High-dose spacers were used in 80% (162/202) of patients. High-dose spacers had a reduced risk of overall (OR, 0.37; P = 0.024) and infectious (OR, 0.35; P = 0.020) failure for infected primary arthroplasties, but not revisions. In multivariate analysis, vancomycin dose ≥2.0 g decreased the risk of infectious failure (OR, 0.31; P = 0.016), although not overall failure (OR, 0.51; P = 0.147). CONCLUSION During two-stage exchange for PJI, spacers with greater than 3.6 g of total antibiotic may reduce overall and infectious failure for infected primary arthroplasties. Furthermore, using at least 2.0 g of vancomycin could independently decrease the risk of infectious failure.
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Affiliation(s)
- Hunter S Warwick
- From the Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco, CA
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Thomas TL, Kothari PD, Baker CM, Tarabichi S, Clark SC, Goh GS. High Incidence of Acute Kidney Injury Following Antibiotic-Loaded Spacer Insertion for Periprosthetic Joint Infection: An Updated Review of the Literature. J Arthroplasty 2024; 39:549-558.e3. [PMID: 37634877 DOI: 10.1016/j.arth.2023.08.055] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Revised: 08/12/2023] [Accepted: 08/14/2023] [Indexed: 08/29/2023] Open
Abstract
BACKGROUND The use of antibiotic-impregnated cement during 2-stage revision arthroplasty for periprosthetic joint infection poses a risk of renal complications following spacer insertion. This systematic review aimed to investigate the rate of acute kidney injury (AKI) following antibiotic-loaded spacer insertion and to identify risk factors associated with this complication. METHODS A systematic review was performed using PubMed, Cochrane Central, and Scopus databases. All clinical studies that documented renal complications following antibiotic-loaded spacer insertion for periprosthetic knee (total knee arthroplasty [TKA]) or hip (total hip arthroplasty [THA]) infection were included. Articles that combined THA and TKA outcomes were also included and labeled "THA + TKA." Descriptive statistics were analyzed when data were available. RESULTS There were 24 studies (9 THA, 7 TKA, 8 THA + TKA) included. The mean incidences of spacer-related AKI across THA, TKA, and THA + TKA cohorts were 4.2 (range, 0 to 10%), 14 (range, 0 to 19%), and 27% (range, 0 to 35%), respectively. The most common patient-related risk factors for AKI were underlying chronic kidney disease or high baseline creatinine, low preoperative hemoglobin, and blood transfusion requirement. Spacer-related risk factors included high antibiotic dosage (>3.6 g/cement batch) and antibiotic type. While most recovered without complication, select patients required hemodialysis for acute management (2 THA, 18 THA + TKA) and/or developed chronic kidney disease (8 TKA, 8 THA). CONCLUSION The rate of AKI following spacer insertion was high and likely under-reported in the literature. Surgeons should be cognizant of this devastating complication and should closely monitor at-risk patients for AKI following antibiotic-loaded spacer insertion.
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Affiliation(s)
- Terence L Thomas
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Purab D Kothari
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Colin M Baker
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Saad Tarabichi
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Sean C Clark
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Graham S Goh
- Department of Orthopaedic Surgery, Boston University Medical Center, Boston, Massachusetts
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7
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Savas MJ, Gray KF, Blackburn BE, Pelt CE, Gililland JM, Certain LK. Association of Acute Kidney Injury With Antibiotic Loaded Cement Used for Treatment of Periprosthetic Joint Infection. J Arthroplasty 2023; 38:2704-2709.e1. [PMID: 37279850 PMCID: PMC10694335 DOI: 10.1016/j.arth.2023.05.061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Revised: 05/20/2023] [Accepted: 05/24/2023] [Indexed: 06/08/2023] Open
Abstract
BACKGROUND Antibiotic-loaded bone cement (ALBC) is commonly used in the treatment of periprosthetic joint infections (PJIs) to increase the local concentration of antibiotic at the site of infection. Use of ALBC has been associated with rare instances of acute kidney injury (AKI) despite low systemic absorption of the nephrotoxic antibiotics; however, the incidence of AKI is unknown. The purpose of this study was to determine the incidence of and risk factors for AKI associated with ALBC. METHODS This single-site, retrospective cohort study compared 162 PJI patients who underwent Stage 1 revision to a spacer with ALBC to 115 PJI patients who underwent debridement, antibiotics, and implant retention (DAIR) without the use of ALBC. Both groups received similar systemic antibiotics postoperatively. Descriptive statistics and multivariable logistic regressions were used to analyze risk factors for AKI. RESULTS There was no statistically significant difference in the rate of AKI: 29 patients (17.9%) in the ALBC group and 17 (14.7%) in DAIR group developed AKI (odds ratio 1.43; 95% CI 0.70 to 2.93). There was a trend toward increased severity of AKI in the ALBC group. Chronic kidney disease, systemic vancomycin, and diuretic use were independent factors associated with the risk of AKI. CONCLUSION An AKI occurred in 17% of PJI patients receiving either a spacer with ALBC or a DAIR. The use of ALBC was not associated with a significant increased risk of AKI. However, the use of systemic vancomycin and diuretic use were independent predictors of AKI in this patient population.
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Affiliation(s)
- Matthew J Savas
- College of Pharmacy, University of Utah, Salt Lake City, Utah
| | - Kristine F Gray
- College of Pharmacy, University of Utah, Salt Lake City, Utah
| | - Brenna E Blackburn
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, Utah
| | - Christopher E Pelt
- 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; Division of Infectious Diseases, Department of Internal Medicine, University of Utah, Salt Lake City, Utah
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8
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Li Z, Maimaiti Z, Yang F, Fu J, Li ZY, Hao LB, Chen JY, Xu C. Incidence, associated factors, and outcomes of acute kidney injury following placement of antibiotic bone cement spacers in two-stage exchange for periprosthetic joint infection: a comprehensive study. Front Cell Infect Microbiol 2023; 13:1243290. [PMID: 37799334 PMCID: PMC10548219 DOI: 10.3389/fcimb.2023.1243290] [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: 06/20/2023] [Accepted: 08/23/2023] [Indexed: 10/07/2023] Open
Abstract
Background Two-stage exchange with placement of antibiotic cement spacer (ACS) is the gold standard for the treatment of chronic periprosthetic joint infection (PJI), but it could cause a high prevalence of acute kidney injury (AKI). However, the results of the current evidence on this topic are too mixed to effectively guide clinical practice. Methods We retrospectively identified 340 chronic PJI patients who underwent the first-stage exchange with placement of ACS. The Kidney Disease Improving Global Outcomes guideline was used to define postoperative AKI. Multivariate logistic analysis was performed to determine the potential factors associated with AKI. Furthermore, a systematic review and meta-analysis on this topic were conducted to summarize the knowledge in the current literature further. Results In our cohort, the incidence of AKI following first-stage exchange was 12.1%. Older age (per 10 years, OR= 1.509) and preoperative hypoalbuminemia (OR= 3.593) were independent predictors for postoperative AKI. Eight AKI patients progressed to chronic kidney disease after 90 days. A meta-analysis including a total of 2525 PJI patients showed the incidence of AKI was 16.6%, and AKI requiring acute dialysis was 1.4%. Besides, host characteristics, poor baseline liver function, factors contributing to acute renal blood flow injury, and the use of nephrotoxic drugs may be associated with the development of AKI. However, only a few studies supported an association between antibiotic dose and AKI. Conclusion AKI occurs in approximately one out of every six PJI patients undergoing first-stage exchange. The pathogenesis of AKI is multifactorial, with hypoalbuminemia could be an overlooked associated factor. Although the need for acute dialysis is uncommon, the fact that some AKI patients will develop CKD still needs to be taken into consideration.
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Affiliation(s)
- Zhuo Li
- School of Medicine, Nankai University, Tianjin, China
- Department of Orthopedics, The First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Zulipikaer Maimaiti
- Department of Orthopedics, The First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Fan Yang
- School of Medicine, Nankai University, Tianjin, China
- Department of Orthopedics, The First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Jun Fu
- Department of Orthopedics, The First Medical Center, Chinese PLA General Hospital, Beijing, China
- Department of Orthopedics, The Fourth Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Zhi-Yuan Li
- Department of Orthopedics, The First Medical Center, Chinese PLA General Hospital, Beijing, China
- Department of Orthopedics, The Fourth Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Li-Bo Hao
- Department of Orthopedics, The First Medical Center, Chinese PLA General Hospital, Beijing, China
- Department of Orthopedics, The Fourth Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Ji-Ying Chen
- School of Medicine, Nankai University, Tianjin, China
- Department of Orthopedics, The First Medical Center, Chinese PLA General Hospital, Beijing, China
- Department of Orthopedics, The Fourth Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Chi Xu
- Department of Orthopedics, The First Medical Center, Chinese PLA General Hospital, Beijing, China
- Department of Orthopedics, The Fourth Medical Center, Chinese PLA General Hospital, Beijing, China
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Nace J, Chen Z, Bains SS, Kahan ME, Gilson GA, Mont MA, Delanois RE. 1.5-Stage Versus 2-Stage Exchange Total Hip Arthroplasty for Chronic Periprosthetic Joint Infections: A Comparison of Survivorships, Reinfections, and Patient-Reported Outcomes. J Arthroplasty 2023; 38:S235-S241. [PMID: 36878441 DOI: 10.1016/j.arth.2023.02.072] [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: 10/11/2022] [Revised: 01/18/2023] [Accepted: 02/27/2023] [Indexed: 03/08/2023] Open
Abstract
BACKGROUND Management of periprosthetic joint infection after total hip arthroplasty (THA) has traditionally consisted of a 2-stage approach. However, 1.5-stage exchange has garnered recent interest. We compared 1.5-stage to 2-stage exchange recipients. Specifically, we assessed (1) infection-free survivorship and risk factors for reinfection; (2) 2-year surgical/medical outcomes (eg, reoperations, readmissions); (3) Hip Disability and Osteoarthritis Outcome Scores for Joint Replacement (HOOS-JR); and (4) radiographic outcomes (ie, progressive radiolucent lines, subsidences, and failures). METHODS We reviewed a consecutive series of 1.5-stage or planned 2-stage THAs. A total of 123 hips were included (1.5-stage: n = 54; 2-stage: n = 69) with mean clinical follow-up of 2.5 years (up to 8 years). Bivariate analyses assessed incidences of medical and surgical outcomes. Additionally, HOOS-JR scores and radiographs were evaluated. RESULTS The 1.5-stage exchange had 11% greater infection-free survivorship at final follow-up compared to 2 stages (94% versus 83%, P = .048). Morbid obesity was the only independent risk factor demonstrating increased reinfection among both cohorts. No differences in surgical/medical outcomes were observed between groups (P = .730). HOOS-JR scores improved markedly for both cohorts (1.5-stage difference = 44.3, 2-stage difference = 32.5; P < .001). A total of 82% of 1.5-stage patients did not demonstrate progressive femoral or acetabular radiolucencies, while 94% of 2-stage recipients did not have femoral radiolucencies and 90% did not have acetabular radiolucencies. CONCLUSION The 1.5-stage exchange appeared to be an acceptable treatment alternative for periprosthetic joint infections after THAs with noninferior infection eradication. Therefore, this procedure should be considered by joint surgeons for treatment of periprosthetic hip infections.
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Affiliation(s)
- James Nace
- LifeBridge Health, Sinai Hospital of Baltimore, Rubin Institute for Advanced Orthopedics, Baltimore, Maryland
| | - Zhongming Chen
- LifeBridge Health, Sinai Hospital of Baltimore, Rubin Institute for Advanced Orthopedics, Baltimore, Maryland
| | - Sandeep S Bains
- LifeBridge Health, Sinai Hospital of Baltimore, Rubin Institute for Advanced Orthopedics, Baltimore, Maryland
| | - Michael E Kahan
- LifeBridge Health, Sinai Hospital of Baltimore, Rubin Institute for Advanced Orthopedics, Baltimore, Maryland
| | - Gregory A Gilson
- LifeBridge Health, Sinai Hospital of Baltimore, Rubin Institute for Advanced Orthopedics, Baltimore, Maryland
| | - Michael A Mont
- LifeBridge Health, Sinai Hospital of Baltimore, Rubin Institute for Advanced Orthopedics, Baltimore, Maryland
| | - Ronald E Delanois
- LifeBridge Health, Sinai Hospital of Baltimore, Rubin Institute for Advanced Orthopedics, Baltimore, Maryland
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10
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Chaudhry YP, LaGreca M, Hayes H, Papadelis E, Rao SS, Amin R. Acute kidney injury in the context of staged revision arthroplasty and the use of antibiotic-laden cement spacers: a systematic review. J Orthop Surg Res 2023; 18:340. [PMID: 37158949 PMCID: PMC10169361 DOI: 10.1186/s13018-023-03809-2] [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: 02/18/2023] [Accepted: 04/21/2023] [Indexed: 05/10/2023] Open
Abstract
BACKGROUND The most common cause of revision arthroplasty is prosthetic joint infection (PJI). Chronic PJI is commonly treated with two-stage exchange arthroplasty involving the placement of antibiotic-laden cement spacers (ACS) in the first stage, often containing nephrotoxic antibiotics. These patients often have significant comorbidity burdens and have higher rates of acute kidney injury (AKI). This systematic review aims to assess the current literature to identify (1) AKI incidence, (2) associated risk factors, and (3) antibiotic concentration thresholds in ACS that increase AKI risk following first-stage revision arthroplasty. METHODS An electronic search was performed of the PubMed database of all studies involving patients undergoing ACS placement for chronic PJI. Studies assessing AKI rates and risk factors were screened by two authors independently. Data synthesis was performed when possible. Significant heterogeneity prevented meta-analysis. RESULTS Eight observational studies consisting of 540 knee PJIs and 943 hip PJIs met inclusion criteria. There were 309 (21%) cases involving AKI. The most commonly reported risk factors included perfusion-related factors (lower preoperative hemoglobin, transfusion requirement, or hypovolemia), older age, increased comorbidity burden, and nonsteroidal anti-inflammatory drug consumption. Only two studies found increased risk with greater ACS antibiotic concentration (> 4 g vancomycin and > 4.8 g tobramycin per spacer in one study, > 3.6 g of vancomycin per batch or > 3.6 g of aminoglycosides per batch in the other); however, these were reported from univariate analyses not accounting for other potential risk factors. DISCUSSION Patients undergoing ACS placement for chronic PJI are at an increased risk for AKI. Understanding the risk factors may lead to better multidisciplinary care and safer outcomes for chronic PJI patients. LEVEL OF EVIDENCE III
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Affiliation(s)
- Yash P Chaudhry
- Department of Orthopaedic Surgery, Philadelphia College of Osteopathic Medicine, Philadelphia, PA, USA.
| | - Mark LaGreca
- Department of Orthopaedic Surgery, Philadelphia College of Osteopathic Medicine, Philadelphia, PA, USA
| | - Hunter Hayes
- Department of Orthopaedic Surgery, Philadelphia College of Osteopathic Medicine, Philadelphia, PA, USA
| | - Efstratios Papadelis
- Department of Orthopaedic Surgery, Philadelphia College of Osteopathic Medicine, Philadelphia, PA, USA
| | - Sandesh S Rao
- Department of Orthopaedic Surgery, Washington Orthopaedics and Sports Medicine, Washington, DC, USA
| | - Raj Amin
- Department of Orthopaedic Surgery, University of California San Francisco Fresno, Fresno, CA, USA
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11
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Steadman W, Chapman PR, Schuetz M, Schmutz B, Trampuz A, Tetsworth K. Local Antibiotic Delivery Options in Prosthetic Joint Infection. Antibiotics (Basel) 2023; 12:antibiotics12040752. [PMID: 37107114 PMCID: PMC10134995 DOI: 10.3390/antibiotics12040752] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Revised: 04/03/2023] [Accepted: 04/07/2023] [Indexed: 04/29/2023] Open
Abstract
Prosthetic Joint Infection (PJI) causes significant morbidity and mortality for patients globally. Delivery of antibiotics to the site of infection has potential to improve the treatment outcomes and enhance biofilm eradication. These antibiotics can be delivered using an intra-articular catheter or combined with a carrier substance to enhance pharmacokinetic properties. Carrier options include non-resorbable polymethylmethacrylate (PMMA) bone cement and resorbable calcium sulphate, hydroxyapatite, bioactive glass, and hydrogels. PMMA allows for creation of structural spacers used in multi-stage revision procedures, however it requires subsequent removal and antibiotic compatibility and the levels delivered are variable. Calcium sulphate is the most researched resorbable carrier in PJI, but is associated with wound leakage and hypercalcaemia, and clinical evidence for its effectiveness remains at the early stage. Hydrogels provide a versatile combability with antibiotics and adjustable elution profiles, but clinical usage is currently limited. Novel anti-biofilm therapies include bacteriophages which have been used successfully in small case series.
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Affiliation(s)
- William Steadman
- Jamieson Trauma Institute, Royal Brisbane and Women's Hospital, Herston, Brisbane 4029, Australia
- Department of Orthopaedics, Royal Brisbane and Women's Hospital, Herston, Brisbane 4029, Australia
- Faculty of Health, Queensland University of Technology, Brisbane 4059, Australia
| | - Paul R Chapman
- Jamieson Trauma Institute, Royal Brisbane and Women's Hospital, Herston, Brisbane 4029, Australia
- Herston Infectious Disease Institute, Royal Brisbane and Women's Hospital, Herston, Brisbane 4029, Australia
- Department of Infectious Diseases, Royal Brisbane and Women's Hospital, Herston, Brisbane 4029, Australia
| | - Michael Schuetz
- Jamieson Trauma Institute, Royal Brisbane and Women's Hospital, Herston, Brisbane 4029, Australia
- Department of Orthopaedics, Royal Brisbane and Women's Hospital, Herston, Brisbane 4029, Australia
- Faculty of Health, Queensland University of Technology, Brisbane 4059, Australia
| | - Beat Schmutz
- Jamieson Trauma Institute, Royal Brisbane and Women's Hospital, Herston, Brisbane 4029, Australia
- School of Mechanical, Medical and Process Engineering, Faculty of Engineering, Queensland University of Technology, Brisbane 4000, Australia
- Centre for Biomedical Technologies, Queensland University of Technology, Brisbane 4059, Australia
- Australian Research Council Training Centre for Multiscale 3D Imaging, Modelling, and Manufacturing, Queensland University of Technology, Brisbane 4059, Australia
| | - Andrej Trampuz
- Center for Musculoskeletal Surgery, Septic Unit Charité-Universitätsmedizin, 10117 Berlin, Germany
| | - Kevin Tetsworth
- Department of Orthopaedics, Royal Brisbane and Women's Hospital, Herston, Brisbane 4029, Australia
- School of Medicine, University of Queensland, Brisbane 4029, Australia
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12
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Hillock NT, Campbell DG, Nelson R, Teoh A, Tan J, Smitham P. Antimicrobial-loaded bone cement use is highly variable in joint replacement surgery: a survey of Australian arthroplasty surgeons. ANZ J Surg 2023. [PMID: 36680316 DOI: 10.1111/ans.18283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Revised: 12/30/2022] [Accepted: 01/08/2023] [Indexed: 01/22/2023]
Affiliation(s)
- Nadine T Hillock
- Communicable Disease Control Branch, Department for Health and Wellbeing, SA Health, Adelaide, South Australia, Australia
| | - David Graham Campbell
- Wakefield Orthopaedic Clinic, Adelaide, South Australia, Australia.,Centre of Orthopaedic and Trauma Research, University of Adelaide, Adelaide, South Australia, Australia
| | - Renjy Nelson
- Department of Microbiology, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Alice Teoh
- Communicable Disease Control Branch, Department for Health and Wellbeing, SA Health, Adelaide, South Australia, Australia
| | - Jonathan Tan
- Adelaide Medical School, University of Adelaide, Adelaide, South Australia, Australia
| | - Peter Smitham
- Centre of Orthopaedic and Trauma Research, University of Adelaide, Adelaide, South Australia, Australia.,Department of Orthopaedics, Royal Adelaide Hospital, Adelaide, South Australia, Australia
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13
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Bourget-Murray J, Azad M, Gofton W, Abdelbary H, Garceau S, Grammatopoulos G. Is the routine use of local antibiotics in the management of periprosthetic joint infections justified? Hip Int 2023; 33:4-16. [PMID: 36447342 DOI: 10.1177/11207000221139467] [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: 12/05/2022]
Abstract
Periprosthetic joint infection (PJI) following total hip and total knee arthroplasty continues to be a leading cause of re-operation and revision arthroplasty. Not only is the treatment of PJI notoriously challenging, but success rates are variable. Regardless of the surgical strategy used, successful management of PJI requires a comprehensive surgical debridement focused at eradicating the underlying biofilm followed by appropriate antimicrobial therapy. Although systemic antimicrobial delivery continues to be a cornerstone in the treatment of PJI, many surgeons have started using local antibiotics to deliver higher concentrations of antibiotics directly into the vulnerable joint and adjacent soft tissues, which often have compromised vascularity. Available evidence on the use of topical powder, bone cement, and calcium sulphate carriers for local delivery of antibiotics during the initial treatment of PJI is limited to studies that are extremely heterogeneous. There is currently no level-1 evidence to support routinely using these products. Further, appropriately powered, prospective studies are needed to quantify the safety and efficacy of antibiotic-located calcium-sulphate carriers to justify their added costs. These products should not encourage surgeons to deviate from best practice guidelines, such as those recommended during the International Consensus Meeting on Musculoskeletal Infections.
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Affiliation(s)
| | - Marisa Azad
- Division of Infectious Diseases, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Wade Gofton
- Division of Orthopaedic Surgery, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Hesham Abdelbary
- Division of Orthopaedic Surgery, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Simon Garceau
- Division of Orthopaedic Surgery, The Ottawa Hospital, Ottawa, Ontario, Canada
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14
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Dedeogullari ES, Caglar O, Danisman M, Tokgozoglu AM, Kamaci S, Atilla B. Low dose vancomycin-loaded spacers for two-stage revision knee arthroplasty: High success, low toxicity. Knee 2023; 40:63-70. [PMID: 36410252 DOI: 10.1016/j.knee.2022.11.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 09/22/2022] [Accepted: 11/03/2022] [Indexed: 11/19/2022]
Abstract
BACKGROUND Two-stage revision arthroplasty is a widely used treatment method for infected knee arthroplasty. Loading high doses of antibiotics to spacer during the first stage is standard practice. However, there are reported systemic side effects attributed to antibiotic-loaded spacers. The aim of our study is to investigate the success rate and systemic toxicity following the first stage revision knee arthroplasty with low-dose vancomycin-loaded spacers. METHOD We included patients with infected knee arthroplasty eligible for two-stage revision arthroplasty from 2001 to 2020. One gram of vancomycin is added per pack of bone cement. Spacers were handmade in the operating theatre. Following the first stage, pre-operative and postoperative culture results, infection parameters, kidney and liver function tests, and functional scores were analyzed. Kaplan-Meier survival analysis was done to determine the success rate. RESULTS Fifty patients with a mean follow-up of 48 months (24-108) were included in the study. A five-year survival analysis showed an 88.5% success rate. Fourteen percent of the patients had acute kidney injury with creatinine levels between 1.12-2.80 mg/dl, and 8% had a mild drug-induced liver injury with elevated serum ALT levels between 223-540 U/L and total bilirubin levels between 0.59-1.23 mg/dl. None of the patients required dialysis. All of the systemic side effects were reversible. CONCLUSION Our results have suggested that low dose antibiotic-loaded spacers are comparable to the studies with high dose antibiotic loaded spacers regarding infection eradication and survival rates. They are less likely to cause severe systemic side effects. Therefore we suggest low dose antibiotic-loaded spacers should be considered when treating patients with vancomycin sensitive Staphylococcal species and culture negative infected knee arthroplasty.
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Affiliation(s)
- Emin Suha Dedeogullari
- Hacettepe University Hospital, Department of Orthopedics and Traumatology, Hacettepe Mh. 06230, Ankara, Turkey.
| | - Omur Caglar
- Hacettepe University Hospital, Department of Orthopedics and Traumatology, Hacettepe Mh. 06230, Ankara, Turkey
| | - Murat Danisman
- Giresun University School of Medicine, Department of Orthopedics and Traumatology, Aksu Mh. Mehmet İzmen Cd. No:145, Giresun, Turkey
| | - A Mazhar Tokgozoglu
- Hacettepe University Hospital, Department of Orthopedics and Traumatology, Hacettepe Mh. 06230, Ankara, Turkey
| | - Saygin Kamaci
- Hacettepe University Hospital, Department of Orthopedics and Traumatology, Hacettepe Mh. 06230, Ankara, Turkey
| | - Bulent Atilla
- Hacettepe University Hospital, Department of Orthopedics and Traumatology, Hacettepe Mh. 06230, Ankara, Turkey
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15
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Niu T, Zhang Y, Li Z, Bian Y, Zhang J, Wang Y. The association between penicillin allergy and surgical site infection after orthopedic surgeries: a retrospective cohort study. Front Cell Infect Microbiol 2023; 13:1182778. [PMID: 37153141 PMCID: PMC10160653 DOI: 10.3389/fcimb.2023.1182778] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Accepted: 04/03/2023] [Indexed: 05/09/2023] Open
Abstract
Background Cephalosporins are used as first-line antimicrobial prophylaxis for orthopedics surgeries. However, alternative antibiotics are usually used in the presence of penicillin allergy (PA), which might increase the risk of surgical site infection (SSI). This study aimed to analyze the relationship between SSI after orthopedic surgeries and PA among surgical candidates and related alternative antibiotic use. Methods In this single-center retrospective cohort study, we compared inpatients with and without PA from January 2015 to December 2021. The primary outcome was SSI, and the secondary outcomes were SSI sites and perioperative antibiotic use. Moreover, pathogen characteristics of all SSIs were also compared between the two cohorts. Results Among the 20,022 inpatient records, 1704 (8.51%) were identified with PA, and a total of 111 (0.55%) SSI incidents were reported. Compared to patients without PA, patients with PA had higher postoperative SSI risk (1.06%, 18/1704 vs. 0.51%, 93/18318), shown both in multivariable regression analysis (odds ratio [OR] 2.11; 95% confidence interval [CI], 1.26-3.50; p= 0.004) and propensity score matching (OR 1.84; 95% CI, 1.05-3.23; p= 0.034). PA was related to elevated deep SSI risk (OR 2.79; 95% CI, 1.47-5.30; p= 0.002) and had no significant impact on superficial SSI (OR 1.39; 95% CI, 0.59-3.29; p= 0.449). The PA group used significantly more alternative antibiotics. Complete mediation effect of alternative antibiotics on SSI among these patients was found in mediation analysis. Pathogen analysis revealed gram-positive cocci as the most common pathogen for SSI in our study cohort, while patients with PA had higher infection rate from gram-positive rods and gram-negative rods than non-PA group. Conclusion Compared to patients without PA, patients with PA developed more SSI after orthopedic surgeries, especially deep SSI. The elevated infection rate could be secondary to the use of alternative prophylactic antibiotics.
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Affiliation(s)
- Tong Niu
- Department of Orthopedics, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Yuelun Zhang
- Medical Research Centre, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Ziquan Li
- Department of Orthopedics, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Yanyan Bian
- Department of Orthopedics, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Jianguo Zhang
- Department of Orthopedics, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Yipeng Wang
- Department of Orthopedics, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
- *Correspondence: Yipeng Wang,
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16
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Teoh APK, Hillock N. Antimicrobial‐impregnated bone cement use in Australian hospitals: scoping pharmacist awareness and involvement in management. JOURNAL OF PHARMACY PRACTICE AND RESEARCH 2022. [DOI: 10.1002/jppr.1846] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Affiliation(s)
| | - Nadine Hillock
- Department of Health and Wellbeing, South Australia Health Adelaide Australia
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17
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One and a Half-Stage Revision With Prosthetic Articulating Spacer for Definitive Management of Knee Periprosthetic Joint Infection. Arthroplast Today 2022; 19:100993. [PMID: 36507285 PMCID: PMC9727150 DOI: 10.1016/j.artd.2022.07.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2022] [Revised: 06/26/2022] [Accepted: 07/08/2022] [Indexed: 12/12/2022] Open
Abstract
This paper is a comprehensive review that describes indications, contraindications, clinical outcomes, and pearls and pitfalls of 1.5-stage revision total knee arthroplasty (TKA) utilizing a primary TKA femoral component, all-polyethylene tibial component, and hand-crafted antibiotic cement for the management of chronic periprosthetic joint infection. The 1.5-stage exchange TKA details placement of an articulating spacer for an indefinite period, prolonging revision until reinfection, deterioration of functional status, or construct failure. A 1.5-stage revision TKA technique is a viable option for treatment of chronic periprosthetic knee infections. The inherent advantages of decreased health-care costs, decreased morbidity and mortality, and improved emotional ease from having a single procedure is attractive, especially if reinfection rates are determined to be equivocal to 2-stage revision.
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18
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Vasso M, Capasso L, Corona K, Pola E, Toro G, Schiavone Panni A. Periprosthetic knee infection: treatment options. Orthop Rev (Pavia) 2022; 14:37537. [PMID: 36349351 PMCID: PMC9635989 DOI: 10.52965/001c.37537] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/26/2024] Open
Abstract
Infection is one of the most catastrophic complication following total knee arthroplasty (TKA) and represents the second most common cause of TKA failure. Treatment of a patient with periprosthetic joint infection (PJI) could require often costly and prolonged hospital stays, weeks or months of antibiotic therapy, and multiple surgical procedures. The best management is still highly debating, whereas many treatment options are available. These include suppressive antibiotics, arthroscopic irrigation and debridement, open debridement with insert exchange, single-stage reimplantation and two-stage reimplantation. The choice of the treatment depends on many variables, including integrity of implant, timing of the infection, host factors (age, health, immunologic status), virulence of the infecting organism and wishes of the patient. The aim of this review is to provide a comprehensive understaning of the different options for knee PJIs.
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Affiliation(s)
- Michele Vasso
- Multidisciplinary Department of Medicine for Surgery and Orthodontics, University of Campania "Luigi Vanvitelli" - Naples (Italy)
| | - Luigi Capasso
- San Giovanni Calibita "Fatebenefratelli - Isola Tiberina" Hospital - Rome (Italy)
| | - Katia Corona
- Department of Medicine and Health Sciences "Vincenzo Tiberio", University of Molise, Campobasso (Italy)
| | - Enrico Pola
- Multidisciplinary Department of Medicine for Surgery and Orthodontics, University of Campania "Luigi Vanvitelli" - Naples (Italy)
| | - Giuseppe Toro
- Multidisciplinary Department of Medicine for Surgery and Orthodontics, University of Campania "Luigi Vanvitelli" - Naples (Italy)
| | - Alfredo Schiavone Panni
- Multidisciplinary Department of Medicine for Surgery and Orthodontics, University of Campania "Luigi Vanvitelli" - Naples (Italy)
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19
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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: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2022] [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.
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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.
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20
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Berberich C, Josse J, Ruiz PS. Patients at a high risk of PJI: Can we reduce the incidence of infection using dual antibiotic-loaded bone cement? ARTHROPLASTY 2022; 4:41. [PMID: 36068617 PMCID: PMC9450350 DOI: 10.1186/s42836-022-00142-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Accepted: 06/26/2022] [Indexed: 11/10/2022] Open
Abstract
AbstractProsthetic joint infection (PJI) is one of the most devastating complications of orthopedic surgery. However, not all patients are equally at the risk of severe infection. The incidences of PJI vary with the host and surgery-related risk factors. It is now generally accepted that some important medical comorbidities may predispose the patients to a high risk of PJI. Time-consuming and invasive surgical procedures, such as revision arthroplasties, are also associated with a high incidence of PJI, presumably due to the increased risk of surgical site contamination. Effective infection-preventing strategies should begin with identifying and optimizing the patients at a high risk of infection prior to surgery. Optimizing the operating room environment and antibiotic prophylaxis are also essential strategies that help minimize the overall incidence of infection in orthopedic surgery. The ideal antibiotic prophylaxis is still under debate, and discussions have emerged about whether variations or adjustments to the standard protocol are justified in patients at a high risk of infection. This also includes evaluating the possible benefits and risks of using high-dose dual antibiotic-loaded bone cement instead of low-dose single antibiotic-loaded bone cement in arthroplasty. This review summarizes the evidence showing that the combination of two local antibiotics in bone cement exerts a strong and longer-lasting antimicrobial effect against PJI-associated pathogens. This conclusion is consistent with the preliminary clinical studies showing a low incidence of PJI in high-risk patients undergoing cemented hemiarthroplasty, cemented revision, and primary arthroplasty if dual ALBC is used. These results may encourage clinicians to consolidate this hypothesis in a wider clinical range.
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21
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Angerett NR, Yevtukh A, Ferguson CM, Kahan ME, Ali M, Hallock RH. Improving Postoperative Acute Kidney Injury Rates Following Primary Total Joint Arthroplasty. J Arthroplasty 2022; 37:S1004-S1009. [PMID: 34952163 DOI: 10.1016/j.arth.2021.12.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Revised: 12/05/2021] [Accepted: 12/15/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Perioperative hip and knee arthroplasty complications remain a significant clinical and financial burden. Our institution has shifted to developing protocols to decrease these perioperative complications. This study focuses on acute kidney injury (AKI) rate status post primary total joint arthroplasty (TJA). Current literature demonstrates a 2%-15% incidence of AKI following TJA. However, there is a paucity of published literature on protocols that have effectively reduced AKI rates following TJA. The purpose of this study is to evaluate the effect that our institutionally developed perioperative renal protocol had on the postoperative AKI rates. METHODS A retrospective cohort study was performed. Patient demographics, baseline creatinine, and postoperative creatinine values during the patient's hospitalization were collected and analyzed. The preintervention cohort data contained all patients at our institution who underwent a primary TJA from November 1, 2016 to January 1, 2018. The postintervention cohort included all primary TJA patients from July 1, 2018 to February 2, 2020. AKI was defined using the AKI Network classification system comparing baseline and postoperative creatinine values. A multivariate analysis was performed to determine the statistical significance of our results. RESULTS Before intervention 1013 patients underwent a primary TJA with 68 patients developing an AKI postoperatively. After intervention 2169 patients underwent primary TJA with 90 patients developing an AKI (6.71% vs 4.15%; P = .0015, odds ratio = 0.59, 95% confidence interval = 0.42-0.82). CONCLUSION This study demonstrated that implementation of a perioperative renal protocol can significantly reduce AKI rates. A reduction in AKI rates following TJA will result in improved outcomes and secondarily decrease the financial impact of postoperative complications seen following TJA.
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Affiliation(s)
- Nathan R Angerett
- Department of Orthopaedic Surgery, UPMC Harrisburg, Harrisburg, PA; Rubin Institute for Advanced Orthopedics, Center for Joint Preservation & Replacement, Sinai Hospital of Baltimore, Baltimore, MD; Department of Orthopaedic Surgery, University of Maryland Medical Center, Baltimore, MD
| | | | | | - Michael E Kahan
- Department of Orthopaedic Surgery, UPMC Harrisburg, Harrisburg, PA; Rubin Institute for Advanced Orthopedics, Center for Joint Preservation & Replacement, Sinai Hospital of Baltimore, Baltimore, MD; Department of Orthopaedic Surgery, University of Maryland Medical Center, Baltimore, MD
| | - Muzaffar Ali
- Department of Orthopaedic Surgery, UPMC Harrisburg, Harrisburg, PA
| | - Richard H Hallock
- Department of Orthopaedic Surgery, UPMC Harrisburg, Harrisburg, PA; Orthopedic Institute of Pennsylvania, Camp Hill, PA
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22
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Judd H, Benito J, Pannu TS, Villa JM, Higuera CA, Corces A. Nephrotoxicity Related to Antibiotic-Loaded Spacers in a 2-Stage Revision for Periprosthetic Joint Infection. Orthopedics 2022; 46:e136-e142. [PMID: 35876777 DOI: 10.3928/01477447-20220719-07] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Antibiotic-loaded bone cement (ALBC) spacers are the mainstay in 2-stage revision, but antibiotics (vancomycin plus aminoglycosides) may undergo systemic absorption, resulting in acute kidney injury (AKI). Data on spacer antibiotics are heterogeneous. Our objective was to review risk factors for AKI and dosage of antibiotics. Significant AKI risk factors were antibiotic concentration greater than 3 or 3.6 g per cement batch, comorbidities, chronic kidney disease, and hypovolemia. Despite similar spacer antibiotic dosing, there was remarkable variability in serum concentrations. To err on the side of caution, it appears that antibiotic dose below 3 g per cement batch might be relatively safe until more evidence surfaces. Consideration of risk factors for AKI calls for appropriate antibiotic use in 2-stage revision. [Orthopedics. 20XX;XX(X):xx-xx.].
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23
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Otero JE, Brown TS, Courtney PM, Kamath AF, Nandi S, Fehring KA. What's New in Musculoskeletal Infection. J Bone Joint Surg Am 2022; 104:1228-1235. [PMID: 35700085 DOI: 10.2106/jbjs.22.00183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- Jesse E Otero
- OrthoCarolina Hip and Knee Center, Atrium Health Musculoskeletal Institute, Charlotte, North Carolina
| | - Timothy S Brown
- Department of Orthopedics and Sports, Houston Methodist Hospital, Houston, Texas
| | | | - Atul F Kamath
- Orthopaedic & Rheumatologic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Sumon Nandi
- University of Maryland School of Medicine, Baltimore, Maryland
| | - Keith A Fehring
- OrthoCarolina Hip and Knee Center, Atrium Health Musculoskeletal Institute, Charlotte, North Carolina
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24
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Valenzuela MM, Odum SM, Griffin WL, Springer BD, Fehring TK, Otero JE. High-Dose Antibiotic Cement Spacers Independently Increase the Risk of Acute Kidney Injury in Revision for Periprosthetic Joint Infection: A Prospective Randomized Controlled Clinical Trial. J Arthroplasty 2022; 37:S321-S326. [PMID: 35210153 DOI: 10.1016/j.arth.2022.01.060] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Revised: 01/08/2022] [Accepted: 01/11/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Standard treatment for periprosthetic joint infection (PJI) involves 2-stage exchange with placement of an antibiotic-impregnated cement spacer (ACS). Conflicting evidence exists on the role of ACS in development of acute kidney injury (AKI) after first-stage surgery. In this randomized clinical trial, we aimed to compare the incidence of AKI between the first-stage of a planned 2-stage exchange vs 1-stage exchange. This study design isolates the effect of the ACS in otherwise identical treatment groups. METHODS The primary outcome variable was AKI, defined as a creatinine ≥1.5 times baseline or an increase of ≥0.3 mg/dL. Risk factors for AKI were evaluated using bivariate statistical tests and multivariable logistic regression. RESULTS Patients who underwent the first stage of a planned 2-stage exchange were significantly more likely to develop AKI compared with the 1-stage exchange group (15 [22.7%] vs 4 [6.6%], P = .011). On multivariable regression analysis, ACS placement (odds ratio 7.48, 95% confidence limit 1.77-31.56) and chronic kidney disease (odds ratio 3.84, 95% confidence limit 1.22-12.08) were independent risk factors for AKI. CONCLUSION Our study provides evidence that high-dose antibiotic cement spacers for treatment of PJI are an independent risk factor for AKI. Therefore, efforts to minimize nephrotoxicity should be employed in revision for PJI when possible.
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Affiliation(s)
| | - Susan M Odum
- OrthoCarolina Research Institute, Charlotte, NC; Atrium Health Musculoskeletal Institute, Charlotte, NC
| | - William L Griffin
- Atrium Health Musculoskeletal Institute, Charlotte, NC; OrthoCarolina Hip and Knee Center, Charlotte, NC
| | - Bryan D Springer
- Atrium Health Musculoskeletal Institute, Charlotte, NC; OrthoCarolina Hip and Knee Center, Charlotte, NC
| | - Thomas K Fehring
- Atrium Health Musculoskeletal Institute, Charlotte, NC; OrthoCarolina Hip and Knee Center, Charlotte, NC
| | - Jesse E Otero
- Atrium Health Musculoskeletal Institute, Charlotte, NC; OrthoCarolina Hip and Knee Center, Charlotte, NC
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25
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DePalma BJ, Nandi S, Chaudhry W, Lee M, Johnson AJ, Doub JB. Assessment of Staphylococcal Clinical Isolates from Periprosthetic Joint Infections for Potential Bacteriophage Therapy. J Bone Joint Surg Am 2022; 104:693-699. [PMID: 35167506 DOI: 10.2106/jbjs.21.00958] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Bacteriophage therapy is a potential adjunctive treatment for periprosthetic joint infections (PJIs) given the capabilities of bacteriophages to degrade biofilms, self-replicate, and lyse bacteria. However, many aspects of this therapeutic are ill-defined, and the narrow spectrum of bacteriophage activity along with limited available bacteriophage strains curb potential use for specific bacteria such as Staphylococcus aureus at the present time. Therefore, the aim of this study was to determine the feasibility of using bacteriophages for PJI by (1) categorizing the causative organisms in hip and knee PJI at a tertiary academic center and (2) evaluating in vitro activity of a group of bacteriophages against clinical S. aureus PJI isolates. METHODS Patients with chronic hip or knee PJI after undergoing the first stage of a 2-stage revision protocol from 2017 to 2020 were identified retrospectively by a query of the hospital billing database. The causative pathogens in 129 cases were reviewed and categorized. From this cohort, preserved S. aureus isolates were tested against a library of 15 staphylococcal bacteriophages to evaluate for bacterial growth inhibition over 48 hours. RESULTS S. aureus was the most common pathogen causing PJI (26% [33] of 129 cases). Of 29 S. aureus samples that were analyzed for bacteriophage activity, 97% showed adequate growth inhibition of the predominant planktonic colonies by at least 1 bacteriophage strain. However, 24% of the 29 samples demonstrated additional smaller, slower-growing S. aureus colonies, none of which had adequate growth inhibition by any of the initial 14 bacteriophages. Of 5 secondary colonies that underwent subsequent testing with another bacteriophage with enhanced biofilm activity, 4 showed adequate growth inhibition. CONCLUSIONS Effective bacteriophage therapeutics are potentially available for S. aureus PJI isolates. The differences in bacteriophage activity against the presumed small-colony variants compared with the planktonic isolates have important clinical implications. This finding suggests that bacteriophage attachment receptors differ between the different bacterial morphologic states, and supports future in vitro testing of bacteriophage therapeutics against both planktonic and stationary states of PJI clinical isolates to ensure activity.
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Affiliation(s)
- Brian J DePalma
- Department of Orthopaedic Surgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Sumon Nandi
- Department of Orthopaedic Surgery, University of Maryland School of Medicine, Baltimore, Maryland
| | | | - Martin Lee
- Adaptive Phage Therapeutics, Gaithersburg, Maryland
| | - Aaron J Johnson
- Department of Orthopaedic Surgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - James B Doub
- Division of Clinical Care and Research, Institute of Human Virology, University of Maryland School of Medicine, Baltimore, Maryland
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Pargas CD, Elhessy AH, Abouei M, Gesheff MG, Conway JD. Tobramycin Blood Levels after Local Antibiotic Treatment of Bone and Soft Tissue Infection. Antibiotics (Basel) 2022; 11:antibiotics11030336. [PMID: 35326799 PMCID: PMC8944707 DOI: 10.3390/antibiotics11030336] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 02/24/2022] [Accepted: 02/28/2022] [Indexed: 02/04/2023] Open
Abstract
Local antibiotic delivery using different carriers plays an important role in both infection prophylaxis and treatment. Besides dead space management, these carriers have the advantage of providing a high concentration of local antibiotics with a lower risk of systemic toxicity. Few studies have reported on systemic toxicity associated with antibiotic-impregnated carriers. The present study investigates the systemic tobramycin concentration at 24, 48 and 72 h postoperatively after using tobramycin-loaded polymethyl methacrylate (PMMA) and calcium sulfate (CS) as local antibiotic carriers. Additionally, this work assesses the renal function postoperatively for indications of acute kidney injury (AKI). Fifty-two patients were treated in 58 procedures with tobramycin and vancomycin-loaded PMMA, CS, or both. All systemic tobramycin levels were <2 mcg/mL at 72 h, and the resulting rate of AKI was 12% (7/58). In conclusion, local tobramycin antibiotic delivery using PMMA, CS, or both remains a safe and effective modality in the treatment of osteomyelitis as long as the surgeon is aware of its possible nephrotoxic effect.
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Crego-Vita D, Aedo-Martín D, Garcia-Cañas R, Espigares-Correa A, Sánchez-Pérez C, Berberich CE. Periprosthetic joint infections in femoral neck fracture patients treated with hemiarthroplasty – should we use antibiotic-loaded bone cement? World J Orthop 2022; 13:150-159. [PMID: 35317403 PMCID: PMC8891664 DOI: 10.5312/wjo.v13.i2.150] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Revised: 08/16/2021] [Accepted: 01/20/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Hemiarthroplasty is the most common treatment in elderly patients with displaced intra-capsular femoral neck fracture (FNF). Prosthetic joint infection (PJI) is one of the most feared and frequent complications post-surgery because of the frail health status of these patients and the need for fast track surgery. Therefore, priorities should lie in effective preventive strategies to mitigate this burden.
AIM To determine how much the implementation of the routine use of antibiotic-loaded bone cement (ALBC) as a relatively easy-to-apply amendment to the surgical practice reduces the infection rate in our hemiarthroplasty cohort.
METHODS We retrospectively assessed all demographic, health status and treatment-related data of our FNF patients undergoing cemented hemiarthroplasty in the period from 2011 to 2017; 241 patients were further analyzed after exclusion of patients with cancer-related sequelae and those who died before the end of the 1-year observation period. The PJI rate as diagnosed on basis of the Musculoskeletal Infection Society (MSIS) criteria 2011 was determined for each included patient and compared in function of the bone cement used for hip stem fixation. Patients were split into a group receiving a plain bone cement in the period from January 2011 to June 2013 (non-ALBC group) and into a group receiving an ALBC in the period July 2013 to December 2017 (ALBC group). Data analysis was performed with statistical software. We further calculated the cost-efficacy of the implementation of routine use of ALBC in the second group balancing the in-hospital infection related treatment costs with the extra costs of use of ALBC.
RESULTS In total 241 FNF patients who received cemented hemiarthroplasty in the period from January 2011 to January 2017 were eligible for inclusion in this retrospective study. There were 8 PJI cases identified in the ALBC group among n = 94 patients, whereas 28 PJI cases were observed in the non-ALBC group among n = 147 patients. The statistical analysis showed an infection risk reduction of 55.3% (in particular due to the avoidance of chronic delayed infections) in the ALBC group (95%CI: 6.2%-78.7%; P = 0.0025). The cost-evaluation analysis demonstrated a considerable cost saving of 3.500 € per patient, related to the implementation of routine use of ALBC in this group.
CONCLUSION Use of ALBC is a potent infection preventive factor in FNF patients receiving cemented hemiarthroplasties. It was further found to be highly cost-effective.
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Affiliation(s)
- Diana Crego-Vita
- Department of Orthopaedic and Trauma Surgery, Hospital Central de la Defensa Gómez Ulla, Madrid 28047, Spain
| | - Daniel Aedo-Martín
- Department of Orthopaedic and Trauma Surgery, Hospital Universitario del Henares, Universidad Francisco de Vitoria, Coslada 28822, Madrid, Spain
| | - Rafael Garcia-Cañas
- Department of Orthopaedic and Trauma Surgery, Hospital Central de la Defensa Gómez Ulla, Madrid 28047, Spain
| | - Andrea Espigares-Correa
- Department of Orthopeadic and Trauma Surgery, Hospital Central de la Defensa Gómez Ulla, Madrid 28047, Spain
| | - Coral Sánchez-Pérez
- Department of Orthopeadic and Trauma Surgery, General University Hospital Gregorio Maranon, Madrid 28007, Spain
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Villa JM, Pannu TS, Higuera-Rueda CA. What's New in Adult Reconstructive Knee Surgery. J Bone Joint Surg Am 2022; 104:97-106. [PMID: 34780387 DOI: 10.2106/jbjs.21.01080] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- Jesus M Villa
- Levitetz Department of Orthopaedic Surgery, Cleveland Clinic Florida, Weston, Florida
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Farrow L, Smillie S, Duncumb J, Chan B, Cranfield K, Ashcroft G, Stevenson I. Acute kidney injury in patients undergoing elective primary lower limb arthroplasty. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2021; 32:661-665. [PMID: 34081198 PMCID: PMC9001222 DOI: 10.1007/s00590-021-03024-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Accepted: 05/27/2021] [Indexed: 11/13/2022]
Abstract
Purpose Recent research has outlined the increasing incidence of acute kidney injury (AKI) and its effect on morbidity/mortality. There is evidence that current rates are significantly under-reported nationally, with uncertainty about pre-operative factors that might influence AKI reduction and the impact on other healthcare outcomes such as mortality and later Chronic Kidney Disease (CKD) development. We set out to help address these current deficiencies in the literature. Methods A retrospective cohort study was undertaken using data collected from patients undergoing elective primary lower limb arthroplasty within our institution from 01/10/16–31/09/17 with a 2-year follow-up. Results 53/782 (6.8%) patients had an AKI during the study time period. This was associated with a longer inpatient stay (p < 0.001). There was no significant difference in 30-day mortality (p = 0.134), 30-day readmission (p = 1.00) or later CKD development (p = 0.63). Independent predictors of AKI were as follows: Diabetes (OR 2.49; 95%CI 1.15–5.38; p = 0.021), CKD (OR 4.59; 95%CI 2.37–8.92; p < 0.001) and Male sex (OR 2.61; 95%CI 1.42–4.78; p = 0.002). Conclusions AKI in those undergoing hip and knee arthroplasty remains under-reported at a national level. AKI development was associated with an increased length of stay, but not long-term healthcare outcomes. This may be due to the mechanism of AKI development or the low absolute numbers of AKI suffered. We have identified three pre-operative factors (Diabetes, CKD & Male Sex) that were independently predictive of AKI. Targeted interventions may reduce the risk of AKI after lower limb arthroplasty.
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Affiliation(s)
- Luke Farrow
- Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK. .,Woodend Hospital, Aberdeen, UK.
| | - Stacey Smillie
- Woodend Hospital, Aberdeen, UK.,University Hospital of Ayr, Ayr, UK
| | - Joseph Duncumb
- Woodend Hospital, Aberdeen, UK.,Royal Infirmary of Edinburgh, Edinburgh, UK
| | | | | | - George Ashcroft
- Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK.,Woodend Hospital, Aberdeen, UK
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