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Najafi F, Hollingsworth N, Peterson NV, Parvizi J. Prevention of prosthetic joint infection/surgical site infection: what did the International Consensus Meeting decide? Expert Rev Med Devices 2023; 20:71-74. [PMID: 36718722 DOI: 10.1080/17434440.2023.2174849] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- Farideh Najafi
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Neusha Hollingsworth
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Nicholas V Peterson
- Department of Orthopaedic Surgery, University of California Los Angeles, Santa Monica, California, USA
| | - Javad Parvizi
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
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2
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Charalambous LT, Wixted CM, Kim BI, Cochrane NH, Belay ES, Joseph HL, Seyler TM. Cost Drivers in Two-Stage Treatment of Hip Periprosthetic Joint Infection With an Antibiotic Coated Cement Hip Spacer. J Arthroplasty 2023; 38:6-12. [PMID: 35872231 DOI: 10.1016/j.arth.2022.07.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Revised: 07/13/2022] [Accepted: 07/15/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND The current gold standard for treating chronic Periprosthetic Joint Infection (PJI) is a 2-stage revision arthroplasty. There has been little investigation into what specific patient and operative factors may be able to predict higher costs of this treatment. METHODS An institutional electronic health record database was retrospectively queried for patients who developed a PJI after a total hip arthroplasty, and underwent removal of the prosthesis and implantation of an antibiotic-impregnated articulating hip cement spacer. Patient demographics, surgical variables, hospital readmissions, emergency department visits, and post-operative complications were collected. Total costs were captured through an internal accounting database through 2 years post-operatively. Negative binomial regressions were utilized for multivariable analyses. A total of 55 hips with PJI were available for cost analyses. RESULTS A comorbidity index score was associated with a 70% increase (Odds Ratio (OR): 1.7 [1.18-2.5], P = .003) in total costs at 2-years. Illicit drug use was associated with a 70% increase in costs at 1-year post-operatively (OR 1.7 [1.18-2.5], P = .003). Metal-on-poly liners were associated with a 22% decrease in cost at 2-years post-operatively when compared to Cement-on-Bone articulating spacers, and Metal-on-poly -constrained liners accounted for 38% lower costs at 1-year (OR 0.62 [0.44-0.87], P = .004). Use of an intraoperative extended trochanteric osteotomy was associated with a 46 and 61% increase in cost at 1-year (OR 1.46 [1.14-1.89]) and 2-years (OR 1.61 [1.26-2.07], P < .001) post-operatively. CONCLUSION Age, comorbidity index score, drug use, and extended trochanteric osteotomy were associated with increased costs of PJI treatment. This may be used to improve reimbursement models and target areas of cost savings.
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Affiliation(s)
| | | | - Billy I Kim
- Duke University School of Medicine, Durham, North Carolina
| | - Niall H Cochrane
- Duke University Medical Center, Department of Orthopaedics, Durham, North Carolina
| | - Elshaday S Belay
- Duke University Medical Center, Department of Orthopaedics, Durham, North Carolina
| | - Hayden L Joseph
- Duke University Medical Center, Department of Orthopaedics, Durham, North Carolina
| | - Thorsten M Seyler
- Duke University Medical Center, Department of Orthopaedics, Durham, North Carolina
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3
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Iqbal F, Shafiq B, Noor SS, Ali Z, Memon N, Memon N. Economic Burden of Periprosthetic Joint Infection Following Primary Total Knee Replacement in a Developing Country. Clin Orthop Surg 2020; 12:470-476. [PMID: 33274024 PMCID: PMC7683183 DOI: 10.4055/cios20037] [Citation(s) in RCA: 7] [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: 02/26/2020] [Accepted: 04/26/2020] [Indexed: 12/19/2022] Open
Abstract
Background Periprosthetic joint infection is one of the devastating complications after primary total knee arthroplasty, which increases the financial burden on patients and affects their quality of life as well. The financial burden of periprosthetic joint infection after joint replacement in developed countries is well known. There is a need to evaluate the economic burden in developing countries such as Pakistan. Methods This is a single-center, retrospective, case-control study conducted at the Department of Orthopedic Surgery, Liaquat National Hospital Karachi. Cases of primary total knee arthroplasty performed during this study were divided into 2 groups: uneventful primary total knee arthroplasty and periprosthetic joint infection treated with 2-stage revision. To calculate the final cost, we divided the total hospital cost into the hospital stay cost and operating room cost. Results During study period, 32 patients were diagnosed with periprosthetic joint infection. The total cost of revision surgery for periprosthetic joint infection considering 2 hospitalizations was 1,780,222 ± 313,686 Pakistani rupee (PKR). The total cost of uneventful arthroplasty was 390,172 ± 51,460 PKR. We observed significant difference with respect to economic details between the 2 groups. Conclusions Management of periprosthetic joint infection was 4.5 times more expensive than uneventful primary total knee arthroplasty. Measures should be undertaken to reduce the prevalence of periprosthetic joint infection, thereby reducing patients' economic burden.
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Affiliation(s)
- Faizan Iqbal
- Department of Orthopedic Surgery Liaquat National Hospital and Medical College, Karachi, Pakistan
| | - Bilal Shafiq
- Department of Orthopedic Surgery Liaquat National Hospital and Medical College, Karachi, Pakistan
| | - Syed Shahid Noor
- Department of Orthopedic Surgery Liaquat National Hospital and Medical College, Karachi, Pakistan
| | - Zulfiqar Ali
- Department of Orthopedic Surgery Liaquat National Hospital and Medical College, Karachi, Pakistan
| | - Nouman Memon
- Department of Orthopedic Surgery Liaquat National Hospital and Medical College, Karachi, Pakistan
| | - Naveed Memon
- Department of Orthopedic Surgery Liaquat National Hospital and Medical College, Karachi, Pakistan
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4
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Scarborough M, Li HK, Rombach I, Zambellas R, Walker AS, McNally M, Atkins B, Kümin M, Lipsky BA, Hughes H, Bose D, Warren S, Mack D, Folb J, Moore E, Jenkins N, Hopkins S, Seaton RA, Hemsley C, Sandoe J, Aggarwal I, Ellis S, Sutherland R, Geue C, McMeekin N, Scarborough C, Paul J, Cooke G, Bostock J, Khatamzas E, Wong N, Brent A, Lomas J, Matthews P, Wangrangsimakul T, Gundle R, Rogers M, Taylor A, Thwaites GE, Bejon P. Oral versus intravenous antibiotics for bone and joint infections: the OVIVA non-inferiority RCT. Health Technol Assess 2020; 23:1-92. [PMID: 31373271 DOI: 10.3310/hta23380] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Management of bone and joint infection commonly includes 4-6 weeks of intravenous (IV) antibiotics, but there is little evidence to suggest that oral (PO) therapy results in worse outcomes. OBJECTIVE To determine whether or not PO antibiotics are non-inferior to IV antibiotics in treating bone and joint infection. DESIGN Parallel-group, randomised (1 : 1), open-label, non-inferiority trial. The non-inferiority margin was 7.5%. SETTING Twenty-six NHS hospitals. PARTICIPANTS Adults with a clinical diagnosis of bone, joint or orthopaedic metalware-associated infection who would ordinarily receive at least 6 weeks of antibiotics, and who had received ≤ 7 days of IV therapy from definitive surgery (or start of planned curative treatment in patients managed non-operatively). INTERVENTIONS Participants were centrally computer-randomised to PO or IV antibiotics to complete the first 6 weeks of therapy. Follow-on PO therapy was permitted in either arm. MAIN OUTCOME MEASURE The primary outcome was the proportion of participants experiencing treatment failure within 1 year. An associated cost-effectiveness evaluation assessed health resource use and quality-of-life data. RESULTS Out of 1054 participants (527 in each arm), end-point data were available for 1015 (96.30%) participants. Treatment failure was identified in 141 out of 1015 (13.89%) participants: 74 out of 506 (14.62%) and 67 out of 509 (13.16%) of those participants randomised to IV and PO therapy, respectively. In the intention-to-treat analysis, using multiple imputation to include all participants, the imputed risk difference between PO and IV therapy for definitive treatment failure was -1.38% (90% confidence interval -4.94% to 2.19%), thus meeting the non-inferiority criterion. A complete-case analysis, a per-protocol analysis and sensitivity analyses for missing data each confirmed this result. With the exception of IV catheter complications [49/523 (9.37%) in the IV arm vs. 5/523 (0.96%) in the PO arm)], there was no significant difference between the two arms in the incidence of serious adverse events. PO therapy was highly cost-effective, yielding a saving of £2740 per patient without any significant difference in quality-adjusted life-years between the two arms of the trial. LIMITATIONS The OVIVA (Oral Versus IntraVenous Antibiotics) trial was an open-label trial, but bias was limited by assessing all potential end points by a blinded adjudication committee. The population was heterogenous, which facilitated generalisability but limited the statistical power of subgroup analyses. Participants were only followed up for 1 year so differences in late recurrence cannot be excluded. CONCLUSIONS PO antibiotic therapy is non-inferior to IV therapy when used during the first 6 weeks in the treatment for bone and joint infection, as assessed by definitive treatment failure within 1 year of randomisation. These findings challenge the current standard of care and provide an opportunity to realise significant benefits for patients, antimicrobial stewardship and the health economy. FUTURE WORK Further work is required to define the optimal total duration of therapy for bone and joint infection in the context of specific surgical interventions. Currently, wide variation in clinical practice suggests significant redundancy that likely contributes to the excess and unnecessary use of antibiotics. TRIAL REGISTRATION Current Controlled Trials ISRCTN91566927. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 23, No. 38. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Matthew Scarborough
- Nuffield Orthopaedic Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Ho Kwong Li
- Nuffield Orthopaedic Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.,Division of Infectious Diseases, Imperial College London, London, UK
| | - Ines Rombach
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Science, University of Oxford, Oxford, UK
| | - Rhea Zambellas
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Science, University of Oxford, Oxford, UK
| | - A Sarah Walker
- MRC Clinical Trials Unit, University College London, London, UK.,Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Martin McNally
- Nuffield Orthopaedic Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Bridget Atkins
- Nuffield Orthopaedic Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Michelle Kümin
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | | | - Harriet Hughes
- Department of Microbiology and Public Health, University Hospital of Wales, Public Health Wales, Cardiff, Wales
| | - Deepa Bose
- Department of Orthopaedic Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Simon Warren
- Infectious Diseases and Microbiology, Royal National Orthopaedic Hospital NHS Trust, Stanmore, UK.,Infectious Diseases and Microbiology, Royal Free London NHS Foundation Trust, London, UK
| | - Damien Mack
- Infectious Diseases and Microbiology, Royal National Orthopaedic Hospital NHS Trust, Stanmore, UK.,Infectious Diseases and Microbiology, Royal Free London NHS Foundation Trust, London, UK
| | - Jonathan Folb
- Department of Microbiology, Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool, UK
| | - Elinor Moore
- Infectious Diseases and Microbiology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Neil Jenkins
- Infectious Diseases, Heart of England NHS Foundation Trust, Birmingham, UK
| | - Susan Hopkins
- Infectious Diseases and Microbiology, Royal Free London NHS Foundation Trust, London, UK
| | - R Andrew Seaton
- Infectious Diseases and Microbiology, Gartnaval General Hospital, NHS Greater Glasgow and Clyde, Glasgow, UK
| | - Carolyn Hemsley
- Department of Microbiology and Infectious Diseases, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Jonathan Sandoe
- Department of Microbiology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Ila Aggarwal
- Department of Microbiology and Infectious Diseases, Ninewells Hospital, NHS Tayside, Dundee, UK
| | - Simon Ellis
- Infectious Diseases, Northumbria Healthcare NHS Foundation Trust, Cramlington, UK
| | - Rebecca Sutherland
- Infectious Diseases Unit, Regional Infectious Diseases Unit, Western General Hospital, NHS Lothian, Edinburgh, UK
| | - Claudia Geue
- Health Economics and Health Technology Assessment, University of Glasgow, Glasgow, UK
| | - Nicola McMeekin
- Health Economics and Health Technology Assessment, University of Glasgow, Glasgow, UK
| | | | - John Paul
- National Infection Service, Public Health England, Horsham, UK
| | - Graham Cooke
- Division of Infectious Diseases, Imperial College London, London, UK
| | - Jennifer Bostock
- Patient and Public Representative, Division of Health and Social Care Research, King's College London, , London, UK
| | - Elham Khatamzas
- Nuffield Orthopaedic Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Nick Wong
- Nuffield Orthopaedic Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Andrew Brent
- Nuffield Orthopaedic Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Jose Lomas
- Nuffield Orthopaedic Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Philippa Matthews
- Nuffield Orthopaedic Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.,Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Tri Wangrangsimakul
- Nuffield Orthopaedic Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Roger Gundle
- Nuffield Orthopaedic Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Mark Rogers
- Nuffield Orthopaedic Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Adrian Taylor
- Nuffield Orthopaedic Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Guy E Thwaites
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Philip Bejon
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
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5
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The Effect of Time Spent with a Dynamic Spacer on Clinical and Functional Outcomes in Two-Stage Revision Knee Arthroplasty. Indian J Orthop 2020; 54:824-830. [PMID: 33133405 PMCID: PMC7572906 DOI: 10.1007/s43465-020-00247-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2020] [Accepted: 08/24/2020] [Indexed: 02/04/2023]
Abstract
INTRODUCTION The present study aimed to evaluate the effect of a longer interval between the first and second stages of infected total knee arthroplasty (TKA) revision on the clinical and functional outcome. METHODS This study included a total of 56 patients who underwent two-stage revision TKA with a dynamic spacer with a minimum of 2 years of follow-up. Patients were categorized into two groups according to time with the spacer: < 3 months (Group 1, 31 patients) or > 3 months (Group 2, 25 patients). Clinical outcome and quality of life were assessed by knee range of motion (ROM), Knee Society Score for Knee (KSS-K), Knee Society Score for Function (KSS-F) and Short Form 36 (SF-36). RESULTS The mean follow-up period was 48 ± 19.1 months (range, 24-84 months). The KSS-K, KSS-F, and ROM values were significantly higher in Group 1 than in Group 2 (p < 0.05). The SF-36 scores for general health, physical function, and bodily pain were significantly higher in Group 1 (p < 0.05). Re-infection occurred in 10 patients (17.8%). Time with spacer was not associated with re-infection development (Group 1, n = 6, 19% vs. Group 2, n = 4, 16%; p > 0.05). CONCLUSION Increased duration with a spacer is associated with poorer clinical and functional outcomes as well as higher treatment costs in two-stage revision knee arthroplasty. Surgeons can attempt to reduce the time patients spend in a spacer to obtain better postoperative functional outcomes, as well as a better quality of life. LEVEL OF EVIDENCE 3.
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6
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McMeekin N, Geue C, Briggs A, Rombach I, Li HK, Bejon P, McNally M, Atkins BL, Ferguson J, Scarborough M. Cost-effectiveness of oral versus intravenous antibiotics (OVIVA) in patients with bone and joint infection: evidence from a non-inferiority trial. Wellcome Open Res 2019. [DOI: 10.12688/wellcomeopenres.15314.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Background: Bone and joint infections are becoming increasingly common and are usually treated with surgery and a course of intravenous antibiotics. However, there is no evidence to support the superiority of intravenous therapy and there is a growing body of literature showing that oral therapy is effective in treating these infections.Given this lack of evidence the clinical trial ‘Oral Versus Intravenous Antibiotics’ (OVIVA) was designed to assess the clinical and cost-effectiveness of intravenous versus oral antibiotics for the treatment of bone and joint infections, using a non-inferiority design. Clinical results from the trial indicate that oral antibiotics are non-inferior to intravenous antibiotics. The aim of this paper is to evaluate the cost-effectiveness of intravenous compared to oral antibiotics for treating bone and joint infections, using data from OVIVA. Methods: A cost-utility analysis was carried out, the main economic outcome measure was the quality adjusted life-year, measured using the EQ-5D-3L questionnaire, combined with costs to estimate cost-effectiveness over 12-months follow-up. Results: Results show that costs were significantly lower in the oral arm compared to the intravenous arm, a difference of £2,740 (95% confidence interval £1,488 to £3,992). Results of four sensitivity analyses were consistent with the base-case results. QALYs were marginally higher in the oral arm, however this difference was not statistically significant; -0.007 (95% confidence interval -0.045 to 0.031). Conclusions: Treating patients with bone and joint infections for the first six weeks of therapy with oral antibiotics is both less costly and does not result in detectable differences in quality of life compared to treatment with intravenous antibiotics. Adopting a practice of treating bone and joint infections with oral antibiotics early in the course of therapy could potentially save the UK National Health Service over £17 million annually.
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7
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McMeekin N, Geue C, Briggs A, Rombach I, Li HK, Bejon P, McNally M, Atkins BL, Ferguson J, Scarborough M. Cost-effectiveness of oral versus intravenous antibiotics (OVIVA) in patients with bone and joint infection: evidence from a non-inferiority trial. Wellcome Open Res 2019. [PMID: 31930174 DOI: 10.12688/wellcomeopenres.15314.1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Background: Bone and joint infections are becoming increasingly common and are usually treated with surgery and a course of intravenous antibiotics. However, there is no evidence to support the superiority of intravenous therapy and there is a growing body of literature showing that oral therapy is effective in treating these infections.Given this lack of evidence the clinical trial 'Oral Versus Intravenous Antibiotics' (OVIVA) was designed to assess the clinical and cost-effectiveness of intravenous versus oral antibiotics for the treatment of bone and joint infections, using a non-inferiority design. Clinical results from the trial indicate that oral antibiotics are non-inferior to intravenous antibiotics. The aim of this paper is to evaluate the cost-effectiveness of intravenous compared to oral antibiotics for treating bone and joint infections, using data from OVIVA. Methods: A cost-utility analysis was carried out, the main economic outcome measure was the quality adjusted life-year, measured using the EQ-5D-3L questionnaire, combined with costs to estimate cost-effectiveness over 12-months follow-up. Results: Results show that costs were significantly lower in the oral arm compared to the intravenous arm, a difference of £2,740 (95% confidence interval £1,488 to £3,992). Results of four sensitivity analyses were consistent with the base-case results. QALYs were marginally higher in the oral arm, however this difference was not statistically significant; -0.007 (95% confidence interval -0.045 to 0.031). Conclusions: Treating patients with bone and joint infections for the first six weeks of therapy with oral antibiotics is both less costly and does not result in detectable differences in quality of life compared to treatment with intravenous antibiotics. Adopting a practice of treating bone and joint infections with oral antibiotics early in the course of therapy could potentially save the UK National Health Service over £17 million annually.
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Affiliation(s)
- Nicola McMeekin
- HEHTA, Institute of Health and Wellbeing, University of Glasgow, Glasgow, G12 8RZ, UK
| | - Claudia Geue
- HEHTA, Institute of Health and Wellbeing, University of Glasgow, Glasgow, G12 8RZ, UK
| | - Andrew Briggs
- HEHTA, Institute of Health and Wellbeing, University of Glasgow, Glasgow, G12 8RZ, UK
| | - Ines Rombach
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, OX3 7LD, UK
| | - Ho Kwong Li
- Division of Infectious Diseases, Imperial College London, London, W12 0NN, UK.,Oxford University Hospitals NHS Foundation Trust, University of Oxford, Oxford, OX3 7HE, UK
| | - Philip Bejon
- Oxford University Hospitals NHS Foundation Trust, University of Oxford, Oxford, OX3 7HE, UK.,Nuffield Department of Medicine, University of Oxford, Oxford, OX3 7FZ, UK.,Wellcome Trust Research Programme, Kenya Medical Research Institute (KEMRI), Kilifi, Kenya
| | - Martin McNally
- The Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals, Oxford, OX3 7HE, UK
| | - Bridget L Atkins
- Oxford University Hospitals NHS Foundation Trust, University of Oxford, Oxford, OX3 7HE, UK
| | - Jamie Ferguson
- Oxford University Hospitals NHS Foundation Trust, University of Oxford, Oxford, OX3 7HE, UK
| | - Matthew Scarborough
- Oxford University Hospitals NHS Foundation Trust, University of Oxford, Oxford, OX3 7HE, UK
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8
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McMeekin N, Geue C, Briggs A, Rombach I, Li HK, Bejon P, McNally M, Atkins BL, Ferguson J, Scarborough M. Cost-effectiveness of oral versus intravenous antibiotics (OVIVA) in patients with bone and joint infection: evidence from a non-inferiority trial. Wellcome Open Res 2019; 4:108. [PMID: 31930174 PMCID: PMC6944252 DOI: 10.12688/wellcomeopenres.15314.4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/18/2019] [Indexed: 11/20/2022] Open
Abstract
Background: Bone and joint infections are becoming increasingly common and are usually treated with surgery and a course of intravenous antibiotics. However, there is no evidence to support the superiority of intravenous therapy and there is a growing body of literature showing that oral therapy is effective in treating these infections. Given this lack of evidence the clinical trial ‘Oral Versus Intravenous Antibiotics’ (OVIVA) was designed to assess the clinical and cost-effectiveness of intravenous versus oral antibiotics for the treatment of bone and joint infections, using a non-inferiority design. Clinical results from the trial indicate that oral antibiotics are non-inferior to intravenous antibiotics. The aim of this paper is to evaluate the cost-effectiveness of intravenous compared to oral antibiotics for treating bone and joint infections, using data from OVIVA. Methods: A cost-utility analysis was carried out, the main economic outcome measure was the quality adjusted life-year, measured using the EQ-5D-3L questionnaire, combined with costs to estimate cost-effectiveness over 12-months follow-up. Results: Results show that costs were significantly lower in the oral arm compared to the intravenous arm, a difference of £2,740 (95% confidence interval £1,488 to £3,992). Results of four sensitivity analyses were consistent with the base-case results. QALYs were marginally higher in the oral arm, however this difference was not statistically significant; -0.007 (95% confidence interval -0.045 to 0.031). Conclusions: Treating patients with bone and joint infections for the first six weeks of therapy with oral antibiotics is both less costly and does not result in detectable differences in quality of life compared to treatment with intravenous antibiotics. Adopting a practice of treating bone and joint infections with oral antibiotics early in the course of therapy could potentially save the UK National Health Service over £17 million annually.
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Affiliation(s)
- Nicola McMeekin
- HEHTA, Institute of Health and Wellbeing, University of Glasgow, Glasgow, G12 8RZ, UK
| | - Claudia Geue
- HEHTA, Institute of Health and Wellbeing, University of Glasgow, Glasgow, G12 8RZ, UK
| | - Andrew Briggs
- HEHTA, Institute of Health and Wellbeing, University of Glasgow, Glasgow, G12 8RZ, UK
| | - Ines Rombach
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, OX3 7LD, UK
| | - Ho Kwong Li
- Division of Infectious Diseases, Imperial College London, London, W12 0NN, UK.,Oxford University Hospitals NHS Foundation Trust, University of Oxford, Oxford, OX3 7HE, UK
| | - Philip Bejon
- Oxford University Hospitals NHS Foundation Trust, University of Oxford, Oxford, OX3 7HE, UK.,Nuffield Department of Medicine, University of Oxford, Oxford, OX3 7FZ, UK.,Wellcome Trust Research Programme, Kenya Medical Research Institute (KEMRI), Kilifi, Kenya
| | - Martin McNally
- The Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals, Oxford, OX3 7HE, UK
| | - Bridget L Atkins
- Oxford University Hospitals NHS Foundation Trust, University of Oxford, Oxford, OX3 7HE, UK
| | - Jamie Ferguson
- Oxford University Hospitals NHS Foundation Trust, University of Oxford, Oxford, OX3 7HE, UK
| | - Matthew Scarborough
- Oxford University Hospitals NHS Foundation Trust, University of Oxford, Oxford, OX3 7HE, UK
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9
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McMeekin N, Geue C, Briggs A, Rombach I, Li HK, Bejon P, McNally M, Atkins BL, Ferguson J, Scarborough M. Cost-effectiveness of oral versus intravenous antibiotics (OVIVA) in patients with bone and joint infection: evidence from a non-inferiority trial. Wellcome Open Res 2019. [PMID: 31930174 DOI: 10.12688/wellcomeopenres.15314.3] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Background: Bone and joint infections are becoming increasingly common and are usually treated with surgery and a course of intravenous antibiotics. However, there is no evidence to support the superiority of intravenous therapy and there is a growing body of literature showing that oral therapy is effective in treating these infections.Given this lack of evidence the clinical trial 'Oral Versus Intravenous Antibiotics' (OVIVA) was designed to assess the clinical and cost-effectiveness of intravenous versus oral antibiotics for the treatment of bone and joint infections, using a non-inferiority design. Clinical results from the trial indicate that oral antibiotics are non-inferior to intravenous antibiotics. The aim of this paper is to evaluate the cost-effectiveness of intravenous compared to oral antibiotics for treating bone and joint infections, using data from OVIVA. Methods: A cost-utility analysis was carried out, the main economic outcome measure was the quality adjusted life-year, measured using the EQ-5D-3L questionnaire, combined with costs to estimate cost-effectiveness over 12-months follow-up. Results: Results show that costs were significantly lower in the oral arm compared to the intravenous arm, a difference of £2,740 (95% confidence interval £1,488 to £3,992). Results of four sensitivity analyses were consistent with the base-case results. QALYs were marginally higher in the oral arm, however this difference was not statistically significant; -0.007 (95% confidence interval -0.045 to 0.031). Conclusions: Treating patients with bone and joint infections for the first six weeks of therapy with oral antibiotics is both less costly and does not result in detectable differences in quality of life compared to treatment with intravenous antibiotics. Adopting a practice of treating bone and joint infections with oral antibiotics early in the course of therapy could potentially save the UK National Health Service over £17 million annually.
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Affiliation(s)
- Nicola McMeekin
- HEHTA, Institute of Health and Wellbeing, University of Glasgow, Glasgow, G12 8RZ, UK
| | - Claudia Geue
- HEHTA, Institute of Health and Wellbeing, University of Glasgow, Glasgow, G12 8RZ, UK
| | - Andrew Briggs
- HEHTA, Institute of Health and Wellbeing, University of Glasgow, Glasgow, G12 8RZ, UK
| | - Ines Rombach
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, OX3 7LD, UK
| | - Ho Kwong Li
- Division of Infectious Diseases, Imperial College London, London, W12 0NN, UK.,Oxford University Hospitals NHS Foundation Trust, University of Oxford, Oxford, OX3 7HE, UK
| | - Philip Bejon
- Oxford University Hospitals NHS Foundation Trust, University of Oxford, Oxford, OX3 7HE, UK.,Nuffield Department of Medicine, University of Oxford, Oxford, OX3 7FZ, UK.,Wellcome Trust Research Programme, Kenya Medical Research Institute (KEMRI), Kilifi, Kenya
| | - Martin McNally
- The Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals, Oxford, OX3 7HE, UK
| | - Bridget L Atkins
- Oxford University Hospitals NHS Foundation Trust, University of Oxford, Oxford, OX3 7HE, UK
| | - Jamie Ferguson
- Oxford University Hospitals NHS Foundation Trust, University of Oxford, Oxford, OX3 7HE, UK
| | - Matthew Scarborough
- Oxford University Hospitals NHS Foundation Trust, University of Oxford, Oxford, OX3 7HE, UK
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10
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Aalirezaie A, Arumugam SS, Austin M, Bozinovski Z, Cichos KH, Fillingham Y, Ghanem E, Greenky M, Huang W, Jenny JY, Lazarovski P, Lee GC, Manrique J, Manzary M, Oshkukov S, Patel NK, Reyes F, Spangehl M, Vahedi H, Voloshin V. Hip and Knee Section, Prevention, Risk Mitigation: Proceedings of International Consensus on Orthopedic Infections. J Arthroplasty 2019; 34:S271-S278. [PMID: 30348568 DOI: 10.1016/j.arth.2018.09.011] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
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11
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Persistent Wound Drainage After Total Joint Arthroplasty: A Narrative Review. J Arthroplasty 2019; 34:175-182. [PMID: 30245124 DOI: 10.1016/j.arth.2018.08.034] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Revised: 08/17/2018] [Accepted: 08/27/2018] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Persistent wound drainage after total joint arthroplasty (TJA) is an important complication with potential substantial adverse consequences, in particular periprosthetic joint infection. METHODS This review evaluated the available literature regarding several issues in the field of persistent wound drainage after TJA and offers a classification of persistent wound drainage and an algorithmic approach to the decision-making process. RESULTS Available literature addressing the diagnosis and treatment of persistent wound drainage after TJA is scarce and an evidence-based clinical guideline is lacking. This is partially caused by the absence of a universally accepted definition of persistent wound drainage. In patients with persistent wound drainage, clinical signs and serological tests can be helpful in the diagnosis of a developing infection. Regarding the treatment of persistent wound drainage, nonsurgical treatment consists of absorbent dressings, pressure bandages, and temporary joint immobilization. Surgical treatment is advised when wound drainage persists for more than 5-7 days and consists of open debridement with irrigation and exchange of modular components and antimicrobial treatment. CONCLUSION Based on this literature review, we proposed a classification and algorithmic approach for the management of patients with persistent wound drainage after TJA. Hopefully, this offers the orthopedic surgeon a practical clinical guideline by finding the right balance between overtreatment and undertreatment, weighing the risks and benefits. However, this classification and algorithmic approach should first be evaluated in a prospective trial.
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12
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Mas-Moruno C, Su B, Dalby MJ. Multifunctional Coatings and Nanotopographies: Toward Cell Instructive and Antibacterial Implants. Adv Healthc Mater 2019; 8:e1801103. [PMID: 30468010 DOI: 10.1002/adhm.201801103] [Citation(s) in RCA: 117] [Impact Index Per Article: 23.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Revised: 10/15/2018] [Indexed: 01/02/2023]
Abstract
In biomaterials science, it is nowadays well accepted that improving the biointegration of dental and orthopedic implants with surrounding tissues is a major goal. However, implant surfaces that support osteointegration may also favor colonization of bacterial cells. Infection of biomaterials and subsequent biofilm formation can have devastating effects and reduce patient quality of life, representing an emerging concern in healthcare. Conversely, efforts toward inhibiting bacterial colonization may impair biomaterial-tissue integration. Therefore, to improve the long-term success of medical implants, biomaterial surfaces should ideally discourage the attachment of bacteria without affecting eukaryotic cell functions. However, most current strategies seldom investigate a combined goal. This work reviews recent strategies of surface modification to simultaneously address implant biointegration while mitigating bacterial infections. To this end, two emerging solutions are considered, multifunctional chemical coatings and nanotopographical features.
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Affiliation(s)
- Carlos Mas-Moruno
- Biomaterials, Biomechanics and Tissue Engineering Group; Department of Materials Science and Engineering & Center in Multiscale Science and Engineering; Universitat Politècnica de Catalunya (UPC); Barcelona 08019 Spain
| | - Bo Su
- Bristol Dental School; University of Bristol; Bristol BS1 2LY UK
| | - Matthew J. Dalby
- Centre for Cell Engineering; University of Glasgow; Glasgow G12 UK
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13
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Sousa A, Carvalho A, Pereira C, Reis E, Santos AC, Abreu M, Soares D, Fragoso R, Ferreira S, Reis M, Sousa R. Economic Impact of Prosthetic Joint Infection - an Evaluation Within the Portuguese National Health System. J Bone Jt Infect 2018; 3:197-202. [PMID: 30416943 PMCID: PMC6215985 DOI: 10.7150/jbji.28508] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2018] [Accepted: 08/20/2018] [Indexed: 01/16/2023] Open
Abstract
Introduction: Prosthetic infection is a devastating complication of arthroplasty and carries significant economic burden. The objective of this study was to analyze the economic impact of prosthetic hip and knee infection in Portuguese National Health System. Material and Methods: Case-control study carried out from January 2014 to December 2015. The mean costs of primary arthroplasties and prosthetic revision surgeries for non-infectious reasons were compared with the costs of prosthetic infections treated with debridement and preservation of the prosthesis or with two-stage exchange arthroplasty.The reimbursement for these cases was also evaluated and compared with its real costs. Results: A total of 715 primary arthroplasties, 35 aseptic revisions, 16 surgical debridements and 15 revisions for infectious reasons were evaluated. The cost of primary arthroplasties was 3,230€ in the hips and 3,618€ in the knees. The cost of aseptic revision was 6,089€ in the hips and 7,985€ in the knees. In the cases treated with debridement and implant retention the cost was 5,528€ in the hips and 4,009€ in the knees. In cases of infections treated with a two-stage revision the cost was 11,415€ and 13,793€ for hips and knees, respectively. Conclusion: As far as we know this is the first study that analyzes the economic impact of prosthetic infection in the Portuguese context. Although direct compensation for treating infected cases is much lower than calculated costs, infected cases push the overall hospital case-mix-index upwards thus increasing financial compensation for the entire cohort of treated patients. This knowledge will allow for more informed decisions about health policies in the future.
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Affiliation(s)
- Arnaldo Sousa
- Department of Orthopedics, Centro Hospitalar do Porto, Porto, Portugal
| | - André Carvalho
- Department of Orthopedics, Centro Hospitalar do Porto, Porto, Portugal
| | - Cláudia Pereira
- Department of Internal Medicine, Centro Hospitalar do Porto, Porto, Portugal
| | - Ernestina Reis
- Department of Internal Medicine, Centro Hospitalar do Porto, Porto, Portugal
| | - Ana Cláudia Santos
- Department of Microbiology, Centro Hospitalar do Porto - Hospital de Santo António, Porto, Portugal
| | - Miguel Abreu
- Department of Infectious Diseases, Centro Hospitalar do Porto, Porto, Portugal
| | - Daniel Soares
- Department of Orthopedics, Centro Hospitalar do Porto, Porto, Portugal
| | - Ricardo Fragoso
- Department of Information Systems, Centro Hospitalar do Porto, Porto, Portugal
| | - Susana Ferreira
- Department of Information Management, Centro Hospitalar do Porto, Porto, Portugal
| | - Marcio Reis
- Orthopedics Department Manager, Centro Hospitalar do Porto, Porto, Portugal
| | - Ricardo Sousa
- Department of Orthopedics, Centro Hospitalar do Porto, Porto, Portugal
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Parisi TJ, Konopka JF, Bedair HS. What is the Long-term Economic Societal Effect of Periprosthetic Infections After THA? A Markov Analysis. Clin Orthop Relat Res 2017; 475:1891-1900. [PMID: 28389865 PMCID: PMC5449335 DOI: 10.1007/s11999-017-5333-6] [Citation(s) in RCA: 91] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2016] [Accepted: 03/22/2017] [Indexed: 01/31/2023]
Abstract
BACKGROUND Current estimates for the direct costs of a single episode of care for periprosthetic joint infection (PJI) after THA are approximately USD 100,000. These estimates do not account for the costs of failed treatments and do not include indirect costs such as lost wages. QUESTIONS/PURPOSES The goal of this study was to estimate the long-term economic effect to society (direct and indirect costs) of a PJI after THA treated with contemporary standards of care in a hypothetical patient of working age (three scenarios, age 55, 60, and 65 years). METHODS We created a state-transition Markov model with health states defined by surgical treatment options including irrigation and débridement with modular exchange, single-stage revision, and two-stage revision. Reoperation rates attributable to septic and aseptic failure modes and indirect and direct costs were calculated estimates garnered via multiple systematic reviews of peer-reviewed orthopaedic and infectious disease journals and Medicare reimbursement data. We conducted an analysis over a hypothetical patient's lifetime from the societal perspective with costs discounted by 3% annually. We conducted sensitivity analysis to delineate the effects of uncertainty attributable to input variables. RESULTS The model found a base case cost of USD 390,806 per 65-year-old patient with an infected THA. One-way sensitivity analysis gives a range of USD 389,307 (65-year-old with a 3% reinfection rate) and USD 474,004 (55-year-old with a 12% reinfection rate). Indirect costs such as lost wages make up a considerable portion of the costs and increase considerably as age at the time of infection decreases. CONCLUSIONS The results of this study show that the overall treatment of a periprosthetic infection after a THA is markedly more expensive to society than previously estimated when accounting for the considerable failure rates of current treatment options and including indirect costs. These overall costs, combined with a large projected increase in THAs and a steady state of septic failures, should be taken into account when considering the total cost of THA. Further research is needed to adequately compare the clinical and economic effectiveness of alternative treatment pathways. LEVEL OF EVIDENCE Level II, economic and decision analysis.
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Affiliation(s)
- Thomas J. Parisi
- Department of Orthopaedics, Massachusetts General Hospital, 55 Fruit Street, Yawkey Building 3B, Boston, MA 02114 USA
| | - Joseph F. Konopka
- Department of Orthopaedics, Massachusetts General Hospital, 55 Fruit Street, Yawkey Building 3B, Boston, MA 02114 USA
| | - Hany S. Bedair
- Department of Orthopaedics, Massachusetts General Hospital, 55 Fruit Street, Yawkey Building 3B, Boston, MA 02114 USA
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Antibacterial and Biocompatible Titanium-Copper Oxide Coating May Be a Potential Strategy to Reduce Periprosthetic Infection: An In Vitro Study. Clin Orthop Relat Res 2017; 475:722-732. [PMID: 26847453 PMCID: PMC5289154 DOI: 10.1007/s11999-016-4713-7] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Periprosthetic infections are devastating for patients and more efficacious preventive strategies are needed. Surface-modified implants using antibacterial coatings represent an option to cope with this problem; however, manufacturing limitations and cytotoxicity have curbed clinical translation. Among metals with antibacterial properties, copper has shown superior in vitro antibacterial performance while maintaining an acceptable cytotoxicity profile. A thin film containing copper could prevent early biofilm formation to limit periprosthetic infections. This pilot study presents the in vitro antibacterial effect, cytotoxicity, and copper ion elution pattern of a thin film of titanium-copper oxide (TiCuO). QUESTIONS/PURPOSES (1) Do titanium alloy (Ti6Al4V) discs coated with a thin film of TiCuO reduce Staphylococcus epidermidis biofilm and planktonic cell density compared with uncoated discs? (2) Do Ti6Al4V discs coated with a thin film of TiCuO affect normal human osteoblast viability compared with untreated cells? (3) Is copper ion concentration generated by coated discs lower than previously published copper ion concentrations that cause 50% toxicity in similar human cell lines in vitro (TC50)? METHODS Ninety Ti6Al4V discs (12.5 mm diameter; 1.25 mm thick) were used in this study. Seventy-two Ti6Al4V discs were coated with a thin film of either titanium oxide (TiO) or TiCuO containing 20%, 40%, or 80% copper using high-power impulse magnetron sputtering (HiPIMS). Eighteen Ti6Al4V discs remained uncoated for control purposes. We tested antibacterial properties of S epidermidis grown on discs in wells containing growth medium. After 24 hours, planktonic bacteria as well as biofilms removed by sonication were quantitatively cultured. Annexin/Pi staining was used to quantify in vitro normal human osteoblast cell viability at 24 hours and Day 7, respectively. Copper elution was measured at Days 1, 2, 3, 7, 14, and 28 using an inductively coupled plasma mass spectrometer to analyze aliquots of culture medium. Copper ion concentration achieved at 24 hours was compared with previously published TC50 for gingival fibroblast, a phenotypically similar cell line with available data regarding copper ion exposure. RESULTS Discs coated with TiCuO 80% copper showed greater biofilm and planktonic cell density reduction when compared with other tested compositions (analysis of variance [ANOVA]; p < 0.001). Discs coated with TiCuO 80% copper showed mean biofilm and planktonic cell density of 4.0 log10 (SD = 0.4) and 5.7 log10 (SD = 0.2). Discs coated with TiCuO 80% showed a mean difference in biofilm and planktonic cell density of 2.5 log10 (95% confidence interval [CI], 1.9-3.1 log10; p < 0.001) and 1.2 (95% CI, 0.6-1.8; p < 0.001), respectively, when compared with uncoated discs. Normal human osteoblast viability did not differ among all groups at 24 hours (ANOVA; p = 0.2) and Day 7 (ANOVA; p = 0.7). Discs coated with TiCuO 80% copper showed a mean difference (95% CI) in relative cell viability (%) at 24 hours and Day 7 of 31.1 (95% CI, -19.4 to 81.7; p = 0.4) and -5.0 (95% CI, -7.8 to 17.9; p = 0.9), respectively, when compared with untreated cells. For all TiCuO-coated discs, copper ion elution peaked at 24 hours and slowly decreased in a curvilinear fashion to nearly undetectable levels by Day 28. Discs coated with TiCuO 80% copper showed mean copper ion concentration at 24 hours of 269.4 µmol/L (SD = 25.2 µmol/L) and this concentration was lower than previously published TC50 for similar human cell lines at 24 hours (344 µmol/L, SEM = 44 µmol/L). CONCLUSIONS This pilot study demonstrates a proof of concept that a thin-film implant coating with TiCuO can provide a potent local antibacterial environment while remaining relatively nontoxic to a human osteoblast cell line. Further research in an animal model will be necessary to establish efficacy and safety of this technique and whether it might be useful in the design of implants. CLINICAL RELEVANCE A thin film coating with TiCuO demonstrates high antibacterial activity and low cellular cytotoxicity to human osteoblasts in vitro. Taken together, these properties represent a potential strategy for preventing periprosthetic infection if further work in animal models can confirm these results in vivo.
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Markatos K, Kaseta M, Nikolaou VS. Perioperative Skin Preparation and Draping in Modern Total Joint Arthroplasty: Current Evidence. Surg Infect (Larchmt) 2015; 16:221-5. [DOI: 10.1089/sur.2014.097] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Affiliation(s)
- Konstantinos Markatos
- Second Orthopedic Department, University of Athens, School of Medicine, Athens, Greece
| | - Maria Kaseta
- Second Orthopedic Department, University of Athens, School of Medicine, Athens, Greece
| | - Vasileios S. Nikolaou
- Second Orthopedic Department, University of Athens, School of Medicine, Athens, Greece
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