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Krueger JS, Ackmann T, Gosheger G, Moellenbeck B, Puetzler J, Theil C. The Change of Serum Interleukin-6 Fails to Identify Subsequent Periprosthetic Joint Infection in Patients Who Have Two-Stage Revision for Periprosthetic Joint Infection. J Arthroplasty 2023; 38:2698-2703. [PMID: 37315631 DOI: 10.1016/j.arth.2023.06.008] [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: 02/01/2023] [Revised: 06/01/2023] [Accepted: 06/03/2023] [Indexed: 06/16/2023] Open
Abstract
BACKGROUND The diagnosis of persistent infection prior to second-stage reimplantation in 2-stage exchanges for periprosthetic joint infection (PJI) can be challenging as there is no optimal diagnostic tool. This study investigates the usefulness of pre-reimplantation serum C-reactive protein (CRP) and interleukin-6 (IL-6) and its change between both stages to identify patients who have subsequent PJI. METHODS There were 125 patients who underwent planned 2-stage exchange for chronic knee or hip PJI from a single center retrospectively identified. Patients were included if preoperative CRP and IL-6 were available for both stages. Subsequent PJI was defined as 2 positive microbiological cultures at reimplantation or subsequent surgery or death due to PJI during follow-up. RESULTS Prior to reimplantation, the median serum CRP (total knee arthroplasties [TKAs]: 1.0 versus 0.5 mg/dL, P = .028; total hip arthroplasties [THAs]: 1.3 versus 0.5 mg/dL, P = .015) and median IL-6 (TKA: 8.0 versus 6.0 pg/mL, P = .052; THA: 7.0 versus 6.0 pg/mL, P = .239) were higher in patients who had subsequent PJI. The IL-6 and CRP values showed moderate sensitivity (TKA/CRP: 66.7%; THA/CRP: 58.8%; TKA/IL-6: 46.7%; THA/IL-6: 35.3%) and good specificity (TKA/CRP: 66.7%; THA/CRP: 81.0%; TKA/IL-6: 86.3%; THA/IL-6: 83.3%). The change in CRP and IL-6 between the stages did not differ between the groups, respectively. CONCLUSIONS Serum CRP and IL-6 show low to moderate sensitivity and good specificity in the diagnosis of subsequent PJI prior to reimplantation, which questions their usefulness as a rule-out test. Furthermore, the change in between stages does not appear to identify subsequent PJI.
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Affiliation(s)
- Johanna S Krueger
- Department of Orthopaedics and Tumor Orthopaedics, Muenster University Hospital, Muenster, Germany
| | - Thomas Ackmann
- Department of Orthopaedics and Tumor Orthopaedics, Muenster University Hospital, Muenster, Germany
| | - Georg Gosheger
- Department of Orthopaedics and Tumor Orthopaedics, Muenster University Hospital, Muenster, Germany
| | - Burkhard Moellenbeck
- Department of Orthopaedics and Tumor Orthopaedics, Muenster University Hospital, Muenster, Germany
| | - Jan Puetzler
- Department of Orthopaedics and Tumor Orthopaedics, Muenster University Hospital, Muenster, Germany
| | - Christoph Theil
- Department of Orthopaedics and Tumor Orthopaedics, Muenster University Hospital, Muenster, Germany
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2
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Li Z, Yuan Z, Cao H, Huan D, Qiu Y, Xia T, Shen J. A case report on Mycobacterium houstonense infection after total hip arthroplasty. BMC Infect Dis 2023; 23:722. [PMID: 37880617 PMCID: PMC10598912 DOI: 10.1186/s12879-023-08705-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2023] [Accepted: 10/12/2023] [Indexed: 10/27/2023] Open
Abstract
BACKGROUND Mycobacterium houstonense is a category of rapidly growing mycobacteria that is gram-positive, acid-fast, polycrystalline, and non-spore-forming. There have been few reports of human infection caused by Mycobacterium houstonense worldwide. CASE PRESENTATION We present a case of chronic periprosthetic joint infection caused by Mycobacterium houstonense in an elderly female patient. The patient developed signs of infection after undergoing total hip arthroplasty. Despite receiving antibiotic treatment and revision surgery, the signs of infection recurred repeatedly. Multiple bacterial cultures during the treatment period were negative. Later, we identified the pathogenic bacteria Mycobacterium houstonense through mNGS testing, isolated the bacteria from the ultrasonically centrifuged fluid of the prosthesis and obtained drug sensitivity results. Finally, we performed a revision surgery and treated the patient with moxifloxacin and clindamycin. After treatment, the patient did not show signs of infection recurrence during 24 months of follow-up. CONCLUSION Through a relevant literature search, we believe that Mycobacterium houstonense may show higher sensitivity to amikacin and quinolone antibiotics. Additionally, clarifying occult infection sources through methods such as gene testing will improve the diagnosis and treatment of periprosthetic joint infection.
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Affiliation(s)
- ZhiPeng Li
- Affiliated Hospital of Nanjing University of Chinese Medicine, Jiangsu Provincial Hospital of Chinese Medicine, Nanjing, 210000, Jiangsu, China
| | - ZhaoFeng Yuan
- Affiliated Hospital of Nanjing University of Chinese Medicine, Jiangsu Provincial Hospital of Chinese Medicine, Nanjing, 210000, Jiangsu, China
| | - HuiLing Cao
- Affiliated Hospital of Nanjing University of Chinese Medicine, Jiangsu Provincial Hospital of Chinese Medicine, Nanjing, 210000, Jiangsu, China
| | - DaWei Huan
- Affiliated Hospital of Nanjing University of Chinese Medicine, Jiangsu Provincial Hospital of Chinese Medicine, Nanjing, 210000, Jiangsu, China
| | - Yue Qiu
- Affiliated Hospital of Nanjing University of Chinese Medicine, Jiangsu Provincial Hospital of Chinese Medicine, Nanjing, 210000, Jiangsu, China
| | - TianWei Xia
- Affiliated Hospital of Nanjing University of Chinese Medicine, Jiangsu Provincial Hospital of Chinese Medicine, Nanjing, 210000, Jiangsu, China
| | - JiRong Shen
- Affiliated Hospital of Nanjing University of Chinese Medicine, Jiangsu Provincial Hospital of Chinese Medicine, Nanjing, 210000, Jiangsu, China.
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3
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Glenn GT, Apple AE, Mears SC, Barnes CL, Stronach BM, Siegel ER, Stambough JB. Articulating Hip Spacers with a Constrained Acetabular Liner: Effect of Acetabular Bone Loss and Cementation Quality. Antibiotics (Basel) 2023; 12:1384. [PMID: 37760681 PMCID: PMC10526049 DOI: 10.3390/antibiotics12091384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Revised: 08/18/2023] [Accepted: 08/24/2023] [Indexed: 09/29/2023] Open
Abstract
Articulating hip spacers for periprosthetic joint infection (PJI) offer numerous advantages over static spacers such as improved patient mobilization, hip functionality, and soft tissue tension. Our study aimed to determine complication rates of a functional articulating spacer using a constrained liner to determine the role of acetabular cementation mantle and bone loss on the need for second-stage surgery. A retrospective review of 103 patients was performed and demographic information, spacer components and longevity, spacer-related complications, reinfection rates, and grade of bone loss and acetabular cement mantle quality were determined. There was no significant difference in spacer-related complications or reinfection rate between PJI and native hip infections. 33 of 103 patients (32.0%) elected to retain their spacers. Between patients who retained their initial spacer and those who underwent reimplantation surgery, there was not a significant difference in cement mantle grade (p = 0.52) or degree of bone loss (p = 0.78). Functional articulating antibiotic spacers with cemented constrained acetabular liners demonstrate promising early results in the treatment of periprosthetic and native hip infections. The rate of dislocation events was low. Further efforts to improve cement fixation may help decrease the need for second-stage reimplantation surgery.
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Affiliation(s)
- Grayson T. Glenn
- Department of Orthopaedic Surgery, University of Arkansas for Medical Sciences, 4301 West Markham Street, Little Rock, AR 72205, USA; (G.T.G.); (S.C.M.); (C.L.B.); (B.M.S.)
| | - Andrew E. Apple
- Department of Orthopaedic Surgery, Tulane University, 1430 Tulane Avenue, New Orleans, LA 70112, USA;
| | - Simon C. Mears
- Department of Orthopaedic Surgery, University of Arkansas for Medical Sciences, 4301 West Markham Street, Little Rock, AR 72205, USA; (G.T.G.); (S.C.M.); (C.L.B.); (B.M.S.)
| | - C. Lowry Barnes
- Department of Orthopaedic Surgery, University of Arkansas for Medical Sciences, 4301 West Markham Street, Little Rock, AR 72205, USA; (G.T.G.); (S.C.M.); (C.L.B.); (B.M.S.)
| | - Benjamin M. Stronach
- Department of Orthopaedic Surgery, University of Arkansas for Medical Sciences, 4301 West Markham Street, Little Rock, AR 72205, USA; (G.T.G.); (S.C.M.); (C.L.B.); (B.M.S.)
| | - Eric R. Siegel
- Department of Biostatistics, University of Arkansas for Medical Sciences, 4301 West Markham Street, Little Rock, AR 72205, USA;
| | - Jeffrey B. Stambough
- Department of Orthopaedic Surgery, University of Arkansas for Medical Sciences, 4301 West Markham Street, Little Rock, AR 72205, USA; (G.T.G.); (S.C.M.); (C.L.B.); (B.M.S.)
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Alrayes MM, Sukeik MT. Emerging Technologies in Diagnosing Periprosthetic Joint Infections. Indian J Orthop 2023; 57:643-652. [PMID: 37128562 PMCID: PMC10147868 DOI: 10.1007/s43465-023-00891-w] [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: 02/04/2023] [Accepted: 04/04/2023] [Indexed: 05/03/2023]
Abstract
Periprosthetic joint infection (PJI) is a well-known serious complication following joint replacement surgeries and is responsible for high failure rates of implanted devices. Any delay in the diagnosis can compromise treatment success, putting a huge burden on the patients' wellness and healthcare systems. Diagnosing PJIs is quite complex as there is still no gold standard test to reach the definitive diagnosis in a timely manner. A number of laboratory tests and radiological imaging inventions have evolved in the past few years, requiring consistent updates of the available guidelines to keep up with the latest advances in the field. This article highlights the recent advances in diagnosing PJIs and discusses their validity for use in clinical practice.
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Affiliation(s)
- Majd M. Alrayes
- Department of Trauma & Orthopedics, Dammam Medical Complex, Dammam, 32210 Saudi Arabia
| | - Mohamed T. Sukeik
- Department of Trauma & Orthopaedics, Dr. Sulaiman Al-Habib Hospital–Al Khobar, Al Khobar, 34423 Saudi Arabia
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5
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Alrayes MM, Sukeik M. Two-stage revision in periprosthetic knee joint infections. World J Orthop 2023; 14:113-122. [PMID: 36998382 PMCID: PMC10044322 DOI: 10.5312/wjo.v14.i3.113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Revised: 12/20/2022] [Accepted: 01/10/2023] [Indexed: 03/17/2023] Open
Abstract
Periprosthetic joint infection (PJI) following total knee arthroplasty is one of the most catastrophic and costly complications that carries significant patient wellness as well as economic burdens. The road to efficiently diagnosing and treating PJI is challenging, as there is still no gold standard method to reach the diagnosis as early as desired. There are also international controversies with respect to the best approach to manage PJI cases. In this review, we highlight recent advances in managing PJI following knee arthroplasty surgery and discuss in depth the two-stage revision method.
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Affiliation(s)
- Majd M Alrayes
- Department of Orthopedics, Imam Abdulrahman bin Faisal University, Khobar 34423, Saudi Arabia
| | - Mohamed Sukeik
- Department of Trauma & Orthopaedics, Dr. Sulaiman Al-Habib Hospital – Al Khobar, Al Khobar 34423, Al Khobar, Saudi Arabia
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6
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Khalifa AA, Hussien SM. The promising role of bacteriophage therapy in managing total hip and knee arthroplasty related periprosthetic joint infection, a systematic review. J Exp Orthop 2023; 10:18. [PMID: 36786898 PMCID: PMC9929010 DOI: 10.1186/s40634-023-00586-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Accepted: 02/08/2023] [Indexed: 02/15/2023] Open
Abstract
PURPOSE Total hip and knee arthroplasty periprosthetic joint infection (PJI) poses a management dilemma owing to the emergence of resistant organisms. A promising option is Bacteriophage therapy (BT) was used as an adjuvant for PJI management, aiming at treating resistant infections, decreasing morbidity, and mortality. The current review aimed to demonstrate the role and safety of using BT as an adjuvant to treat PJIs. METHODS A systematic search was performed through four databases (Embase, PubMed, Web of Science, and Scopus) up to March 2022, according to the predetermined inclusion and exclusion criteria. RESULTS Our systematic review included 11 case reports of 13 patients in which 14 joints (11 TKAs and three THAs) were treated. The patients' average age was 73.7 years, underwent an average of 4.5 previous surgeries. The most common organism was the Staphylococcus aureus species. All patients underwent surgical debridement; for the 13 patients, eight received a cocktail, and five received monophage therapy. All patients received postoperative suppressive antibiotic therapy. After an average follow-up of 14.5 months, all patients had satisfactory outcomes. No recurrence of infection in any patient. Transaminitis complicating BT was developed in three patients, needed stoppage in only one, and the condition was reversible and non-life-threatening. CONCLUSION BT is a safe and potentially effective adjuvant therapy for treating resistant and relapsing PJIs. However, further investigations are needed to clarify some BT-related issues to create effective and reproducible therapeutics. Furthermore, new ethical regulations should be implemented to facilitate its widespread use.
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Affiliation(s)
- Ahmed A. Khalifa
- grid.412707.70000 0004 0621 7833Orthopaedic Department, Qena Faculty of Medicine and University Hospital, South Valley University, Kilo 6 Qena-Safaga Highway, Qena, 83523 Egypt ,grid.412707.70000 0004 0621 7833Qena Faculty of Medicine, South Valley University, Qena, Egypt
| | - Sarah M. Hussien
- grid.412707.70000 0004 0621 7833Qena Faculty of Medicine, South Valley University, Qena, Egypt
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7
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Wignadasan W, Ibrahim M, Haddad FS. One- or two-stage reimplantation for infected total knee prosthesis? Orthop Traumatol Surg Res 2023; 109:103453. [PMID: 36302451 DOI: 10.1016/j.otsr.2022.103453] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Revised: 02/08/2022] [Accepted: 03/02/2022] [Indexed: 11/07/2022]
Abstract
A prosthetic joint infection (PJI) is possibly the most significant potential complication of total knee arthroplasty (TKA) and is associated with substantial morbidity and socioeconomic burden. It is a devastating complication for both the patient and the surgeon alike. A two-stage revision approach for infected TKA has been the standard for surgical management; however, there is growing interest in single-stage revision surgery due to fewer procedures, reduced inpatient hospital stay and reduced costs to healthcare systems. A one-stage exchange is indicated when there is no sign of systemic sepsis and in cases where a microorganism has been isolated. It involves removal of the old prosthesis, debridement of all infected tissue, a copious washout and re-draping, and finally, re-implantation of a new prosthesis. The two-stage approach involves the use of an antibiotic spacer before the second stage is carried out. The length of time between the stages is discussed. Patients with a PJI should be managed by a multidisciplinary team. We recommend these patients are managed in specialist arthroplasty centres by high volume revision arthroplasty specialists.
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Affiliation(s)
- Warran Wignadasan
- University College London Hospitals, 250, Euston Road, London NW1 2 PG, United Kingdom.
| | - Mazin Ibrahim
- University College London Hospitals, 250, Euston Road, London NW1 2 PG, United Kingdom
| | - Fares S Haddad
- University College London Hospitals, 250, Euston Road, London NW1 2 PG, United Kingdom
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8
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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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9
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Wang Y, Teng W, Zhang Z, Ma S, Jin Z, Zhou X, Ye Y, Zhang C, Gou Z, Yu X, Ye Z, Ren Y. Remote Eradication of Bacteria on Orthopedic Implants via Delayed Delivery of Polycaprolactone Stabilized Polyvinylpyrrolidone Iodine. J Funct Biomater 2022; 13:jfb13040195. [PMID: 36278664 PMCID: PMC9589933 DOI: 10.3390/jfb13040195] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Revised: 10/08/2022] [Accepted: 10/15/2022] [Indexed: 11/16/2022] Open
Abstract
Bacteria-associated late infection of the orthopedic devices would further lead to the failure of the implantation. However, present ordinary antimicrobial strategies usually deal with early infection but fail to combat the late infection of the implants due to the burst release of the antibiotics. Thus, to fabricate long-term antimicrobial (early antibacterial, late antibacterial) orthopedic implants is essential to address this issue. Herein, we developed a sophisticated MAO-I2-PCLx coating system incorporating an underlying iodine layer and an upper layer of polycaprolactone (PCL)-controlled coating, which could effectively eradicate the late bacterial infection throughout the implantation. Firstly, micro-arc oxidation was used to form a microarray tubular structure on the surface of the implants, laying the foundation for iodine loading and PCL bonding. Secondly, electrophoresis was applied to load iodine in the tubular structure as an efficient bactericidal agent. Finally, the surface-bonded PCL coating acts as a controller to regulate the release of iodine. The hybrid coatings displayed great stability and control release capacity. Excellent antibacterial ability was validated at 30 days post-implantation via in vitro experiments and in vivo rat osteomyelitis model. Expectedly, it can become a promising bench-to-bedside strategy for current infection challenges in the orthopedic field.
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Affiliation(s)
- Yikai Wang
- Department of Orthopedics, Renmin Hospital of Wuhan University, Jiefang Road 238, Wuhan 430060, China
| | - Wangsiyuan Teng
- Department of Orthopedics, Centre for Orthopaedic Research, Orthopedics Research Institute of Zhejiang University, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310009, China
- Key Laboratory of Motor System Disease Research and Precision Therapy of Zhejiang Province, Hangzhou 310009, China
| | - Zengjie Zhang
- Department of Orthopedics, Centre for Orthopaedic Research, Orthopedics Research Institute of Zhejiang University, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310009, China
- Key Laboratory of Motor System Disease Research and Precision Therapy of Zhejiang Province, Hangzhou 310009, China
| | - Siyuan Ma
- Department of Orthopedics, Renmin Hospital of Wuhan University, Jiefang Road 238, Wuhan 430060, China
| | - Zhihui Jin
- Department of Orthopedics, Renmin Hospital of Wuhan University, Jiefang Road 238, Wuhan 430060, China
| | - Xingzhi Zhou
- Department of Orthopedics, Centre for Orthopaedic Research, Orthopedics Research Institute of Zhejiang University, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310009, China
- Key Laboratory of Motor System Disease Research and Precision Therapy of Zhejiang Province, Hangzhou 310009, China
| | - Yuxiao Ye
- School of Material Science and Engineering, University of New South Wales, Sydney 2052, Australia
| | - Chongda Zhang
- New York University Medical Center, New York University, New York, NY 10016, USA
| | - Zhongru Gou
- Bio-Nanomaterials and Regenerative Medicine Research Division, Zhejiang-California International Nanosystem Institute, Zhejiang University, Hangzhou 310058, China
| | - Xiaohua Yu
- Department of Orthopedics, Centre for Orthopaedic Research, Orthopedics Research Institute of Zhejiang University, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310009, China
- Key Laboratory of Motor System Disease Research and Precision Therapy of Zhejiang Province, Hangzhou 310009, China
| | - Zhaoming Ye
- Department of Orthopedics, Centre for Orthopaedic Research, Orthopedics Research Institute of Zhejiang University, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310009, China
- Key Laboratory of Motor System Disease Research and Precision Therapy of Zhejiang Province, Hangzhou 310009, China
- Correspondence: (Z.Y.); (Y.R.); Tel.: +86-571-8778-3777 (Z.Y.); +86-027-8804-1911 (ext. 83380) (Y.R.)
| | - Yijun Ren
- Department of Orthopedics, Renmin Hospital of Wuhan University, Jiefang Road 238, Wuhan 430060, China
- Correspondence: (Z.Y.); (Y.R.); Tel.: +86-571-8778-3777 (Z.Y.); +86-027-8804-1911 (ext. 83380) (Y.R.)
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10
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LOGROSCINO G, SARACCO M. Hip periprosthetic joint infections: prevention, diagnosis and treatment. MINERVA ORTHOPEDICS 2022; 73. [DOI: 10.23736/s2784-8469.21.04186-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/31/2023]
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11
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Bureau A, Bourget-Murray J, Azad MA, Abdelbary H, Grammatopoulos G, Garceau SP. Management of Periprosthetic Joint Infections After Hemiarthroplasty of the Hip: A Critical Analysis Review. JBJS Rev 2022; 10:01874474-202209000-00006. [PMID: 36155552 DOI: 10.2106/jbjs.rvw.22.00020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
➢ Periprosthetic joint infection (PJI) following hip hemiarthroplasty (HA) is a devastating complication, incurring immense health-care costs associated with its treatment and placing considerable burden on patients and their families. These patients often require multiple surgical procedures, extended hospitalization, and prolonged antimicrobial therapy. ➢ Notable risk factors include older age, higher American Society of Anesthesiologists (ASA) score, inadequate antibiotic prophylaxis, non-antibiotic-loaded cementation of the femoral implant, longer duration of the surgical procedure, and postoperative drainage and hematoma. ➢ Although the most frequent infecting organisms are gram-positive cocci such as Staphylococcus aureus, there is a higher proportion of patients with gram-negative and polymicrobial infections after hip HA compared with patients who underwent total hip arthroplasty. ➢ Several surgical strategies exist. Regardless of the preferred surgical treatment, successful management of these infections requires a comprehensive surgical debridement focused on eradicating the biofilm followed by appropriate antibiotic therapy. ➢ A multidisciplinary approach led by surgeons familiar with PJI treatment and infectious disease specialists is recommended for all cases of PJI after hip HA to increase the likelihood of treatment success.
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Affiliation(s)
- Antoine Bureau
- Division of Orthopaedic Surgery, The Ottawa Hospital, Ottawa, Ontario, Canada
| | | | - Marisa A Azad
- Division of Infectious Diseases, Department of Medicine, Mayo Clinic, Rochester, Minnesota
| | - Hesham Abdelbary
- Division of Orthopaedic Surgery, The Ottawa Hospital, Ottawa, Ontario, Canada
| | | | - Simon P Garceau
- Division of Orthopaedic Surgery, The Ottawa Hospital, Ottawa, Ontario, Canada
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12
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Rachh SS, Basu S, Alavi A. Fluorodeoxyglucose PET/Computed Tomography in Evaluation of Prosthetic Joints and Diabetic Foot: A Comparative Perspective with Other Functional Imaging Modalities. PET Clin 2022; 17:517-531. [PMID: 35717105 DOI: 10.1016/j.cpet.2022.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Infection imaging has been an important part of nuclear medicine practice. Infections in prosthetic joints and diabetic foot are associated with devastating complications, posing substantial challenge for both diagnosis and overall management. For many years, conventional nuclear medicine techniques have been used to frame a painful joint arthroplasty or diabetic foot infection. The various functional nuclear imaging modalities used include labeled leukocyte imaging, combined leukocyte-marrow scintigraphy, antigranulocyte antibody scintigraphy, 3-phase bone scintigraphy, and fluorodeoxyglucose PET/computed tomography, yet no single method has proved to be highly sensitive and specific and at the same time safe, simple, and time-effective.
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Affiliation(s)
- Swati Sodagar Rachh
- Department of Nuclear Medicie, Gujarat Cancer & Research Institute, Civil Hospital Campus, Asarwa, Ahmedabad 380016, India; Radiation Medicine Centre (B.A.R.C), Tata Memorial Centre Annexe, Parel, Mumbai, India
| | - Sandip Basu
- Radiation Medicine Centre (B.A.R.C), Tata Memorial Centre Annexe, Parel, Mumbai, India; Homi Bhabha National Institute, Mumbai, India.
| | - Abass Alavi
- Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
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13
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Barretto JM, Campos ALS, Ooka NHM. Periprosthetic Knee Infection - Part 2: Treatment. Rev Bras Ortop 2022; 57:193-199. [PMID: 35652024 PMCID: PMC9142269 DOI: 10.1055/s-0041-1729936] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Accepted: 12/17/2020] [Indexed: 11/29/2022] Open
Abstract
Several treatment modalities are proposed for periprosthetic infections, with variable success rates. However, efficacy is related to the appropriate selection of cases for each type of treatment. Debridement with implant retention is indicated in acute infections with fixed implant, and its success depends on the type of infection, comorbidities of the host, and virulence of the etiological agent. One- or two-stage revision is required in cases in which biofilm is forming, or of implant loosening. The choice between performing the review in one or two stages depends on factors such as etiological agent identification, pathogen virulence, local and systemic host factors. Rescue procedures such as arthrodesis, amputation, resection arthroplasty or even antibiotic suppression are reserved for cases in which the infection has not been eradicated.
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Affiliation(s)
| | - André Luiz Siqueira Campos
- Departamento de Ortopedia e Traumatologia, Hospital Federal dos Servidores do Estado, Rio de Janeiro, RJ, Brasil
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Bui TI, Gill AL, Mooney RA, Gill SR. Modulation of Gut Microbiota Metabolism in Obesity-Related Type 2 Diabetes Reduces Osteomyelitis Severity. Microbiol Spectr 2022; 10:e0017022. [PMID: 35315698 PMCID: PMC9045376 DOI: 10.1128/spectrum.00170-22] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Accepted: 03/03/2022] [Indexed: 12/01/2022] Open
Abstract
Staphylococcus aureus is an opportunistic pathogen causing osteomyelitis through hematogenous seeding or contamination of implants and open wounds following orthopedic surgeries. The severity of S. aureus-mediated osteomyelitis is enhanced in obesity-related type 2 diabetes (obesity/T2D) due to chronic inflammation impairing both adaptive and innate immunity. Obesity-induced inflammation is linked to gut dysbiosis, with modification of the gut microbiota by high-fiber diets leading to a reduction in the symptoms and complications of obesity/T2D. However, our understanding of the mechanisms by which modifications of the gut microbiota alter host infection responses is limited. To address this gap, we monitored tibial S. aureus infections in obese/T2D mice treated with the inulin-like fructan fiber oligofructose. Treatment with oligofructose significantly decreased S. aureus colonization and lowered proinflammatory signaling postinfection in obese/T2D mice, as observed by decreased circulating inflammatory cytokines (tumor necrosis factor-α [TNF-α]) and chemokines (interferon-γ-induced protein 10 kDa [IP-10], keratinocyte-derived chemokine [KC], monokine induced by interferon-γ [MIG], monocyte chemoattractant protein-1 [MCP-1], and regulated upon activation, normal T cell expressed and presumably secreted [RANTES]), indicating partial reduction in inflammation. Oligofructose markedly shifted diversity in the gut microbiota of obese/T2D mice, with notable increases in the anti-inflammatory bacterium Bifidobacterium pseudolongum. Analysis of the cecum and plasma metabolome suggested that polyamine production was increased, specifically spermine and spermidine. Oral administration of these polyamines to obese/T2D mice resulted in reduced infection severity similar to oligofructose supplementation, suggesting that polyamines can mediate the beneficial effects of fiber on osteomyelitis severity. These results demonstrate the contribution of gut microbiota metabolites to the control of bacterial infections distal to the gut and polyamines as an adjunct therapeutic for osteomyelitis in obesity/T2D. IMPORTANCE Individuals with obesity-related type 2 diabetes (obesity/T2D) are at a five times increased risk for invasive Staphylococcus aureus osteomyelitis (bone infection) following orthopedic surgeries. With increasing antibiotic resistance and limited discoveries of novel antibiotics, it is imperative that we explore other avenues for therapeutics. In this study, we demonstrated that the dietary fiber oligofructose markedly reduced osteomyelitis severity and hyperinflammation following acute prosthetic joint infections in obese/T2D mice. Reduced infection severity was associated with changes in gut microbiota composition and metabolism, as indicated by increased production of natural polyamines in the gut and circulating plasma. This work identifies a novel role for the gut microbiome in mediating control of bacterial infections and polyamines as beneficial metabolites involved in improving the obesity/T2D host response to osteomyelitis. Understanding the impact of polyamines on host immunity and mechanisms behind decreasing susceptibility to severe implant-associated osteomyelitis is crucial to improving treatment strategies for this patient population.
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Affiliation(s)
- Tina I. Bui
- Department of Microbiology and Immunology, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Ann Lindley Gill
- Department of Microbiology and Immunology, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Robert A. Mooney
- Department of Pathology and Laboratory Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
- Center for Musculoskeletal Research, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Steven R. Gill
- Department of Microbiology and Immunology, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
- Center for Musculoskeletal Research, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
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15
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Lopez W, Azizpour K, Raskin K, Lozano-Calderón S. Periprosthetic Joint Infection after Endoprosthetic Reconstruction: Saving the Limb-Salvage. THE ARCHIVES OF BONE AND JOINT SURGERY 2021; 9:677-685. [PMID: 35106333 PMCID: PMC8765206 DOI: 10.22038/abjs.2021.52948.2628] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Accepted: 06/23/2021] [Indexed: 01/24/2023]
Abstract
BACKGROUND This study evaluates mega-endoprosthetic survival after revision for periprosthetic joint infection (PJI) and two-staged reconstruction using a cement spacer. Mega-endoprosthetics offer patients an important treatment option for limb salvage. However, PJI is a devastating complication which affects between 2-10% of patients. It commonly results in revisions, amputation, and sometimes death. Literature in terms of success rates, limb salvage and Megaprostheses survival after revision for infection is limited. We present here our experience and the impact of length of the spacer in prostheses survival. METHODS A retrospective chart review was implemented using Fisher's exact test for categorical data and the Kaplan-Meier method for prosthesis survival. Patient information was acquired through our institution's electronic medical records. Variables such as diagnosis, complications, length of cement spacer, and number of surgeries were recorded. We analyzed spacer length and prosthesis survival based on these variables. RESULTS Fisher's Exact test showed no correlation between length of spacer and amount of repeat surgery (p = 0.245). After two-stage revision and mega-prosthesis insertion, there was a 63.2% chance of complication and a 26.3% chance of amputation. This indicates a 73.7% probability for limb salvage in this sample (Kaplan-Meier). CONCLUSION These data suggest long-term viability of mega-endoprostheses after two-stage revision despite a high complication rate.
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Affiliation(s)
- Wylie Lopez
- Department of Orthopaedic Surgery, Massachusetts General Hospital, MA, USA
| | | | - Kevin Raskin
- Department of Neurosurgery, Leiden University Medical Center, Leiden, The Netherlands
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16
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Fröschen FS, Walter SG, Randau TM, Gravius N, Gravius S, Hischebeth GTR. The use of negative pressure wound therapy increases failure rate in debridement and implant retention for acute prosthetic joint infection. Technol Health Care 2021; 28:721-731. [PMID: 32444587 DOI: 10.3233/thc-192095] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND To date only scanty data exist regarding the effect of failed debridement, antibiotics, irrigation and retention of the prostheses (DAIR) and negative pressure wound therapy (NPWT) on the outcome of a subsequent exchange arthroplasty. OBJECTIVE The objective of this study was to determine the success rate of a two- or multi-stage procedure after initial failed DAIR/NPWT in patients with an acute periprosthetic joint infection (PJI) and to evaluate the influence of possible risk factors for treatment failure. METHODS Nineteen consecutive patients with a persisting PJI and ongoing NPWT after treatment of an acute PJI with DAIR of the hip or knee joint from October 2010 to June 2017 were included. All patients were treated according to a structured treatment algorithm after referral to our hospital. The endpoint was a successful reimplantation with absence of signs of infection two years after replantation ("replantation group") or treatment failure ("treatment failure group") in terms of a permanent girdlestone arthroplasty, fistula, amputation or death. A risk factor analysis was performed between the two groups. RESULTS Explantation was performed in 15 cases, amputation in one case, and DAIR/establishment of a fistula in three cases. The treatment success rate after reimplantation in terms of "definitively free of infection" two years after surgery according to Laffer was 36.85% (seven out of 19 patients). Statistical analysis revealed the number of surgeries until wound consolidation (p= 0.007), number of detected bacterial strains (p= 0.041), a polymicrobial PJI (p= 0.041) and detection of a difficult-to-treat organism (p= 0.005) as factors associated with treatment failure. After failed DAIR/NPWT we could detect a significant higher number of different bacterial strains (p= 0.001). CONCLUSIONS The treatment success rate after failed DAIR and NPWT with 36% is low and associated with a high treatment failure rate (permanent girdlestone arthroplasty, fistula or amputation, death). Thus, the definition of risk factors is crucial. We found that the number of revisions until wound consolidation, a polymicrobial PJI and detection of a difficult-to-treat organisms were risk factors for treatment failure. Furthermore, after failed DAIR/NPWT we could detect a significant higher number of different bacterial strains, with a possible adverse effect on a consecutive exchange.
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Affiliation(s)
| | | | - Thomas Martin Randau
- Department of Orthopaedics and Trauma Surgery, University Hospital Bonn, Bonn, Germany
| | - Nadine Gravius
- Department of Orthopaedics and Trauma Surgery, University Hospital Bonn, Bonn, Germany
| | - Sascha Gravius
- Department of Orthopaedics and Trauma Surgery, University Hospital Bonn, Bonn, Germany.,Orthopaedic and Trauma Surgery Centre, University Hospital Mannheim, Medical Faculty Mannheim of the University of Heidelberg, Mannheim, Germany
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17
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Wang Y, Teng W, Zhang Z, Zhou X, Ye Y, Lin P, Liu A, Wu Y, Li B, Zhang C, Yang X, Li W, Yu X, Gou Z, Ye Z. A trilogy antimicrobial strategy for multiple infections of orthopedic implants throughout their life cycle. Bioact Mater 2021; 6:1853-1866. [PMID: 33336116 PMCID: PMC7732879 DOI: 10.1016/j.bioactmat.2020.11.030] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Revised: 11/20/2020] [Accepted: 11/27/2020] [Indexed: 01/03/2023] Open
Abstract
Bacteria-associated infection represents one of the major threats for orthopedic implants failure during their life cycles. However, ordinary antimicrobial treatments usually failed to combat multiple waves of infections during arthroplasty and prosthesis revisions etc. As these incidents could easily introduce new microbial pathogens in/onto the implants. Herein, we demonstrate that an antimicrobial trilogy strategy incorporating a sophisticated multilayered coating system leveraging multiple ion exchange mechanisms and fine nanotopography tuning, could effectively eradicate bacterial infection at various stages of implantation. Early stage bacteriostatic effect was realized via nano-topological structure of top mineral coating. Antibacterial effect at intermediate stage was mediated by sustained release of zinc ions from doped CaP coating. Strong antibacterial potency was validated at 4 weeks post implantation via an implanted model in vivo. Finally, the underlying zinc titanate fiber network enabled a long-term contact and release effect of residual zinc, which maintained a strong antibacterial ability against both Staphylococcus aureus and Escherichia coli even after the removal of top layer coating. Moreover, sustained release of Sr2+ and Zn2+ during CaP coating degradation substantially promoted implant osseointegration even under an infectious environment by showing more peri-implant new bone formation and substantially improved bone-implant bonding strength.
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Affiliation(s)
- Yikai Wang
- Department of Orthopedics, Centre for Orthopaedic Research, Orthopedics Research Institute of Zhejiang University, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310000, PR China
| | - Wangsiyuan Teng
- Department of Orthopedics, Centre for Orthopaedic Research, Orthopedics Research Institute of Zhejiang University, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310000, PR China
| | - Zengjie Zhang
- Department of Orthopedics, Centre for Orthopaedic Research, Orthopedics Research Institute of Zhejiang University, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310000, PR China
| | - Xingzhi Zhou
- Department of Orthopedics, Centre for Orthopaedic Research, Orthopedics Research Institute of Zhejiang University, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310000, PR China
| | - Yuxiao Ye
- School of Material Science and Engineering, University of New South Wales, Sydney 2052, Australia
| | - Peng Lin
- Department of Orthopedics, Centre for Orthopaedic Research, Orthopedics Research Institute of Zhejiang University, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310000, PR China
| | - An Liu
- Department of Orthopedics, Centre for Orthopaedic Research, Orthopedics Research Institute of Zhejiang University, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310000, PR China
| | - Yan Wu
- Department of Orthopedics, Centre for Orthopaedic Research, Orthopedics Research Institute of Zhejiang University, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310000, PR China
| | - Binghao Li
- Department of Orthopedics, Centre for Orthopaedic Research, Orthopedics Research Institute of Zhejiang University, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310000, PR China
| | - Chongda Zhang
- New York University Medical Center, New York University, New York, 10016, USA
| | - Xianyan Yang
- Bio-nanomaterials and Regenerative Medicine Research Division, Zhejiang-California International Nanosystem Institute, Zhejiang University, Hangzhou 310058, PR China
| | - Weixu Li
- Department of Orthopedics, Centre for Orthopaedic Research, Orthopedics Research Institute of Zhejiang University, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310000, PR China
| | - Xiaohua Yu
- Department of Orthopedics, Centre for Orthopaedic Research, Orthopedics Research Institute of Zhejiang University, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310000, PR China
| | - Zhongru Gou
- Bio-nanomaterials and Regenerative Medicine Research Division, Zhejiang-California International Nanosystem Institute, Zhejiang University, Hangzhou 310058, PR China
| | - Zhaoming Ye
- Department of Orthopedics, Centre for Orthopaedic Research, Orthopedics Research Institute of Zhejiang University, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310000, PR China
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18
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Vuorinen M, Mäkinen T, Rantasalo M, Huotari K. Effect of a multidisciplinary team on the treatment of hip and knee prosthetic joint infections: a single-centre study of 154 infections. Infect Dis (Lond) 2021; 53:700-706. [PMID: 34060985 DOI: 10.1080/23744235.2021.1925341] [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: 10/21/2022] Open
Abstract
BACKGROUND A multidisciplinary team responsible for the management plan of prosthetic joint infections (PJI) was founded in January 2008. The aim of this study was to investigate whether a decrease in the number of surgeries and length of stay (LOS) was seen in the management of PJI with the aid of the multidisciplinary team. METHODS This retrospective cohort study consisted of a total of 154 postoperative PJIs from three time periods: 21 PJIs from 2005 to 2007 (Group 1), 65 PJIs from 2011 to 2013 (Group 2), and 68 PJIs from 2015 to 2016 (Group 3). Successful outcome was classified as the retention of the original implant or revised implant and no infection-related death. RESULTS The median number of operations decreased from 2.0 operations (Group 1) to 1.0 operation (Group 3) (p = .023), and the median LOS was shortened from 49.0 days (Group 1) to 17.0 days (Group 3) (p = .000). The number of PJIs treated with two-stage exchange decreased from 52.4% (11/21, Group 1) to 16.2% (11/68, Group 3) (p = .004). Simultaneously, debridement, antibiotics, and implant retention (DAIR) as primary surgical treatment increased from 42.9% (9/21, Group 1) to 89.7% (61/68, Group 3) (p = .000). The successful outcome of DAIR improved from 55.6% (5/9, Group 1) to 85.2% (52/61, Group 3) (p = .077). CONCLUSIONS Treatment of PJI in a specialized centre with the aid of a multidisciplinary team lead to fewer surgeries and reduced LOS. Successful outcome of DAIR improved over time.
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Affiliation(s)
- Markku Vuorinen
- Department of Orthopaedics and Traumatology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Tatu Mäkinen
- Department of Orthopaedics and Traumatology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Mikko Rantasalo
- Department of Orthopaedics and Traumatology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Kaisa Huotari
- Department of Infectious Diseases, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
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19
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Management of Large Segmental Bone Defects at the Knee With Intramedullary Stabilized Antibiotic Spacers During Two-Stage Treatment of Endoprosthetic Joint Infection. J Arthroplasty 2021; 36:2165-2170. [PMID: 33546952 DOI: 10.1016/j.arth.2021.01.026] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 12/20/2020] [Accepted: 01/11/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Following debridement of infected prostheses that require reconstruction with an endoprosthetic replacement (EPR), instability related to segmental residual bone defects present a challenge in management with 2-stage reimplantation. METHODS We retrospectively reviewed all patients treated for revision total joint or endoprosthetic infection at the knee from 1998 to 2018. At our institution, patients with skeletal defects >6 cm following explant of prosthesis and debridement (stage 1) were managed with intramedullary nail-stabilized antibiotic spacers. Following stage 1, antimicrobial therapy included 6 weeks of intravenous antibiotics and a minimum of 6 weeks of oral antibiotics. Following resolution of inflammatory markers and negative tissue cultures, reimplantation (stage 2) of an EPR was performed. RESULTS Twenty-one patients at a mean age of 54 ± 21 years were treated for prosthetic joint infection at the knee. Polymicrobial growth was detected in 38% of cases, followed by coagulase-negative staphylococci (24%) and Staphylococcus aureus (19%). Mean residual skeletal defect after stage 1 treatment was 20 cm. Prosthetic joint infection eradication was achieved in 18 (86%) patients, with a mean Musculoskeletal Tumor Society score of 77% and mean knee range of motion of 100°. Patients with polymicrobial infections had a greater number of surgeries prior to infection (P = .024), and were more likely to require additional debridement prior to EPR (odds ratio 12.0, P = .048). CONCLUSION Management of large segmental skeletal defects at the knee following explant using intramedullary stabilized antibiotic spacers maintain stability and result in high rates of limb salvage with conversion to an endoprosthesis.
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20
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Rollo G, Logroscino G, Stomeo D, Cioffi R, Calvisi V, Meccariello L. Comparing the use of preformed vs hand-made antibiotic spacer cement in two stages revision of hip periprosthetic infection. J Clin Orthop Trauma 2020; 11:S772-S778. [PMID: 32999554 PMCID: PMC7503155 DOI: 10.1016/j.jcot.2020.08.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Revised: 08/08/2020] [Accepted: 08/09/2020] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND The number of periprosthetic joint infections (PJI) is continuously increasing because of the increasing number of arthroprostheses performed every year. Two-stage revision, using antibiotic-loaded spacers, remains the gold standard for their treatment. The aim of our study is to compare the use of preformed vs hand-made spacers in hip arthroplasty infections evaluating infection eradication, bone loss and clinical/functional outcomes. METHODS From January 2010 to December 2017 we performed a prospective nonrandomized study. We pooled 50 patients affected by infected hip joint replacements, and divided them in 2 groups, one receiving commercially preformed spacers and the other receiving hand-made spacers. The study endpoint was set at 12 months. Intra-operative and peri-operative complications, Harris Hip Score (HHS), Short Form 12 Health Survey, intra-operative and radiological evaluation of bone loss were collected. Data were analyzed using descriptive statistics, T-test and Fisher Exact test. RESULTS We found a statistically significant differences (p < 0.05) between the two groups in favour of the VancogenX group for the following variables: surgical time, first and second stage intraoperative complication rates, infection eradication. Moreover, the preformed-spacers group had better results in the preservation of bone stock, even though the difference was not statistically significant (p > 0.05). CONCLUSION Our results support the use of preformed antibiotic spacers, even though more studies are needed.
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Affiliation(s)
- Giuseppe Rollo
- Department of Orthopedics and Traumatology, Vito Fazzi Hospital, Lecce, Italy
| | - Giandomenico Logroscino
- Mininvasive and Computer Assisted Orthopaedic Surgery, University of L’Aquila, L’Aquila, Italy
| | - Daniele Stomeo
- Orthopaedics and Traumatology, Di Summa-Perrino Hospital, Brindisi, Italy
| | - Raffaele Cioffi
- Mininvasive and Computer Assisted Orthopaedic Surgery, University of L’Aquila, L’Aquila, Italy
| | - Vittorio Calvisi
- Mininvasive and Computer Assisted Orthopaedic Surgery, University of L’Aquila, L’Aquila, Italy
| | - Luigi Meccariello
- Department of Orthopedics and Traumatology, Vito Fazzi Hospital, Lecce, Italy,Corresponding author. Department of Orthopedics and Traumatology, Vito Fazzi Hospital, Piazzetta Filippo Muratore, Block: A- Floor:V, Lecce, Italy.
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21
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Sosa BR, Niu Y, Turajane K, Staats K, Suhardi V, Carli A, Fischetti V, Bostrom M, Yang X. 2020 John Charnley Award: The antimicrobial potential of bacteriophage-derived lysin in a murine debridement, antibiotics, and implant retention model of prosthetic joint infection. Bone Joint J 2020; 102-B:3-10. [DOI: 10.1302/0301-620x.102b7.bjj-2019-1590.r1] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Aims Current treatments of prosthetic joint infection (PJI) are minimally effective against Staphylococcus aureus biofilm. A murine PJI model of debridement, antibiotics, and implant retention (DAIR) was used to test the hypothesis that PlySs2, a bacteriophage-derived lysin, can target S. aureus biofilm and address the unique challenges presented in this periprosthetic environment. Methods The ability of PlySs2 and vancomycin to kill biofilm and colony-forming units (CFUs) on orthopaedic implants were compared using in vitro models. An in vivo murine PJI model of DAIR was used to assess the efficacy of a combination of PlySs2 and vancomycin on periprosthetic bacterial load. Results PlySs2 treatment reduced 99% more CFUs and 75% more biofilm compared with vancomycin in vitro. A combination of PlySs2 and vancomycin in vivo reduced the number of CFUs on the surface of implants by 92% and in the periprosthetic tissue by 88%. Conclusion PlySs2 lysin was able to reduce biofilm, target planktonic bacteria, and work synergistically with vancomycin in our in vitro models. A combination of PlySs2 and vancomycin also reduced bacterial load in periprosthetic tissue and on the surface of implants in a murine model of DAIR treatment for established PJI. Cite this article: Bone Joint J 2020;102-B(7 Supple B):3–10.
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Affiliation(s)
| | - YingZhen Niu
- Hospital for Special Surgery, New York, New York, USA
- Hebei Medical University Third Affiliated Hospital, Department of Joint Surgery, Hebei Medical University Third Affiliated Hospital, Shijiazhuang, China
| | | | - Kevin Staats
- Hospital for Special Surgery, Department of Orthopedics and Trauma Surgery, New York, New York, USA
- Medical University of Vienna, Department of Orthopedics and Trauma Surgery, Vienna, Austria
| | | | - Alberto Carli
- Hospital for Special Surgery, New York, New York, USA
| | | | | | - Xu Yang
- Hospital for Special Surgery, New York, New York, USA
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22
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Wang X, Zhang W. [Research progress of two-stage revision for periprosthetic joint infection after hip and knee arthroplasties]. ZHONGGUO XIU FU CHONG JIAN WAI KE ZA ZHI = ZHONGGUO XIUFU CHONGJIAN WAIKE ZAZHI = CHINESE JOURNAL OF REPARATIVE AND RECONSTRUCTIVE SURGERY 2019; 33:1566-1571. [PMID: 31823560 DOI: 10.7507/1002-1892.201901098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Objective To summarize the research progress of two-stage revision for periprosthetic joint infection (PJI) after hip and knee arthroplasties. Methods The related literature on two-stage revision for PJI was summarized, and the new progress in the choice of spacers, systemic antibiotic therapy, and risk factors were analyzed. Results Two-stage revision is a common way to treat infection after hip and knee arthroplasties. The types of spacers used in the one-stage operation are diverse and each has its own advantages and disadvantages. Non-articular spacers are mainly used for the patients with poor soft tissue conditions around the joints and severe bone defects. But the joint mobility is not good after the placement of the spacer. Articular spacers can restore the affected joint movement after operation, which is beneficial to the joint mobility after two-stage operation. The use of antibiotics is an indispensable part of the treatment process, and the effectiveness of short-term antibiotic treatment is similar to long-term treatment. Identifying the relevant risk factors that influence the prognosis of the two-stage revision can help preoperative management and reduce the recurrence rate of infection. Conclusion There are still controversies about the choice of spacers and systemic antibiotic therapy during the two-stage revision and treatment of PJI. The factors affecting the prognosis of the two-stage revision need to be explored and the further high-quality research is needed.
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Affiliation(s)
- Xiangxuan Wang
- Department of Orthopedics, the First Affiliated Hospital of Fujian Medical University, Fuzhou Fujian, 350000, P.R.China
| | - Wenming Zhang
- Department of Orthopedics, the First Affiliated Hospital of Fujian Medical University, Fuzhou Fujian, 350000,
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Two-Stage Exchange Arthroplasty for Periprosthetic Joint Infection: The Rate and Reason for the Attrition After the First Stage. J Arthroplasty 2019; 34:2749-2756. [PMID: 31285090 DOI: 10.1016/j.arth.2019.06.021] [Citation(s) in RCA: 58] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Revised: 05/17/2019] [Accepted: 06/10/2019] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Two-stage exchange arthroplasty remains a popular surgical treatment for patients with chronic periprosthetic joint infection (PJI). Patients who do not receive reimplantation were largely overlooked in the current literature. We aimed at investigating the clinical outcomes of these patients. METHODS Our institutional PJI database was retrospectively reviewed to identify 616 patients (237 hips, 379 knees) who were treated with an intended 2-stage exchange. Of them, 111 (18%) did not receive reimplantation within a minimum follow-up of 1 year. Chart review and targeted interviews were performed to elucidate the cause of attrition. Patients were considered to have failed treatment in the absence of reimplantation if they remained medically unfit for reimplantation, underwent a salvage procedure, or died during the study period. RESULTS Of the 111 patients without reimplantation, 29 (26.1%) did well with their retained spacer and were unwilling to proceed with reimplantation, 23 (20.7%) underwent salvage procedures, and the remaining 59 (53.2%) were considered medically unfit for reimplantation, with 34 of them dying within 1 year of initial spacer insertion. The overall success rate for 2-stage exchange cohort at 2 years was 65.7% when treatment failure without reimplantation was taken into account. Several factors associated with increased risk of treatment failure without reimplantation were identified using a multivariate regression model. CONCLUSION Almost 1 in 5 patients may never receive the intended reimplantation. Among many reasons for attrition, mortality appears to be a relatively common event. The current definition of treatment success does not take into account the attrition group and thus inflates the relative success of 2-stage exchange arthroplasty.
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Rava A, Bruzzone M, Cottino U, Enrietti E, Rossi R. Hip Spacers in Two-Stage Revision for Periprosthetic Joint Infection: A Review of Literature. JOINTS 2019; 7:56-63. [PMID: 31879732 PMCID: PMC6930843 DOI: 10.1055/s-0039-1697608] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/18/2018] [Accepted: 08/06/2019] [Indexed: 02/06/2023]
Abstract
Infection after total hip arthroplasty (THA) is a devastating complication with significant consequences for patients. In literature, single and two-stage revision, irrigation and debridement, Girdlestone resection arthroplasty, and arthrodesis and amputation are reported as possible treatments. Recently, two-stage revision has become popular as the gold standard treatment for chronic hip joint infections after THA. In this review, we evaluate the current literature about microbiology of periprosthetic joint infections and the use of antibiotic-loaded cement spacers. We aim to give an overview about indications, clinical results, and mechanical complications for spacers implantation, evaluating also selection criteria, pharmacokinetic properties, and systemic safety of the most frequently used antibiotics.
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Affiliation(s)
- Alessandro Rava
- Scuola di Specializzazione in Ortopedia e Traumatologia, Università degli Studi di Torino, Torino, Italy
| | - Matteo Bruzzone
- SC Ortopedia e Traumatologia, AO Ospedale Mauriziano Umberto I, Torino, Italy
| | - Umberto Cottino
- SC Ortopedia e Traumatologia, AO Ospedale Mauriziano Umberto I, Torino, Italy
| | - Emilio Enrietti
- Scuola di Specializzazione in Ortopedia e Traumatologia, Università degli Studi di Torino, Torino, Italy
| | - Roberto Rossi
- SC Ortopedia e Traumatologia, AO Ospedale Mauriziano Umberto I, Torino, Italy
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Castaño J, Moreno LA, Bautista MP, Suarez C, Bonilla GA. Letter to the Editor on "Continuous Antibiotic Therapy Can Reduce Recurrence of Prosthetic Joint Infection in Patients Undergoing 2-Stage Exchange". J Arthroplasty 2019; 34:2519-2520. [PMID: 31358325 DOI: 10.1016/j.arth.2019.06.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2019] [Accepted: 06/10/2019] [Indexed: 02/01/2023] Open
Affiliation(s)
- Juliana Castaño
- Department of Orthopedics and Traumatology, Hospital Universitario Fundación Santa Fe de Bogotá, Bogotá, Colombia
| | | | - Maria P Bautista
- Department of Orthopedics and Traumatology, Hospital Universitario Fundación Santa Fe de Bogotá, Bogotá, Colombia; School of Medicine, Universidad del Rosario, Bogotá, Colombia
| | - Cristina Suarez
- Department of Orthopedics and Traumatology, Hospital Universitario Fundación Santa Fe de Bogotá, Bogotá, Colombia
| | - Guillermo A Bonilla
- Department of Orthopedics and Traumatology, Hospital Universitario Fundación Santa Fe de Bogotá, Bogotá, Colombia; School of Medicine, Universidad del Rosario, Bogotá, Colombia; School of Medicine, Universidad de Los Andes, Bogotá, Colombia
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Shakked R, Da Rin de Lorenzo F. What Determines the Type and Dose of Antibiotic That Is Needed to Be Added to the Cement Spacer in Patients With Infected Total Ankle Arthroplasty (TAA)? Foot Ankle Int 2019; 40:48S-52S. [PMID: 31322933 DOI: 10.1177/1071100719861098] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
RECOMMENDATION We recommend tailoring the antibiotic in cement spacers to the infecting organism if it has been identified, as is typically done in total knee and hip arthroplasty. Otherwise, broad-spectrum antibiotics may be utilized. Medical comorbidities should always be considered, especially with regard to renal function and allergy profile. A thermostable antibiotic should be added to cement. LEVEL OF EVIDENCE Consensus. DELEGATE VOTE Agree: 100%, Disagree: 0%, Abstain: 0% (Unanimous, Strongest Consensus).
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Ntalos D, Berger-Groch J, Rohde H, Grossterlinden LG, Both A, Luebke A, Hartel MJ, Klatte TO. Implementation of a multidisciplinary infections conference affects the treatment plan in prosthetic joint infections of the hip: a retrospective study. Arch Orthop Trauma Surg 2019; 139:467-473. [PMID: 30488282 DOI: 10.1007/s00402-018-3079-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2018] [Indexed: 12/24/2022]
Abstract
INTRODUCTION Establishing a systematic multidisciplinary approach in the treatment of prosthetic joint infections (PJI) of the hip and analyzing its effect on clinical decision-making. PATIENTS AND METHODS Forty-six patients diagnosed with PJI of the hip were included in the retrospective study. The treatment plan was either established by a single-discipline approach (n = 20) or by a weekly multidisciplinary infections conference (n = 26) consisting of at least an orthopedic surgeon, microbiologist and pathologist. Recorded data included the length of hospital stay, number and type of surgeries, medical complications, recovered organisms as well as the number of applied antibiotics. RESULTS Patients discussed in the multidisciplinary infections conference showed a significantly shorter in-hospital stay (29 vs 62 days; p < 0.05), a significant reduction in surgeries (1.8 vs 5.1; p < 0.05) and a smaller number of antibiotics required (2.8 vs 4.2; p < 0.05). No significant difference could be found comparing inpatient complications between the two groups. Staphylococcus aureus and coagulase-negative staphylococci were the most frequently recovered organisms in both patient groups. CONCLUSION This study demonstrates the successful implementation of a weekly infections conference as an instrument to introduce a multidisciplinary approach to PJI of the hip. Implementation of these conferences significantly improves the treatment plan compared to a single-discipline approach, which we therefore highly recommend for other institutions. Multidiscipline may even affect clinical outcome which needs to be further investigated.
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Affiliation(s)
- Dimitris Ntalos
- Department of Trauma-, Hand-, and Reconstructive Surgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany.
| | - J Berger-Groch
- Department of Trauma-, Hand-, and Reconstructive Surgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - H Rohde
- Institute of Medical Microbiology, Virology and Hygiene, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - L G Grossterlinden
- Department of Orthopaedic, Trauma and Spine Surgery, Asklepios Hospital Altona, Hamburg, Germany
| | - A Both
- Institute of Medical Microbiology, Virology and Hygiene, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - A Luebke
- Institute of Pathology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - M J Hartel
- Department of Trauma-, Hand-, and Reconstructive Surgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - T O Klatte
- Department of Trauma-, Hand-, and Reconstructive Surgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
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Sukeik M, Haddad FS. Periprosthetic joint infections after total hip replacement: an algorithmic approach. SICOT J 2019; 5:5. [PMID: 30816089 PMCID: PMC6394232 DOI: 10.1051/sicotj/2019004] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Accepted: 01/28/2019] [Indexed: 12/25/2022] Open
Abstract
An algorithm for managing periprosthetic joint infections (PJIs) after total hip replacement (THR) surgery using a multidisciplinary approach and a clearly defined protocol may improve infection eradication rates. In this article, we present an algorithm for the management of different types of PJIs including the acutely infected cemented and cementless THRs where the components are well-fixed postoperatively and when the infection is secondary to haematogenous spread in previously well-functioning and well-fixed implants. For chronic PJIs where the components are often loose, the standard treatment includes a two-stage revision procedure. However, in a highly selected subset of patients, a single-stage approach has been utilised with high rates of eradicating infections.
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Affiliation(s)
- Mohamed Sukeik
- Foothills Medical Centre, 1403 29 St NW Calgary, AB T2N 2T9, Canada
| | - Fares Sami Haddad
- University College London Hospital, 235 Euston Road, London NW1 2BU, UK
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Song X, Li X, Song J, Xu C, Li R, Li H, Chen J. [Clinical research of debridement with prosthesis retention for periprosthetic joint infection after arthroplasty]. ZHONGGUO XIU FU CHONG JIAN WAI KE ZA ZHI = ZHONGGUO XIUFU CHONGJIAN WAIKE ZAZHI = CHINESE JOURNAL OF REPARATIVE AND RECONSTRUCTIVE SURGERY 2019; 32:685-693. [PMID: 29905045 DOI: 10.7507/1002-1892.201711105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Objective To investigate the mid-term effectiveness of debridement with prosthesis retention for periprosthetic joint infection (PJI) after total hip arthroplasty (THA) and total knee arthroplasty (TKA), and analyze the influence factors that affected the effectiveness. Methods A clinical data of 45 cases with PJI after THA (16 cases) and TKA (29 cases) that were treated with debridement with prosthesis retention between January 2011 and January 2015 were collected and analyzed. There were 19 males and 26 females with a mean age of 58.4 years (range, 23-78 years). PJI occurred after primary joint arthroplasty in 40 cases and after revision in 5 cases. The mean time interval between the performance of infection symptoms and the arthroplasty or revision was 15.5 months (range, 0.5-72.0 months). The time interval between the performance of infection symptoms and debridment was 35 days (range, 3-270 days). There were early postoperative infections in 13 cases, acute hematogenous infections in 24 cases, and late chronic infections in 8 cases. X-ray films showed that the location of prosthesis was good. The results of bacilli culture showed that 28 cases were positive and 17 were negative. Twelve cases had sinuses. Length of stay, Hospital for Special Surgery (HSS) score, and Harris score were recorded to evaluate risk factors by using a multivariate logistic regression. Results The mean length of stay was 22.6 days (range, 5-79 days). All patients were followed up 24-74 months (mean, 52 months). There were 33 cases that retained the prosthesis without further evidence of infection with the success rate was 73.3%. There were significant differences in Harris score and HSS score between pre- and post-operation ( P<0.05). The univariate analysis results showed that the failure of debridement with prosthesis retention had a significant correlation with sinus developing and duration of infection symptoms more than 14 days ( P<0.05). Multivariate logistic regression analysis results showed that sinus developing was an independent risk factor of failure ( P<0.05). Conclusion Debridement with prosthesis retention plays an important role in treating PJI after THA and TKA. These patients with sinus performing and duration of infection symptoms more than 14 days have higher risk to develop infection again.
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Affiliation(s)
| | - Xin Li
- Department of Orthopaedics, General Hospital of Chinese PLA, Beijing, 100853, P.R.China
| | - Junlei Song
- Department of Orthopaedics, General Hospital of Chinese PLA, Beijing, 100853, P.R.China
| | - Chi Xu
- Department of Orthopaedics, General Hospital of Chinese PLA, Beijing, 100853, P.R.China
| | - Rui Li
- Department of Orthopaedics, General Hospital of Chinese PLA, Beijing, 100853, P.R.China
| | - Heng Li
- Department of Orthopaedics, General Hospital of Chinese PLA, Beijing, 100853, P.R.China
| | - Jiying Chen
- Department of Orthopaedics, General Hospital of Chinese PLA, Beijing, 100853,
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Abdel MP, Barreira P, Battenberg A, Berry DJ, Blevins K, Font-Vizcarra L, Frommelt L, Goswami K, Greiner J, Janz V, Kendoff DO, Limberg AK, Manrique J, Moretti B, Murylev V, O'Byrne J, Petrie MJ, Porteous A, Saleri S, Sandiford NA, Sharma V, Shubnyakov I, Sporer S, Squire MW, Stockley I, Tibbo ME, Turgeon T, Varshneya A, Wellman S, Zahar A. Hip and Knee Section, Treatment, Two-Stage Exchange Spacer-Related: Proceedings of International Consensus on Orthopedic Infections. J Arthroplasty 2019; 34:S427-S438. [PMID: 30348562 DOI: 10.1016/j.arth.2018.09.027] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [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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31
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Aalirezaie A, Abolghasemian M, Busato T, Dennis D, Ghazavi M, Holst DC, Kelly M, Kissin YD, Kuijpers M, Lange J, Lichstein P, Moojen DJ, Poolman R, Schreurs BW, Velázquez Moreno JD, Veltman ES. Hip and Knee Section, Treatment, Two-Stage Exchange: Proceedings of International Consensus on Orthopedic Infections. J Arthroplasty 2019; 34:S439-S443. [PMID: 30348583 DOI: 10.1016/j.arth.2018.09.028] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [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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32
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Carli AV, Bhimani S, Yang X, de Mesy Bentley KL, Ross FP, Bostrom MPG. Vancomycin-Loaded Polymethylmethacrylate Spacers Fail to Eradicate Periprosthetic Joint Infection in a Clinically Representative Mouse Model. J Bone Joint Surg Am 2018; 100:e76. [PMID: 29870449 DOI: 10.2106/jbjs.17.01100] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Periprosthetic joint infection (PJI) remains a devastating complication following total joint arthroplasty. Current animal models of PJI do not effectively recreate the clinical condition and thus provide limited help in understanding why treatments fail. We developed a mouse model of the first-stage surgery of a 2-stage revision for PJI involving a 3-dimensionally printed Ti-6Al-4V implant and a mouse-sized cement spacer that elutes vancomycin. METHODS Vancomycin was mixed with polymethylmethacrylate (PMMA) cement and inserted into custom-made mouse-sized spacer molds. Twenty C57BL/6 mice received a proximal tibial implant and an intra-articular injection of 3 × 10 colony-forming units of Staphylococcus aureus Xen36. At 2 weeks, 9 mice underwent irrigation and debridement of the leg with revision of the implant to an articulating vancomycin-loaded PMMA spacer. Postoperatively, mice underwent radiography and serum inflammatory-marker measurements. Following euthanasia of the mice at 6 weeks, bone and soft tissues were homogenized to quantify bacteria within periprosthetic tissues. Implants and articulating spacers were either sonicated to quantify adherent bacteria or examined under scanning electron microscopy (SEM) to characterize the biofilm. RESULTS Vancomycin-loaded PMMA spacers eluted vancomycin for ≤144 hours and retained antimicrobial activity. Control mice had elevated levels of inflammatory markers, radiographic evidence of septic loosening of the implant, and osseous destruction. Mice treated with a vancomycin-loaded PMMA spacer had significantly lower levels of inflammatory markers (p < 0.01), preserved tibial bone, and no intra-articular purulence. Retrieved vancomycin-loaded spacers exhibited significantly lower bacterial counts compared with implants (p < 0.001). However, bacterial counts in periprosthetic tissue did not significantly differ between the groups. SEM identified S. aureus encased within biofilm on control implants, while vancomycin-loaded spacers contained no bacteria. CONCLUSIONS This animal model is a clinically representative model of PJI treatment. The results suggest that the antimicrobial effects of PMMA spacers are tightly confined to the articular space and must be utilized in conjunction with thorough tissue debridement and systemic antibiotics. CLINICAL RELEVANCE These data provide what we believe to be the first insight into the effect of antibiotic-loaded cement spacers in a clinically relevant animal model and justify the adjunctive use of intravenous antibiotics when performing a 2-stage revision for PJI.
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Affiliation(s)
| | | | - Xu Yang
- Hospital for Special Surgery, New York, NY
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Farnsworth CW, Schott EM, Benvie A, Zukoski J, Kates SL, Schwarz EM, Gill SR, Zuscik MJ, Mooney RA. Obesity/type 2 diabetes increases inflammation, periosteal reactive bone formation, and osteolysis during Staphylococcus aureus implant-associated bone infection. J Orthop Res 2018; 36:1614-1623. [PMID: 29227579 PMCID: PMC5995608 DOI: 10.1002/jor.23831] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2017] [Accepted: 11/29/2017] [Indexed: 02/04/2023]
Abstract
Obese and type 2 diabetic (T2D) patients have a fivefold increased rate of infection following placement of an indwelling orthopaedic device. Though implant infections are associated with inflammation, periosteal reactive bone formation, and osteolysis, the effect of obesity/T2D on these complicating factors has not been studied. To address this question, C57BL/6J mice were fed a high fat diet (60% Kcal from fat) to induce obesity/T2D, or a control diet (10% Kcal from fat) for 3 months, and challenged with a transtibial pin coated with a bioluminescent USA300 strain of S. aureus. In the resulting infected bone, obesity/T2D was associated with increased S. aureus proliferation and colony forming units. RNA sequencing of the infected tibiae on days 7 and 14 revealed an increase in 635 genes in obese/T2D mice relative to controls. Pathways associated with ossification, angiogenesis, and immunity were enriched. MicroCT and histology on days 21 and 35 demonstrated significant increased periosteal reactive bone formation in infected obese/T2D mice versus infected controls (p < 0.05). The enhanced periosteal bone formation was associated with increased osteoblastic activity and robust endochondral ossification, with persistant cartilage on day 21 that was only observed in infected obesity/T2D. Osteolysis and osteoclast numbers in obesity/T2D were also significantly increased versus infected controls (p < 0.05). Consistent with an up-regulated immune transcriptome, macrophages were more abundant within both the periosteum and the new reactive bone of obese/T2D mice. In conclusion, we find that implant-associated S. aureus osteomyelitis in obesity/T2D is associated with increased inflammation, reactive bone formation, and osteolysis. © 2017 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 36:1614-1623, 2018.
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Affiliation(s)
- Christopher W Farnsworth
- Department of Pathology and Laboratory Medicine, University of Rochester, Rochester New York, USA,Center for Musculoskeletal Research, University of Rochester, Rochester New York, USA
| | - Eric M Schott
- Department of Pathology and Laboratory Medicine, University of Rochester, Rochester New York, USA,Center for Musculoskeletal Research, University of Rochester, Rochester New York, USA
| | - Abigail Benvie
- Department of Pathology and Laboratory Medicine, University of Rochester, Rochester New York, USA,Center for Musculoskeletal Research, University of Rochester, Rochester New York, USA
| | - Jacob Zukoski
- Department of Pathology and Laboratory Medicine, University of Rochester, Rochester New York, USA,Center for Musculoskeletal Research, University of Rochester, Rochester New York, USA
| | - Stephen L Kates
- Department of Orthopaedic Surgery, Virginia Commonwealth University, Richmond Virginia, USA
| | - Edward M Schwarz
- Center for Musculoskeletal Research, University of Rochester, Rochester New York, USA
| | - Steven R Gill
- Department of Microbiology and Immunology, University of Rochester, Rochester New York, USA
| | - Michael J Zuscik
- Center for Musculoskeletal Research, University of Rochester, Rochester New York, USA
| | - Robert A Mooney
- Department of Pathology and Laboratory Medicine, University of Rochester, Rochester New York, USA,Center for Musculoskeletal Research, University of Rochester, Rochester New York, USA
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Structural and Morselized Allografting Combined with a Cementless Cup for Acetabular Defects in Revision Total Hip Arthroplasty: A 4- to 14-Year Follow-Up. BIOMED RESEARCH INTERNATIONAL 2018; 2018:2364269. [PMID: 29511673 PMCID: PMC5817297 DOI: 10.1155/2018/2364269] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/02/2017] [Accepted: 12/10/2017] [Indexed: 11/18/2022]
Abstract
Using morselized and structural allograft to restore bone stock for massive acetabular bone defect in revision total hip arthroplasty (THA) is an appealing procedure. However, concerns about inability to achieve long-term stability following allograft resorption remained. From 2003 to 2012, 59 hips in 58 patients undergoing revision THA for Paprosky type II or III acetabular defects were retrospectively reviewed. The acetabular defects were managed with deep-frozen morselized and structural allografts, and a press-fit cementless cup along with supplementary screws. Clinical outcomes and radiographic results were analyzed with a mean follow-up of 8.7 years. The clinical successful rate was 100% for hips with Paprosky type II defect, 95.2% for IIIA defect, and 92.8% for IIIB defect. Three hips with type III defect failed at 4, 7, and 9 years, respectively. Harris Hip Score improved significantly from 60.1 preoperatively to 91.3 at the latest follow-up. All hips with good clinical results showed trabecular bridging in the allograft-host bone interface. Deep-frozen structural and morselized allograft in combination with a press-fit cementless cup represented a viable option to reconstruct acetabular defects in revision THA.
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Ohtsuru T, Morita Y, Murata Y, Munakata Y, Itoh M, Kato Y, Okazaki K. Custom-made, antibiotic-loaded, acrylic cement spacers using a dental silicone template for treatment of infected hip prostheses. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2018; 28:615-620. [PMID: 29332203 DOI: 10.1007/s00590-017-2117-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/16/2017] [Accepted: 12/18/2017] [Indexed: 12/27/2022]
Abstract
PURPOSE Antibiotic-loaded acrylic cement (ALAC) spacers are useful for treatment of infected prostheses in the course of a two-stage revision. Spacers are handmade or are made using a commercial template, with reportedly good treatment outcomes. This study aimed to confirm the usefulness of custom-made ALAC spacers shaped like bipolar hip prostheses using a dental silicone template for treatment of infected hip prostheses, and described their manufacture. METHODS This study evaluated 10 patients who underwent two-stage revision for treatment of infected hip prostheses. Custom-made ALAC spacers were used in all patients. Templates were made with dental silicone. We investigated the following in treatment of the infected hip prostheses: bacterial pathogens; antibiotic-cement mixtures; waiting time to revision; dislocation, breakage, and migration of custom-made ALAC spacers; current hip status; progress during follow-up; presence or absence of recurrence; and walking ability. RESULTS Dislocation, breakage, and migration were not observed in custom-made ALAC spacers. All patients recovered after two-stage revision without additional surgery and showed no recurrence during the follow-up period. CONCLUSION Custom-made ALAC spacers shaped like bipolar hip prostheses using a template made of dental silicone may be useful for treatment of infected hip prostheses.
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Affiliation(s)
- Tadahiko Ohtsuru
- Department of Orthopaedic Surgery, Tokyo Women's Medical University, 8-1 Kawada-Cho, Shinjuku Ward, Tokyo, 162-8666, Japan.
| | - Yuji Morita
- Department of Orthopaedic Surgery, Tokyo Women's Medical University, 8-1 Kawada-Cho, Shinjuku Ward, Tokyo, 162-8666, Japan
| | - Yasuaki Murata
- Department of Orthopaedic Surgery, Teikyo University, Chiba, Japan
| | - Yutaro Munakata
- Department of Orthopaedic Surgery, Tokyo Women's Medical University, 8-1 Kawada-Cho, Shinjuku Ward, Tokyo, 162-8666, Japan
| | - Masafumi Itoh
- Department of Orthopaedic Surgery, Tokyo Women's Medical University, 8-1 Kawada-Cho, Shinjuku Ward, Tokyo, 162-8666, Japan
| | - Yoshiharu Kato
- Kita Shinagawa 3rd Hospital, Shinagawa Ward, Tokyo, Japan
| | - Ken Okazaki
- Department of Orthopaedic Surgery, Tokyo Women's Medical University, 8-1 Kawada-Cho, Shinjuku Ward, Tokyo, 162-8666, Japan
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Yan Z, Fang R, Liu T. Partial component-retained two-stage reconstruction for chronic infection after uncemented total hip arthroplasty: good or bad? INTERNATIONAL ORTHOPAEDICS 2018; 42:729-730. [PMID: 29297104 DOI: 10.1007/s00264-017-3748-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/28/2017] [Accepted: 12/19/2017] [Indexed: 10/18/2022]
Affiliation(s)
- Zuyun Yan
- Department of Orthopedics, the 2nd Xiangya Hospital, Central South University, 139 Renmin Road, Changsha, Hunan, 410011, China
| | - Rui Fang
- Department of Orthopedics, the 2nd Xiangya Hospital, Central South University, 139 Renmin Road, Changsha, Hunan, 410011, China
| | - Tang Liu
- Department of Orthopedics, the 2nd Xiangya Hospital, Central South University, 139 Renmin Road, Changsha, Hunan, 410011, China.
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Self-Resolution of a Draining Sinus Tract in a Patient with Chronic Periprosthetic Hip Infection. Case Rep Orthop 2018; 2018:8657562. [PMID: 29670791 PMCID: PMC5836394 DOI: 10.1155/2018/8657562] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2017] [Accepted: 01/29/2018] [Indexed: 11/21/2022] Open
Abstract
We report a novel case of a patient who had a draining sinus soon after a total hip arthroplasty that spontaneously resolved. The patient voluntarily discontinued antibiotic suppressive therapy (AST) after 10 years of treatment and paradoxically experienced full resolution of signs of chronic prosthetic joint infection (PJI), including recovery of his left-sided draining sinus tract. Now 8 years after discontinuing AST, the patient has no pain, good function, and no major or minor criteria of joint infection according to the Musculoskeletal Infection Society (MSIS) workgroup. The authors have not identified literature describing a similar resolution of draining sinus tracts from around a prosthetic joint after discontinuing AST. Despite the resolution of this patient's sinus tract, the authors do not advocate for discontinuing AST in patients with a draining sinus tract. However, in spite of the fact that the MSIS consensus statement suggests that a draining sinus is a sure sign of PJI and that the assumption is that the infection will not go away until explant, this case was different.
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Lu J, Han J, Zhang C, Yang Y, Yao Z. Infection after total knee arthroplasty and its gold standard surgical treatment: Spacers used in two-stage revision arthroplasty. Intractable Rare Dis Res 2017; 6:256-261. [PMID: 29259853 PMCID: PMC5735278 DOI: 10.5582/irdr.2017.01049] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Revised: 09/25/2017] [Accepted: 09/28/2017] [Indexed: 12/14/2022] Open
Abstract
Periprosthetic joint infection (PJI) is one of the most devastating postoperative complications of total knee arthroplasty (TKA). Treatment varies depending on the type of infection, but two-stage revision arthroplasty using an antibiotic spacer is considered to be the gold standard of treatment. Several types of spacers are available at the moment, each with different benefits and indications, and these spacers may be improved in the future. The primary goals of selecting a given spacer are to locally deliver antibiotics and to preserve soft tissue. Use of an appropriate spacer subsequently decreases the difficulty of the second revision, the operating time, and ultimately the risk of postoperative complications.
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Affiliation(s)
- Junren Lu
- Orthopedic Surgery, Zhongshan Hospital affiliated with Fudan University, Shanghai, China
| | - Jing Han
- Orthopedic Surgery, Zhongshan Hospital affiliated with Fudan University, Shanghai, China
| | - Chi Zhang
- Orthopedic Surgery, Zhongshan Hospital affiliated with Fudan University, Shanghai, China
| | - Yi Yang
- Orthopedic Surgery, Zhongshan Hospital affiliated with Fudan University, Shanghai, China
| | - Zhenjun Yao
- Orthopedic Surgery, Zhongshan Hospital affiliated with Fudan University, Shanghai, China
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