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Shang G, Zhao S, Yang S, Li J. The heavy burden and treatment challenges of fungal periprosthetic joint infection: a systematic review of 489 joints. BMC Musculoskelet Disord 2024; 25:648. [PMID: 39152412 PMCID: PMC11328363 DOI: 10.1186/s12891-024-07616-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2024] [Accepted: 06/20/2024] [Indexed: 08/19/2024] Open
Abstract
BACKGROUND Fungal periprosthetic joint infection (FPJI) is an infrequent but devastating complication that imposes a heavy burden on patients. At present, a consensus regarding the most optimal surgical option for patients with FPJI, the ideal duration of systemic antifungal treatment, and many other issues has not been reached. METHODS A comprehensive literature search was performed on the PubMed and Embase databases. The search criteria employed were as follows: (fungal OR candida OR mycotic) AND periprosthetic joint infection. Initially, the titles and abstracts were screened, and subsequently, studies deemed irrelevant or duplicative were eliminated. Following this, the complete texts of remaining articles were thoroughly examined. According to the inclusion and exclusion criteria, 489 joints in 24 articles were screened out. We further extracted the demographic characteristics (age, gender, body mass index, etc.), clinical presentation, fungal species, presence of bacterial coinfection, surgical methods, systemic and local antifungal therapy, and treatment outcomes. Subgroup data were analyzed according to fungal species and bacterial coinfection. Univariate logistic regression analysis was conducted to ascertain the risk factors associated with the infection recurrence. RESULTS A total of 506 fungi were identified within 489 joints. The most prevalent fungal species were Candida albicans (41.5%). Out of 247 joints (50.5%) presenting with concurrent fungal and bacterial infections. Among the initial surgical interventions, two-stage exchange was the most common (59.1%). The infection recurrence rates of DAIR, resection arthroplasty, two-stage, one-stage, and three-stage exchange were 81.4%, 53.1%, 47.7%, 35.0%, and 30%, respectively. The mean duration of systemic antifungal therapy was 12.8 weeks. The most common drugs used both in intravenous (55.9%) and oral therapy (84.0%) were fluconazole. The proportion of patients who used antifungal drugs after replantation (two-stage and three-stage) was 87.6%. 33.2% of cement spacer or fixed cement contained antifungal drugs, of which amphotericin B was the main choice (82.7%). FPJI caused by candida albicans (OR = 1.717, p = 0.041) and DAIR (OR = 8.433, p = 0.003) were risk factors for infection recurrence. CONCLUSIONS Two-stage exchange remains the most commonly used surgical approach. The reliability of one- and three-exchange needs further evaluation due to the small sample size. Antifungal-loaded cement spacers, and direct intra-articular injections of antimycotics after reimplatation should be strongly considered. Medication is not standardized but rather individualized according to microbiology and the status of patients.
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Affiliation(s)
- Guangqian Shang
- Department of Orthopedics, The Fourth Medical Center of Chinese People's Liberation Army General Hospital, No.51 Fucheng Road, Haidian District, Beijing, China
- School of Medicine, Nankai University, No.94 Weijin Road, Nankai District, Tianjin, China
| | - Siqi Zhao
- Operation Room, The People's Hospital of Linqing, No.317 Xinhua Road, Linqing District, Liaocheng, Shandong, China
| | - Shuai Yang
- Institute of Orthopedics, Third Hospital of Hebei Medical University, No.139 Ziqiang Road, Qiaoxi District, Shijiazhuang, Hebei, China.
| | - Ji Li
- Department of Orthopedics, The Fourth Medical Center of Chinese People's Liberation Army General Hospital, No.51 Fucheng Road, Haidian District, Beijing, China.
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Sutton R, Lizcano JD, Fraval A, Wiafe B, Courtney PM, Brown S. Comparable Results of Single and Two-Stage Exchange for Select Periprosthetic Hip and Knee Infection. J Am Acad Orthop Surg 2024:00124635-990000000-01009. [PMID: 38833728 DOI: 10.5435/jaaos-d-24-00013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Accepted: 04/26/2024] [Indexed: 06/06/2024] Open
Abstract
INTRODUCTION Although two-stage exchange has been the standard of care for periprosthetic joint infection (PJI) in the United States, single-stage exchange is emerging as an option in select patients. The purpose of this study was to compare outcomes of patients undergoing single-stage and two-stage exchange using strict surgical indications. METHODS We reviewed a consecutive series of 196 patients with diagnosed PJI undergoing revision total knee and hip arthroplasty from 2017 to 2021. Patients were excluded if they had PJI history, plastic surgery coverage, or extensive bone loss requiring endoprosthesis. We compared the number of patients PJI-free at 1-year follow-up using MusculoSkeletal Infection Society criteria and patients requiring re-revision between the single-stage and two-stage groups. RESULTS In total, 126 patients met inclusion criteria. Of 61 knee patients (48.4%), 22 underwent single-stage (36%) and 39 underwent two-stage (63.9%). Of 65 hip patients (51.6%), 38 underwent single-stage (58.5%) and 27 underwent two-stage (41.5%). At a mean follow-up of 1.95 ± 0.88 years, a higher rate of knee patients were classified as having treatment success in the single-stage group (77.3% versus 69.2%, P = 0.501), however with comparable septic failure rates (18.1% single-stage versus 17.9% two-stage; P = 0.982). At a mean follow-up of 1.81 ± 0.9 years, a higher rate of hip patients were classified as having treatment success in the single-stage group (94.7% versus 81.5%, P = 0.089), and more patients had septic failures in the two-stage group (18.5% versus 5.3%; P = 0.089). No differences were observed in the microorganism profile. More total complications (P = 0.021) and mortalities were found in the single-stage knee cohort than in the two-stage cohort (22.7% versus 2.6%; P = 0.011). CONCLUSION Single-stage arthroplasty is a viable alternative to standard two-stage exchange in patients with PJI without a history of infection and with no bone or soft-tissue compromise. Additional studies with longer term follow-up are needed to evaluate its efficacy.
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Affiliation(s)
- Ryan Sutton
- From Rothman Orthopaedic Institute, Philadelphia, PA
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Kheir M, Anderson C, Chiu YF, Carli A. Do one-stage indications predict success following two-stage arthroplasty for chronic periprosthetic joint infection? J Bone Jt Infect 2024; 9:75-85. [PMID: 38600996 PMCID: PMC11002939 DOI: 10.5194/jbji-9-75-2024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Accepted: 11/14/2023] [Indexed: 04/12/2024] Open
Abstract
Introduction: The 2018 International Consensus Meeting (ICM) proposed criteria for one-stage exchange arthroplasty in treating periprosthetic joint infection (PJI). Our study aimed to determine what proportion of PJI patients met the 2018 ICM criteria and how this affected infection-free survivorship for patients. Methods: All chronic PJI patients treated with two-stage exchange within our institution between 2017-2020 were retrospectively reviewed. Included cases met 2011 Musculoskeletal Infection Society (MSIS) criteria for PJI and had a 2-year minimum follow-up. Treatment success was defined as Tier 1A in the 2019 MSIS working group definition. ICM one-stage criteria included non-immunocompromised host, absence of sepsis, adequate soft tissue for closure, known preoperative pathogen, and susceptibility. Immunocompromised host was analyzed as two separate definitions. Kaplan-Meier survivorship, Cox regression, and univariate analyses were performed. Results: A total of 293 chronic PJI patients were included. Overall, treatment failure occurred in 64 / 293 (21.8 %) patients. Only 13 % (n = 37 ) met ICM criteria definition no. 1 for one-stage exchange; 12 % (n = 33 ) met definition no. 2. In both definitions, infection-free survivorship at 2 years did not differ between patients who met and did not meet criteria (p > 0.05 ). Cox proportional hazard regression analyses demonstrated that the only variable predicting treatment failure was knee joint involvement (p = 0.01 ). Conclusions: We found that a very limited number of chronic PJI patients were suitable for a one-stage exchange. Furthermore, the supposition that healthier hosts with known pathogens (the basis of the ICM criteria) yield better PJI treatment outcomes was not observed. These results justify the ongoing multicenter randomized control trial comparing one-stage versus two-stage treatment for chronic PJI.
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Affiliation(s)
- Michael M. Kheir
- Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Christopher G. Anderson
- Department of Orthopaedic Surgery, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Yu-Fen Chiu
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York, USA
| | - Alberto V. Carli
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York, USA
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Liukkonen R, Honkanen M, Skyttä E, Eskelinen A, Karppelin M, Reito A. Trends in Revision Knee Arthroplasty for Prosthetic Joint Infection: A Single-Center Study of 384 Knees at a High-Volume Center Between 2008 and 2021. J Arthroplasty 2023; 38:2447-2454. [PMID: 37236284 DOI: 10.1016/j.arth.2023.05.033] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Revised: 05/15/2023] [Accepted: 05/17/2023] [Indexed: 05/28/2023] Open
Abstract
BACKGROUND Prosthetic joint infection (PJI) is one of the most devastating complications after total knee arthroplasty (TKA), and comorbidities increase the risk. We examined whether a temporal change has occurred in the demographics, especially regarding comorbidities, of patients who have PJI and were treated at our institution over a 13-year study period. In addition, we assessed the surgical methods used and the microbiology of the PJIs. METHODS Revisions (n = 384, 377 patients) due to PJI of the knee performed at our institution between 2008 and September 2021 were identified. All included PJIs fulfilled the 2013 International Consensus Meeting diagnostic criteria. The surgeries were categorized into one of the following categories: debridement, antibiotics, and retention (DAIR), 1-stage revision, and 2-stage revision. Infections were classified as early, acute hematogenous, and chronic. RESULTS No changes in the median age of the patients nor comorbidity burden were observed during the study period. However, the proportion of 2-stage revisions decreased remarkably from 57.6% in 2008 to 2009 to 6.3% in 2020 to 2021. A DAIR was the most used treatment strategy, but the proportion of 1-stage revisions increased the most. In 2008 to 2009, 12.1% of the revisions were 1-stage, but in 2020 to 2021, the proportion was 43.8%. The most common pathogen was Staphylococcus aureus (27.8%). CONCLUSION The comorbidity burden remained at the same level with no trends. A DAIR was the most used strategy, but the proportion of 1-stage revisions rose to almost the same level. The incidence of PJI varied between the years, but remained relatively low.
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Affiliation(s)
- Rasmus Liukkonen
- Coxa Hospital for Joint Replacement, and Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Meeri Honkanen
- Department of Internal Medicine, Tampere University Hospital, Tampere, Finland
| | - Eerik Skyttä
- Coxa Hospital for Joint Replacement, and Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Antti Eskelinen
- Coxa Hospital for Joint Replacement, and Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Matti Karppelin
- Department of Internal Medicine, Tampere University Hospital, Tampere, Finland
| | - Aleksi Reito
- Coxa Hospital for Joint Replacement, and Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
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Traverso G, Núñez JH, Gehrke T, Citak M. Hypoalbuminemia increases the risk of failure following one-stage septic revision for periprosthetic joint infection. Arch Orthop Trauma Surg 2023; 143:5641-5648. [PMID: 37071192 DOI: 10.1007/s00402-023-04885-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Accepted: 04/10/2023] [Indexed: 04/19/2023]
Abstract
PURPOSE Malnutrition is a potentially modifiable risk factor of periprosthetic joint infection (PJI). The purpose of this study was to analyze the role of nutritional status as a risk factor for failure after one- stage revision hip or knee arthroplasty for PJI. METHODS Retrospective, single-center, case-control study. Patients with PJI according to the 2018 International Consensus Meeting criteria were evaluated. Minimum follow-up was 4 years. Total lymphocyte count (TLC), albumin values, hemoglobin, C-reactive protein, white blood cell (WBC) count and glucose levels were analyzed. An analysis was also made of the index of malnutrition. Malnutrition was defined as serum albumin < 3.5 g/dL and TLC < 1500/mm3. Septic failure was defined as the presence of local or systemic symptoms of infection and the need of further surgery as a result of persistent PJI. RESULTS No significant differences were found between increased failure rates after a one-stage revision hip or knee arthroplasty for PJI and TLC, hemoglobin level, WBC count, glucose levels, or malnutrition. Albumin and C-reactive protein values were found to have a positive and significant relationship with failure (p < 0.05). Multivariate logistic regression identified only hypoalbuminemia (serum albumin < 3.5 g/dL) (OR 5.64, 95% CI 1.26-25.18, p = 0.023) as a significant independent risk factor for failure. The receiver operating characteristic (ROC) curve for the model yielded an area under the curve of 0.67. CONCLUSION TLC, hemoglobin; WBC count; glucose levels; and malnutrition, understood as the combination of albumin and TLC, were not found to be statically significant risk factors for failure after single-stage revision for PJI. However, albumin < 3.5 g/dL, alone was a statically significant risk factor for failure after single-stage revision for PJI. As hypoalbuminemia seems to influence the failure rate, it is advisable to measure albumin levels in preoperative workups.
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Affiliation(s)
- Giacomo Traverso
- Department of Orthopaedic Surgery, ENDO-Klinik Hamburg, Holstenstr 2, 22767, Hamburg, Germany
- Department of Orthopedic Surgery, University Hospital San Martino, Largo Rosanna Benzi 10, 16132, Genova, Italy
| | - Jorge H Núñez
- Department of Orthopedic Surgery, University Hospital of Mutua Terrasa, Plaça del Doctor Robert, 5, 08221, Terrassa, Barcelona, Spain.
| | - Thorsten Gehrke
- Department of Orthopaedic Surgery, ENDO-Klinik Hamburg, Holstenstr 2, 22767, Hamburg, Germany
| | - Mustafa Citak
- Department of Orthopaedic Surgery, ENDO-Klinik Hamburg, Holstenstr 2, 22767, Hamburg, Germany
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Qiao YJ, Li F, Zhang LD, Yu XY, Zhang HQ, Yang WB, Song XY, Xu RL, Zhou SH. Analysis of the clinical efficacy of two-stage revision surgery in the treatment of periprosthetic joint infection in the knee: A retrospective study. World J Clin Cases 2022; 10:13239-13249. [PMID: 36683646 PMCID: PMC9851019 DOI: 10.12998/wjcc.v10.i36.13239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Revised: 11/15/2022] [Accepted: 12/05/2022] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Periprosthetic joint infection (PJI) is a catastrophic complication that can occur following total knee arthroplasty (TKA). Currently, the treatment for PJI mainly includes the use of antibiotics alone, prosthetic debridement lavage, primary revision, secondary revision, joint fusion, amputation, etc.
AIM To explore the clinical effect of two-stage revision surgery for the treatment of PJI after TKA.
METHODS The clinical data of 27 patients (3 males and 24 females; age range, 47–80 years; mean age, 66.7 ± 8.0 years; 27 knees) with PJI treated with two-stage revision surgery in our hospital between January 1, 2010 and December 31, 2020 were analyzed retrospectively. The following outcomes were compared for changes between preoperative and last follow-up results: Erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), visual analogue scale (VAS) scores, Hospital for Special Surgery (HSS) scores, knee range of motion (ROM), and infection cure rates.
RESULTS All 27 patients were followed up (range, 13–112 mo). The ESR (14.5 ± 6.3 mm/h) and CRP (0.6 ± 0.4 mg/dL) of the patients at the last follow-up were significantly lower than those at admission; the difference was statistically significant (P < 0.001). The postoperative VAS score (1.1 ± 0.7), HSS score (82.3 ± 7.1), and knee ROM (108.0° ± 19.7°) were significantly improved compared with those before the surgery; the difference was statistically significant (P < 0.001). Of the 27 patients, 26 were cured of the infection, whereas 1 case had an infection recurrence; the infection control rate was 96.3%.
CONCLUSION Two-stage revision surgery can effectively relieve pain, control infection, and retain good joint function in the treatment of PJI after TKA.
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Affiliation(s)
- Yong-Jie Qiao
- Department of Joint Surgery, The 940th Hospital of Joint Logistic Support Force of Chinese People’s Liberation Army, Lanzhou 730050, Gansu Province, China
| | - Feng Li
- Department of Orthopedics, The 943rd Hospital of Joint Logistic Support Force of Chinese People’s Liberation Army, Wuwei 733000, Gansu Province, China
| | - Lv-Dan Zhang
- Department of Respiratory Medicine, The 940th Hospital of Joint Logistic Support Force of Chinese People’s Liberation Army, Lanzhou 730050, Gansu Province, China
| | - Xin-Yuan Yu
- Department of Joint Surgery, The 940th Hospital of Joint Logistic Support Force of Chinese People’s Liberation Army, Lanzhou 730050, Gansu Province, China
| | - Hao-Qiang Zhang
- Department of Joint Surgery, The 940th Hospital of Joint Logistic Support Force of Chinese People’s Liberation Army, Lanzhou 730050, Gansu Province, China
| | - Wen-Bin Yang
- Department of Joint Surgery, The 940th Hospital of Joint Logistic Support Force of Chinese People’s Liberation Army, Lanzhou 730050, Gansu Province, China
| | - Xiao-Yang Song
- Department of Joint Surgery, The 940th Hospital of Joint Logistic Support Force of Chinese People’s Liberation Army, Lanzhou 730050, Gansu Province, China
| | - Rui-Ling Xu
- Department of Joint Surgery, The 940th Hospital of Joint Logistic Support Force of Chinese People’s Liberation Army, Lanzhou 730050, Gansu Province, China
| | - Sheng-Hu Zhou
- Department of Joint Surgery, The 940th Hospital of Joint Logistic Support Force of Chinese People’s Liberation Army, Lanzhou 730050, Gansu Province, China
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Lunz A, Omlor GW, Schmidt G, Moradi B, Lehner B, Streit MR. Quality of life, infection control, and complication rates using a novel custom-made articulating hip spacer during two-stage revision for periprosthetic joint infection. Arch Orthop Trauma Surg 2022; 142:4041-4054. [PMID: 34853867 PMCID: PMC9596578 DOI: 10.1007/s00402-021-04274-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2021] [Accepted: 11/19/2021] [Indexed: 01/04/2023]
Abstract
INTRODUCTION Two-stage revision remains the gold standard treatment for most chronically infected and complex total hip arthroplasty infections. To improve patient outcome and reduce complication rates, we have developed a novel custom-made articulating hip spacer technique and present our short-term results. MATERIALS AND METHODS Between November 2017 and November 2019, 27 patients (mean age 70 years) underwent two-stage revision for periprosthetic joint infection of the hip using the articulating spacer design described here. We retrospectively analyzed spacer-related complications as well as rates for complication, infection control, and implant survivorship after final reimplantation. Furthermore, we prospectively collected patient-reported health-related quality of life (HRQoL) scores prior to spacer implantation, with the spacer and after reimplantation of the new prosthesis. RESULTS An additional round of spacer exchange was performed in two patients (8.3%), persistent wound discharge was the reason in both cases. We had one (4.2%) spacer-related mechanical complication, a dislocation that was treated with closed reduction. After reimplantation, infection control was achieved in 96% with an implant survivorship of 92% after a mean follow-up time of 19 (range 7-32, SD 7.2) months. While the scores for VR-12 MCS, VAS hip pain and patient-reported overall satisfaction significantly improved after first stage surgery, the scores for WOMAC, UCLA and VR-12 PCS significantly improved after second stage surgery. CONCLUSIONS Our two-stage approach for periprosthetic joint infection shows high infection eradication and implant survivorship rates at short-term follow-up. Spacer-related complication rates were low, and we achieved high patient satisfaction rates and low pain levels already during the spacer period. To further simplify comparison between different spacer designs, we propose a new hip spacer classification system.
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Affiliation(s)
- Andre Lunz
- Clinic for Orthopedics and Trauma Surgery, Center for Orthopedics, Trauma Surgery and Spinal Cord Injury, Heidelberg University Hospital, Schlierbacher Landstrasse 200a, 69118, Heidelberg, Germany.
| | - Georg W Omlor
- Clinic for Orthopedics and Trauma Surgery, Center for Orthopedics, Trauma Surgery and Spinal Cord Injury, Heidelberg University Hospital, Schlierbacher Landstrasse 200a, 69118, Heidelberg, Germany
| | - Gunter Schmidt
- Clinic for Orthopedics and Trauma Surgery, Center for Orthopedics, Trauma Surgery and Spinal Cord Injury, Heidelberg University Hospital, Schlierbacher Landstrasse 200a, 69118, Heidelberg, Germany
| | - Babak Moradi
- Clinic for Orthopedics and Traumatology, University Medical Center Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Burkhard Lehner
- Clinic for Orthopedics and Trauma Surgery, Center for Orthopedics, Trauma Surgery and Spinal Cord Injury, Heidelberg University Hospital, Schlierbacher Landstrasse 200a, 69118, Heidelberg, Germany
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Ohlmeier M, Jachczik I, Citak M, Gehrke T, Hawi N, Haasper C, Abdelaziz H. High re-revision rate following one-stage exchange for streptococcal periprosthetic joint infection of the hip. Hip Int 2022; 32:488-492. [PMID: 33601967 DOI: 10.1177/1120700021991467] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
INTRODUCTION This study was undertaken to analyse the outcome of 1-stage exchange in the management of streptococcal periprosthetic joint infection (PJI) of the hip at a single hospital. METHODS We identified 30 patients with a streptococcal PJI of the hip who had been treated by 1-stage exchange at our hospital between 2002 and 2017. Postoperative complications and the need for any subsequent re-revision for infection or other reasons were analysed. The Harris Hip Score (HHS) was evaluated at final follow-up. RESULTS The mean follow-up was 8.2 years (SD 4.1). The overall re-revision rate for any reason was 53% (16/30) at a mean 5.3 years (SD 0.68 years). Re-revision for infection was 20% (6/30) at a mean 1.8 years (SD 0.74 years). All re-revisions for PJI (6/6; 100%) were for relapse of the streptococcal infection. At final follow-up, the mean HHS was 68 points (SD 20). CONCLUSIONS The rate of re-revision after 1-stage exchange for streptococcal PJI is high. Eradication of a streptococcal PJI of the hip remains challenging. Further extensive and comparative studies between 1-and 2-stage exchange are encouraged.
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Affiliation(s)
- Malte Ohlmeier
- Department of Joint Surgery, Helios ENDO-Klinik Hamburg, Hamburg, Germany
| | - Insa Jachczik
- Department of Joint Surgery, Helios ENDO-Klinik Hamburg, Hamburg, Germany
| | - Mustafa Citak
- Department of Joint Surgery, Helios ENDO-Klinik Hamburg, Hamburg, Germany
| | - Thorsten Gehrke
- Department of Joint Surgery, Helios ENDO-Klinik Hamburg, Hamburg, Germany
| | - Nael Hawi
- Department of Trauma, Hannover Medical School, Hannover, Germany
| | - Carl Haasper
- Department of Orthopaedic Surgery, AMEOS Klinikum Seepark, Geestland, Germany
| | - Hussein Abdelaziz
- Department of Joint Surgery, Helios ENDO-Klinik Hamburg, Hamburg, Germany
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Periprosthetic Joint Infection (PJI)—Results of One-Stage Revision with Antibiotic-Impregnated Cancellous Allograft Bone—A Retrospective Cohort Study. Antibiotics (Basel) 2022; 11:antibiotics11030310. [PMID: 35326773 PMCID: PMC8944641 DOI: 10.3390/antibiotics11030310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Revised: 02/21/2022] [Accepted: 02/23/2022] [Indexed: 02/04/2023] Open
Abstract
Controversy exists regarding the optimal treatment of periprosthetic joint infection (PJI), considering control of infection, functional results as well as quality of life. Difficulties in treatment derive from the formation of biofilms within a few days after infection. Biofilms are tolerant to systemically applied antibiotics, requiring extreme concentrations for a prolonged period. Minimum biofilm eradicating concentrations (MBEC) are only feasible by the local application of antibiotics. One established approach is the use of allograft bone as a carrier, granting a sustained release of antibiotics in very high concentrations after appropriate impregnation. The purpose of this study was to determine the rate of reinfection after a one-stage revision of infected hip or knee prostheses, using antibiotic-impregnated allograft bone as the carrier and avoiding cement. Between 1 January 2004 and 31 January 2018, 87 patients with PJI, according to MSIS, underwent a one-stage revision with antibiotic-impregnated cancellous allograft bone. An amount of 17 patients had insufficient follow-ups. There were 70 remaining patients (34 male, 36 female) with a mean follow-up of 5.6 years (range 2–15.6) and with a mean age of 68.2 years (range 31.5–86.9). An amount of 38 hips and 11 knees were implanted without any cement; and 21 knees were implanted with moderate cementing at the articular surface with stems always being uncemented. Within 2 years after surgery, 6 out of 70 patients (8.6%, CI 2–15.1) showed reinfection and after more than 2 years, an additional 6 patients showed late-onset infection. Within 2 years after surgery, 11 out of 70 patients (15.7%, CI 7.2–24.2) had an implant failure for any reason (including infection) and after more than 2 years, an additional 7 patients had an implant failure. Using Kaplan-Meier analysis for all 87 patients, the estimated survival for reinfection was 93.9% (CI 88.8–99.1) at 1 year, 89.9% (CI 83.2–96.6) at 2 years and 81.5% (CI 72.1–90.9) at 5 years. The estimated survival for implant failure for any reason was 90.4% (CI 84.1–96.7) at 1 year, 80.9% (CI 72.2–89.7) at 2 years and 71.1% (CI 60.3–81.8) at 5 years. One-stage revision with antibiotic-impregnated cancellous allograft bone grants comparable results regarding infection control as with multiple stages, while shortening rehabilitation, improving quality of life for the patients and reducing costs for the health care system.
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Logoluso N, Pedrini FA, Morelli I, De Vecchi E, Romanò CL, Pellegrini AV. Megaprostheses for the revision of infected hip arthroplasties with severe bone loss. BMC Surg 2022; 22:68. [PMID: 35216567 PMCID: PMC8876444 DOI: 10.1186/s12893-022-01517-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Accepted: 02/14/2022] [Indexed: 01/14/2023] Open
Abstract
Background Periprosthetic hip infections with severe proximal femoral bone loss may require the use of limb salvage techniques, but no agreement exists in literature regarding the most effective treatment. Aim of this study is to analyze the infection eradication rate and implant survival at medium-term follow-up in patients treated with megaprostheses for periprosthetic hip infections with severe bone loss. Methods Twenty-one consecutive patients were retrospectively reviewed at a mean 64-month follow-up (24–120). Functional and pain scores, microbiological, radiological and intraoperative findings were registered. Kaplan Meier survival analysis and log rank test were used for infection free survival and implant survival analyses. Results The infection eradication rate was 90.5%, with an infection free survival of 95.2% at 2 years (95%CI 70.7–99.3) and 89.6%(95%CI 64.3–97.3) at 5 years. Only two patients required major implant revisions for aseptic implant loosening. The most frequent complication was dislocation (38.1%). The major revision-free survival of implants was 95.2% (95%CI 70.7–99.3) at 2 years and 89.6% (95%CI 64.3–97.3) at 5 years. The overall implant survival was 83.35% (CI95% 50.7–93.94) at 2 and 5 years. Subgroup analyses (cemented versus cementless MPs, coated versus uncoated MPs) revealed no significant differences at log rank test, but its reliability was limited by the small number of patients included. Conclusions Proximal femoral arthroplasty is useful to treat periprosthetic hip infections with severe bone loss, providing good functional results with high infection eradication rates and rare major revisions at medium-term follow-up. No conclusions can be drawn on the role of cement and coatings.
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Affiliation(s)
- Nicola Logoluso
- IRCCS Istituto Ortopedico Galeazzi, Centre for Reconstructive Surgery and Osteoarticular Infections (C.R.I.O. Unit), via Riccardo Galeazzi 4, 20161, Milan, Italy
| | - Francesca Alice Pedrini
- Residency Program in Orthopaedics and Traumatology, University of Milan, via Festa del Perdono 7, 20122, Milan, Italy
| | - Ilaria Morelli
- ASST Ovest Milanese, Ospedale di Legnano, UOC Ortopedia e Traumatologia, via Papa Giovanni Paolo II, 20025, Legnano, MI, Italy.
| | - Elena De Vecchi
- IRCCS Istituto Ortopedico Galeazzi, Laboratory of Clinical Chemistry and Microbiology, via Riccardo Galeazzi 4, 20161, Milan, Italy
| | | | - Antonio Virgilio Pellegrini
- IRCCS Istituto Ortopedico Galeazzi, Centre for Reconstructive Surgery and Osteoarticular Infections (C.R.I.O. Unit), via Riccardo Galeazzi 4, 20161, Milan, Italy
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Thiesen DM, Sobhani H, Gehrke T, Suero EM, Klatte TO, Citak M. A comparison of short term complication rate between 44 two- and 385 one-stage septic exchange arthroplasties in chronic periprosthetic joint infections. Orthop Traumatol Surg Res 2021; 107:102668. [PMID: 32798125 DOI: 10.1016/j.otsr.2020.05.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Revised: 05/11/2020] [Accepted: 05/18/2020] [Indexed: 02/03/2023]
Abstract
BACKGROUND Periprosthetic joint infection is a serious disease with severe consequences for the patient's life. It is not known whether one-stage or two-stage replacement arthroplasty is superior. So far, there have been no studies on short-term complications between both surgical procedures. Therefore, we performed a retrospective study aiming to determine: 1) Does two-stage septic exchange arthroplasty have a higher short-term complication rate than one-stage? 2) Is there a difference in length of hospital stay and the in-hospital mortality rate between two- and one-stage septic exchange arthroplasty? HYPOTHESIS Two-stage septic exchange arthroplasty has a higher short-term complication rate than one-stage. PATIENTS AND METHODS Retrospectively 429 patients who underwent a one- or two stage revision arthroplasty (288 hips and 141 knees) due to chronic PJI between January 2015 and December 2016 were recruited (one-stage: n=385, two-stage: n=44). Differences in postoperative complications, surgical therapy, ASA, Charlson Comorbidity Index (CCI), length of hospital, need for plastic surgery, pathogen, in-hospital morbidity and in-hospital mortality were compared using multiple logistic and Poisson regression. Regarding comorbidities, age, gender and BMI the groups were comparable. RESULTS It was 3.5 times more likely to suffer from a medical complication if a two stage septic exchange was performed (OR 3.465, (95% CI: 2.573-4.358) [p<0.01]). In medical complications the two-stage group showed significantly more events (two-stage: 9 of 44=20.5%; one-stage: 30 of 385=7.8% [p=0.013]). The one-stage group showed more (not significant) nerve palsies after hip septic exchange. There was no difference in mortality between the groups (two-stage: 1/44=2.3%; one-stage: 3/385=0.8% [p=0.882]), the overall mortality was 0.93%. The duration of hospital stay was 23.9±19 days for the one-stage and 42.2±17.7 days for the two-stage group (p<0.001). CONCLUSION We found that it is more likely to develop a medical complication after two-stage septic revision arthroplasty. There was no difference in overall surgical complications between the two surgical approaches. We did not find a significant difference in short term mortality between the two techniques, although the mortality rate was slightly higher in the two-stage group. LEVEL OF EVIDENCE III, retrospective case control study.
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Affiliation(s)
- Darius M Thiesen
- Department of Orthopaedic Surgery, Helios ENDO-Klinik Hamburg, Hamburg, Holstenstr 2, 22767 Hamburg, Germany; Department of Trauma- and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Martinistr 52, 20246 Hamburg, Germany.
| | - Human Sobhani
- Department of Orthopaedic Surgery, Helios ENDO-Klinik Hamburg, Hamburg, Holstenstr 2, 22767 Hamburg, Germany
| | - Thorsten Gehrke
- Department of Orthopaedic Surgery, Helios ENDO-Klinik Hamburg, Hamburg, Holstenstr 2, 22767 Hamburg, Germany
| | - Eduardo M Suero
- Department of General, Trauma and Reconstructive Surgery, Ludwig Maximilian University of Marchioninistr 15, 81377 Munich, Germany
| | - Till O Klatte
- Department of Trauma- and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Martinistr 52, 20246 Hamburg, Germany
| | - Mustafa Citak
- Department of Orthopaedic Surgery, Helios ENDO-Klinik Hamburg, Hamburg, Holstenstr 2, 22767 Hamburg, Germany
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Costa-Pinto AR, Lemos AL, Tavaria FK, Pintado M. Chitosan and Hydroxyapatite Based Biomaterials to Circumvent Periprosthetic Joint Infections. MATERIALS (BASEL, SWITZERLAND) 2021; 14:804. [PMID: 33567675 PMCID: PMC7914941 DOI: 10.3390/ma14040804] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Revised: 01/23/2021] [Accepted: 02/02/2021] [Indexed: 02/06/2023]
Abstract
Every year, worldwide, millions of people suffering from joint pain undergo joint replacement. For most patients, joint arthroplasty reduces pain and improve function, though a small fraction will experience implant failure. One of the main reasons includes prosthetic joint infection (PJI), involving the prosthesis and adjacent tissues. Few microorganisms (MO) are required to inoculate the implant, resulting in the formation of a biofilm on its surface. Standard treatment includes not only removal of the infected prosthesis but also the elimination of necrotic bone fragments, local and/or systemic administration of antibiotics, and revision arthroplasty with a new prosthesis, immediately after the infection is cleared. Therefore, an alternative to the conventional therapeutics would be the incorporation of natural antimicrobial compounds into the prosthesis. Chitosan (Ch) is a potential valuable biomaterial presenting properties such as biocompatibility, biodegradability, low immunogenicity, wound healing ability, antimicrobial activity, and anti-inflammatory potential. Regarding its antimicrobial activity, Gram-negative and Gram-positive bacteria, as well as fungi are highly susceptible to chitosan. Calcium phosphate (CaP)-based materials are commonly utilized in orthopedic and dentistry for their excellent biocompatibility and bioactivity, particularly in the establishment of cohesive bone bonding that yields effective and rapid osteointegration. At present, the majority of CaP-based materials are synthetic, which conducts to the depletion of the natural resources of phosphorous in the future due to the extensive use of phosphate. CaP in the form of hydroxyapatite (HAp) may be extracted from natural sources as fish bones or scales, which are by-products of the fish food industry. Thus, this review aims to enlighten the fundamental characteristics of Ch and HAp biomaterials which makes them attractive to PJI prevention and bone regeneration, summarizing relevant studies with these biomaterials to the field.
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Affiliation(s)
| | | | | | - Manuela Pintado
- Universidade Católica Portuguesa, CBQF-Centro de Biotecnologia e Química Fina-Laboratório Associado, Escola Superior de Biotecnologia, Rua Diogo Botelho 1327, 4169-005 Porto, Portugal; (A.L.L.); (F.K.T.)
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Low-dose vancomycin-loaded cement spacer for two-stage revision of infected total hip arthroplasty. Jt Dis Relat Surg 2021; 31:449-455. [PMID: 32962574 PMCID: PMC7607947 DOI: 10.5606/ehc.2020.76108] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
OBJECTIVES This study aims to evaluate the success rate in terms of eradication of infection and long-term outcomes of two- stage revision arthroplasty with spacers loaded with low-dose vancomycin alone for the treatment of an infected hip arthroplasty. PATIENTS AND METHODS The records of 42 two-stage exchange arthroplasty patients (16 males, 26 females; mean age 61 years; range, 30 to 80 years) treated between January 1999 and January 2009 were included in this retrospective study. In the first stage, following removal of the prosthesis and debridement, a spacer consisting of 1 g of vancomycin per 40 g of cement was placed in the infected joint space. Patients received six weeks of intravenous antibiotics according to intraoperative cultures. After cessation of systemic antibiotic treatment, with normal C-reactive protein and erythrocyte sedimentation rate levels, second stage surgery with cementless components was performed. RESULTS The mean follow-up duration was seven (range, 3 to 13) years. Two patients (4.7%) developed re-infection after two-stage reimplantation and one patient underwent a resection arthroplasty after repeated debridements. Five years of survival was 92.9% with Kaplan-Meier survival analysis. CONCLUSION For chronic infected total hip revisions, two-stage revision arthroplasty with low-dose vancomycin impregnated cement spacers have comparable re-infection and success rates. Low-dose vancomycin promotes effective infection control and reduces antibiotic toxicity.
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Rossmann M, Minde T, Citak M, Gehrke T, Sandiford NA, Klatte TO, Abdelaziz H. High Rate of Reinfection With New Bacteria Following One-Stage Exchange for Enterococcal Periprosthetic Infection of the Knee: A Single-Center Study. J Arthroplasty 2021; 36:711-716. [PMID: 32863076 DOI: 10.1016/j.arth.2020.08.015] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 08/05/2020] [Accepted: 08/06/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND A wide range of success rates following the surgical management of enterococcal periprosthetic joint infection (PJI) with a tendency toward worse outcomes have been reported. However, the role of 1-stage exchange remains under-investigated. Therefore, we aimed to evaluate our results after the 1-stage knee exchange for enterococcal PJI. METHODS Forty patients were retrospectively included between 2002 and 2017 with a mean follow-up of survivors of 80 months (range 22-172; standard deviation [SD] = 5). Polymicrobial infections occurred in 45% (18/40) of patients. Patients' characteristics, joint-related data, and antibiotic therapy were recorded. Rates of enterococcal infection relapse, reinfection with new microorganisms, and re-revision for any reason were determined. Bivariate analysis was conducted to identify risk factors of infection recurrence. RESULTS Revision surgery was required in 22 cases (55%) with a mean time to revision surgery of 27 months (range 1-78; SD = 25). Indications for aseptic revisions (18%) included aseptic loosening (10%), periprosthetic fracture (5%), and patellar instability (3%). The most common cause of re-revision was a subsequent PJI (15/22; 68%) after a mean time of 22 months (range 1-77; SD = 24). Overall infection recurrence rate was 37.5% (15/40), substantially due to entirely non-enterococcal infections (9/15; 60%). Infection relapse with Enterococci occurred in 4 cases (10%) within 16 months postoperatively. Older patients (P = .05) and male gender (P = .05) were associated with a higher risk of infection recurrence. CONCLUSION Overcoming the Enterococci using the 1-stage exchange for knee PJI is achievable but the rate of reinfection due to new microorganisms is high . However, the overall infection recurrence rate is comparable to other treatment approaches.
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Affiliation(s)
- Markus Rossmann
- Department of Joint Replacement Surgery, Helios ENDO-Klinik Hamburg, Hamburg, Germany
| | - Thore Minde
- Department of Joint Replacement Surgery, Helios ENDO-Klinik Hamburg, Hamburg, Germany
| | - Mustafa Citak
- Department of Joint Replacement Surgery, Helios ENDO-Klinik Hamburg, Hamburg, Germany
| | - Thorsten Gehrke
- Department of Joint Replacement Surgery, Helios ENDO-Klinik Hamburg, Hamburg, Germany
| | | | - Till Orla Klatte
- Department of Trauma, Hand, and Reconstructive Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Hussein Abdelaziz
- Department of Joint Replacement Surgery, Helios ENDO-Klinik Hamburg, Hamburg, Germany
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Hip Spacers with a Metal-on-Cement Articulation Did Not Show Significant Surface Alterations of the Metal Femoral Head in Two-Stage Revision for Periprosthetic Joint Infection. MATERIALS 2020; 13:ma13173882. [PMID: 32887457 PMCID: PMC7503536 DOI: 10.3390/ma13173882] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Revised: 08/25/2020] [Accepted: 08/31/2020] [Indexed: 02/06/2023]
Abstract
Two-stage revision is considered the gold standard treatment for chronic periprosthetic joint infection (PJI). During the interim period, between explantation of the infected hip endoprosthesis and revision arthroplasty, individually formed articulating hip spacers made of polymethylmethacrylate (PMMA) bone cement can be used to provide better soft tissue preservation, local antibiotic release, and improved postoperative mobilization. If effective prevention from luxation is achieved, hip function and hence overall patient satisfaction is improved. Zirconium oxide particles inside conventional PMMA bone cement, however, are known to enhance third-body wear, which may cause alterations of the metal head in the articulating spacer and hence become a serious risk for the patient. Therefore, the aim of our study was to analyze whether the articular surface of cobalt-chrome (CoCr) femoral heads is significantly altered in the setting of a metal-on-cement articulation during the interim period of two-stage revision for PJI. We analyzed a consecutive series of 23 spacer cases and compared them with femoral heads from two series of conventional hip arthroplasty revisions with metal-on-polyethylene articulations and different time intervals in situ. To investigate metallic wear, the femoral heads were thoroughly examined, and their surface roughness was measured and analyzed. We found no significant differences between the two conventional hip arthroplasty groups, despite their very different times in situ. Furthermore, the individually different times in situ within the spacer group had no significant impact on surface roughness, either. Compared with the spacer group, the surface roughness of the metal femoral heads from both conventional hip arthroplasty groups were even higher. Within the spacer group, roughness parameters did not show significant differences regarding the five predefined locations on the metal head. We conclude that metal-on-cement articulations do not cause enhanced surface alterations of the metal femoral head and hence do not limit the application in articulating hip spacers in the setting of two-stage revision for PJI.
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Six-week antibiotic therapy after one-stage replacement arthroplasty for hip and knee periprosthetic joint infection. Med Mal Infect 2020; 50:567-574. [PMID: 32284220 DOI: 10.1016/j.medmal.2020.03.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2019] [Revised: 09/09/2019] [Accepted: 03/18/2020] [Indexed: 01/15/2023]
Abstract
OBJECTIVES One-stage replacement arthroplasty for treatment of periprosthetic joint infection (PJI) results in similar cure rate than two-stage (around 85-92%), but antibiotic therapy duration is not well established. The aim of this study was to evaluate the efficacy of a short six-week antibiotic course in periprosthetic joint infections after onstage exchange. PATIENTS AND METHODS Retrospective, observational study conducted at Orthopaedic Department of Cochin Hospital, Paris, between 1st January 2010 and 31 December 2015. Patients with a microbiologically proven PJI, treated with one-stage replacement and 6 weeks (+/1week) of antimicrobial therapy were included. Pearson's-χ2 and Wilcoxon tests were used to compare categorical and continuous variables. RESULTS Fifty patients with periprosthetic joint infections (42 hip, 8 knee PJI) treated with one-stage replacement arthroplasty were included. Median age was 69.3 years (IQR 24.5-97.4). Infections occurred after a mean of 36 months (IQR 1-216). Bone biopsy cultures were positive for Staphylococcus spp. in 29 patients (58%), Cutibacterium acnes in 19 (38%), Gram-negative bacilli in 6 (12%). Polymicrobial infections occurred in 12 (24%). Intravenous antibiotics were administered for a median of 11 days (IQR 4-45) and 46 patients (92%) were switched to an oral therapy. Medium follow-up was of 32 months (IQR 12-101). Overall remission rate was 90%. CONCLUSIONS A six-week course of antibiotics in knee and hip PJIs treated with one-stage RA has a satisfactory remission rate in this open study.
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Primary Total Knee Arthroplasty Implants as Functional Prosthetic Spacers for Definitive Management of Periprosthetic Joint Infection: A Multicenter Study. J Arthroplasty 2019; 34:3040-3047. [PMID: 31378510 DOI: 10.1016/j.arth.2019.07.007] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Revised: 05/25/2019] [Accepted: 07/04/2019] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND There are limited data on the utility of a standard primary total knee arthroplasty (TKA) femoral component with an all polyethylene tibia as a functional prosthetic spacer in place of a conventional all cement spacer for the management of periprosthetic joint infection (PJI). The aim of this multicenter study was to retrospectively review (1) ultimate treatment success; (2) reimplantation rates; (3) reoperation rates; and (4) change in knee range of motion in patients managed with functional prosthetic spacers following TKA PJI. METHODS A retrospective review was performed for patients at 2 tertiary care centers who underwent a functional prosthetic spacer implantation as part of a functional single-stage (n = 57) or all cement spacer conventional two-stage (n = 137) revision arthroplasty protocol over a 5-year period. Outcomes including reinfection, reimplantation, and reoperation rates, success rate as defined by the Delphi criteria, and final range of motion were compared between the 2 cohorts at a minimum of 2-year follow-up. RESULTS There was no significant difference in reinfection (14.0 vs 24.1%), reoperation (19.3 vs 27.7%), or success rates (78.9 vs 70.8%; P > .05 for all) between the one-stage and two-stage revision TKA cohorts. Mean final total arc of motion was also similar between the 2 groups (105.8 vs 101.8 degrees, respectively). CONCLUSION Functional prosthetic spacers offer the advantage of a single procedure with decreased overall hospitalization and improved cost-effectiveness with analogous success rates (78.9%) compared with two-stage exchange (70.8%) at mid-term follow-up. Although long-term data are required to determine its longevity and efficacy, the outcomes in this study are encouraging. LEVEL OF EVIDENCE 3.
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What are the Factors Associated with Re-revision After One-stage Revision for Periprosthetic Joint Infection of the Hip? A Case-control Study. Clin Orthop Relat Res 2019; 477:2258-2263. [PMID: 31135547 PMCID: PMC6999925 DOI: 10.1097/corr.0000000000000780] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Despite increased interest in one-stage revision arthroplasty for periprosthetic joint infection (PJI) of the hip, the reported infection-free proportions after the one-stage approach are still comparable to that of two-stage revision. However, we still lack studies that analyze factors associated with any re-revision after one-stage revision arthroplasty for PJI. QUESTIONS/PURPOSES After one-stage revision arthroplasty for PJI of the hip, what factors were associated with an increased risk of re-revision, and what factors were associated with an increased risk of reinfection? METHODS We performed a single-center retrospective case-control analysis. Patients who underwent one-stage revision arthroplasty for PJI of the hip in our hospital between 2009 and 2017, and who were subsequently re-revised due to any reason, including reinfection, were identified from our electronic medical records. A total of 121 patients who underwent repeat revision for any reason after one-stage exchange for PJI of the hip were identified. The re-revision procedures were performed after a mean of 407 days. The primary reasons for re-revision were repeated hip dislocation in 53 of 121 patients (44%), reinfection including both new and persistent infections in 40 of 121 patients (33%), and aseptic loosening in 16 patients (13%). Forty-three patients underwent another revision procedure after the re-revision procedure (43 of 121; 36%). More than 40 potential patient-, joint- and surgery-related risk factors were investigated and compared with a 1:1 matched control participants by age, sex and year of the one-stage revision. Similar to the re-revision patients, controls were treated for PJI with one-stage revision arthroplasty; however, they did not undergo subsequent revision for any reason by the latest followup examination. The mean followup of the control group was 66 months (range, 17-119 months). The mean length of hospital stay was 26 days in the re-revised group (SD, 11.6 days) compared with 22 days for the controls (SD, 6.6 days). All analyses were performed to identify factors associated with general re-revision and reinfection. RESULTS The independent factors associated with repeat revision for any reason were persistent wound drainage for at least 1 week (odds ratio [OR], 7.4; 95% CI, 2.6-20.6; p < 0.001), isolation of enterococci (OR, 4.8; 95% CI, 1.4-15.7; p = 0.010), and prior surgery due to infection before the one-stage hip revision (OR, 3.6; 95% CI, 2.0-6.4; p < 0.001). The factors associated with reinfection including both new and persistent infections were prolonged wound drainage (OR, 6.9; 95% CI, 2.2-21.5; p = 0.001) and prior surgery due to infection (OR, 4.3; 95% CI, 1.9-9.5; p < 0.001). CONCLUSIONS Prolonged wound drainage after the one-stage revision arthroplasty for PJI of the hip must be treated rigorously. Patients with a history of a prior surgical procedure due to hip infection should be informed about the risk of further re-revision when deciding for the one-stage exchange. In case of enterococcal isolation, surgeons may consider another treatment approach rather than the one-stage exchange. Furthermore, we recommend the use of dual mobility cups when performing the one-stage revision hip arthroplasty to reduce the risk of dislocation.Level of Evidence Level III, therapeutic study.
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Abstract
Fungal periprosthetic joint infection (PJI) is a devastating complication because it can be difficult to diagnose, manage, and eradicate. Fungal PJI treatment requires a systematic approach. Increased awareness is essential when patients with painful arthroplasties present with immunosuppression, significant comorbidities, multiple surgeries, and history of drug use. Every suspected fungal PJI should be promptly diagnosed using readily available serum and synovial fluid markers. Surgical management involves débridement, antibiotics, and implant retention, one-stage exchange arthroplasty, prosthetic articulating spacers, and two-stage exchange arthroplasty. Because mycotic infections develop robust biofilms, the utility of débridement, antibiotics, and implant retention and one-stage revisions seem limited. A thorough irrigation and débridement is essential to decrease infection burden. Adjunctive local and systemic antifungal therapy is critical, although the agent choice and duration should be tailored appropriately. Future high-quality studies are needed to develop standardized guidelines for the management of fungal PJI.
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Citak M, Friedenstab J, Abdelaziz H, Suero EM, Zahar A, Salber J, Gehrke T. Risk Factors for Failure After 1-Stage Exchange Total Knee Arthroplasty in the Management of Periprosthetic Joint Infection. J Bone Joint Surg Am 2019; 101:1061-1069. [PMID: 31220022 DOI: 10.2106/jbjs.18.00947] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND One-stage exchange arthroplasty in the management of periprosthetic joint infection was introduced at our institution. The purpose of this study was to analyze the risk factors of failure after periprosthetic joint infection following total knee arthroplasty treated with 1-stage exchange. METHODS Ninety-one patients who underwent failed treatment following 1-stage exchange total knee arthroplasty due to periprosthetic joint infection from January 2008 to December 2017 were included. From the same period, we randomly selected a 1:1 matched control group without a subsequent revision surgical procedure. Bivariate analyses, including preoperative, intraoperative, and postoperative factors, as well as logistic regression, were performed to identify risk factors for failure. RESULTS Bivariate analysis yielded 10 predictors (variables with significance at p < 0.05) for failure involving re-revision for any reason and 11 predictors for failure involving re-revision for reinfection. The binary logistic regression model revealed the following risk factors for re-revision for any reason: history of a 1-stage exchange for infection (odds ratio [OR], 26.706 [95% confidence interval (CI), 5.770 to 123.606]; p < 0.001), history of a 2-stage exchange (OR, 3.948 [95% CI, 1.869 to 8.339]; p < 0.001), and isolation of enterococci (OR, 16.925 [95% CI, 2.033 to 140.872]; p = 0.009). The risk factors for reinfection in the binary logistic regression analysis were history of 1-stage or 2-stage exchange arthroplasty, isolation of enterococci, and isolation of streptococci (OR, 6.025 [95% CI, 1.470 to 24.701]; p = 0.013). CONCLUSIONS We identified several risk factors of failure after 1-stage exchange arthroplasty for periprosthetic joint infection, most of which were not related to the patient comorbidities. Among them, previous exchange due to periprosthetic joint infection and the isolation of Enterococcus or Streptococcus species were associated with a higher risk of failure. Besides a multidisciplinary approach, being aware of the identified risk factors when evaluating patients with periprosthetic joint infection could lead to better outcomes. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Mustafa Citak
- Department of Orthopaedic Surgery, Helios ENDO-Klinik Hamburg, Hamburg, Germany
| | - Jasmin Friedenstab
- Department of Orthopaedic Surgery, Helios ENDO-Klinik Hamburg, Hamburg, Germany.,Department of Surgery, Ruhr-University Hospital, Bochum, Germany
| | - Hussein Abdelaziz
- Department of Orthopaedic Surgery, Helios ENDO-Klinik Hamburg, Hamburg, Germany
| | - Eduardo M Suero
- Department of General, Trauma and Reconstructive Surgery, Ludwig-Maximilians-University München, München, Germany
| | - Akos Zahar
- Department of Orthopaedic Surgery, Helios ENDO-Klinik Hamburg, Hamburg, Germany
| | - Jochen Salber
- Department of Surgery, Ruhr-University Hospital, Bochum, Germany
| | - Thorsten Gehrke
- Department of Orthopaedic Surgery, Helios ENDO-Klinik Hamburg, 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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Thakrar RR, Horriat S, Kayani B, Haddad FS. Indications for a single-stage exchange arthroplasty for chronic prosthetic joint infection. Bone Joint J 2019; 101-B:19-24. [DOI: 10.1302/0301-620x.101b1.bjj-2018-0374.r1] [Citation(s) in RCA: 54] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Aims Prosthetic joint infections (PJIs) of the hip and knee are associated with significant morbidity and socioeconomic burden. We undertook a systematic review of the current literature with the aim of proposing criteria for the selection of patients for a single-stage exchange arthroplasty in the management of a PJI. Material and Methods A comprehensive review of the current literature was performed using the OVID-MEDLINE, EMBASE, and Cochrane Library databases and the search terms: infection and knee arthroplasty OR knee revision OR hip arthroplasty OR hip revision, and one stage OR single stage OR direct exchange. All studies involving fewer than ten patients and follow-up of less than two years in the study group were excluded as also were systematic reviews, surgical techniques, and expert opinions. Results The initial search revealed 875 potential articles of which 22 fulfilled the inclusion and exclusion criteria. There were 16 case series and six comparative studies; five were prospective and 14 were retrospective. The studies included 962 patients who underwent single stage revision arthroplasty of an infected hip or knee joint. The rate of recurrent infection ranged from 0% to 18%, at a minimum of two years’ follow-up. The rate was lower in patients who were selected on the basis of factors relating to the patient and the local soft-tissue and bony conditions. Conclusion We conclude that single-stage revision is an acceptable form of surgical treatment for the management of a PJI in selected patients. The indications for this approach include the absence of severe immunocompromise and significant soft-tissue or bony compromise and concurrent acute sepsis. We suggest that a two-stage approach should be used in patients with multidrug resistant or atypical organisms such as fungus.
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Affiliation(s)
- R. R. Thakrar
- Department of Orthopaedics, University College London Hospitals, London, UK
| | - S. Horriat
- Department of Orthopaedics, University College London Hospitals, London, UK
| | - B. Kayani
- Department of Orthopaedics, University College London Hospitals, London, UK
| | - F. S. Haddad
- University College London Hospitals, The Princess Grace Hospital, and The NIHR Biomedical Research Centre at UCLH, London, UK
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Blood loss and allogeneic transfusion for surgical treatment of periprosthetic joint infection: a comparison of one- vs. two-stage exchange total hip arthroplasty. INTERNATIONAL ORTHOPAEDICS 2018; 43:2025-2030. [DOI: 10.1007/s00264-018-4137-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Accepted: 08/29/2018] [Indexed: 02/07/2023]
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Kuiper JW, Rustenburg CM, Willems JH, Verberne SJ, Peters EJ, Saouti R. Results and Patient Reported Outcome Measures (PROMs) after One-Stage Revision for Periprosthetic Joint Infection of the Hip: A Single-centre Retrospective Study. J Bone Jt Infect 2018; 3:143-149. [PMID: 30013896 PMCID: PMC6043468 DOI: 10.7150/jbji.24366] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2017] [Accepted: 06/13/2018] [Indexed: 12/21/2022] Open
Abstract
Background: Little is known about functional outcome and quality of life (QoL) after one-stage revision for periprosthetic joint infection (PJI) of the hip. Methods: a cohort of 30 subjects treated with one-stage revision between 2011 and 2015 was identified, and questionnaires on functional outcome and QoL were distributed. Results: 28 subjects were successfully treated (93%). Most subjects were referred from other hospitals. Coagulase-negative Staphylococcus was found in 50% of the cases, and 40% of all cultured bacteria were multidrug-resistant. 25% had subsequent revision surgery, unrelated to PJI. Functional outcome was good and QoL scores were high, comparable to prosthetic joint revision surgery in general. Conclusion: Although the cohort was small and statistical analysis was not performed, this study showed that excellent results can be obtained with one-stage revision for hip PJI. Functional outcome and QoL was comparable to prosthetic joint revision surgery in general.
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Affiliation(s)
- Jesse W.P. Kuiper
- Department of Orthopaedic Surgery, VU University Medical Centre, Amsterdam, the Netherlands
- Department of Orthopaedic Surgery, Noord-West Ziekenhuisgroep, Alkmaar, the Netherlands
| | | | - Jore H. Willems
- Department of Orthopaedic Surgery, Noord-West Ziekenhuisgroep, Alkmaar, the Netherlands
- Department of Orthopaedic Surgery, Spaarne Gasthuis, Hoofddorp, the Netherlands
| | - Steven J. Verberne
- Department of Orthopaedic Surgery, Noord-West Ziekenhuisgroep, Alkmaar, the Netherlands
| | - Edgar J.G. Peters
- Department of Internal Medicine, VU University Medical Centre, Amsterdam, the Netherlands
- Amsterdam Infection and Immunity Institute, Amsterdam, the Netherlands
| | - Rachid Saouti
- Department of Orthopaedic Surgery, VU University Medical Centre, Amsterdam, the Netherlands
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Single-Stage Revision for Chronic Fungal Periprosthetic Joint Infection: An Average of 5 Years of Follow-Up. J Arthroplasty 2017; 32:2523-2530. [PMID: 28478188 DOI: 10.1016/j.arth.2017.03.030] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2017] [Revised: 02/25/2017] [Accepted: 03/13/2017] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Periprosthetic infections caused by fungal pathogens are a rare entity, and there exist no definite guidelines according to which these infections can be successfully managed. In these situations, we wondered whether patients could be treated successfully for their fungal infections with single-stage revision. METHODS A retrospective analysis between January 2004 and October 2014 included 11 patients (4 hips and 7 knees) with chronic fungal periprosthetic joint infection who underwent single-stage revision, including aggressive soft-tissue debridement, thorough removal of infected components and cement, pouring powdered vancomycin into the medullary cavity and direct intra-articular injection of fungus-sensitive antibiotics, and a reasonable combination of antifungal agents and antibacterial medications. Recurrence of infection and clinical outcomes were evaluated. The average follow-up was 5 years (range, 2-10 years). RESULTS There were 3 failures during the study period; 1 patient died during the perioperative period because of acute heart failure on the eighth postoperative day. Of the 11 patients, 7 patients had satisfactory outcomes and required no additional surgical or medical treatment for recurrence of infection. The mean postoperative Harris hip score and Hospital for Special Surgery knee score was 77 points (67-88 points; P < .05) and 78 points (73-84 points; P < .05), respectively, at the most recent assessment. CONCLUSION Treatment of chronic fungal periprosthetic joint infection with single-stage revision can be fairly effective for achieving acceptable functional outcomes, which indicated that this may be a feasible alternative strategy in selected patients.
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