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Kato H, Hamada Y, Takano S, Ikeda S, Seto Y, Matsushita K, Yamada K, Uchiyama K. A systematic review and meta-analysis of antibiotic-loaded bone cement for prevention of deep surgical site infections following primary total joint replacement. J Infect Chemother 2024; 30:904-911. [PMID: 38479573 DOI: 10.1016/j.jiac.2024.03.003] [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: 05/30/2023] [Revised: 01/22/2024] [Accepted: 03/02/2024] [Indexed: 03/18/2024]
Abstract
BACKGROUND The use of antibiotic-loaded bone cement (ALBC) as a mean for preventing deep surgical site infections (SSI) after total joint replacement is controversial. Therefore, we have conducted a meta-analysis to evaluate the prophylactic effect of ALBC for SSI prevention in patients undergoing arthroplasty. This study was conducted to revise treatment guidelines for MRSA infections in Japan. METHODS PubMed (Medline), Scopus, Embase, Web of Science and Cochrane library were searched for relevant articles comparing preventive effect of ALBC for patients undergoing primary total joint arthroplasty by August 2022. Primary outcome was the incidence of deep SSI. Subgroup analyses by type of surgery (total hip (THA) or knee (TKA) arthroplasty) and by causative pathogen (methicillin-resistant Staphylococcus aureus (MRSA)) were performed. RESULTS Of the 3379 studies identified for screening, six studies involving 5745 patients were included. The use of ALBC significantly reduced the incidence of deep SSI in overall patients (risk ratio [RR] 0.60, 95% confidential interval [CI] 0.39-0.92), but the evidence level was very low. There was no significant preventive effect for ALBC compared with non-ALBC in both THA and TKA (THA, RR 0.52, 95% CI 0.23-1.16; TKA, RR 0.64, 95% CI 0.38-1.06), and for preventing MRSA-SSI (RR 0.27, 95% CI 0.03-2.41). CONCLUSIONS Although the overall preventive effect of ALBC was significant, the evidence level was very low. Thus, the routine use of ALBC as a mean to prevent SSI in arthroplasty may not be suggested.
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Affiliation(s)
- Hideo Kato
- Department of Pharmacy, Mie University Hospital, Mie, Japan
| | - Yukihiro Hamada
- Department of Pharmacy, Tokyo Women's Medical University, Tokyo, Japan; Department of Pharmacy, Kochi Medical School Hospital, Kochi, Japan.
| | - Shotaro Takano
- Department of Orthopaedic Surgery, School of Medicine, Kitasato University, Kanagawa, Japan
| | - Shinsuke Ikeda
- Department of Orthopaedic Surgery, School of Medicine, Kitasato University, Kanagawa, Japan
| | - Yoshinori Seto
- Department of Pharmacy, Kitasato University Hospital, Kanagawa, Japan
| | | | - Koji Yamada
- Nakanoshima Orthopaedics, Kanagawa, 214-0012, Japan
| | - Katsufumi Uchiyama
- Department of Patient Safety and Healthcare Administration, School of Medicine, Kitasato University Kanagawa, Japan
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Lizcano JD, Fernández-Rodríguez D, Goh GS, DeMik DE, Hughes AJ, Parvizi J, Courtney PM, Purtill JJ, Austin MS. In Vivo Intra-Articular Antibiotic Concentrations at 24 Hours After TKA Fall Below the Minimum Inhibitory Concentration for Most Bacteria: A Randomized Study of Commercially Available Bone Cement. J Bone Joint Surg Am 2024:00004623-990000000-01162. [PMID: 39052763 DOI: 10.2106/jbjs.23.01412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/27/2024]
Abstract
BACKGROUND The use of antibiotic-loaded bone cement (ALBC) to help reduce the risk of infection after primary total knee arthroplasty (TKA) is controversial. There is a paucity of in vivo data on the elution characteristics of ALBC. We aimed to determine whether the antibiotic concentrations of 2 commercially available ALBCs met the minimum inhibitory concentration (MIC) and minimum biofilm eradication concentration (MBEC) for common infecting organisms. METHODS Forty-five patients undergoing TKA were randomized to receive 1 of the following: bone cement without antibiotic (the negative control; n = 5), a commercially available formulation containing 1 g of tobramycin (n = 20), or a commercially available formulation containing 0.5 g of gentamicin (n = 20). Intra-articular drains were placed, and fluid was collected at 4 and 24 hours postoperatively. An automated immunoassay measuring antibiotic concentration was performed, and the results were compared against published MIC and MBEC thresholds. RESULTS The ALBC treatment groups were predominantly of White (65%) or Black (32.5%) race and were 57.5% female and 42.4% male. The mean age (and standard deviation) was 72.6 ± 7.2 years in the gentamicin group and 67.6 ± 7.4 years in the tobramycin group. The mean antibiotic concentration in the tobramycin group was 55.1 ± 37.7 μg/mL at 4 hours and 19.5 ± 13.0 μg/mL at 24 hours, and the mean concentration in the gentamicin group was 38.4 ± 25.4 μg/mL at 4 hours and 17.7 ± 15.4 μg/mL at 24 hours. Time and antibiotic concentration had a negative linear correlation coefficient (r = -0.501). Most of the reference MIC levels were reached at 4 hours. However, at 24 hours, a considerable percentage of patients had concentrations below the MIC for many common pathogens, including Staphylococcus epidermidis (gentamicin: 65% to 100% of patients; tobramycin: 50% to 85%), methicillin-sensitive Staphylococcus aureus (gentamicin: 5% to 90%; tobramycin: 5% to 50%), methicillin-resistant S. aureus (gentamicin: 5% to 65%; tobramycin: 50%), Streptococcus species (gentamicin: 10% to 100%), and Cutibacterium acnes (gentamicin: 10% to 65%; tobramycin: 100%). The aforementioned ranges reflect variation in the MIC among different strains of each organism. Gentamicin concentrations reached MBEC threshold values at 4 hours only for the least virulent strains of S. aureus and Escherichia coli. Tobramycin concentrations did not reach the MBEC threshold for any of the bacteria at either time point. CONCLUSIONS The elution of antibiotics from commercially available ALBC decreased rapidly following TKA, and only at 4 hours postoperatively did the mean antibiotic concentrations exceed the MIC for most of the pathogens. Use of commercially available ALBC may not provide substantial antimicrobial coverage following TKA. LEVEL OF EVIDENCE Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Juan D Lizcano
- Rothman Orthopaedic Institute, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
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Leta TH, Lie SA, Fenstad AM, Lygre SHL, Lindberg-Larsen M, Pedersen AB, W-Dahl A, Rolfson O, Bülow E, van Steenbergen LN, Nelissen RGHH, Harries D, de Steiger R, Lutro O, Mäkelä K, Venäläinen MS, Willis J, Wyatt M, Frampton C, Grimberg A, Steinbrück A, Wu Y, Armaroli C, Gentilini MA, Picus R, Bonetti M, Dragosloveanu S, Vorovenci AE, Dragomirescu D, Dale H, Brand C, Christen B, Shapiro J, Wilkinson JM, Armstrong R, Wooster K, Hallan G, Gjertsen JE, Chang RN, Prentice HA, Sedrakyan A, Paxton EW, Furnes O. Periprosthetic Joint Infection After Total Knee Arthroplasty With or Without Antibiotic Bone Cement. JAMA Netw Open 2024; 7:e2412898. [PMID: 38780939 PMCID: PMC11117087 DOI: 10.1001/jamanetworkopen.2024.12898] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Accepted: 03/20/2024] [Indexed: 05/25/2024] Open
Abstract
Importance Despite increased use of antibiotic-loaded bone cement (ALBC) in joint arthroplasty over recent decades, current evidence for prophylactic use of ALBC to reduce risk of periprosthetic joint infection (PJI) is insufficient. Objective To compare the rate of revision attributed to PJI following primary total knee arthroplasty (TKA) using ALBC vs plain bone cement. Design, Setting, and Participants This international cohort study used data from 14 national or regional joint arthroplasty registries in Australia, Denmark, Finland, Germany, Italy, New Zealand, Norway, Romania, Sweden, Switzerland, the Netherlands, the UK, and the US. The study included primary TKAs for osteoarthritis registered from January 1, 2010, to December 31, 2020, and followed-up until December 31, 2021. Data analysis was performed from April to September 2023. Exposure Primary TKA with ALBC vs plain bone cement. Main Outcomes and Measures The primary outcome was risk of 1-year revision for PJI. Using a distributed data network analysis method, data were harmonized, and a cumulative revision rate was calculated (1 - Kaplan-Meier), and Cox regression analyses were performed within the 10 registries using both cement types. A meta-analysis was then performed to combine all aggregated data and evaluate the risk of 1-year revision for PJI and all causes. Results Among 2 168 924 TKAs included, 93% were performed with ALBC. Most TKAs were performed in female patients (59.5%) and patients aged 65 to 74 years (39.9%), fully cemented (92.2%), and in the 2015 to 2020 period (62.5%). All participating registries reported a cumulative 1-year revision rate for PJI of less than 1% following primary TKA with ALBC (range, 0.21%-0.80%) and with plain bone cement (range, 0.23%-0.70%). The meta-analyses based on adjusted Cox regression for 1 917 190 TKAs showed no statistically significant difference at 1 year in risk of revision for PJI (hazard rate ratio, 1.16; 95% CI, 0.89-1.52) or for all causes (hazard rate ratio, 1.12; 95% CI, 0.89-1.40) among TKAs performed with ALBC vs plain bone cement. Conclusions and Relevance In this study, the risk of revision for PJI was similar between ALBC and plain bone cement following primary TKA. Any additional costs of ALBC and its relative value in reducing revision risk should be considered in the context of the overall health care delivery system.
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Affiliation(s)
- Tesfaye H. Leta
- The Norwegian Arthroplasty Register, Department of Orthopedic Surgery, Haukeland University Hospital, Bergen, Norway
- Faculty of Health Science, VID Specialized University, Oslo, Norway
- Department of Population Health Sciences, Weill Medical College of Cornell University, New York, New York
- Medical Device Surveillance and Assessment, Kaiser Permanente, San Diego, California
| | - Stein Atle Lie
- The Norwegian Arthroplasty Register, Department of Orthopedic Surgery, Haukeland University Hospital, Bergen, Norway
- Center for Translational Oral Research, Department of Dentistry, University of Bergen, Bergen, Norway
| | - Anne Marie Fenstad
- The Norwegian Arthroplasty Register, Department of Orthopedic Surgery, Haukeland University Hospital, Bergen, Norway
| | - Stein Håkon L. Lygre
- The Norwegian Arthroplasty Register, Department of Orthopedic Surgery, Haukeland University Hospital, Bergen, Norway
- Department of Occupational Medicine, Haukeland University Hospital, Bergen, Norway
| | - Martin Lindberg-Larsen
- The Danish Knee Arthroplasty Register, Odense, Denmark
- Department of Orthopaedic Surgery and Traumatology, Odense University Hospital, Odense, Denmark
| | - Alma B. Pedersen
- The Danish Knee Arthroplasty Register, Odense, Denmark
- Department of Clinical Epidemiology, Aarhus University Hospital and Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Annette W-Dahl
- The Swedish Arthroplasty Register, Gothenburg, Sweden
- Department of Clinical Sciences Lund, Orthopedics, Lund University, Lund, Sweden
| | - Ola Rolfson
- The Swedish Arthroplasty Register, Gothenburg, Sweden
- Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Erik Bülow
- Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Centre of Registers Västra Götaland, Gothenburg, Sweden
| | | | - Rob G. H. H. Nelissen
- The Dutch Arthroplasty Register, ‘s-Hertogenbosch, the Netherlands
- Department Orthopaedics, Leiden University Medical Center, Leiden, the Netherlands
| | - Dylan Harries
- South Australian Health and Medical Research Institute, Adelaide, Australia
| | - Richard de Steiger
- The Australian Orthopaedic Association National Joint Replacement Registry, Adelaide, Australia
| | - Olav Lutro
- Department of Medicine, Stavanger University Hospital, Stavanger, Norway
| | - Keijo Mäkelä
- The Finnish Arthroplasty Register, Helsinki, Finland
- Turku University Hospital and University of Turku, Turku, Finland
| | | | - Jinny Willis
- The New Zealand Joint Registry, Christchurch, New Zealand
| | - Michael Wyatt
- The New Zealand Joint Registry, Christchurch, New Zealand
| | - Chris Frampton
- The New Zealand Joint Registry, Christchurch, New Zealand
| | | | | | - Yinan Wu
- German Arthroplasty Registry, Berlin, Germany
| | - Cristiana Armaroli
- Arthroplasty Registry of the Autonomous Province of Trento, Clinical Epidemiology Service, Provincial Agency for Health Services of Trento, Trento, Italy
| | - Maria Adalgisa Gentilini
- Arthroplasty Registry of the Autonomous Province of Trento, Clinical Epidemiology Service, Provincial Agency for Health Services of Trento, Trento, Italy
| | - Roberto Picus
- Arthroplasty Register of Autonomous Province of Bolzano, Observatory of Health, Health Department AP of Bolzano, Bolzano, Italy
| | - Mirko Bonetti
- Arthroplasty Register of Autonomous Province of Bolzano, Observatory of Health, Health Department AP of Bolzano, Bolzano, Italy
| | - Serban Dragosloveanu
- Romanian Arthroplasty Registry, Bucharest, Romania
- University of Medicine and Pharmacy–Carol Davila, Bucharest, Romania
- Foisor Orthopaedic Hospital, Bucharest, Romania
| | - Andreea E. Vorovenci
- Romanian Arthroplasty Registry, Bucharest, Romania
- Economic Cybernetics and Statistics Doctoral School, Bucharest University of Economic Studies, Bucharest, Romania
| | - Dan Dragomirescu
- Romanian Arthroplasty Registry, Bucharest, Romania
- Economic Cybernetics and Statistics Doctoral School, Bucharest University of Economic Studies, Bucharest, Romania
| | - Håvard Dale
- The Norwegian Arthroplasty Register, Department of Orthopedic Surgery, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, Faculty of Medicine, University of Bergen, Bergen, Norway
| | - Christian Brand
- Swiss National Hip and Knee Joint Registry, Bern, Switzerland
- Institute of Social and Preventive Medicine, SwissRDL, University of Bern, Bern, Switzerland
| | - Bernhard Christen
- Swiss National Hip and Knee Joint Registry, Bern, Switzerland
- Articon, Bern, Switzerland
| | - Joanne Shapiro
- The National Joint Registry for England, Wales, Northern Ireland, The Isle of Man and Guernsey, London, United Kingdom
- NEC Software Solutions, Hemel Hempstead, United Kingdom
| | - J. Mark Wilkinson
- The National Joint Registry for England, Wales, Northern Ireland, The Isle of Man and Guernsey, London, United Kingdom
- Division of Clinical Medicine, School of Medicine and Population Health, University of Sheffield, Sheffield, United Kingdom
| | - Richard Armstrong
- The National Joint Registry for England, Wales, Northern Ireland, The Isle of Man and Guernsey, London, United Kingdom
- NEC Software Solutions, Hemel Hempstead, United Kingdom
| | - Kate Wooster
- The National Joint Registry for England, Wales, Northern Ireland, The Isle of Man and Guernsey, London, United Kingdom
- NEC Software Solutions, Hemel Hempstead, United Kingdom
| | - Geir Hallan
- The Norwegian Arthroplasty Register, Department of Orthopedic Surgery, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, Faculty of Medicine, University of Bergen, Bergen, Norway
| | - Jan-Erik Gjertsen
- The Norwegian Arthroplasty Register, Department of Orthopedic Surgery, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, Faculty of Medicine, University of Bergen, Bergen, Norway
| | - Richard N. Chang
- Medical Device Surveillance and Assessment, Kaiser Permanente, San Diego, California
| | - Heather A. Prentice
- Medical Device Surveillance and Assessment, Kaiser Permanente, San Diego, California
| | - Art Sedrakyan
- Department of Population Health Sciences, Weill Medical College of Cornell University, New York, New York
| | - Elizabeth W. Paxton
- Medical Device Surveillance and Assessment, Kaiser Permanente, San Diego, California
| | - Ove Furnes
- The Norwegian Arthroplasty Register, Department of Orthopedic Surgery, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, Faculty of Medicine, University of Bergen, Bergen, Norway
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Cieremans D, Muthusamy N, Singh V, Rozell JC, Aggarwal V, Schwarzkopf R. Does antibiotic bone cement reduce infection rates in primary total knee arthroplasty? EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2023; 33:3379-3385. [PMID: 37133753 DOI: 10.1007/s00590-023-03557-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Accepted: 04/23/2023] [Indexed: 05/04/2023]
Abstract
INTRODUCTION Infection after total knee arthroplasty (TKA) impacts the patient, surgeon, and healthcare system significantly. Surgeons routinely use antibiotic-loaded bone cement (ALBC) in attempts to mitigate infection; however, little evidence supports the efficacy of ALBC in reducing infection rates compared to non-antibiotic-loaded bone cement (non-ALBC) in primary TKA. Our study compares infection rates of patients undergoing TKA with ALBC to those with non-ALBC to assess its efficacy in primary TKA. METHODS A retrospective review of all primary, elective, cemented TKA patients over the age of 18 between 2011 and 2020 was conducted at an orthopedic specialty hospital. Patients were stratified into two cohorts based on cement type: ALBC (loaded with gentamicin or tobramycin) or non-ALBC. Baseline characteristics and infection rates determined by MSIS criteria were collected. Multilinear and multivariate logistic regressions were performed to limit significant differences in demographics. Independent samples t test and chi-squared test were used to compare means and proportions, respectively, between the two cohorts. RESULTS In total, 9366 patients were included in this study, 7980 (85.2%) of whom received non-ALBC and 1386 (14.8%) of whom received ALBC. There were significant differences in five of the six demographic variables analyzed; patients with higher Body Mass Index (33.40 ± 6.27 vs. 32.09 ± 6.21; kg/m2) and Charlson Comorbidity Index values (4.51 ± 2.15 vs. 4.04 ± 1.92) were more likely to receive ALBC. The infection rate in the non-ALBC was 0.8% (63/7,980), while the rate in the ALBC was 0.5% (7/1,386). After adjusting for confounders, the difference in rates was not significant between the two groups (OR [95% CI]: 1.53 [0.69-3.38], p = 0.298). Furthermore, a sub-analysis comparing the infection rates within various demographic categories also showed no significant differences between the two groups. CONCLUSION Compared to non-ALBC, the overall infection rate in primary TKA was slightly lower when using ALBC; however, the difference was not statistically significant. When stratifying by comorbidity, use of ALBC still showed no statistical significance in reducing the risk of periprosthetic joint infection. Therefore, the advantage of antibiotics in bone cement to prevent infection in primary TKA is not yet elucidated. Further prospective, multicenter studies regarding the clinical benefits of antibiotic use in bone cement for primary TKA are warranted.
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Affiliation(s)
- David Cieremans
- Division of Adult Reconstruction, Department of Orthopedic Surgery, NYU Langone Health, New York University, Langone Orthopedic Hospital, 301 East 17th Street, New York, NY, 10003, USA
| | - Nishanth Muthusamy
- Division of Adult Reconstruction, Department of Orthopedic Surgery, NYU Langone Health, New York University, Langone Orthopedic Hospital, 301 East 17th Street, New York, NY, 10003, USA
| | - Vivek Singh
- Division of Adult Reconstruction, Department of Orthopedic Surgery, NYU Langone Health, New York University, Langone Orthopedic Hospital, 301 East 17th Street, New York, NY, 10003, USA
| | - Joshua C Rozell
- Division of Adult Reconstruction, Department of Orthopedic Surgery, NYU Langone Health, New York University, Langone Orthopedic Hospital, 301 East 17th Street, New York, NY, 10003, USA
| | - Vinay Aggarwal
- Division of Adult Reconstruction, Department of Orthopedic Surgery, NYU Langone Health, New York University, Langone Orthopedic Hospital, 301 East 17th Street, New York, NY, 10003, USA
| | - Ran Schwarzkopf
- Division of Adult Reconstruction, Department of Orthopedic Surgery, NYU Langone Health, New York University, Langone Orthopedic Hospital, 301 East 17th Street, New York, NY, 10003, USA.
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5
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Blom AW, Beswick AD, Burston A, Carroll FE, Garfield K, Gooberman-Hill R, Harris S, Kunutsor SK, Lane A, Lenguerrand E, MacGowan A, Mallon C, Moore AJ, Noble S, Palmer CK, Rolfson O, Strange S, Whitehouse MR. Infection after total joint replacement of the hip and knee: research programme including the INFORM RCT. PROGRAMME GRANTS FOR APPLIED RESEARCH 2022. [DOI: 10.3310/hdwl9760] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Background
People with severe osteoarthritis, other joint conditions or injury may have joint replacement to reduce pain and disability. In the UK in 2019, over 200,000 hip and knee replacements were performed. About 1 in 100 replacements becomes infected, and most people with infected replacements require further surgery.
Objectives
To investigate why some patients are predisposed to joint infections and how this affects patients and the NHS, and to evaluate treatments.
Design
Systematic reviews, joint registry analyses, qualitative interviews, a randomised controlled trial, health economic analyses and a discrete choice questionnaire.
Setting
Our studies are relevant to the NHS, to the Swedish health system and internationally.
Participants
People with prosthetic joint infection after hip or knee replacement and surgeons.
Interventions
Revision of hip prosthetic joint infection with a single- or two-stage procedure.
Main outcome measures
Long-term patient-reported outcomes and reinfection. Cost-effectiveness of revision strategies over 18 months from two perspectives: health-care provider and Personal Social Services, and societal.
Data sources
National Joint Registry; literature databases; published cohort studies; interviews with 67 patients and 35 surgeons; a patient discrete choice questionnaire; and the INFORM (INFection ORthopaedic Management) randomised trial.
Review methods
Systematic reviews of studies reporting risk factors, diagnosis, treatment outcomes and cost comparisons. Individual patient data meta-analysis.
Results
In registry analyses, about 0.62% and 0.75% of patients with hip and knee replacement, respectively, had joint infection requiring surgery. Rates were four times greater after aseptic revision. The costs of inpatient and day-case admissions in people with hip prosthetic joint infection were about five times higher than those in people with no infection, an additional cost of > £30,000. People described devastating effects of hip and knee prosthetic joint infection and treatment. In the treatment of hip prosthetic joint infection, a two-stage procedure with or without a cement spacer had a greater negative impact on patient well-being than a single- or two-stage procedure with a custom-made articulating spacer. Surgeons described the significant emotional impact of hip and knee prosthetic joint infection and the importance of a supportive multidisciplinary team. In systematic reviews and registry analyses, the risk factors for hip and knee prosthetic joint infection included male sex, diagnoses other than osteoarthritis, high body mass index, poor physical status, diabetes, dementia and liver disease. Evidence linking health-care setting and surgeon experience with prosthetic joint infection was inconsistent. Uncemented fixation, posterior approach and ceramic bearings were associated with lower infection risk after hip replacement. In our systematic review, synovial fluid alpha-defensin and leucocyte esterase showed high diagnostic accuracy for prosthetic joint infection. Systematic reviews and individual patient data meta-analysis showed similar reinfection outcomes in patients with hip or knee prosthetic joint infection treated with single- and two-stage revision. In registry analysis, there was a higher rate of early rerevision after single-stage revision for hip prosthetic joint infection, but, overall, 40% fewer operations are required as part of a single-stage procedure than as part of a two-stage procedure. The treatment of hip or knee prosthetic joint infection with early debridement and implant retention may be effective in > 60% of cases. In the INFORM randomised controlled trial, 140 patients with hip prosthetic joint infection were randomised to single- or two-stage revision. Eighteen months after randomisation, pain, function and stiffness were similar between the randomised groups (p = 0.98), and there were no differences in reinfection rates. Patient outcomes improved earlier in the single-stage than in the two-stage group. Participants randomised to a single-stage procedure had lower costs (mean difference –£10,055, 95% confidence interval –£19,568 to –£542) and higher quality-adjusted life-years (mean difference 0.06, 95% confidence interval –0.07 to 0.18) than those randomised to a two-stage procedure. Single-stage was the more cost-effective option, with an incremental net monetary benefit at a threshold of £20,000 per quality-adjusted life-year of £11,167 (95% confidence interval £638 to £21,696). In a discrete choice questionnaire completed by 57 patients 18 months after surgery to treat hip prosthetic joint infection, the most valued characteristics in decisions about revision were the ability to engage in valued activities and a quick return to normal activity.
Limitations
Some research was specific to people with hip prosthetic joint infection. Study populations in meta-analyses and registry analyses may have been selected for joint replacement and specific treatments. The INFORM trial was not powered to study reinfection and was limited to 18 months’ follow-up. The qualitative study subgroups were small.
Conclusions
We identified risk factors, diagnostic biomarkers, effective treatments and patient preferences for the treatment of hip and knee prosthetic joint infection. The risk factors include male sex, diagnoses other than osteoarthritis, specific comorbidities and surgical factors. Synovial fluid alpha-defensin and leucocyte esterase showed high diagnostic accuracy. Infection is devastating for patients and surgeons, both of whom describe the need for support during treatment. Debridement and implant retention is effective, particularly if performed early. For infected hip replacements, single- and two-stage revision appear equally efficacious, but single-stage has better early results, is cost-effective at 18-month follow-up and is increasingly used. Patients prefer treatments that allow full functional return within 3–9 months.
Future work
For people with infection, develop information, counselling, peer support and care pathways. Develop supportive care and information for patients and health-care professionals to enable the early recognition of infections. Compare alternative and new treatment strategies in hip and knee prosthetic joint infection. Assess diagnostic methods and establish NHS diagnostic criteria.
Study registration
The INFORM randomised controlled trial is registered as ISRCTN10956306. All systematic reviews were registered in PROSPERO (as CRD42017069526, CRD42015023485, CRD42018106503, CRD42018114592, CRD42015023704, CRD42017057513, CRD42015016559, CRD42015017327 and CRD42015016664).
Funding
This project was funded by the National Institute for Health and Care Research (NIHR) Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 10, No. 10. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Ashley W Blom
- National Institute for Health and Care Research Bristol Biomedical Research Centre, University Hospitals Bristol and Weston NHS Foundation Trust and University of Bristol, Bristol, UK
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Andrew D Beswick
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Amanda Burston
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Fran E Carroll
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Kirsty Garfield
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- Bristol Randomised Trials Collaboration, University of Bristol, Bristol, UK
| | - Rachael Gooberman-Hill
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Shaun Harris
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- Bristol Randomised Trials Collaboration, University of Bristol, Bristol, UK
| | - Setor K Kunutsor
- National Institute for Health and Care Research Bristol Biomedical Research Centre, University Hospitals Bristol and Weston NHS Foundation Trust and University of Bristol, Bristol, UK
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Athene Lane
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- Bristol Randomised Trials Collaboration, University of Bristol, Bristol, UK
| | - Erik Lenguerrand
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | | | - Charlotte Mallon
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Andrew J Moore
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Sian Noble
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Cecily K Palmer
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- National Institute for Health and Care Research Applied Research Collaboration West (NIHR ARC West), University Hospitals Bristol NHS Foundation Trust and University of Bristol, Bristol, UK
| | - Ola Rolfson
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Simon Strange
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Michael R Whitehouse
- National Institute for Health and Care Research Bristol Biomedical Research Centre, University Hospitals Bristol and Weston NHS Foundation Trust and University of Bristol, Bristol, UK
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
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Small I, Meghpara M, Stein J, Goh GS, Banerjee S, Courtney PM. Intermediate-Term Survivorship of Metaphyseal Cones and Sleeves in Revision Total Knee Arthroplasty. J Arthroplasty 2022; 37:1839-1843. [PMID: 35398228 DOI: 10.1016/j.arth.2022.03.085] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2021] [Revised: 03/22/2022] [Accepted: 03/31/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Both cones or sleeves have been developed to address metaphyseal bone loss in revision total knee arthroplasty (TKA), but few studies have directly compared the outcomes. The purpose of this study was to compare the survivorship and aseptic revision rates between metaphyseal cones and sleeves at intermediate follow-up. METHODS We reviewed a consecutive series of 1,172 revision TKA patients between 2009 and 2018 with a minimum two-year follow-up on all patients. We compared demographics, surgical indication, stem fixation, constraint, rates of rerevision, and Short-Form-12 scores between patients with cones and sleeves. A multivariate analysis was performed to identify the effect of cones and sleeves on aseptic rerevision. Kaplan-Meier curves were generated to compare aseptic survivorship of cones and sleeves. RESULTS There were 194 tibial cones (17%), 107 tibial sleeves (9%), 31 femoral cones (3%), and 135 femoral sleeves (12%) with a mean follow-up of 6.5 years (range: 2-12 years). There was no difference in demographics, indication, stem fixation, or constraint (P > .05). Although overall aseptic failure rates may be lower for tibial sleeves, there were no significant differences in survivorship over a one-year, two-year, and five-year follow-up when both tibial and femoral sleeves were directly compared to cones. CONCLUSION Both tibial and femoral sleeves and cones perform well at an intermediate-term follow-up. Further investigation of these two are required to better understand their survivorship relative to each other.
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Affiliation(s)
- Ilan Small
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Michael Meghpara
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Jonah Stein
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Graham S Goh
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Samik Banerjee
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - P Maxwell Courtney
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
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7
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Schwarz EM, McLaren AC, Sculco TP, Brause B, Bostrom M, Kates SL, Parvizi J, Alt V, Arnold WV, Carli A, Chen AF, Choe H, Coraça‐Huber DC, Cross M, Ghert M, Hickok N, Jennings JA, Joshi M, Metsemakers W, Ninomiya M, Nishitani K, Oh I, Padgett D, Ricciardi B, Saeed K, Sendi P, Springer B, Stoodley P, Wenke JC. Adjuvant antibiotic-loaded bone cement: Concerns with current use and research to make it work. J Orthop Res 2021; 39:227-239. [PMID: 31997412 PMCID: PMC7390691 DOI: 10.1002/jor.24616] [Citation(s) in RCA: 57] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Revised: 01/07/2020] [Accepted: 01/13/2020] [Indexed: 02/04/2023]
Abstract
Antibiotic-loaded bone cement (ALBC) is broadly used to treat orthopaedic infections based on the rationale that high-dose local delivery is essential to eradicate biofilm-associated bacteria. However, ALBC formulations are empirically based on drug susceptibility from routine laboratory testing, which is known to have limited clinical relevance for biofilms. There are also dosing concerns with nonstandardized, surgeon-directed, hand-mixed formulations, which have unknown release kinetics. On the basis of our knowledge of in vivo biofilms, pathogen virulence, safety issues with nonstandardized ALBC formulations, and questions about the cost-effectiveness of ALBC, there is a need to evaluate the evidence for this clinical practice. To this end, thought leaders in the field of musculoskeletal infection (MSKI) met on 1 August 2019 to review and debate published and anecdotal information, which highlighted four major concerns about current ALBC use: (a) substantial lack of level 1 evidence to demonstrate efficacy; (b) ALBC formulations become subtherapeutic following early release, which risks induction of antibiotic resistance, and exacerbated infection from microbial colonization of the carrier; (c) the absence of standardized formulation protocols, and Food and Drug Administration-approved high-dose ALBC products to use following resection in MSKI treatment; and (d) absence of a validated assay to determine the minimum biofilm eradication concentration to predict ALBC efficacy against patient specific micro-organisms. Here, we describe these concerns in detail, and propose areas in need of research.
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Affiliation(s)
- Edward M. Schwarz
- Department of Orthopaedics, Center for Musculoskeletal Research University of Rochester Rochester New York
| | - Alex C. McLaren
- Department of Orthopaedic Surgery, College of Medicine‐Phoenix University of Arizona Phoenix Arizona
| | - Thomas P. Sculco
- Department of Orthopaedic Surgery, Weill Cornell Medicine Hospital for Special Surgery New York New York
| | - Barry Brause
- Department of Infectious Diseases, Weill Cornell Medicine Hospital for Special Surgery New York New York
| | - Mathias Bostrom
- Department of Orthopaedic Surgery, Weill Cornell Medicine Hospital for Special Surgery New York New York
| | - Stephen L. Kates
- Department of Orthopaedic Surgery Virginia Commonwealth University Richmond Virginia
| | - Javad Parvizi
- Department of Orthopaedics Rothman Institute at Thomas Jefferson University Hospital Philadelphia Pennsylvania
| | - Volker Alt
- Department of Trauma Surgery University Medical Centre Regensburg Regensburg Germany
| | - William V. Arnold
- Department of Orthopaedics Rothman Institute at Thomas Jefferson University Hospital Philadelphia Pennsylvania
| | - Alberto Carli
- Department of Orthopaedic Surgery, Weill Cornell Medicine Hospital for Special Surgery New York New York
| | - Antonia F. Chen
- Department of Orthopaedics, Brigham and Women's Hospital Harvard Medical School Boston Massachusetts
| | - Hyonmin Choe
- Department of Orthopaedic Yokohama City University Yokohama Japan
| | - Débora C. Coraça‐Huber
- Department of Orthopaedic Surgery, Experimental Orthopedics, Research Laboratory for Biofilms and Implant Associated Infections Medical University of Innsbruck Innsbruck Austria
| | - Michael Cross
- Department of Orthopaedic Surgery, Weill Cornell Medicine Hospital for Special Surgery New York New York
| | - Michelle Ghert
- Division of Orthopaedic Surgery, Department of Surgery McMaster University Hamilton Ontario Canada
| | - Noreen Hickok
- Department of Orthopaedic Surgery, Department of Biochemistry & Molecular Biology Thomas Jefferson University Philadelphia Pennsylvania
| | | | - Manjari Joshi
- Division of Infectious Diseases, R Adams Cowley Shock Trauma Center University of Maryland Baltimore Maryland
| | | | - Mark Ninomiya
- Department of Orthopaedics, Center for Musculoskeletal Research University of Rochester Rochester New York
| | - Kohei Nishitani
- Department of Orthopaedic Surgery Graduate School of Medicine, Kyoto University Sakyo Kyoto Japan
| | - Irvin Oh
- Department of Orthopaedics, Center for Musculoskeletal Research University of Rochester Rochester New York
| | - Douglas Padgett
- Department of Orthopaedic Surgery, Weill Cornell Medicine Hospital for Special Surgery New York New York
| | - Benjamin Ricciardi
- Department of Orthopaedics, Center for Musculoskeletal Research University of Rochester Rochester New York
| | - Kordo Saeed
- Southampton University Hospitals NHS Foundation Trust, Department of Microbiology, Microbiology and Innovation Research Unit (MIRU) and University of Southampton, School of Medicine Southampton UK
| | - Parham Sendi
- Institute for Infectious Diseases University of Bern, Bern and Department of Infectious Diseases, Hospital Epidemiology and Department of Orthopaedics and Traumatology, University of Basel Basel Switzerland
- Department of Orthopaedics and Traumatology University Hospital Basel Basel Switzerland
| | - Bryan Springer
- Department of Orthopaedic Surgery, OrthoCarolina Hip and Knee Center Atrium Musculoskeletal Institute Charlotte North Carolina
| | - Paul Stoodley
- Department of Microbial Infection and Immunity and Orthopaedics The Ohio State University Columbus Ohio
| | - Joseph C. Wenke
- Orthopaedic Trauma Department U.S. Army Institute of Surgical Research Fort Sam Houston Texas
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8
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Farhan-Alanie MM, Burnand HG, Whitehouse MR. The effect of antibiotic-loaded bone cement on risk of revision following hip and knee arthroplasty. Bone Joint J 2021; 103-B:7-15. [PMID: 33380204 DOI: 10.1302/0301-620x.103b1.bjj-2020-0391.r1] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
AIMS This study aimed to compare the effect of antibiotic-loaded bone cement (ALBC) versus plain bone cement (PBC) on revision rates for periprosthetic joint infection (PJI) and all-cause revisions following primary elective total hip arthroplasty (THA) and total knee arthroplasty (TKA). METHODS MEDLINE, Embase, Web of Science, and Cochrane databases were systematically searched for studies comparing ALBC versus PBC, reporting on revision rates for PJI or all-cause revision following primary elective THA or TKA. A random-effects meta-analysis was performed. The study was registered in the International Prospective Register of Systematic Reviews (PROSPERO ID CRD42018107691). RESULTS Nine studies and one registry report were identified, enabling the inclusion of 371,977 THA and 671,246 TKA. Pooled analysis for THA demonstrated ALBC was protective against revision for PJI compared with PBC (relative risk (RR) 0.66, 95% confidence interval (CI) 0.56 to 0.77; p < 0.001), however, no differences were seen for all-cause revision rate (RR 0.62, 95% CI 0.35 to 1.09; p = 0.100). For TKA, there were no significant differences in revision rates for PJI or all causes between ALBC and PBC (RR 0.92, 95% CI 0.59 to 1.45; p = 0.730, and RR 0.73, 95% CI 0.53 to 1.02; p = 0.060, respectively). CONCLUSION ALBC demonstrated a protective effect against revision for PJI compared with PBC in THA with no difference in all-cause revisions. No differences in revision rates for PJI and all-cause revision between ALBC and PBC for TKA were observed. Cite this article: Bone Joint J 2021;103-B(1):7-15.
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Affiliation(s)
- Muhamed M Farhan-Alanie
- Medical School, University of Warwick, Coventry, UK.,Trauma & Orthopaedics, University Hospital Coventry & Warwickshire, Coventry, UK
| | - Henry G Burnand
- University of Bristol, Learning & Research Centre, Bristol, UK
| | - Michael R Whitehouse
- National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol, Bristol, UK
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9
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Cara A, Ballet M, Hemery C, Ferry T, Laurent F, Josse J. Antibiotics in Bone Cements Used for Prosthesis Fixation: An Efficient Way to Prevent Staphylococcus aureus and Staphylococcus epidermidis Prosthetic Joint Infection. Front Med (Lausanne) 2021; 7:576231. [PMID: 33553196 PMCID: PMC7856860 DOI: 10.3389/fmed.2020.576231] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Accepted: 11/30/2020] [Indexed: 12/18/2022] Open
Abstract
Prosthetic joint infections (PJIs) are one of the most frequent reasons for arthroplasty revision. These infections are mostly associated with the formation of biofilm, notably by staphylococci, such as Staphylococcus aureus and Staphylococcus epidermidis. To minimize the rates of PJIs following primary or revision total joint arthroplasty, antibiotic-loaded bone cements (ALBCs) can be used for prosthesis fixation. However, its use is still debated. Indeed, various studies reported opposite results. In this context, we aimed to compare the prophylactic anti-biofilm activity of ALBCs loaded with two antibiotics with ALBC loaded with only one antibiotic. We compared commercial ready-to-use cements containing gentamicin alone, gentamicin plus vancomycin, and gentamicin plus clindamycin to plain cement (no antibiotic), investigating staphylococcal biofilm formation for 10 strains of S. aureus and S. epidermidis with specific resistance to gentamicin, vancomycin, or clindamycin. Firstly, we performed disk diffusion assays with the elution solutions. We reported that only the cement containing gentamicin and clindamycin was able to inhibit bacterial growth at Day 9, whereas cements with gentamicin only or gentamicin and vancomycin lost their antibacterial activity at Day 3. Then, we observed that all the tested ALBCs can inhibit biofilm formation by methicillin-susceptible staphylococci without other antibiotic resistance ability. Similar results were observed when we tested vancomycin-resistant or clindamycin-resistant staphylococci, with some strain-dependent significant increase of efficacy for the two antibiotic ALBCs when compared with gentamicin-loaded cement. However, adding vancomycin or clindamycin to gentamicin allows a better inhibition of biofilm formation when gentamicin-resistant strains were used. Our in vitro results suggest that using commercially available bone cements loaded with gentamicin plus vancomycin or clindamycin for prosthesis fixation can help in preventing staphylococcal PJIs following primary arthroplasties, non-septic revisions or septic revisions, especially to prevent PJIs caused by gentamicin-resistant staphylococci.
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Affiliation(s)
- Andréa Cara
- Centre International de Recherche en Infectiologie, CIRI, Inserm U1111, CNRS UMR5308, ENS de Lyon, UCBL1, Lyon, France
| | - Mathilde Ballet
- Centre International de Recherche en Infectiologie, CIRI, Inserm U1111, CNRS UMR5308, ENS de Lyon, UCBL1, Lyon, France.,Laboratoire de Bactériologie, Institut des Agents Infectieux, Hôpital de la Croix-Rousse, Hospices Civils de Lyon, Lyon, France
| | - Claire Hemery
- Centre International de Recherche en Infectiologie, CIRI, Inserm U1111, CNRS UMR5308, ENS de Lyon, UCBL1, Lyon, France
| | - Tristan Ferry
- Centre International de Recherche en Infectiologie, CIRI, Inserm U1111, CNRS UMR5308, ENS de Lyon, UCBL1, Lyon, France.,Université Claude Bernard Lyon 1, Lyon, France.,Service de Maladies Infectieuses, Hôpital de la Croix-Rousse, Hospices Civils de Lyon, Lyon, France.,Centre Interrégional de Référence des Infections Ostéo-Articulaires complexes (CRIOAc Lyon), Hospices Civils de Lyon, Lyon, France
| | - Frédéric Laurent
- Centre International de Recherche en Infectiologie, CIRI, Inserm U1111, CNRS UMR5308, ENS de Lyon, UCBL1, Lyon, France.,Laboratoire de Bactériologie, Institut des Agents Infectieux, Hôpital de la Croix-Rousse, Hospices Civils de Lyon, Lyon, France.,Université Claude Bernard Lyon 1, Lyon, France.,Centre Interrégional de Référence des Infections Ostéo-Articulaires complexes (CRIOAc Lyon), Hospices Civils de Lyon, Lyon, France
| | - Jérôme Josse
- Centre International de Recherche en Infectiologie, CIRI, Inserm U1111, CNRS UMR5308, ENS de Lyon, UCBL1, Lyon, France.,Université Claude Bernard Lyon 1, Lyon, France.,Centre Interrégional de Référence des Infections Ostéo-Articulaires complexes (CRIOAc Lyon), Hospices Civils de Lyon, Lyon, France
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10
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Xu YM, Peng HM, Feng B, Weng XS. Progress of antibiotic-loaded bone cement in joint arthroplasty. Chin Med J (Engl) 2020; 133:2486-2494. [PMID: 32960839 PMCID: PMC7575178 DOI: 10.1097/cm9.0000000000001093] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Indexed: 11/26/2022] Open
Abstract
Bone cement, consisting of polymethyl methacrylate, is a bioinert material used for prothesis fixation in joint arthroplasty. To treat orthopedic infections, such as periprosthetic joint infection, antibiotic-loaded bone cement (ALBC) was introduced into clinical practice. Recent studies have revealed the limitations of the antibacterial effect of ALBC. Moreover, with the increase in high infection risk patients and highly resistant microbes, more researches and modification of ALBC are required. This paper reviewed latest findings about ALBC for most popular and destructive pathogens, summarized the influence of antibiotic kind, drug dosage, application method, and environment towards characteristic of ALBC. Subsequently, new cement additives and clinical applications of ALBC in joint arthroplasty were also discussed.
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Affiliation(s)
- Yi-Ming Xu
- Department of Orthopedics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100730, China
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11
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Prevention of Prosthetic Joint Infection: From Traditional Approaches towards Quality Improvement and Data Mining. J Clin Med 2020; 9:jcm9072190. [PMID: 32664491 PMCID: PMC7408657 DOI: 10.3390/jcm9072190] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Revised: 07/08/2020] [Accepted: 07/09/2020] [Indexed: 02/06/2023] Open
Abstract
A projected increased use of total joint arthroplasties will naturally result in a related increase in the number of prosthetic joint infections (PJIs). Suppression of the local peri-implant immune response counters efforts to eradicate bacteria, allowing the formation of biofilms and compromising preventive measures taken in the operating room. For these reasons, the prevention of PJI should focus concurrently on the following targets: (i) identifying at-risk patients; (ii) reducing “bacterial load” perioperatively; (iii) creating an antibacterial/antibiofilm environment at the site of surgery; and (iv) stimulating the local immune response. Despite considerable recent progress made in experimental and clinical research, a large discrepancy persists between proposed and clinically implemented preventative strategies. The ultimate anti-infective strategy lies in an optimal combination of all preventative approaches into a single “clinical pack”, applied rigorously in all settings involving prosthetic joint implantation. In addition, “anti-infective” implants might be a choice in patients who have an increased risk for PJI. However, further progress in the prevention of PJI is not imaginable without a close commitment to using quality improvement tools in combination with continual data mining, reflecting the efficacy of the preventative strategy in a particular clinical setting.
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12
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Li C, Ojeda-Thies C, Xu C, Trampuz A. Meta-analysis in periprosthetic joint infection: a global bibliometric analysis. J Orthop Surg Res 2020; 15:251. [PMID: 32650802 PMCID: PMC7350679 DOI: 10.1186/s13018-020-01757-9] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Accepted: 06/16/2020] [Indexed: 02/07/2023] Open
Abstract
Background Periprosthetic joint infection (PJI) is the most serious complication of joint replacement surgery. Further comorbidities include bedsore, deep vein thrombosis, reinfection, or even death. An increasing number of researchers are focusing on this challenging complication. The aim of the present study was to estimate global PJI research based on bibliometrics from meta-analysis studies. Methods A database search was performed in PubMed, Scopus, and Web of Science. Relevant studies were assessed using the bibliometric analysis. Results A total of 117 articles were included. The most relevant literature on PJI was found on Scopus. China made the highest contributions to global research, followed by the USA and the UK. The institution with the most contributions was the University of Bristol. The journal with the highest number of publications was The Journal of Arthroplasty, whereas the Journal of Clinical Medicine had the shortest acceptance time. Furthermore, the top three frequently used databases were Embase, MEDLINE, and Cochrane. The most frequent number of authors in meta-analysis studies was four. Most studies focused on the periprosthetic hip and knee. The alpha-defensin diagnostic test, preventive measures on antibiotics use, and risk factors of intra-articular steroid injections were the most popular topic in recent years. Conclusion Based on the results of the present study, we found that there was no single database that covered all relevant articles; the optimal method for bibliometric analysis is a combination of databases. The most popular research topics on PJI focused on alpha-defensin, antibiotic use, risk factors of intra-articular steroid injections, and the location of prosthetic hip and knee infection.
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Affiliation(s)
- Cheng Li
- Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Center for Musculoskeletal Surgery (CMSC), Charitéplatz 1, D-10117, Berlin, Germany
| | | | - Chi Xu
- Department of Orthopaedic Surgery, General Hospital of People's Liberation Army, Beijing, People's Republic of China
| | - Andrej Trampuz
- Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Center for Musculoskeletal Surgery (CMSC), Charitéplatz 1, D-10117, Berlin, Germany.
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13
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Onggo J, Onggo J, Phan K, Wilson C. Comparison of infection in cemented, cementless and hybrid primary total knee arthroplasty: a network meta-analysis and systematic review of randomized clinical trials. ANZ J Surg 2020; 90:1289-1298. [PMID: 32594649 DOI: 10.1111/ans.16078] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Revised: 04/11/2020] [Accepted: 05/14/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Prosthetic joint infection (PJI) is a serious complication of joint replacement surgeries. Surgeons often take extra measures to reduce the risk of PJI. Whilst many studies have compared between cemented, cementless and hybrid fixation (femoral cementless, tibial cemented), most focus on survivorship, clinical and function outcome scores as primary endpoints. This meta-analysis aims to study the association between fixation methods and risk of PJI in primary total knee arthroplasty (TKA). METHODS A systematic review and network meta-analysis of randomized controlled trials (RCT) were performed according to Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines. Data from studies assessing prevalence of PJI in each fixation type were extracted and analysed. RESULTS Twelve RCT comprising a total of 1573 knees were included. Six RCT compared between cemented (n = 486 knees) and cementless (n = 440 knees) fixation, while six RCT compared between hybrid (n = 324 knees) and cementless (n = 323 knees) fixation. Network meta-analysis did not reveal any fixation type that significantly increased the infection rate in TKA. Rate of all infection was lowest in cemented TKA as compared to cementless (odds ratio (OR) 0.90, 95% confidence interval (CI) 0.35-2.28) and hybrid (OR 0.63, 95%CI 0.13-2.99) TKA. Rate of PJI requiring revision surgery was lowest in cementless TKA as compared to cemented (OR 0.89, 95%CI 0.30-2.41) and hybrid (OR 0.57, 95%CI 0.09-2.71) TKA. Rate of PJI not requiring revision surgery was lowest in cemented TKA as compared to hybrid (OR 0.56, 95%CI 0.06-6.10) and cementless (OR 0.55, 95% 0.14-5.63). CONCLUSION Unlike total hip arthroplasties, fixation method is not a predisposing risk factor for infections in TKA. However, this meta-analysis may not have sufficient statistical power to show a significant difference between fixation types. It is recommended that prophylactic precautions against other known risk factors for infection should still be clinically practiced. LEVEL OF EVIDENCE Level I, meta-analysis of randomized controlled trials.
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Affiliation(s)
- James Onggo
- Department of Orthopaedic Surgery, Box Hill Hospital, Melbourne, Victoria, Australia
| | - Jason Onggo
- Department of Orthopaedic Surgery, Flinders Medical Centre, Adelaide, South Australia, Australia
| | - Kevin Phan
- Department of Medicine, Liverpool Hospital, Sydney, New South Wales, Australia
| | - Christopher Wilson
- Department of Orthopaedic Surgery, Flinders Medical Centre, Adelaide, South Australia, Australia.,Department of Orthopaedic Surgery, Repatriation General Hospital, Adelaide, South Australia, Australia.,Department of Orthopaedics, The International Musculoskeletal Research Institute Inc., Adelaide, South Australia, Australia
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14
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Sebastian S, Liu Y, Christensen R, Raina DB, Tägil M, Lidgren L. Antibiotic containing bone cement in prevention of hip and knee prosthetic joint infections: A systematic review and meta-analysis. J Orthop Translat 2020; 23:53-60. [PMID: 32489860 PMCID: PMC7256060 DOI: 10.1016/j.jot.2020.04.005] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Revised: 04/07/2020] [Accepted: 04/10/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Prosthetic joint infection (PJI) is the most serious total joint arthroplasty (TJA) complication despite several aseptic and antiseptic preventive measures. There is no clear evidence or even consensus, whether antibiotic-loaded bone cement (ALBC) should be used, in addition to systemic short-term routine antibiotic prophylaxis, to reduce the risk of PJI in primary TJA. We aimed to analyze the efficacy of ALBC for prevention of PJI in patients undergoing primary TJA. METHODS We searched systematically for randomized controlled trials (RCTs) in PubMed, Scopus, Embase, Web of Science and Cochrane library. Two reviewers independently screened potentially eligible studies according to predefined selection criteria and assessed the risk of bias using a modified version of the Cochrane risk of bias tool. PJI was prespecified as the primary outcome of interest. The meta-analyses were based on risk ratios using random-effects model per default. For the purpose of sensitivity, the corresponding fixed effects model odds ratios were calculated with the use of the Peto method as well. To evaluate a potential difference in effect sizes using different types (subgroups) of antibiotics used in bone cement, and at different follow-up periods, we performed stratified meta-analyses. RESULTS Thirty-seven studies were eligible for the systematic review and qualitative synthesis, and 9 trials (6507 total joint arthroplasties) were included in this meta-analysis. Overall ALBC significantly reduced the risk of PJI following primary TJAs (RRs, 0.36; 95% CIs, 0.16 to 0.80; P = 0.01) with a moderate degree of inconsistency (I2 = 47%). Based on stratified meta-analyses the use of gentamicin appeared to have a better effect (P = 0.0005) in the total hip arthroplasty. Pooled data of different antibiotics used in knee arthroplasties showed a significant association of cefuroxime (RRs, 0.08; 95% CIs, 0.01 to 0.63; P = 0.02). Further, ALBCs significantly reduced the PJI at one and two years of follow-up (P = 0.03 and P = 0.005 respectively). CONCLUSIONS The evidence suggests that ALBCs are effective in reducing the PJI following primary TJA; i.e. between 20 and 84% reduced risk. However, the clear limitations of the available trial evidence highlight the need for joint-specific confirmatory trials, that will need to be designed as cluster-randomized trials of clinics in countries with well-functioning arthroplasty registries.The translational potential of this article: This meta-analysis highlights the prophylactic potential of ALBCs in lowering the risk of infection following primary hip or knee arthroplasties but emphasizes the need for more recent confirmatory trials.
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Affiliation(s)
- Sujeesh Sebastian
- Lund University, Faculty of Medicine, Department of Clinical Sciences Lund, Orthopedics, Lund, Sweden
| | - Yang Liu
- Lund University, Faculty of Medicine, Department of Clinical Sciences Lund, Orthopedics, Lund, Sweden
| | - Robin Christensen
- Musculoskeletal Statistics Unit, The Parker Institute, Bispebjerg and Frederiksberg Hospital, Copenhagen & Research Unit of Rheumatology, Department of Clinical Research, University of Southern Denmark, Odense University Hospital, Denmark
| | - Deepak Bushan Raina
- Lund University, Faculty of Medicine, Department of Clinical Sciences Lund, Orthopedics, Lund, Sweden
| | - Magnus Tägil
- Lund University, Faculty of Medicine, Department of Clinical Sciences Lund, Orthopedics, Lund, Sweden
| | - Lars Lidgren
- Lund University, Faculty of Medicine, Department of Clinical Sciences Lund, Orthopedics, Lund, Sweden
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15
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Lenguerrand E, Whitehouse MR, Blom AW. Risk factors associated with revision for prosthetic joint infection after knee replacement - Authors' reply. THE LANCET. INFECTIOUS DISEASES 2019; 19:807-808. [PMID: 31345450 DOI: 10.1016/s1473-3099(19)30348-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Accepted: 07/01/2019] [Indexed: 12/11/2022]
Affiliation(s)
- Erik Lenguerrand
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol BS10 5NB, UK.
| | - Michael R Whitehouse
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol BS10 5NB, UK; National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol National Health Service Foundation Trust, University of Bristol, Bristol BS10 5NB, UK
| | - Ashley W Blom
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol BS10 5NB, UK; National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol National Health Service Foundation Trust, University of Bristol, Bristol BS10 5NB, UK
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