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Cianni L, Taccari F, Bocchi MB, Micheli G, Sangiorgi F, Ziranu A, Fantoni M, Maccauro G, Vitiello R. Characteristics and Epidemiology of Megaprostheses Infections: A Systematic Review. Healthcare (Basel) 2024; 12:1283. [PMID: 38998818 PMCID: PMC11241048 DOI: 10.3390/healthcare12131283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2024] [Revised: 05/18/2024] [Accepted: 06/18/2024] [Indexed: 07/14/2024] Open
Abstract
BACKGROUND Megaprostheses were first employed in oncological orthopedic surgery, but more recently, additional applications have arisen. These implants are not without any risks and device failure is quite frequent. The most feared complication is undoubtedly the implants' infection; however, the exact incidence is still unknown. This systematic review aims to estimate in the current literature the overall incidence of megaprosthesis infections and to investigate possible risk/protective factors. METHODS We conducted a systematic search for studies published from July 1971 to December 2023 using specific keywords. To be included, studies needed to report either the megaprosthesis anatomical site, and/or whether the megaprosthesis was coated, and/or the surgical indication as oncological or non-oncological reasons. RESULTS The initial literature search resulted in 1281 studies. We evaluated 10,456 patients and the overall infection rate was 12%. In cancer patients, the infection rate was 22%, while in non-oncological patients, this was 16% (trauma 12%, mechanical failure 17%, prosthetic joint infections 26%). The overall infection rates comparing coated and uncoated implants were 10% and 12.5%, respectively. CONCLUSIONS The number of megaprosthesis implants is increasing considerably. In traumatological patients, the infection rate is lower compared to all the other subgroups, while the infection rate remains higher in the cancer patient group. As these devices become more common, focused studies exploring epidemiological data, clinical outcomes, and long-term complications are needed to address the uncertainties in prevention and management.
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Affiliation(s)
- Luigi Cianni
- Dipartimento di Scienze dell'invecchiamento, Ortopediche e Reumatologiche, Unità Operativa Complessa di Ortopedia e Traumatologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
- Dipartimento di Sicurezza e Bioetica-Sezione di Malattie Infettive, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Francesco Taccari
- Dipartimento di Scienze Mediche e Chirurgiche, Unità Operativa Complessa di Malattie infettive, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
| | - Maria Beatrice Bocchi
- Dipartimento di Scienze dell'invecchiamento, Ortopediche e Reumatologiche, Unità Operativa Complessa di Ortopedia e Traumatologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
- Dipartimento di Sicurezza e Bioetica-Sezione di Malattie Infettive, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Giulia Micheli
- Dipartimento di Sicurezza e Bioetica-Sezione di Malattie Infettive, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
- Dipartimento di Scienze Mediche e Chirurgiche, Unità Operativa Complessa di Malattie infettive, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
| | - Flavio Sangiorgi
- Dipartimento di Sicurezza e Bioetica-Sezione di Malattie Infettive, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
- Dipartimento di Scienze Mediche e Chirurgiche, Unità Operativa Complessa di Malattie infettive, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
| | - Antonio Ziranu
- Dipartimento di Sicurezza e Bioetica-Sezione di Malattie Infettive, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
- Ospedale Isola Tiberina-Gemelli Isola, 00186 Rome, Italy
| | - Massimo Fantoni
- Dipartimento di Sicurezza e Bioetica-Sezione di Malattie Infettive, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
- Dipartimento di Scienze Mediche e Chirurgiche, Unità Operativa Complessa di Malattie infettive, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
| | - Giulio Maccauro
- Dipartimento di Scienze dell'invecchiamento, Ortopediche e Reumatologiche, Unità Operativa Complessa di Ortopedia e Traumatologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
- Dipartimento di Sicurezza e Bioetica-Sezione di Malattie Infettive, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Raffaele Vitiello
- Dipartimento di Scienze dell'invecchiamento, Ortopediche e Reumatologiche, Unità Operativa Complessa di Ortopedia e Traumatologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
- Dipartimento di Sicurezza e Bioetica-Sezione di Malattie Infettive, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
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Gonzalez MR, Karczewski D, Bedi AD, Denwood H, Lozano-Calderon SA. Neoplastic pathologic hip fractures are associated with a higher risk of post-operative bleeding and thromboembolic events. Surg Oncol 2024; 54:102076. [PMID: 38608626 DOI: 10.1016/j.suronc.2024.102076] [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: 02/22/2024] [Revised: 04/03/2024] [Accepted: 04/08/2024] [Indexed: 04/14/2024]
Abstract
INTRODUCTION Surgical treatment of hip fractures leads to significant post-operative complications. Although pathologic fractures (PF) are associated with worse outcomes, most studies do not differentiate between etiology (neoplastic and non-neoplastic PF). We seek to compare 30-day complication rates between 1) native hip fractures and neoplastic PF, and 2) neoplastic and non-neoplastic PF. MATERIALS AND METHODS A total of 127,819 patients with hip fractures and 5104 with PF diagnosed from 2005 to 2021 were retrieved from the NSQIP database. We included 1843 patients with neoplastic PF and 3261 with non-neoplastic PF. Demographics, pre-operative labs and co-morbidities, and post-operative outcomes were analyzed. Propensity-score matching was conducted to control for confounders. RESULTS Patients with a neoplastic PF had a significantly higher rate of deep venous thrombosis (DVT) (4 % vs 1.2 %, p = 0.001) and pulmonary embolism (PE) (2.4 % vs 0.7 %, p < 0.001), than native hip fractures. Rates of post-operative bleeding were significantly higher in the neoplastic PF group (29.3 % vs 23.9 %, p < 0.001) than non-neoplastic PF. No differences in soft tissue complications were found. When comparing neoplastic and non-neoplastic PF, the former had a higher rate of PE (2.5 % vs 1.0 %, p = 0.015) and post-operative bleeding (27.6 % vs 22.0 %, p = 0.009). Unplanned readmission rates and 30-day mortality rate were also higher in the neoplastic PF group. CONCLUSION Neoplastic PF of the hip are associated with higher risk of thromboembolic event rates and post-operative bleeding than both native hip fractures and non-neoplastic PF. No differences in rates of soft tissue complications were found between groups.
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Affiliation(s)
- Marcos R Gonzalez
- Division of Orthopaedic Oncology, Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, 02144, USA
| | - Daniel Karczewski
- Division of Orthopaedic Oncology, Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, 02144, USA
| | - Angad Ds Bedi
- Division of Orthopaedic Oncology, Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, 02144, USA; Department of Orthopaedic Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Hayley Denwood
- Division of Orthopaedic Oncology, Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, 02144, USA
| | - Santiago A Lozano-Calderon
- Division of Orthopaedic Oncology, Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, 02144, USA.
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Karampikas V, Gavriil P, Goumenos S, Trikoupis IG, Roustemis AG, Altsitzioglou P, Kontogeorgakos V, Mavrogenis AF, Papagelopoulos PJ. Risk factors for peri-megaprosthetic joint infections in tumor surgery: A systematic review. SICOT J 2024; 10:19. [PMID: 38819289 PMCID: PMC11141517 DOI: 10.1051/sicotj/2024008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Accepted: 03/05/2024] [Indexed: 06/01/2024] Open
Abstract
BACKGROUND Peri-megaprosthetic joint infections (PJI) in tumor surgery are complex and challenging complications that significantly impact the outcomes of the patients. The occurrence of PJI poses a substantial threat to the success of these operations. This review aims to identify and summarize the risk factors associated with PJI in tumor surgery with megaprosthetic reconstruction as well as to determine the overall risk of PJI in limb salvage surgery. METHODS A thorough examination of published literature, scrutinizing the incidence of PJI in tumor prostheses after limb salvage surgery was done. Research studies that documented the incidence of PJI in tumor patients who underwent limb salvage surgery, and explored the risk factors associated with the occurrence of PJI were deemed eligible. RESULTS A total of 15 studies were included in the analysis and underwent comprehensive examination. After the exploration of key parameters, several significant risk factors for PJI concerning the type of implant coating, surgical site characteristics, patient demographics, and procedural factors were recorded. DISCUSSION The findings underscore the need for a nuanced approach in managing tumor patients undergoing limb salvage surgery and megaprosthetic reconstruction, with emphasis on individualized risk assessments and individualized preventive strategies.
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Affiliation(s)
- Vasileios Karampikas
- First Department of Orthopaedics, National and Kapodistrian University of Athens, School of Medicine, 41 Ventouri Street, 15562, Holargos, Athens, Greece
| | - Panayiotis Gavriil
- First Department of Orthopaedics, National and Kapodistrian University of Athens, School of Medicine, 41 Ventouri Street, 15562, Holargos, Athens, Greece
| | - Stavros Goumenos
- First Department of Orthopaedics, National and Kapodistrian University of Athens, School of Medicine, 41 Ventouri Street, 15562, Holargos, Athens, Greece
| | - Ioannis G Trikoupis
- First Department of Orthopaedics, National and Kapodistrian University of Athens, School of Medicine, 41 Ventouri Street, 15562, Holargos, Athens, Greece
| | - Anastasios G Roustemis
- First Department of Orthopaedics, National and Kapodistrian University of Athens, School of Medicine, 41 Ventouri Street, 15562, Holargos, Athens, Greece
| | - Pavlos Altsitzioglou
- First Department of Orthopaedics, National and Kapodistrian University of Athens, School of Medicine, 41 Ventouri Street, 15562, Holargos, Athens, Greece
| | - Vasileios Kontogeorgakos
- First Department of Orthopaedics, National and Kapodistrian University of Athens, School of Medicine, 41 Ventouri Street, 15562, Holargos, Athens, Greece
| | - Andreas F Mavrogenis
- First Department of Orthopaedics, National and Kapodistrian University of Athens, School of Medicine, 41 Ventouri Street, 15562, Holargos, Athens, Greece
| | - Panayiotis J Papagelopoulos
- First Department of Orthopaedics, National and Kapodistrian University of Athens, School of Medicine, 41 Ventouri Street, 15562, Holargos, Athens, Greece
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Andreani L, Ipponi E, Varchetta G, Ruinato AD, De-Franco S, Campo FR, D'Arienzo A. Topical Application of Vancomycin Powder to Prevent Infections after Massive Bone Resection and the implantation of Megaprostheses in Orthopaedic Oncology Surgery. Malays Orthop J 2024; 18:125-132. [PMID: 38638658 PMCID: PMC11023351 DOI: 10.5704/moj.2403.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Accepted: 10/06/2023] [Indexed: 04/20/2024] Open
Abstract
Introduction Periprosthetic joint infection (PJI) represents a serious burden in orthopaedic oncology. Through the years, several local expedients have been proposed to minimise the risk of periprosthetic infection. In this study, we report our outcomes using topical vancomycin powder (VP) with the aim to prevent PJIs. Materials and methods Fifty oncological cases treated with massive bone resection and the implant of a megaprosthesis were included in our study. Among them, 22 [(GGroup A) received one gram of vancomycin powder on the surface of the implant and another gram on the surface of the muscular fascia]. The remaining 28 did not receive such a treatment (Group B). The rest of surgical procedures and the follow-up were the same for the two groups. Patients underwent periodical outpatient visits, radiographs and blood exams' evaluations. Diagnosis of PJIs and adverse reactions to topical vancomycin were recorded. Results None of the cases treated with topical vancomycin developed infections, whereas 6 of the 28 cases (21.4%) who did not receive the powder suffered from PJIs. These outcomes suggest that cases treated with VP had a significantly lower risk of post-operative PJI (p=0.028). None of our cases developed acute kidney failures or any other complication directly or indirectly attributable to the local administration of VP. Conclusions The topical use of vancomycin powder on megaprosthetic surfaces and the overlying fascias, alongside with a correct endovenous antibiotic prophylaxis, can represent a promising approach in order to minimise the risk of periprosthetic infections in orthopaedic oncology surgery.
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Affiliation(s)
- L Andreani
- Department of Orthopedics and Trauma Surgery, University of Pisa, Pisa, Italy
| | - E Ipponi
- Department of Orthopedics and Trauma Surgery, University of Pisa, Pisa, Italy
| | - G Varchetta
- Department of Orthopedics and Trauma Surgery, University of Pisa, Pisa, Italy
| | - A D Ruinato
- Department of Orthopedics and Trauma Surgery, University of Pisa, Pisa, Italy
| | - S De-Franco
- Department of Orthopedics and Trauma Surgery, University of Pisa, Pisa, Italy
| | - F R Campo
- Department of Orthopedics and Trauma Surgery, University of Pisa, Pisa, Italy
| | - A D'Arienzo
- Department of Orthopedics and Trauma Surgery, University of Pisa, Pisa, Italy
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Rodrigues-Lopes R, Silva F, Torres J. Periprosthetic shoulder infection management: one-stage should be the way: a systematic review and meta-analysis. J Shoulder Elbow Surg 2024; 33:722-737. [PMID: 37839627 DOI: 10.1016/j.jse.2023.09.007] [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: 05/20/2023] [Revised: 08/29/2023] [Accepted: 09/03/2023] [Indexed: 10/17/2023]
Abstract
BACKGROUND There is still no consensus among surgeons on whether to perform a 1- or 2-stage surgical revision in infected shoulder arthroplasties. The aim of this systematic review and meta-analysis is to rigorously synthesize published studies evaluating the clinical outcomes, recurrence of infection, and other clinical complications in order to discuss which is the best strategy for treating periprosthetic joint infection after shoulder arthroplasty. METHODS Upon research using the PubMed, Scopus, and Web of Science databases, in November 2022, studies that presented 1- or 2-stage surgical revision as a treatment for periprosthetic joint infection after shoulder arthroplasty and assessed the reinfection rate on these patients, as well as other clinical outcomes, with a minimum follow-up of 12 months, were included. Study quality was evaluated using the Methodological Index for Non-Randomized Studies (MINORS) score. Reinfection and complication rates were extracted, and pooled estimates were calculated using the random-effect model. RESULTS After careful screening, 44 studies were included, 5 reporting on 1-stage and 30 on 2-stage revisions and 9 assessing both strategies. A total of 185 shoulders were reported in 1-stage revision studies, whereas 526 shoulders were reported in 2-stage revision studies. The overall pooled random-effects reinfection rate was 6.68% (95% confidence interval [CI]: 3.76-10.13), with low heterogeneity (I2 = 28%, P = .03). One-stage revision showed a reinfection rate of 1.14% (95% CI: 0.00-4.88), whereas 2-stage revision analysis revealed a reinfection rate of 8.81% (95% CI: 4.96-13.33). There were significant statistical differences between 1- and 2-stage reinfection rates (P = .04). The overall pooled rate for other clinical complications was 16.76% (95% CI: 9.49-25.15), with high heterogeneity (I2 = 70%, P < .01). One-stage revision had a complication rate of 6.11% (95% CI: 1.58-12.39), whereas the 2-stage revision complication rate was 21.26% (95% CI: 11.51-32.54). This difference was statistically significant (P = .03). CONCLUSIONS This is the first systematic review and meta-analysis showing significant statistical differences between 1- and 2-stage surgical revision in infected shoulder arthroplasties. Provided the right conditions exist, 1-stage revision shows better results in infection control, with lower clinical complications and possible better clinical outcomes.
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Affiliation(s)
| | - Fábia Silva
- Department of Orthopaedics and Traumatology, University Hospital Center of São João, Porto, Portugal
| | - João Torres
- Faculty of Medicine of the University of Porto, Porto, Portugal; Department of Orthopaedics and Traumatology, University Hospital Center of São João, Porto, Portugal
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Berger C, Parai C, Tillander J, Bergh P, Wennergren D, Brisby H. High Risk for Persistent Peri-Prosthetic Infection and Amputation in Mega-Prosthesis Reconstruction. J Clin Med 2023; 12:jcm12103575. [PMID: 37240683 DOI: 10.3390/jcm12103575] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 05/07/2023] [Accepted: 05/17/2023] [Indexed: 05/28/2023] Open
Abstract
A peri-prosthetic joint infection is a feared complication after mega-prosthesis reconstruction of large bone defects. The current study investigates how patients operated with a mega-prosthesis due to sarcoma, metastasis, or trauma, are affected by a deep infection focusing on re-operations, risk for persistent infection, arthrodesis, or subsequent amputation. Time to infection, causative bacterial strains, mode of treatment and length of hospital stay are also reported. A total of 114 patients with 116 prostheses were evaluated, a median of 7.6 years (range 3.8-13.7) after surgery, of which 35 (30%) were re-operated due to a peri-prosthetic infection. Of the infected patients, the prosthesis was still in place in 51%, 37% were amputated, and 9% had an arthrodesis. The infection was persistent in 26% of the infected patients at follow-up. The mean total length of hospital stay was 68 (median 60) days and the mean number of reoperations was 8.9 (median 6.0). The mean length of antibiotic treatment was 340 days (median 183). Coagulase-negative staphylococci and Staphylococcus aureus were the most frequent bacterial agents isolated in deep cultures. No MRSA- or ESBL-producing Enterobacterales were found but vancomycin-resistant Enterococcus faecium was isolated in one patient. In summary, there is a high risk for peri-prosthetic infection in mega-prostheses, resulting in persistent infection or amputation relatively often.
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Affiliation(s)
- Christina Berger
- Institution of Clinical Sciences, Department of Orthopaedics, Sahlgrenska Academy, University of Gothenburg, 416 45 Gothenburg, Sweden
- Department of Orthopedics, Sahlgrenska University Hospital, 413 45 Gothenburg, Sweden
| | - Catharina Parai
- Institution of Clinical Sciences, Department of Orthopaedics, Sahlgrenska Academy, University of Gothenburg, 416 45 Gothenburg, Sweden
- Department of Orthopedics, Sahlgrenska University Hospital, 413 45 Gothenburg, Sweden
| | - Jonatan Tillander
- Institution of Biomedicine, Department of Infectious Diseases, University of Gothenburg, 413 90 Gothenburg, Sweden
| | - Peter Bergh
- Department of Orthopedics, Sahlgrenska University Hospital, 413 45 Gothenburg, Sweden
| | - David Wennergren
- Institution of Clinical Sciences, Department of Orthopaedics, Sahlgrenska Academy, University of Gothenburg, 416 45 Gothenburg, Sweden
- Department of Orthopedics, Sahlgrenska University Hospital, 413 45 Gothenburg, Sweden
| | - Helena Brisby
- Institution of Clinical Sciences, Department of Orthopaedics, Sahlgrenska Academy, University of Gothenburg, 416 45 Gothenburg, Sweden
- Department of Orthopedics, Sahlgrenska University Hospital, 413 45 Gothenburg, Sweden
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