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Ascione T, Balato G, Pagliano P. Upcoming evidence in clinical practice of two-stage revision arthroplasty for prosthetic joint infection. J Orthop Traumatol 2024; 25:26. [PMID: 38761247 PMCID: PMC11102413 DOI: 10.1186/s10195-024-00767-1] [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: 03/15/2024] [Accepted: 04/23/2024] [Indexed: 05/20/2024] Open
Abstract
Total joint arthroplasty is the recommended treatment for patients with end-stage osteoarthritis, as it reduces disability and pain and restores joint function. However, prosthetic joint infection is a serious complication of this procedure, with the two-stage exchange being the most common treatment method. While there is consensus on diagnosing prosthetic joint infection, there is a lack of agreement on the parameters that can guide the surgeon in performing definitive reimplantation in a two-stage procedure. One approach that has been suggested to improve the accuracy of microbiologic investigations before definitive reimplantation is to observe a holiday period from antibiotic therapy to improve the accuracy of cultures from periprosthetic tissues, but these cultures report some degree of aspecificity. Therefore, several pieces of evidence highlight that performing reimplantation using continuous antibiotic therapy should be considered a safe and effective approach, leading to higher cure rates and a shorter period of disability. Dosage of C-reactive protein (CRP), erythrocyte sedimentation rate (ERS) and D-dimer are helpful in diagnosing prosthetic joint infection, but only D-dimer has shown sufficient accuracy in predicting the risk of infection recurrence after a two-stage procedure. Synovial fluid analysis before reimplantation has been shown to be the most accurate in predicting recurrence, and new cutoff values for leukocyte count and neutrophil percentage have shown a useful predictive rule to identify patients at risk of unfavourable outcome. A new scoring system based on a numerical score calculated from the beta coefficient derived through multivariate analysis of D-dimer levels, synovial fluid leukocytes and relative neutrophils percentage has demonstrated high accuracy when it comes to guiding the second step of two-stage procedure. In conclusion, reimplantation may be a suitable option for patients who are on continuous therapy without local symptoms, and with CRP and ERS within the normal range, with low synovial fluid leukocytes (< 952/mL) and a low relative neutrophil percentage (< 52%) and D-dimer below 1100 µg/mL. A numerical score derived from analysing these three parameters can serve as a valuable tool in determining the feasibility of reimplantation in these patients.
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Affiliation(s)
- Tiziana Ascione
- Service of Infectious Diseases, Cardarelli Hospital, Via A. Cardarelli 9, 80131, Naples, Italy.
| | - Giovanni Balato
- Department of Public Health, Orthopedic Unit, "Federico II" University, Naples, Italy
| | - Pasquale Pagliano
- Unit of Infectious Diseases, Department of Medicine, Surgery and Dentistry, "Scuola Medica Salernitana", University of Salerno, Baronissi, Italy
- Clinica Malattie Infettive, AOU San Giovanni di Dio e Ruggi d'Aragona, Salerno, Italy
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Umbel BD, Haghverdian BA, Schweitzer KM, Adams SB. Diagnosis and Management of Infected Total Ankle Replacements. Orthop Clin North Am 2024; 55:285-297. [PMID: 38403374 DOI: 10.1016/j.ocl.2023.08.001] [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] [Indexed: 02/27/2024]
Abstract
As the number of primary total ankle replacements increases for treatment of end-stage ankle arthritis, failures are also expected to rise. Periprosthetic joint infection is among the causes of failures and has been reported to be as high as 5%. Diagnosis is usually made by a combination of clinical examination findings, imaging, laboratory, and microbiological workup. Management is generally separated into limb salvage or amputation. Limb salvage can be challenging and may involve a single versus staged approach. Options include revision arthroplasty or arthrodesis procedures (ankle versus tibiotalocalcaneal), and a multidisciplinary approach is sought to eradicate infection before definitive management.
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Affiliation(s)
- Benjamin D Umbel
- Department of Orthopedic Surgery, Duke University Medical Center, 200 Trent Drive, Durham, NC 27710, USA.
| | - Brandon A Haghverdian
- Department of Orthopedic Surgery, Duke University Medical Center, 200 Trent Drive, Durham, NC 27710, USA
| | - Karl M Schweitzer
- Duke Orthopaedics of Raleigh, 3480 Wake Forest Road, Suite 204, Raleigh, NC 27609, USA
| | - Samuel B Adams
- Department of Orthopedic Surgery, Duke University Medical Center, 200 Trent Drive, Durham, NC 27710, USA
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Sousa R, Carvalho A, Soares D, Abreu MA. Interval between two-stage exchanges: what is optimal and how do you know? ARTHROPLASTY 2023; 5:33. [PMID: 37403130 PMCID: PMC10320898 DOI: 10.1186/s42836-023-00185-4] [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: 12/27/2022] [Accepted: 04/04/2023] [Indexed: 07/06/2023] Open
Abstract
BACKGROUND Two-stage exchange arthroplasty remains the most popular option for the treatment of chronic periprosthetic joint infection (PJI). Determining infection eradication and optimal timing of reimplantation can be challenging. Information to allow for a truly informed evidence-based decision is scarce. METHODS We conducted a critical review of available evidence on the presently available tests to help determine timing of reimplantation. RESULTS Serology is traditionally used to follow up patients after the first stage. Despite tradition mandates waiting for normal inflammatory markers, there is actually no evidence that they correlate with persistent infection. The role of synovial fluid investigation between stages is also explored. Cultures lack sensitivity and neither differential leukocyte counts nor alternative biomarkers have proven to be accurate in identifying persistent infection with a spacer in situ. We also examined the evidence regarding the optimal time interval between resection and reimplantation and whether there is evidence to support the implementation of a two week "antibiotic holiday" prior to proceeding with reimplantation. Finally, wound healing and other important factors in this setting will be discussed. CONCLUSION Currently there are no accurate metrics to aid in the decision on the optimal timing for reimplantation. Decision must therefore rely on the resolution of clinical signs and down trending serological and synovial markers.
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Affiliation(s)
- Ricardo Sousa
- Department of Orthopedics, Centro Hospitalar Universitário de Santo António, 4099-001, Porto, Portugal.
- Porto Bone and Joint Infection Group (GRIP), Centro Hospitalar Universitário de Santo António and CUF Hospitais E Clínicas, 4099-001, Porto, Portugal.
| | - André Carvalho
- Department of Orthopedics, Centro Hospitalar Universitário de Santo António, 4099-001, Porto, Portugal
- Porto Bone and Joint Infection Group (GRIP), Centro Hospitalar Universitário de Santo António and CUF Hospitais E Clínicas, 4099-001, Porto, Portugal
| | - Daniel Soares
- Department of Orthopedics, Centro Hospitalar Universitário de Santo António, 4099-001, Porto, Portugal
- Porto Bone and Joint Infection Group (GRIP), Centro Hospitalar Universitário de Santo António and CUF Hospitais E Clínicas, 4099-001, Porto, Portugal
| | - Miguel Araújo Abreu
- Porto Bone and Joint Infection Group (GRIP), Centro Hospitalar Universitário de Santo António and CUF Hospitais E Clínicas, 4099-001, Porto, Portugal
- Department of Infectious Diseases, Centro Hospitalar Universitário de Santo António, 4099-001, Porto, Portugal
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Fraval A, Wang J, Tarabichi S, Parvizi J. Optimal timing for reimplantation in the setting of two stage revision for prosthetic joint infection. Rev Esp Cir Ortop Traumatol (Engl Ed) 2023; 67:246-252. [PMID: 36787833 DOI: 10.1016/j.recot.2023.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 02/10/2023] [Indexed: 02/14/2023] Open
Affiliation(s)
- A Fraval
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA, United States.
| | - J Wang
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA, United States
| | - S Tarabichi
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA, United States
| | - J Parvizi
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA, United States
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Fraval A, Wang J, Tarabichi S, Parvizi J. Optimal timing for reimplantation in the setting of two stage revision for prosthetic joint infection. Rev Esp Cir Ortop Traumatol (Engl Ed) 2023; 67:T246-T252. [PMID: 36940848 DOI: 10.1016/j.recot.2023.02.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 02/10/2023] [Indexed: 03/22/2023] Open
Affiliation(s)
- A Fraval
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pensilvania, Estados Unidos.
| | - J Wang
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pensilvania, Estados Unidos
| | - S Tarabichi
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pensilvania, Estados Unidos
| | - J Parvizi
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pensilvania, Estados Unidos
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Khan IA, Boyd BO, Chen AF, Cortés-Penfield N, Myers TG, Brown TS, Suh GA, McGwin G, Ghanem ES, Fillingham YA. Utility of Diagnostic Tests Before Reimplantation in Patients Undergoing 2-Stage Revision Total Joint Arthroplasty: A Systematic Review and Meta-analysis. JBJS Rev 2023; 11:01874474-202303000-00007. [PMID: 36947634 DOI: 10.2106/jbjs.rvw.22.00201] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/24/2023]
Abstract
INTRODUCTION Periprosthetic joint infection (PJI) is a devastating complication after total joint arthroplasty (TJA), with treatment failure occurring in 12% to 28% after 2-stage revision. It is vital to identify diagnostic tools indicative of persistent infection or treatment failure after 2-stage revision for PJI. METHODS The Cochrane Library, PubMed (MEDLINE), and EMBASE were searched for randomized controlled trials and comparative observational studies published before October 3, 2021, which evaluated the utility of serum/plasma biomarkers (erythrocyte sedimentation rate [ESR], C-reactive protein [CRP], interleukin-6 [IL-6], fibrinogen, D-dimer), synovial biomarkers (white blood cell [WBC] count, neutrophil percentage [PMN %], alpha-defensin [AD], leukocyte esterase [LE]), tissue frozen section, tissue culture, synovial fluid culture, or sonicated spacer fluid culture indicative of persistent infection before the second stage of 2-stage revision for PJI or treatment failure after 2-stage revision for PJI. RESULTS A total of 47 studies including 6,605 diagnostic tests among 3,781 2-stage revisions for PJI were analyzed. Among those cases, 723 (19.1%) experienced persistent infection or treatment failure. Synovial LE (sensitivity 0.25 [0.10-0.47], specificity 0.99 [0.93-1.00], positive likelihood ratio 14.0 [1.45-135.58]) and serum IL-6 (sensitivity 0.52 [0.33-0.70], specificity 0.92 [0.85-0.96], positive likelihood ratio 7.90 [0.86-72.61]) had the highest diagnostic accuracy. However, no biomarker was associated with a clinically useful negative likelihood ratio. In subgroup analysis, synovial PMN %, synovial fluid culture, serum ESR, and serum CRP had limited utility for detecting persistent infection before reimplantation (positive likelihood ratios ranging 2.33-3.74; negative likelihood ratios ranging 0.31-0.9) and no utility for predicting failure after the second stage of 2-stage revision. CONCLUSIONS Synovial WBC count, synovial PMN %, synovial fluid culture, serum ESR, and serum CRP have modest sensitivity and specificity for predicting persistent infection during the second stage of 2-stage revision, suggesting some combination of these diagnostic tests might be useful before reimplantation. No biomarker or culture accurately predicted treatment failure after reimplantation. LEVEL OF EVIDENCE Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Irfan A Khan
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Brandon O Boyd
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Antonia F Chen
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | | | - Thomas G Myers
- Department of Orthopaedics and Physical Performance, University of Rochester Medical Center, Rochester, New York
| | - Timothy S Brown
- Department of Orthopaedic Surgery, Houston Methodist Orthopaedics & Sports Medicine, Houston, Texas
| | - Gina A Suh
- Division of Infectious Diseases, Mayo Clinic, Rochester, Minnesota
| | - Gerald McGwin
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Elie S Ghanem
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Yale A Fillingham
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
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Impact and Modification of the New PJI-TNM Classification for Periprosthetic Joint Infections. J Clin Med 2023; 12:jcm12041262. [PMID: 36835798 PMCID: PMC9967834 DOI: 10.3390/jcm12041262] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2022] [Revised: 01/31/2023] [Accepted: 02/03/2023] [Indexed: 02/08/2023] Open
Abstract
The comprehensive "PJI-TNM classification" for the description of periprosthetic joint infections (PJI) was introduced in 2020. Its structure is based on the well-known oncological TNM classification to appreciate the complexity, severity, and diversity of PJIs. The main goal of this study is to implement the new PJI-TNM classification into the clinical setting to determine its therapeutic and prognostic value and suggest modifications to further improve the classification for clinical routine use. A retrospective cohort study was conducted at our institution between 2017 and 2020. A total of 80 consecutive patients treated with a two-stage revision for periprosthetic knee joint infection were included. We retrospectively assessed correlations between patients' preoperative PJI-TNM classification and their therapy and outcome and identified several statistically significant correlations for both classifications, the original and our modified version. We have demonstrated that both classifications provide reliable predictions already at the time of diagnosis regarding the invasiveness of surgery (duration of surgery, blood and bone loss during surgery), likelihood of reimplantation, and patient mortality during the first 12 months after diagnosis. Orthopedic surgeons can use the classification system preoperatively as an objective and comprehensive tool for therapeutic decisions and patient information (informed consent). In the future, comparisons between different treatment options for truly similar preoperative baseline situations can be obtained for the first time. Clinicians and researchers should be familiar with the new PJI-TNM classification and start implementing it into their routine practice. Our adjusted and simplified version ("PJI-pTNM") might be a more convenient alternative for the clinical setting.
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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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Huguet S, Bernaus M, Gómez L, Cuchí E, Soriano A, Font-Vizcarra L. Role of joint aspiration before re-implantation in patients with a cement spacer in place. World J Orthop 2022; 13:615-621. [PMID: 35949711 PMCID: PMC9244963 DOI: 10.5312/wjo.v13.i6.615] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Revised: 02/04/2022] [Accepted: 05/14/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND The usefulness of a mandatory joint aspiration before re-implantation in patients with a cement spacer already in place is unclear.
AIM To evaluate the role of culturing synovial fluid obtained by joint aspiration before re-implantation in patients who underwent a two-stage septic revision.
METHODS A retrospective observational study was conducted, including patients that underwent a two-stage septic revision (hip or knee) from 2010 to 2017. After the first stage revision and according to intraoperative culture results, all patients were treated with an antibiotic protocol for 6-8 wk. Following 2 wk without antibiotics, a culture of synovial fluid was obtained. The results of these cultures were recorded and compared with cultures obtained during re-implantation surgery.
RESULTS Forty-one patients (20 hip and 21 knee spacers) were included in the final analysis. In 39 cases, the culture of synovial fluid was negative, while in the remaining 2 cases (knee spacers) no analysis was possible due to dry tap. In 5 of the patients, two or more intraoperative cultures taken during the re-implantation surgery were positive.
CONCLUSION We found no evidence to support mandatory joint aspiration before re-implantation in patients with a cement spacer in place.
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Affiliation(s)
- Sandra Huguet
- Department of Traumatology and Orthopaedics, Hospital Universitari Mútua Terrassa, Terrassa 08221, Spain
- Department of Traumatology and Orthopaedics, Consorci Sanitari de l’Alt Penedès - Garraf, Vilafranca del Penedès 08720, Spain
| | - Martí Bernaus
- Department of Traumatology and Orthopaedics, Osteoarticular Infections Unit, Hospital Universitari Mútua Terrassa, Terrassa 08221, Spain
| | - Lucía Gómez
- Osteoarticular Infections Unit, Hospital Universitari Mútua Terrassa, Terrassa 08221, Spain
| | - Eva Cuchí
- Osteoarticular Infections Unit, Hospital Universitari Mútua Terrassa, Terrassa 08221, Spain
- Department of Microbiology, CATLAB, Viladecavalls 08232, Spain
| | - Alex Soriano
- Department of Infectious Diseases, Osteoarticular Infections Unit, Hospital Clínic, Barcelona 08036, Spain
| | - Lluís Font-Vizcarra
- Department of Traumatology and Orthopaedics, Osteoarticular Infections Unit, Hospital Universitari Mútua Terrassa, Terrassa 08221, Spain
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Barretto JM, Campos ALS, Ooka NHM. Periprosthetic Knee Infection - Part 2: Treatment. Rev Bras Ortop 2022; 57:193-199. [PMID: 35652024 PMCID: PMC9142269 DOI: 10.1055/s-0041-1729936] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Accepted: 12/17/2020] [Indexed: 11/29/2022] Open
Abstract
Several treatment modalities are proposed for periprosthetic infections, with variable success rates. However, efficacy is related to the appropriate selection of cases for each type of treatment. Debridement with implant retention is indicated in acute infections with fixed implant, and its success depends on the type of infection, comorbidities of the host, and virulence of the etiological agent. One- or two-stage revision is required in cases in which biofilm is forming, or of implant loosening. The choice between performing the review in one or two stages depends on factors such as etiological agent identification, pathogen virulence, local and systemic host factors. Rescue procedures such as arthrodesis, amputation, resection arthroplasty or even antibiotic suppression are reserved for cases in which the infection has not been eradicated.
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Affiliation(s)
- João Maurício Barretto
- Coordenador de Ortopedia da Clínica São Vicente da Gávea, Rede D'or São Luiz, Rio de Janeiro, RJ, Brasil
| | - André Luiz Siqueira Campos
- Departamento de Ortopedia e Traumatologia, Hospital Federal dos Servidores do Estado, Rio de Janeiro, RJ, Brasil
| | - Nelson Hiroyuki Miyabe Ooka
- Departamento de Ortopedia e Traumatologia, Hospital Universitário Pedro Ernesto, Rio de Janeiro, RJ, Brasil
- Departamento de Ortopedia e Traumatologia, Hospital Universitário Clementino Fraga Filho, Rio de Janeiro, RJ, Brasil
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Anagnostakos K, Grzega C, Sahan I, Geipel U, Becker SL. Occurrence of Rare Pathogens at the Site of Periprosthetic Hip and Knee Joint Infections: A Retrospective, Single-Center Study. Antibiotics (Basel) 2021; 10:antibiotics10070882. [PMID: 34356802 PMCID: PMC8300814 DOI: 10.3390/antibiotics10070882] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Revised: 07/08/2021] [Accepted: 07/16/2021] [Indexed: 12/31/2022] Open
Abstract
The frequency and clinical relevance of rare pathogens at the site of periprosthetic infections of the hip and knee joint and their antibiotic resistance profiles have not yet been assessed in-depth. We retrospectively analyzed all periprosthetic hip and knee joint infections that occurred between 2016 and 2020 in a single center in southwest Germany. Among 165 infections, 9.7% were caused by rare microorganisms such as Veilonella sp., Pasteurella sp., Pantoea sp., Citrobacter koseri, Serratia marcescens, Parvimonas micra, Clostridium difficile, Finegoldia magna, Morganella morganii, and yeasts. No resistance to piperacillin/tazobactam, carbapenemes, fluoroquinolones, or gentamicin was observed. Some bacteria displayed resistance to ampicillin, ampicillin/sulbactam, and cefuroxime. We present follow-up data of patients with infections due to rare pathogens and discuss the importance of close, interdisciplinary collaboration between orthopedic surgeons and clinical microbiologists to carefully select the most appropriate anti-infective treatment regimens for the increasing number of patients with such infections.
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Affiliation(s)
- Konstantinos Anagnostakos
- Zentrum für Orthopädie und Unfallchirurgie, Klinikum Saarbrücken, 66119 Saarbrücken, Germany; (C.G.); (I.S.)
- Correspondence:
| | - Christoph Grzega
- Zentrum für Orthopädie und Unfallchirurgie, Klinikum Saarbrücken, 66119 Saarbrücken, Germany; (C.G.); (I.S.)
| | - Ismail Sahan
- Zentrum für Orthopädie und Unfallchirurgie, Klinikum Saarbrücken, 66119 Saarbrücken, Germany; (C.G.); (I.S.)
| | - Udo Geipel
- Bioscientia MVZ Saarbrücken GmbH, 66119 Saarbrücken, Germany;
| | - Sören L. Becker
- Institut für Medizinische Mikrobiologie und Hygiene, Universitätsklinikum des Saarlandes, 66421 Homburg/Saar, Germany;
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Bielefeld C, Engler H, JÄger M, Wegner A, Wassenaar D, Busch A. Synovial Alpha-defensin at Reimplantation in Two-stage Revision Arthroplasty to Rule Out Persistent Infection. In Vivo 2021; 35:1073-1081. [PMID: 33622904 DOI: 10.21873/invivo.12352] [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: 11/23/2020] [Revised: 12/06/2020] [Accepted: 12/07/2020] [Indexed: 11/10/2022]
Abstract
BACKGROUND/AIM Owing to the lack of a diagnostic gold standard, ruling out persistent periprosthetic joint infection (PJI) before second-stage surgery in the setting of two-stage revision arthroplasty constitutes a major challenge. We evaluated if the alpha-defensin-1 (AD-1) test could predict successful infection eradication before reimplantation of a new prosthesis. PATIENTS AND METHODS Our prospective study included 20 patients who underwent two-stage revision arthroplasty for treatment of PJI. A standard quantitative enzyme AD-1 immunoassay of synovial fluid, the synovial leukocyte esterase test and routine laboratory blood testing were performed prior to explantation and reimplantation. Treatment failure was defined according to the Delphi-based consensus criteria after a minimum follow-up of 1 year. RESULTS A 15% of our patients met the Delphi Criteria within 1 year. None of the markers investigated were significantly different in patients with and without reinfection. CONCLUSION Further research is necessary to identify biomarkers more suitable for indicating persistent infection before reimplantation.
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Affiliation(s)
- Charlotte Bielefeld
- Department of Orthopaedics, Trauma and Reconstructive Surgery, St. Marien Hospital, Mülheim an der Ruhr, Germany.,Department of Orthopaedics and Trauma Surgery, University of Duisburg-Essen, Mülheim an der Ruhr, Germany
| | - Harald Engler
- Institute of Medical Psychology and Behavioral Immunobiology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Marcus JÄger
- Department of Orthopaedics, Trauma and Reconstructive Surgery, St. Marien Hospital, Mülheim an der Ruhr, Germany; .,Department of Orthopaedics and Trauma Surgery, University of Duisburg-Essen, Mülheim an der Ruhr, Germany
| | - Alexander Wegner
- Department of Orthopaedics, Trauma and Reconstructive Surgery, St. Marien Hospital, Mülheim an der Ruhr, Germany.,Department of Orthopaedics and Trauma Surgery, University of Duisburg-Essen, Mülheim an der Ruhr, Germany
| | - Dennis Wassenaar
- Department of Orthopaedics, Trauma and Reconstructive Surgery, St. Marien Hospital, Mülheim an der Ruhr, Germany.,Department of Orthopaedics and Trauma Surgery, University of Duisburg-Essen, Mülheim an der Ruhr, Germany
| | - Andre Busch
- Department of Orthopaedics, Trauma and Reconstructive Surgery, St. Marien Hospital, Mülheim an der Ruhr, Germany.,Department of Orthopaedics and Trauma Surgery, University of Duisburg-Essen, Mülheim an der Ruhr, Germany
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Anagnostakos K, Sahan I. Are Cement Spacers and Beads Loaded with the Correct Antibiotic(s) at the Site of Periprosthetic Hip and Knee Joint Infections? Antibiotics (Basel) 2021; 10:antibiotics10020143. [PMID: 33535704 PMCID: PMC7912871 DOI: 10.3390/antibiotics10020143] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Revised: 01/26/2021] [Accepted: 01/29/2021] [Indexed: 01/22/2023] Open
Abstract
The optimal impregnation of antibiotic-loaded bone cement in the treatment of periprosthetic hip and knee joint infection is unknown. It is also unclear, whether a suboptimal impregnation might be associated with a higher persistence of infection. A total of 93 patients (44 knee, 49 hip) were retrospectively evaluated, and the most common organism was a methicillin-resistant Staphylococcus epidermidis, followed by methicillin-susceptible Staphylococcus aureus. Of all the organisms, 37.1% were resistant against gentamicin and 54.2% against clindamycin. All organisms were susceptible against vancomycin. In 41 cases, gentamicin-loaded beads were inserted and in 52 cases, spacers: (2 loaded only with gentamicin, 18 with gentamicin + vancomycin, 19 with gentamicin + clindamycin, and 13 with gentamicin + vancomycin + clindamycin). The analysis of each antibiotic impregnation showed that complete susceptibility was present in 38.7% of the cases and partial susceptibility in 28%. In the remaining 33.3%, no precise statement can be made because either there was a culture-negative infection or the antibiotic(s) were not tested against the specific organism. At a mean follow-up of 27.9 months, treatment failure was observed in 6.7% of the cases. Independent of which antibiotic impregnation was used, when the organism was susceptible against the locally inserted antibiotics or not tested, reinfection or persistence of infection was observed in the great majority of cases. Future studies about the investigation of the optimal impregnation of antibiotic-loaded bone cement are welcome.
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Twenty common errors in the diagnosis and treatment of periprosthetic joint infection. INTERNATIONAL ORTHOPAEDICS 2019; 44:3-14. [PMID: 31641803 PMCID: PMC6938795 DOI: 10.1007/s00264-019-04426-7] [Citation(s) in RCA: 66] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Accepted: 09/23/2019] [Indexed: 12/23/2022]
Abstract
Background Misconceptions and errors in the management of periprosthetic joint infection (PJI) can compromise the treatment success. The goal of this paper is to systematically describe twenty common mistakes in the diagnosis and management of PJI, to help surgeons avoid these pitfalls. Materials and methods Common diagnostic and treatment errors are described, analyzed and interpreted. Results Diagnostic errors include the use of serum inflammatory biomarkers (such as C-reactive protein) to rule out PJI, incomplete evaluation of joint aspirate, and suboptimal microbiological procedures (such as using swabs or collection of insufficient number of periprosthetic samples). Further errors are missing possible sources of distant infection in hematogenous PJI or overreliance on suboptimal diagnostic criteria which can hinder or delay the diagnosis of PJI or mislabel infections as aseptic failure. Insufficient surgical treatment or inadequate antibiotic treatment are further reasons for treatment failure and emergence of antimicrobial resistance. Finally, wrong surgical indication, both underdebridement and overdebridement or failure to individualize treatment can jeopardize surgical results. Conclusion Multidisciplinary teamwork with infectious disease specialists and microbiologists in collaboration with orthopedic surgeons have a synergistic effect on the management of PJI. An awareness of the possible pitfalls can improve diagnosis and treatment results.
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Management of Chronically Infected Total Knee Arthroplasty With Severe Bone Loss Using Static Spacers With Intramedullary Rods. J Arthroplasty 2019; 34:1462-1469. [PMID: 31023514 DOI: 10.1016/j.arth.2019.03.053] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2019] [Revised: 03/06/2019] [Accepted: 03/13/2019] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Two-stage revision with static antibiotic spacers is the preferred treatment for chronically infected total knee arthroplasty (TKA) associated with severe bone loss. Intramedullary rods to reinforce static spacers have been described. On those, however, bacterial colonization may occur and hamper infection control. This study reports the microbiological findings on the spacer rods and the treatment outcome among these patients. METHODS We reviewed 97 infected TKA with extensive bone loss treated with antibiotic-loaded cement spacers reinforced with intramedullary rods. Mean interim period with the spacer in situ was 9 weeks (range: 6-24 weeks). Intraoperative cultures and sonicated spacer rods were analyzed. Mean follow-up after TKA reimplantation was 41 months (range: 27-56 months). Treatment success was defined using the modified Delphi consensus criteria. RESULTS Twenty-two patients (23%) had treatment failure, including 3 reinfections caused by the same organism, 9 reinfections caused by a different organism, 9 patients required interim spacer exchange, and 1 patient died in the early postoperative course. Sonication cultures of the spacer rods were positive in 2 cases (2%), and none of them failed. Host and limb status was significantly worse in patients who sustained reinfection. At the latest follow-up, all patients had a TKA in place, and 2 patients received chronic antibiotic suppression. CONCLUSION Two-stage revision with the use of intramedullary rods is a safe and efficient treatment for chronically infected TKA with severe bone loss. Most reinfections grew different organisms compared with initial infection. Compromised hosts and extremities may be subjected to chronic antibiotic suppression.
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Akgün D, Müller M, Perka C, Winkler T. High cure rate of periprosthetic hip joint infection with multidisciplinary team approach using standardized two-stage exchange. J Orthop Surg Res 2019; 14:78. [PMID: 30866970 PMCID: PMC6415338 DOI: 10.1186/s13018-019-1122-0] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2018] [Accepted: 03/06/2019] [Indexed: 02/08/2023] Open
Abstract
Background Two-stage exchange arthroplasty is still the preferred treatment choice for chronic PJI. However, the results remain unpredictable. We analyzed the treatment success of patients with an infected hip prosthesis, who were treated according to a standardized algorithm with a multidisciplinary team approach and evaluated with a strict definition of failure. Methods In this single-center prospective cohort study, all hip PJI episodes from March 2013 to May 2015 were included. Treatment failure was assessed according to the Delphi-based consensus definition. The Kaplan-Meier survival method was used to estimate the probability of infection-free survival. Patients were dichotomized into two groups depending on the number of previous septic revisions, duration of prosthesis-free interval, positive culture with difficult-to-treat microorganisms, microbiology at explantation, and microbiology at reimplantation. Results Eighty-four patients with hip PJI were the subject of this study. The most common isolated microorganisms were coagulase-negative staphylococci (CNS) followed by Staphylococcus aureus and Propionibacterium. Almost half of the study cohort (46%) had at least one previous septic revision before admission. The Kaplan-Meier estimated infection-free survival after 3 years was 89.3% (95% CI, 80% to 94%) with 30 patients at risk. The mean follow-up was 33.1 months (range, 24–48 months) with successful treatment of PJI. There were no statistical differences in infect eradication rate among the dichotomized groups. Conclusions High infect eradication rates were achieved in a challenging cohort using a standardized two-stage exchange supported by a multidisciplinary approach.
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Affiliation(s)
- Doruk Akgün
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Center for Musculoskeletal Surgery, Berlin, Germany. .,Charite Universitätsmedizin, Augustenburger Platz 1, 13353, Berlin, Germany.
| | - Michael Müller
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Center for Musculoskeletal Surgery, Berlin, Germany
| | - Carsten Perka
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Center for Musculoskeletal Surgery, Berlin, Germany
| | - Tobias Winkler
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Center for Musculoskeletal Surgery, Berlin, Germany
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17
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Outcome of short versus long interval in two-stage exchange for periprosthetic joint infection: a prospective cohort study. Arch Orthop Trauma Surg 2019; 139:295-303. [PMID: 30443674 DOI: 10.1007/s00402-018-3052-4] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2018] [Indexed: 12/17/2022]
Abstract
INTRODUCTION A two-stage exchange is the standard treatment approach for chronic periprosthetic joint infection (PJI). While a 6-8 week interval is commonly used before reimplantation, the optimal length of the prosthesis-free interval has not yet been determined. We evaluated the influence of a short (< 4 weeks) and long (≥ 4 weeks) interval on reinfection rate and functional outcome of hip and knee PJI. METHODS In this prospective cohort, patients undergoing two-stage revision for PJI were assigned to prosthesis reimplantation after a short (< 4 weeks) or long (≥ 4 weeks) interval. All patients received standardized antimicrobial therapy, which consisted of antibiogram-adapted, non-biofilm-active antibiotics during the interval and an antimicrobial combination therapy with biofilm-active antibiotics after reimplantation. Follow-up was performed for infection, joint function, pain, need for care and quality of life. RESULTS Thirty-eight patients undergoing two-stage revision for PJI (18 hips and 20 knees) were included. Short interval was used in 19 patients having a mean interval of 17.9 days (range 7-27 days), long interval in 19 patients having a mean interval of 63.0 days (range 28-204 days). At a mean follow-up of 39.5 months (range 32-48 months), 37 of 38 patients (97.4%) were infection-free. One failure occurred among patients with long interval and none among patients with short interval. Functional results (ROM, HHS, KSS, VAS) and quality of life (SF-36) were similar in both groups. Patients treated with long interval required cumulatively additional 204 inpatient days for nursing care compared to patients with short interval. CONCLUSIONS This study suggests that two-stage exchange with short interval has a similar outcome than with long interval, when highly active antibiotic therapy is used. Patient inconvenience and care costs due to immobilization were lower when strategies with a short interval were used.
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Abdel MP, Barreira P, Battenberg A, Berry DJ, Blevins K, Font-Vizcarra L, Frommelt L, Goswami K, Greiner J, Janz V, Kendoff DO, Limberg AK, Manrique J, Moretti B, Murylev V, O'Byrne J, Petrie MJ, Porteous A, Saleri S, Sandiford NA, Sharma V, Shubnyakov I, Sporer S, Squire MW, Stockley I, Tibbo ME, Turgeon T, Varshneya A, Wellman S, Zahar A. Hip and Knee Section, Treatment, Two-Stage Exchange Spacer-Related: Proceedings of International Consensus on Orthopedic Infections. J Arthroplasty 2019; 34:S427-S438. [PMID: 30348562 DOI: 10.1016/j.arth.2018.09.027] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
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New diagnostic tools for prosthetic joint infection. Orthop Traumatol Surg Res 2019; 105:S23-S30. [PMID: 30056239 DOI: 10.1016/j.otsr.2018.04.029] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Revised: 04/20/2018] [Accepted: 04/26/2018] [Indexed: 02/02/2023]
Abstract
The diagnosis of peri-prosthetic bone and joint infections relies on converging information from clinical, laboratory and imaging assessments. Clinical findings alone may suffice: a sinus tract is a major criterion that establishes the diagnosis of infection. Identifying the causative organism is crucial and requires the early collection of high-quality samples from sites in contact with the prosthetic material. The bacteriological samples may be obtained by aspiration or open surgery. Imaging techniques have undergone remarkable improvements over the last two decades. Ultrasonography can be performed early and can be used to guide a needle biopsy if appropriate. Computed tomography or magnetic resonance imaging shows the extent of bone and/or soft-tissue involvement, provided effective artefact-suppression techniques are applied. Nuclear medicine methods have an undefined place in the diagnostic strategy and their possible role must be evaluated during a multidisciplinary discussion. The array of new laboratory methods introduced in recent years includes microbiological culture techniques, molecular biology tests, antigen and antibody assays and tests for immune markers in blood and/or joint fluid. When the first-line investigations fail to provide a definitive diagnosis, a multidisciplinary discussion at a referral centre for complex osteo-articular infections makes a major contribution to defining the subsequent diagnostic strategy. This lecture focusses on the following six questions: does the clinical assessment still have diagnostic relevance? What is the diagnostic contribution of imaging studies? Must the infection be documented pre-operatively and if so, how? Which microbiological techniques should be used? Which non-microbiological investigations help to diagnosis peri-prosthetic bone and joint infections? What role do referral centres for complex bone and joint infections play in the diagnostic strategy?
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20
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Aalirezaie A, Bauer TW, Fayaz H, Griffin W, Higuera CA, Krenn V, Krenn V, Molano M, Moojen DJ, Restrepo C, Shahi A, Shubnyakov I, Sporer S, Tanavalee A, Teloken M, Velázquez Moreno JD. Hip and Knee Section, Diagnosis, Reimplantation: Proceedings of International Consensus on Orthopedic Infections. J Arthroplasty 2019; 34:S369-S379. [PMID: 30343965 DOI: 10.1016/j.arth.2018.09.021] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
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21
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Abdel MP, Akgün D, Akin G, Akinola B, Alencar P, Amanatullah DF, Babazadeh S, Borens O, Vicente Cabral RM, Cichos KH, Deirmengian C, de Steiger R, Ghanem E, Radtke Gonçalves JR, Goodman S, Hamlin B, Hwang K, Klatt BA, Lee GC, Manrique J, Moon AS, Ogedegbe F, Salib CG, Tian S, Winkler T. Hip and Knee Section, Diagnosis, Pathogen Isolation, Culture: Proceedings of International Consensus on Orthopedic Infections. J Arthroplasty 2019; 34:S361-S367. [PMID: 30343972 DOI: 10.1016/j.arth.2018.09.020] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
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22
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Bian T, Shao H, Zhou Y, Huang Y, Song Y. Tests for predicting reimplantation success of two-stage revision for periprosthetic joint infection: A systematic review and meta-analysis. Orthop Traumatol Surg Res 2018; 104:1115-1123. [PMID: 30030145 DOI: 10.1016/j.otsr.2018.03.017] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2018] [Revised: 03/25/2018] [Accepted: 03/29/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND Several tests are used before reimplantation to detect persistent infection in patients with periprosthetic joint infection (PJI) undergoing two-stage revision. However, there is no consensus as to the optimal tests for excluding persistent infection or predicting successful reimplantation by stage. We aimed to determine the accuracy of different tests used to detect persistent infection after the first stage, and/or predicting failure following reimplantation in patients with PJI. METHODS We conducted a systematic review and meta-analysis of PubMed, Embase and the Cochrane Library databases. Two reviewers independently conducted quality assessments and data extractions to estimate pooled sensitivity and specificity, diagnostic odds ratio and area under the receiver operating characteristic curves (AUSROC) for each test. RESULTS We included 24 studies published between May 1999 and September 2017. Synovial fluid polymorphonuclear neutrophils (PMN)% had the highest sensitivity of 0.70, followed by serum erythrocyte sedimentation rate (0.57) and spacer sonication fluid culture (0.53). Synovial fluid culture had the highest specificity of 0.97, followed by frozen section (0.93) and the Musculoskeletal Infection Society criteria (0.92). Spacer sonication fluid culture was the most accurate test with an AUSROC of 0.8089, followed by synovial fluid culture (0.7749) and frozen section (0.7819). DISCUSSION Spacer sonication fluid culture had a relatively high diagnostic accuracy. We emphasize that no test can be used alone to exclude persistent infection beyond the first stage and/or predict failed reimplantation beyond the second stage. LEVEL OF EVIDENCE II, systematic review and meta-analysis of level 2 to level 4 studies with inconsistent results.
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Affiliation(s)
- Tao Bian
- Department of Orthopedic Surgery, Beijing Jishuitan Hospital, Fourth Clinical College of Peking University, No. 31 Xinjiekou East Street, 100035 Beijing, Xicheng District, China
| | - Hongyi Shao
- Department of Orthopedic Surgery, Beijing Jishuitan Hospital, Fourth Clinical College of Peking University, No. 31 Xinjiekou East Street, 100035 Beijing, Xicheng District, China
| | - Yixin Zhou
- Department of Orthopedic Surgery, Beijing Jishuitan Hospital, Fourth Clinical College of Peking University, No. 31 Xinjiekou East Street, 100035 Beijing, Xicheng District, China.
| | - Yong Huang
- Department of Orthopedic Surgery, Beijing Jishuitan Hospital, Fourth Clinical College of Peking University, No. 31 Xinjiekou East Street, 100035 Beijing, Xicheng District, China
| | - Yang Song
- Department of Orthopedic Surgery, Beijing Jishuitan Hospital, Fourth Clinical College of Peking University, No. 31 Xinjiekou East Street, 100035 Beijing, Xicheng District, China
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Affiliation(s)
- Alex McLaren
- College of Medicine-Phoenix, University of Arizona, Phoenix, Arizona
| | | | - Antonia F Chen
- Brigham and Women's Hospital, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Sandra B Nelson
- Harvard Medical School, Boston, Massachusetts.,Massachusetts General Hospital, Boston, Massachusetts
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24
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Akgün D, Perka C, Trampuz A, Renz N. Outcome of hip and knee periprosthetic joint infections caused by pathogens resistant to biofilm-active antibiotics: results from a prospective cohort study. Arch Orthop Trauma Surg 2018; 138:635-642. [PMID: 29352435 DOI: 10.1007/s00402-018-2886-0] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2017] [Indexed: 02/06/2023]
Abstract
BACKGROUND Periprosthetic joint infections (PJI) caused by pathogens, for which no biofilm-active antibiotics are available, are often referred to as difficult-to-treat (DTT). However, it is unclear whether the outcome of DTT PJI is worse than those of non-DTT PJI. We evaluated the outcome of DTT and non-DTT PJI in a prospective cohort treated with a two-stage exchange according to a standardized algorithm. METHODS Patients with hip and knee PJI from 2013 to 2015 were prospectively included and followed up for ≥ 2 years. DTT PJI was defined as growth of microorganism(s) resistant to all available biofilm-active antibiotics. The Kaplan-Meier survival analysis was used to compare the probability of infection-free survival between DTT and non-DTT PJI and the 95% confidence interval (95% CI) was calculated. RESULTS Among 163 PJI, 30 (18.4%) were classified as DTT and 133 (81.6%) as non-DTT. At a mean follow-up of 33 months (range 24-48 months), the overall treatment success was 82.8%. The infection-free survival rate at 2 years was 80% (95% CI 61-90%) for DTT PJI and 84% (95% CI 76-89%) for non-DTT PJI (p = 0.61). The following mean values were longer in DTT PJI than in non-DTT PJI: hospital stay (45 vs. 28 days; p < 0.001), prosthesis-free interval (89 vs. 58 days; p < 0.001) and duration of antimicrobial treatment (151 vs. 117 days; p = 0.003). CONCLUSIONS The outcome of DTT and non-DTT PJI was similar (80-84%), however, at the cost of longer hospital stay, longer prosthesis-free interval and longer antimicrobial treatment. It remains unclear whether patients undergoing two-stage exchange with a long interval need biofilm-active antibiotics. Further studies need to evaluate the outcome in patients treated with biofilm-active antibiotics undergoing short vs. long interval.
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Affiliation(s)
- Doruk Akgün
- Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Center for Musculoskeletal Surgery, Charité, Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany.
| | - Carsten Perka
- Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Center for Musculoskeletal Surgery, Charité, Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Andrej Trampuz
- Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Center for Musculoskeletal Surgery, Charité, Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Nora Renz
- Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Center for Musculoskeletal Surgery, Charité, Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany
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Akgün D, Müller M, Perka C, Winkler T. A positive bacterial culture during re-implantation is associated with a poor outcome in two-stage exchange arthroplasty for deep infection. Bone Joint J 2017; 99-B:1490-1495. [DOI: 10.1302/0301-620x.99b11.bjj-2017-0243-r1] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2017] [Accepted: 06/29/2017] [Indexed: 01/19/2023]
Abstract
Aims The aim of this study was to identify the incidence of positive cultures during the second stage of a two-stage revision arthroplasty and to analyse the association between positive cultures and an infection-free outcome. Patients and Methods This single-centre retrospective review of prospectively collected data included patients with a periprosthetic joint infection (PJI) of either the hip or the knee between 2013 and 2015, who were treated using a standardised diagnostic and therapeutic algorithm with two-stage exchange. Failure of treatment was assessed according to a definition determined by a Delphi-based consensus. Logistic regression analysis was performed to assess the predictors of positive culture and risk factors for failure. The mean follow-up was 33 months (24 to 48). Results A total of 163 two-stage revision arthroplasties involving 84 total hip arthroplasties (THAs) and 79 total knee arthroplasties (TKAs) were reviewed. In 27 patients (16.6%), ≥ 1 positive culture was identified at re-implantation and eight (29.6%) of these subsequently failed compared with 20 (14.7%) patients who were culture-negative. The same initially infecting organism was isolated at re-implantation in nine of 27 patients (33.3%). The organism causing re-infection in none of the patients was the same as that isolated at re-implantation. The risk of the failure of treatment was significantly higher in patients with a positive culture (odds ratio (OR) 1.7; 95% confidence interval (CI) 1.0 to 3.0; p = 0.049) and in patients with a higher Charlson Comorbidity Index (OR 1.5; 95% CI 1.6 to 1.8; p = 0.001). Conclusion Positive culture at re-implantation was independently associated with subsequent failure. Surgeons need to be aware of this association and should consider the medical optimisation of patients with severe comorbidities both before and during treatment. Cite this article: Bone Joint J 2017;99-B:1490–5.
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Affiliation(s)
- D. Akgün
- Charite – Universitätsmedizin Berlin,
corporate member of Freie Universität Berlin, Humboldt-Universität
zu Berlin and Berlin Institute of Health, Center for Musculoskeletal Surgery, Charitéplatz
1, D-10117 Berlin, Germany
| | - M. Müller
- Charite – Universitätsmedizin Berlin,
corporate member of Freie Universität Berlin, Humboldt-Universität
zu Berlin and Berlin Institute of Health, Center for Musculoskeletal Surgery, Charitéplatz
1, D-10117 Berlin, Germany
| | - C. Perka
- Charite – Universitätsmedizin Berlin,
corporate member of Freie Universität Berlin, Humboldt-Universität
zu Berlin and Berlin Institute of Health, Center for Musculoskeletal Surgery, Charitéplatz
1, D-10117 Berlin, Germany
| | - T. Winkler
- Charite – Universitätsmedizin Berlin,
corporate member of Freie Universität Berlin, Humboldt-Universität
zu Berlin and Berlin Institute of Health, Center for Musculoskeletal Surgery, Charitéplatz
1, D-10117 Berlin, Germany
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