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Vranceanu DM, Ungureanu E, Ionescu IC, Parau AC, Pruna V, Titorencu I, Badea M, Gălbău CȘ, Idomir M, Dinu M, (Dragomir) AV, Cotrut CM. In Vitro Characterization of Hydroxyapatite-Based Coatings Doped with Mg or Zn Electrochemically Deposited on Nanostructured Titanium. Biomimetics (Basel) 2024; 9:244. [PMID: 38667255 PMCID: PMC11047857 DOI: 10.3390/biomimetics9040244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2024] [Revised: 04/04/2024] [Accepted: 04/16/2024] [Indexed: 04/28/2024] Open
Abstract
Biomaterials are an important and integrated part of modern medicine, and their development and improvement are essential. The fundamental requirement of a biomaterial is found to be in its interaction with the surrounding environment, with which it must coexist. The aim of this study was to assess the biological characteristics of hydroxyapatite (HAp)-based coatings doped with Mg and Zn ions obtained by the pulsed galvanostatic electrochemical method on the surface of pure titanium (cp-Ti) functionalized with titanium dioxide nanotubes (NTs TiO2) obtained by anodic oxidation. The obtained results highlighted that the addition of Zn or Mg into the HAp structure enhances the in vitro response of the cp-Ti surface functionalized with NT TiO2. The contact angle and surface free energy showed that all the developed surfaces have a hydrophilic character in comparison with the cp-Ti surface. The HAp-based coatings doped with Zn registered superior values than the ones with Mg, in terms of biomineralization, electrochemical behavior, and cell interaction. Overall, it can be said that the addition of Mg or Zn can enhance the in vitro behavior of the HAp-based coatings in accordance with clinical requirements. Antibacterial tests showed that the proposed HAp-Mg coatings had no efficiency against Escherichia coli, while the HAp-Zn coatings registered the highest antibacterial efficiency.
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Affiliation(s)
- Diana M. Vranceanu
- Faculty of Materials Science and Engineering, National University of Science and Technology Politehnica Bucharest, 313 Splaiul Independentei, 060042 Bucharest, Romania; (D.M.V.)
| | - Elena Ungureanu
- Faculty of Materials Science and Engineering, National University of Science and Technology Politehnica Bucharest, 313 Splaiul Independentei, 060042 Bucharest, Romania; (D.M.V.)
| | - Ionut C. Ionescu
- Faculty of Materials Science and Engineering, National University of Science and Technology Politehnica Bucharest, 313 Splaiul Independentei, 060042 Bucharest, Romania; (D.M.V.)
| | - Anca C. Parau
- National Institute of Research and Development for Optoelectronics INOE2000, 409 Atomistilor, 077125 Magurele, Romania
| | - Vasile Pruna
- Romanian Academy Institute of Cellular Biology and Pathology “Nicolae Simionescu”, 8 B.P. Hasdeu, 050568 Bucharest, Romania
| | - Irina Titorencu
- Romanian Academy Institute of Cellular Biology and Pathology “Nicolae Simionescu”, 8 B.P. Hasdeu, 050568 Bucharest, Romania
| | - Mihaela Badea
- Prophylactic and Clinical Disciplines, Department of Fundamental, Faculty of Medicine, Transilvania University of Brasov, 56 Nicolae Balcescu, 500019 Brasov, Romania
- Research Center for Fundamental Research and Prevention Strategies in Medicine, Research and Development Institute, Transilvania University of Brasov, Romania Institutului, 10, 500484 Brașov, Romania
| | - Cristina-Ștefania Gălbău
- Prophylactic and Clinical Disciplines, Department of Fundamental, Faculty of Medicine, Transilvania University of Brasov, 56 Nicolae Balcescu, 500019 Brasov, Romania
- Research Center for Fundamental Research and Prevention Strategies in Medicine, Research and Development Institute, Transilvania University of Brasov, Romania Institutului, 10, 500484 Brașov, Romania
| | - Mihaela Idomir
- Prophylactic and Clinical Disciplines, Department of Fundamental, Faculty of Medicine, Transilvania University of Brasov, 56 Nicolae Balcescu, 500019 Brasov, Romania
- Research Center for Fundamental Research and Prevention Strategies in Medicine, Research and Development Institute, Transilvania University of Brasov, Romania Institutului, 10, 500484 Brașov, Romania
| | - Mihaela Dinu
- National Institute of Research and Development for Optoelectronics INOE2000, 409 Atomistilor, 077125 Magurele, Romania
| | - Alina Vladescu (Dragomir)
- National Institute of Research and Development for Optoelectronics INOE2000, 409 Atomistilor, 077125 Magurele, Romania
| | - Cosmin M. Cotrut
- Faculty of Materials Science and Engineering, National University of Science and Technology Politehnica Bucharest, 313 Splaiul Independentei, 060042 Bucharest, Romania; (D.M.V.)
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Mirghaderi P, Gholamshahi H, Jahromi A, Iranmehr A, Dabbagh-Ohadi MA, Eshraghi N. Unexpected positive culture (UPC) in adults revision spine surgery: a systematic review and meta-analysis of incidence, risk factors, and management. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2024:10.1007/s00586-024-08229-2. [PMID: 38573385 DOI: 10.1007/s00586-024-08229-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Revised: 03/07/2024] [Accepted: 03/12/2024] [Indexed: 04/05/2024]
Abstract
BACKGROUND Without clear signs of infection, spinal implant failure is attributed to mechanical overloads and aseptic loosening. However, how low-grade infections contribute to seemingly aseptic implant failure is unclear. PURPOSE The systematic review examined unexpected positive cultures (UPCs) in revision spine surgery regarding prevalence, isolated pathogens, risk factors, and strategies to reduce infection among asymptomatic patients undergoing revision spine surgery. METHODS We followed the PRISMA guidelines and searched four main databases (PubMed, EMBASE, SCOPUS, Web of Science) comprehensively until January 2023 for articles reporting UPC after presumed aseptic adult revision spine surgery. The UPC rates were pooled, and risk factors were compared with the culture-negative control group and represented as odds ratio (OR) or mean difference (MD). RESULTS Fifteen studies of 1057 individuals were included in two groups: culture-positive or UPCs (n = 317) and culture-negative or control (n = 740). The overall UPC prevalence was 33.2% (317/1057, range: 0 to 53%, 95% CI = 30.2%-36.4%), and Cutibacterium acnes (43.0%, 95% CI = 37.4%-48.8%), Coagulase-negative Staphylococci (CoNS), (39.5%, 95% CI = 33.2%-46.2%), and Staphylococcus species in general (49.5%, 95%CI = 43.7%-55.4%) were reported the most common isolated microbes. 16.1% of the UPCs were polymicrobial. Risk factors associated with UPC rates were female sex (OR = 2.62, 95%CI = 1.76-3.90, P < 0.001), screw loosening (OR = 4.43, 95%CI = 1.31-15.02, P = 0.02), number of operated levels (MD = 0.77, 95%CI = 0.33-1.22, P = 0.0007), and shorter time since index surgery (MD = - 8.57 months, 95%CI = - 14.76, -2.39, P = 0.02). CONCLUSIONS One-third of patients undergoing spine revision surgery revealed UPC in this study. Each UPC pathogen interpretation and antibiotic use decision should be interpreted case by case. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Peyman Mirghaderi
- Surgical Research Society (SRS), Students' Scientific Research Center, Tehran University of Medical Sciences, Tehran, Iran.
| | - Hediye Gholamshahi
- Surgical Research Society (SRS), Students' Scientific Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Ali Jahromi
- Surgical Research Society (SRS), Students' Scientific Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Arad Iranmehr
- Neurosurgery Department, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammad Amin Dabbagh-Ohadi
- Surgical Research Society (SRS), Students' Scientific Research Center, Tehran University of Medical Sciences, Tehran, Iran
- Students' Scientific Research Center (SSRC), Tehran University of Medical Sciences, Tehran, Iran
| | - Nasim Eshraghi
- Surgical Research Society (SRS), Students' Scientific Research Center, Tehran University of Medical Sciences, Tehran, Iran
- Vali-e-Asr Reproductive Health Research Center, Family Health Research Institute, Tehran University of Medical Sciences, Tehran, Iran
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Sadhwani S, Kamson A, Frear AJ, Sadaka N, Urish KL. Current Concepts on the Clinical and Economic Impact of Periprosthetic Joint Infections. Orthop Clin North Am 2024; 55:151-159. [PMID: 38403362 DOI: 10.1016/j.ocl.2023.09.001] [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
Total joint arthroplasty (TJA) is a common procedure performed throughout the entire world in hopes of alleviating debilitating hip or knee pain. The projected number of TJAs performed in the United States alone is projected to exceed 1.9 million by 2030 and 5 million by 2040. With the significant increase in TJA performed, more periprosthetic joint infections (PJIs) are likely to be encountered. PJIs are a devastating complication of TJA. The economic and clinical burden must be understood and respected to minimize occurrence and allow optimal patient outcomes.
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Affiliation(s)
- Shaan Sadhwani
- Arthritis and Arthroplasty Design Group, Department of Orthopaedic Surgery, School of Medicine, University of Pittsburgh, Pittsburgh, PA 15219, USA; Department of Orthopaedic Surgery, UPMC Central PA, Harrisburg, PA 17109, USA
| | - Anthony Kamson
- Arthritis and Arthroplasty Design Group, Department of Orthopaedic Surgery, School of Medicine, University of Pittsburgh, Pittsburgh, PA 15219, USA; Department of Orthopaedic Surgery, UPMC Central PA, Harrisburg, PA 17109, USA
| | - Andrew J Frear
- Arthritis and Arthroplasty Design Group, Department of Orthopaedic Surgery, School of Medicine, University of Pittsburgh, Pittsburgh, PA 15219, USA
| | - Nadine Sadaka
- Arthritis and Arthroplasty Design Group, Department of Orthopaedic Surgery, School of Medicine, University of Pittsburgh, Pittsburgh, PA 15219, USA
| | - Kenneth L Urish
- Arthritis and Arthroplasty Design Group, Department of Orthopaedic Surgery, School of Medicine, University of Pittsburgh, Pittsburgh, PA 15219, USA; Arthritis and Arthroplasty Design Group, The Bone and Joint Center, Magee Womens Hospital of the University of Pittsburgh Medical Center; Department of Orthopaedic Surgery, Clinical and Translational Science Institute, University of Pittsburgh; Department of Bioengineering, Clinical and Translational Science Institute, University of Pittsburgh.
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Sabater-Martos M, Boadas L, Trebše R, Grenho A, Sanz-Ruiz P, Marais LC, Vaznaisiene D, Ferrari M, Soriano A. Impact of Positive Cultures During the Second Stage of a Two-Stage Exchange: Systematic Review and Meta-Analysis. J Arthroplasty 2024; 39:839-845.e15. [PMID: 37757980 DOI: 10.1016/j.arth.2023.09.022] [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: 06/27/2023] [Revised: 09/13/2023] [Accepted: 09/16/2023] [Indexed: 09/29/2023] Open
Abstract
BACKGROUND Two-stage exchange is a frequently performed procedure in patients who have a periprosthetic joint infection. Positive cultures when performing the second stage are perceived as a risk factor for reinfection. This study aimed to determine the impact of positive cultures during the second stage on the outcome of patients undergoing a 2-stage septic exchange and the impact of stopping the antibiotic treatment before reimplantation. METHODS We systematically searched four databases. We performed a meta-analysis on the risk of complications after positive cultures during second stage and a subgroup analysis by antibiotic holiday period. We included 24 studies. RESULTS Failure in the positive group was 37.0% and in the negative group was 13.7% with an odds ratio (OR) of 4.05. In the subgroup analysis by antibiotic holidays, failure rate without holidays was 15% and with holidays was 17.3% (P = .21). Failure in each group was higher when cultures were positive (without holidays, 25 versus 12.2%, P = .0003, and with holidays 41.1 versus 12.7%, P < .0001), but the risk of failure when cultures were positive was higher in the holiday group (OR 4.798) than in the nonholiday group (OR 2.225) in comparison to those patients who were culture negative at the second stage. CONCLUSIONS Microbiological eradication at second stage was not obtained in 18% of cases and it was associated with a higher failure rate. In patients with positive cultures, withholding antibiotic treatment was associated with lower failure rate. Further studies to define the antibiotic strategy in 2-stage exchange procedure are necessary.
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Affiliation(s)
- Marta Sabater-Martos
- Orthopedic and Traumatology Department, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Laia Boadas
- Orthopedic and Traumatology Department, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Rihard Trebše
- Faculty of Medicine, Valdoltra Orthopedic Hospital, Akaran Slovenija, University of Ljubljana, Ljubljana, Slovenija
| | - André Grenho
- CHULC - Hospital de Curry Cabral Orthopaedics Department, Lisbon, Portugal
| | - Pablo Sanz-Ruiz
- Orthopedic and Traumatology Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Leonard C Marais
- Department of Orthopaedics, School of Clinical Medicine, University of KwaZulu-Natal, KwaZulu-Natal, South Africa
| | - Danguole Vaznaisiene
- Department of Infectious Diseases, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | | | - Alex Soriano
- Department of Infectious Diseases, Hospital Clínic of Barcelona, Barcelona, Spain; University of Barcelona, CIBERINF, Barcelona, Spain
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Youssef Y, Roschke E, Dietze N, Dahse AJ, Chaberny IF, Ranft D, Pempe C, Goralski S, Ghanem M, Kluge R, Lübbert C, Rodloff AC, Roth A. Early-Outcome Differences between Acute and Chronic Periprosthetic Joint Infections-A Retrospective Single-Center Study. Antibiotics (Basel) 2024; 13:198. [PMID: 38534633 DOI: 10.3390/antibiotics13030198] [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: 01/28/2024] [Revised: 02/14/2024] [Accepted: 02/17/2024] [Indexed: 03/28/2024] Open
Abstract
Periprosthetic joint infections (PJI) are serious complications after arthroplasty, associated with high morbidity, mortality, and complex treatment processes. The outcomes of different PJI entities are largely unknown. The aim of this study was to access the early outcomes of different PJI entities. A retrospective, single-center study was conducted. The characteristics and outcomes of patients with PJI treated between 2018 and 2019 were evaluated 12 months after the completion of treatment. Primary endpoints were mortality, relapse free survival (RFS) and postoperative complications (kidney failure, sepsis, admission to ICU). A total of 115 cases were included [19.1% early (EI), 33.0% acute late (ALI), and 47.8% chronic infections (CI)]. Patients with ALI were older (p = 0.023), had higher ASA scores (p = 0.031), preoperative CRP concentrations (p = 0.011), incidence of kidney failure (p = 0.002) and sepsis (p = 0.026). They also tended towards higher in-house mortality (ALI 21.1%, 13.6% EI, 5.5% CI) and admission to ICU (ALI 50.0%, 22.7% EI, 30.9% CI). At 12 months, 15.4% of patients with EI had a relapse, compared to 38.1% in ALI and 36.4% in CI. There are differences in patient characteristics and early outcomes between PJI entities. Patients with EI have better early clinical outcomes. Patients with ALI require special attention during follow-up because they have higher occurrences of relapses and postoperative complications than patients with EI and CI.
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Affiliation(s)
- Yasmin Youssef
- Department of Orthopedics, Traumatology and Plastic Surgery, University Hospital Leipzig, Liebigstraße 20, 04103 Leipzig, Germany
| | - Elisabeth Roschke
- Department of Orthopedics, Traumatology and Plastic Surgery, University Hospital Leipzig, Liebigstraße 20, 04103 Leipzig, Germany
| | - Nadine Dietze
- Institute of Medical Microbiology and Virology, University Hospital Leipzig, Liebigstraße 21, 04103 Leipzig, Germany
| | - Anna-Judith Dahse
- Hospital Pharmacy, University Hospital Leipzig, Liebigstraße 20, 04103 Leipzig, Germany
| | - Iris F Chaberny
- Institute of Hygiene, Hospital Epidemiology and Environmental Health, University Hospital Leipzig, Liebigstraße 22, 04103 Leipzig, Germany
- Institute of Hospital Epidemiology and Environmental Hygiene, University Medical Center Schleswig-Holstein, Arnold-Heller-Str. 3, 24105 Kiel, Germany
| | - Donald Ranft
- Hospital Pharmacy, University Hospital Leipzig, Liebigstraße 20, 04103 Leipzig, Germany
| | - Christina Pempe
- Department of Orthopedics, Traumatology and Plastic Surgery, University Hospital Leipzig, Liebigstraße 20, 04103 Leipzig, Germany
| | - Szymon Goralski
- Department of Orthopedics, Traumatology and Plastic Surgery, University Hospital Leipzig, Liebigstraße 20, 04103 Leipzig, Germany
| | - Mohamed Ghanem
- Department of Orthopedics, Traumatology and Plastic Surgery, University Hospital Leipzig, Liebigstraße 20, 04103 Leipzig, Germany
| | - Regine Kluge
- Department of Nuclear Medicine, University Hospital Leipzig, Liebigstraße 18, 04103 Leipzig, Germany
| | - Christoph Lübbert
- Division of Infectious Diseases and Tropical Medicine, Department of Medicine I, University Hospital Leipzig, Liebigstraße 20, 04103 Leipzig, Germany
- Interdisciplinary Center for Infectious Diseases, University Hospital Leipzig, Liebigstraße 20, 04103 Leipzig, Germany
| | - Arne C Rodloff
- Institute of Medical Microbiology and Virology, University Hospital Leipzig, Liebigstraße 21, 04103 Leipzig, Germany
| | - Andreas Roth
- Department of Orthopedics, Traumatology and Plastic Surgery, University Hospital Leipzig, Liebigstraße 20, 04103 Leipzig, Germany
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Rodriguez-Merchan EC. Re-revision Total Knee Arthroplasty: Causes, Risk Factors and Results. THE ARCHIVES OF BONE AND JOINT SURGERY 2024; 12:328-332. [PMID: 38817414 PMCID: PMC11134262 DOI: 10.22038/abjs.2024.75456.3490] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Accepted: 03/10/2024] [Indexed: 06/01/2024]
Abstract
The rate of re-revision total knee arthroplasty (TKA) ranges between 4% and 10%, depending on the cause of the procedure. Periprosthetic joint infection (PJI) and periprosthetic fracture are the main causes of re-revision TKA. The likelihood of implant survival of re-revision TKA diminishes with each subsequent revision, with PJI being the main cause of multiple revisions. Acute early aseptic revision TKA (within 90 days of surgery) involves a high risk of re-revision at 2 years and a high risk of subsequent PJI. The use of antibiotic-loaded cement is associated with lower risk of re-revision. Patients younger than 50 years experiencing aseptic revision TKA have a 1 in 3 risk of re-revision. Patients revised for instability or having prior TKA revisions have the highest risk of re-revision at 10 years. Patients younger than 55 years experiencing revision TKA have a 5-year revision-free survival of 80%.
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Cance N, Batailler C, Shatrov J, Canetti R, Servien E, Lustig S. Tibial Tubercle Osteotomy in Revision Total Knee Arthroplasty for Periprosthetic Infection: Indications and Outcomes. J Bone Joint Surg Am 2023; 105:1768-1776. [PMID: 37437007 DOI: 10.2106/jbjs.23.00256] [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] [Indexed: 07/14/2023]
Abstract
BACKGROUND Adequate exposure is essential in revision total knee arthroplasty (RTKA). Tibial tubercle osteotomy (TTO) enhances exposure, but its use is controversial in the setting of periprosthetic infection. The purposes of this study were to determine (1) the rates of complications and revisions due to TTO during RTKA in the setting of a periprosthetic infection, (2) the rate of septic failure, and (3) functional outcomes at a minimum 2-year follow-up. METHODS A single-center retrospective study from 2010 to 2020 was performed. The cases of a total of 68 patients who received a TTO during RTKA in the setting of periprosthetic infection with a minimum follow-up of 2 years (mean, 53.3 months; range, 24 to 117 months) were analyzed. Complications and revisions due to TTO were reported. The functional outcomes were assessed using the Knee Society Score (KSS) and range of motion. RESULTS Seven knees (10.3%) had complications secondary to the TTO (3 had fracture-displacement of the TTO; 2, nonunion; 1, delayed union; and 1, wound dehiscence). The mean time to union (and standard deviation) was 3.8 ± 3.2 months (range, 1.5 to 24 months). Two knees (2.9%) underwent a TTO-related revision (1 had wound debridement, and 1 had tibial tubercle osteosynthesis). Eighteen knees (26.5%) had recurrence of infection requiring revision: 17 were managed with debridement, antibiotics, and implant retention (DAIR), and 1 had 2-stage RTKA. Flexion improved after surgery (from a mean of 70° to a mean of 86°; p = 0.009), as did the KSS knee (46.6 to 79; p < 0.001) and function (35.3 to 71.5; p < 0.001) subscores. Overall, 42.6% of infected knees managed with RTKA with the TTO procedure were considered successful without any complication at the last follow-up. Only 2 knees (2.9%) required revision related to the TTO. CONCLUSIONS TTO in RTKA involving periprosthetic infection is an effective surgical exposure aid and has excellent rates of union (97.1%) despite the presence of infection. However, the risk of failure because of persistent or recurrent infection remains high in the first 2 years following RTKA for infection. LEVEL OF EVIDENCE Therapeutic Level IV . See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Nicolas Cance
- Orthopedic Surgery Department, Croix-Rousse Hospital, Lyon, France
| | - Cécile Batailler
- Orthopedic Surgery Department, Croix-Rousse Hospital, Lyon, France
- IFSTTAR, LBMC UMR_T9406, Université Claude Bernard Lyon 1, Université Lyon, Villeurbanne, France
| | - Jobe Shatrov
- Orthopedic Surgery Department, Croix-Rousse Hospital, Lyon, France
- Hornsby and Ku-Ring-Gai Hospital, Sydney, New South Wales, Australia
- Sydney Orthopaedic Research Institute, Sydney, New South Wales, Australia
| | - Robin Canetti
- Orthopedic Surgery Department, Croix-Rousse Hospital, Lyon, France
| | - Elvire Servien
- Orthopedic Surgery Department, Croix-Rousse Hospital, Lyon, France
- EA 7424 - Interuniversity Laboratory of Human Movement Science, Université Claude Bernard Lyon 1, Lyon, France
| | - Sébastien Lustig
- Orthopedic Surgery Department, Croix-Rousse Hospital, Lyon, France
- IFSTTAR, LBMC UMR_T9406, Université Claude Bernard Lyon 1, Université Lyon, Villeurbanne, France
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Lee CR, Kim CW, Park DH, Kwon YU, Yoon JM. Risk of Infection After Septic and Aseptic Revision Total Knee Arthroplasty: A Systematic Review. J Bone Joint Surg Am 2023; 105:1630-1637. [PMID: 37616387 DOI: 10.2106/jbjs.23.00361] [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] [Indexed: 08/26/2023]
Abstract
BACKGROUND The causes of primary total knee arthroplasty (TKA) failure can be divided into septic and aseptic etiologies. It is unclear whether the etiology affects the infection rate after revision TKA. This systematic review was conducted to evaluate whether there is a difference in infection rates between septic and aseptic revision TKA. We hypothesized that infection rates would be higher after septic revision TKA. METHODS The PubMed and Embase databases and the Cochrane Library were searched to find studies evaluating infection rates following septic and aseptic revision TKA. We included studies that compared the postoperative infection rates of a group that received revision TKA for aseptic failure and a group that received 1- or 2-stage revision TKA for septic failure. Studies on re-revision TKA and on revision surgery after partial knee arthroplasty were excluded, as were studies of debridement, antibiotics, and implant retention (DAIR). RESULTS Twelve studies were included in this systematic review. In studies in which 1- or 2-stage revision TKA was performed for septic failure, septic revision TKA had a significantly higher infection rate than aseptic revision TKA (odds ratio [OR], 6.83; 95% confidence interval [CI], 1.54 to 30.33; p = 0.01). Similarly, in studies in which 2-stage revision TKA was performed for septic failure, septic revision TKA had a significantly higher infection rate than aseptic revision TKA (OR, 4.14; 95% CI, 2.33 to 7.36; p < 0.00001). In the comparison of revision TKA for aseptic loosening and septic revision TKA, septic revision TKA had a higher infection rate than aseptic revision TKA (OR, 4.45; 95% CI, 2.28 to 8.70; p < 0.0001). CONCLUSIONS Overall, septic revision TKA had a higher infection rate than aseptic revision TKA. Even when 2-stage revision TKA was performed for septic failure, the infection rate was higher after septic revision TKA than after aseptic revision. Surgeons should explain the relatively high infection rates to patients undergoing revision TKA for septic failure of their primary joint replacement. LEVEL OF EVIDENCE Therapeutic Level IV . See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Chang-Rack Lee
- Department of Orthopedic Surgery, Inje University Busan Paik Hospital, Busan, Republic of Korea
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Shichman I, Ward SA, Lu L, Garceau S, Piuzzi NS, Seyler TM, Schwarzkopf R. Failed 2-Stage Revision Knee Arthroplasty for Periprosthetic Joint Infection-Patient Characteristics and Outcomes. J Arthroplasty 2023; 38:2177-2182. [PMID: 37179023 DOI: 10.1016/j.arth.2023.04.063] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2022] [Revised: 04/26/2023] [Accepted: 04/30/2023] [Indexed: 05/15/2023] Open
Abstract
BACKGROUND Chronic prosthetic joint infection (PJI) is most frequently treated with 2-stage revision in conjunction with antibiotic treatment. The aims of this study were 1) to investigate the characteristics of patients who have recurrent infection following 2-stage revision for PJI and 2) to identify risk factors associated with treatment failure. METHODS A multicenter retrospective review of 90 total knee arthroplasty (TKA) patients who underwent 2-stage revision for treatment of PJI from March 1, 2003 to July 31, 2019, and had recurrent PJI was conducted. The minimum follow-up was 12 months (median follow up of 2.4 years). Microorganisms, subsequent revision, PJI control status, and final joint status were collected. The infection-free survival after initial 2-stage revision was plotted utilizing the Kaplan-Meier method. RESULTS Mean survival time to reinfection was 21.3 months (range, 0.3 to 160.5). There were 14 recurrent infections that were acute PJIs treated with debridement, antibiotics, and implant retention (DAIR), while 76 were chronic and treated with repeat 2-stage revision. The most common pathogen identified for both index and recurrent PJI was coagulase-negative Staphylococci. Pathogen persistence was observed in 14 (22.2%) of recurrent PJIs. In total, 61 (67.8%) patients possessed a prosthetic reimplantation at their most recent follow-up, and 29 (35.6%) patients required intervention following repeat 2-stage. CONCLUSION Overall, 31.1% of the patients obtained infection control after treatment of a failed 2-stage revision due to PJI. The high rate of pathogen persistence and the relatively low survival time to recurrence suggests a need to more closely monitor PJIs cases within 2 years.
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Affiliation(s)
- Ittai Shichman
- Division of Adult Reconstruction, Department of Orthopedic Surgery, NYU Langone Health, New York, New York; Division of Orthopedic Surgery, Tel-Aviv Sourasky Medical Center, Sackler School of Medicine, Tel-Aviv, Israel
| | - Spencer A Ward
- Division of Adult Reconstruction, Department of Orthopedic Surgery, NYU Langone Health, New York, New York
| | - Laura Lu
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Simon Garceau
- Division of Orthopedics, Ottawa University Hospital, Ottawa, Ontario, Canada
| | - Nicolas S Piuzzi
- Department of Orthopedic Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Thorsten M Seyler
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina
| | - Ran Schwarzkopf
- Division of Adult Reconstruction, Department of Orthopedic Surgery, NYU Langone Health, New York, New York
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Li S, Meng Y, Pan J, Sun Y. Novel, static, permanent spacers to treat chronic knee periprosthetic joint infections. INTERNATIONAL ORTHOPAEDICS 2023; 47:2585-2589. [PMID: 37421425 PMCID: PMC10522755 DOI: 10.1007/s00264-023-05884-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/04/2023] [Accepted: 06/28/2023] [Indexed: 07/10/2023]
Abstract
PURPOSE To discuss a static and permanent spacer in the treatment of chronic periprosthetic knee infection. Methods In this study, patients who were diagonised with chronic periprosthetic knee infection and not appropriate to undergo revision operations were included and were treated with static and permanent spacers. Infection recurrence rate was recorded, Visual Analogue Scale (VAS) score and Knee Society Score (KSS) were used to record patients' pain and knee function before the operation and at the final follow-up (minimum 24 months). RESULTS Fifteen patients were identified for this study. Pain and function were significantly improved at the latest follow-up evaluation. One patient had a recurrent infection and underwent amputation. No patients had signs of residual instability at the final follow-up evaluation, and no breakage or subsidence of the antibiotic spacer were identified at the final radiographic follow-up evaluation. CONCLUSION Our study provided evidence that the static and permanent spacer was a reliable salvage procedure to treat periprosthetic knee infection in compromised patients.
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Affiliation(s)
- Shuailei Li
- Henan Luoyang Orthopedic Hospital (Henan Provincial Orthopedic Hospital), Zhengzhou, 450000, Henan, China
| | - Yanyan Meng
- Department of Neurology, Zhengzhou Central Hospital, Zhengzhou, 450000, Henan, China
| | - Jiankang Pan
- Henan Luoyang Orthopedic Hospital (Henan Provincial Orthopedic Hospital), Zhengzhou, 450000, Henan, China.
| | - Yongqiang Sun
- Henan Luoyang Orthopedic Hospital (Henan Provincial Orthopedic Hospital), Zhengzhou, 450000, Henan, China.
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11
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Walker LC, Clement ND, Yapp LZ, Deehan DJ. Change in organism between first- and second-stage revision for periprosthetic joint infection of knee arthroplasty independently associated with increased risk of failure. Bone Jt Open 2023; 4:720-727. [PMID: 37730212 PMCID: PMC10511290 DOI: 10.1302/2633-1462.49.bjo-2023-0067.r1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/22/2023] Open
Abstract
Aims Achievement of accurate microbiological diagnosis prior to revision is key to reducing the high rates of persistent infection after revision knee surgery. The effect of change in the microorganism between the first- and second-stage revision of total knee arthroplasty for periprosthetic joint infection (PJI) on the success of management is not clear. Methods A two-centre retrospective cohort study was conducted to review the outcome of patients who have undergone two-stage revision for treatment of knee arthroplasty PJI, focusing specifically on isolated micro-organisms at both the first- and second-stage procedure. Patient demographics, medical, and orthopaedic history data, including postoperative outcomes and subsequent treatment, were obtained from the electronic records and medical notes. Results The study cohort consisted of 84 patients, of whom 59.5% (n = 50) had successful eradication of their infection at a mean follow-up of 4.7 years. For the 34 patients who had recurrence of infection, 58.8% (n = 20) had a change in isolated organism, compared to 18% (n = 9) in the infection eradication group (p < 0.001). When adjusting for confound, there was no association when the growth on the second stage was the same as the first (odd ratio (OR) 2.50, 95% confidence interval (CI) 0.49 to 12.50; p = 0.269); however, when a different organism was identified at the second stage, this was independently associated with failure of treatment (OR 8.40, 95% CI 2.91 to 24.39; p < 0.001). There were no other significant differences between the two cohorts with regard to patient demographics or type of organisms isolated. Conclusion Change in the identified microorganism between first- and second-stage revision for PJI was associated with failure of management. Identification of this change in the microorganism prior to commencement of the second stage may help target antibiotic management and could improve the success of surgery in these patients.
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Affiliation(s)
- Lucy C. Walker
- Wessex Deanery, Health Education England, Winchester, UK
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12
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Hulleman CWJ, de Windt TS, Veerman K, Goosen JHM, Wagenaar FCBM, van Hellemondt GG. Debridement, Antibiotics and Implant Retention: A Systematic Review of Strategies for Treatment of Early Infections after Revision Total Knee Arthroplasty. J Clin Med 2023; 12:5026. [PMID: 37568428 PMCID: PMC10419891 DOI: 10.3390/jcm12155026] [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: 07/06/2023] [Revised: 07/26/2023] [Accepted: 07/27/2023] [Indexed: 08/13/2023] Open
Abstract
GOAL The purpose of this review is to provide a systematic and comprehensive overview of the available literature on the treatment of an early prosthetic joint infection (PJI) after revision total knee arthroplasty (TKA) and provide treatment guidelines. METHODS This systematic review was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. The search was conducted using the electronic databases of PubMed, Trip, Cochrane, Embase, LILACS and SciElo. After the inclusion of the relevant articles, we extracted the data and results to compose a treatment algorithm for early and acute PJI after revision TKA. RESULTS After applying the in- and exclusion criteria, seven articles were included in this systematic review focusing on debridement, antibiotics and implant retention (DAIR) for PJI following revision TKA, of which one was prospective and six were retrospective. All studies were qualified as level IV evidence. CONCLUSIONS The current literature suggests that DAIR is a valid treatment option for early infections after revision TKA with success rates of 50-70%. Repeat DAIR shows success rates of around 50%. Further research should be aimed at predicting successful (repeat/two-stage) DAIRs in larger study populations, antibiotic regimes and the cost effectiveness of a second DAIR after revision TKA.
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Affiliation(s)
- Caspar W. J. Hulleman
- Sint Maartenskliniek, Orthopedic Surgery, 6574 NA Nijmegen, The Netherlands; (C.W.J.H.)
| | - Tommy S. de Windt
- Orthopedisch Centrum Oost Nederland, Orthopedic Center, 7555 DL Hengelo, The Netherlands
| | - Karin Veerman
- Sint Maartenskliniek, Orthopedic Surgery, 6574 NA Nijmegen, The Netherlands; (C.W.J.H.)
| | - Jon H. M. Goosen
- Sint Maartenskliniek, Orthopedic Surgery, 6574 NA Nijmegen, The Netherlands; (C.W.J.H.)
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13
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Yu JS, Bornes TD, Youssef M, Tam KW, Nocon AA, Sculco PK, Carli AV. Which Combination is Best? A Comparison of the Predictive Potential of Serum Biomarker Combinations to Diagnose Periprosthetic Joint Infection. J Arthroplasty 2023:S0883-5403(23)00549-1. [PMID: 37230226 DOI: 10.1016/j.arth.2023.05.025] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Revised: 05/09/2023] [Accepted: 05/15/2023] [Indexed: 05/27/2023] Open
Abstract
BACKGROUND Without a gold standard test, recent periprosthetic joint infections (PJI) literature has explored the utility of combining serological results, with promising findings. However, previous studies evaluated fewer than 200 patients and often studied only 1 to 2 test combinations. The purpose of this study was to accumulate a large single institution cohort of revision total joint arthroplasty (rTJA) patients to determine the diagnostic utility of combination serum biomarkers to identify PJI. METHODS A single institution longitudinal database was assessed to identify all patients who underwent rTJA from 2017 to 2020. There were 1,363 rTJA patients (715 rTKA patients and 648 rTHA patients) including 273 PJI cases (20%) analyzed. The PJI was diagnosed post-rTJA utilizing 2011 Musculoskeletal Infection Society (MSIS) criteria. Erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), D-dimer, and interleukin 6 (IL-6) were systematically collected for all patients. RESULTS The rTKA combination markers of CRP+ESR (sensitivity: 78.3%, specificity: 88.8%, positive predictive value (PPV): 70.0%, negative predictive value (NPV): 92.5%), CRP+D-dimer (sensitivity: 60.5%, specificity: 92.6%, PPV: 63.4%, NPV: 91.7%), and CRP+IL-6 (sensitivity: 38.5%, specificity: 100.0%, PPV: 100.0%, NPV: 92.9%) all yielded higher specificity than CRP alone (sensitivity: 94.4%, specificity: 75.0%, PPV: 55.5%, NPV: 97.6%). Similarly, the rTHA combination markers of CRP+ESR (sensitivity: 70.1%, specificity: 88.8%, PPV: 58.1%, NPV: 93.1%), CRP+D-dimer (sensitivity: 57.1%, specificity: 90.1%, PPV: 43.2%, NPV: 94.1%), and CRP+IL-6 (sensitivity: 21.4%, specificity: 98.4%, PPV: 60.0%, NPV: 91.7%) all yielded higher specificity than CRP alone (sensitivity: 84.7%, specificity: 77.5%, PPV: 45.4%, NPV: 95.8%). CONCLUSIONS Overall, in diagnosing PJI for both rTKA and rTHA, two marker combinations yielded higher specificity, while three marker combinations yielded higher sensitivity compared to CRP alone. However, compared to all two and three marker combinations, CRP demonstrated superior overall diagnostic utility. These findings suggest that routine combination testing of markers for PJI diagnosis may be excessive and an unnecessary use of resources, especially in resource-limited situations.
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Affiliation(s)
- Jonathan S Yu
- Stavros Niarchos Complex Joint Reconstruction Center, Adult Reconstruction and Joint Replacement Service, Hospital for Special Surgery, New York, NY; Weill Cornell Medical College, New York, NY.
| | - Troy D Bornes
- Stavros Niarchos Complex Joint Reconstruction Center, Adult Reconstruction and Joint Replacement Service, Hospital for Special Surgery, New York, NY
| | - Mark Youssef
- Stavros Niarchos Complex Joint Reconstruction Center, Adult Reconstruction and Joint Replacement Service, Hospital for Special Surgery, New York, NY
| | - Kathleen W Tam
- Stavros Niarchos Complex Joint Reconstruction Center, Adult Reconstruction and Joint Replacement Service, Hospital for Special Surgery, New York, NY
| | - Allina A Nocon
- Stavros Niarchos Complex Joint Reconstruction Center, Adult Reconstruction and Joint Replacement Service, Hospital for Special Surgery, New York, NY
| | - Peter K Sculco
- Stavros Niarchos Complex Joint Reconstruction Center, Adult Reconstruction and Joint Replacement Service, Hospital for Special Surgery, New York, NY
| | - Alberto V Carli
- Stavros Niarchos Complex Joint Reconstruction Center, Adult Reconstruction and Joint Replacement Service, Hospital for Special Surgery, New York, NY
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14
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Saliba L, Sammut K, Tonna C, Pavli F, Valdramidis V, Gatt R, Giordmaina R, Camilleri L, Atanasio W, Buhagiar J, Schembri Wismayer P. FeMn and FeMnAg biodegradable alloys: An in vitro and in vivo investigation. Heliyon 2023; 9:e15671. [PMID: 37159706 PMCID: PMC10163621 DOI: 10.1016/j.heliyon.2023.e15671] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Revised: 04/16/2023] [Accepted: 04/18/2023] [Indexed: 05/11/2023] Open
Abstract
Iron-based biodegradable metal bone graft substitutes are in their infancy but promise to fill bone defects that arise after incidents such as trauma and revision arthroplasty surgery. Before clinical use however, a better understanding of their in vivo biodegradability, potential cytotoxicity and biocompatibility is required. In addition, these implants must ideally be able to resist infection, a complication of any implant surgery. In this study there was significant in vitro cytotoxicity caused by pure Fe, FeMn, FeMn1Ag and FeMn5Ag on both human foetal osteoblast (hFOB) and mouse pre-osteoblast (MC3T3-E1) cell lines. In vivo experiments on the other hand showed no signs of ill-effect on GAERS rats with the implanted FeMn, FeMn1Ag and FeMn5Ag pins being removed largely uncorroded. All Fe-alloys showed anti-bacterial performance but most markedly so in the Ag-containing alloys, there is significant bacterial resistance in vitro.
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Affiliation(s)
- Luke Saliba
- Department of Trauma, Orthopaedics and Sports Medicine, Mater Dei Hospital, Msida, MSD 2090, Malta
- Department of Anatomy, University of Malta, Msida, MSD 2080, Malta
| | - Keith Sammut
- Department of Trauma, Orthopaedics and Sports Medicine, Mater Dei Hospital, Msida, MSD 2090, Malta
- Department of Anatomy, University of Malta, Msida, MSD 2080, Malta
| | - Christabelle Tonna
- Department of Metallurgy and Materials Engineering, University of Malta, Msida, MSD 2080, Malta
| | - Foteini Pavli
- Department of Food Sciences and Nutrition, University of Malta, Msida, MSD 2080, Malta
| | - Vasilis Valdramidis
- Department of Food Sciences and Nutrition, University of Malta, Msida, MSD 2080, Malta
| | - Ray Gatt
- Department of Trauma, Orthopaedics and Sports Medicine, Mater Dei Hospital, Msida, MSD 2090, Malta
| | - Ryan Giordmaina
- Department of Trauma, Orthopaedics and Sports Medicine, Mater Dei Hospital, Msida, MSD 2090, Malta
| | - Liberato Camilleri
- Department of Statistics and Operations Research, University of Malta, Msida, MSD 2080, Malta
| | - William Atanasio
- Mortuary and Anatomic Pathology Department, Mater Dei Hospital, Msida, MSD 2090, Malta
| | - Joseph Buhagiar
- Department of Metallurgy and Materials Engineering, University of Malta, Msida, MSD 2080, Malta
- Corresponding author.
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15
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Li F, Qiao Y, Zhang H, Cao G, Zhou S. Comparable clinical outcomes of culture-negative and culture-positive periprosthetic joint infections: a systematic review and meta-analysis. J Orthop Surg Res 2023; 18:210. [PMID: 36927390 PMCID: PMC10018887 DOI: 10.1186/s13018-023-03692-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Accepted: 03/08/2023] [Indexed: 03/18/2023] Open
Abstract
PURPOSE The aim of this study was to compare the clinical outcomes of culture-negative periprosthetic joint infection (CN PJI) with those of culture-positive periprosthetic joint infection (CP PJI). METHODS Data were obtained from Embase, Web of Science and EBSCO for all available studies comparing the clinical outcomes of CN PJI with those of CP PJI. The quality of the studies was scored using the Newcastle-Ottawa scale (NOS). Pooled odds ratios (ORs) and 95% confidence intervals (CIs) were used to assess clinical outcomes. Subgroup analyses were performed to explain heterogeneity among the included studies. Publication bias was estimated using Begg's funnel plot. Sensitivity analysis was performed to test the stability of pooled results. RESULTS Thirty studies with 1630 (38.7%) CN PJI and 2577 (61.3%) CP PJI were included in this meta-analysis. The pooled results of the included studies showed that overall failure rate in CN PJI group (19.0%, 309/1630) was significantly lower than that in CP PJI group (23.4%, 604/2577) (OR 0.63, 95% CI 0.47-0.84, P = 0.002). We performed the subgroup analysis based on the surgical strategies, the pooled results of nine studies for patients undergoing debridement, antibiotics and implant retention (DAIR) revealed that failure rate in CN PJI group (22.2%, 53/239) was significantly lower than that in CP PJI group (29.3%, 227/775) (OR 0.62, 95% CI 0.43-0.90, P = 0.01), the pooled results of four studies for patients undergoing one-stage revision revealed that failure rate between CN PJI group (11.5%, 11/96) and CP PJI group (7.6%, 27/355) had no significant difference (OR 1.57, 95% CI 0.75-3.26, P = 0.23), and the pooled results of 19 studies for patients undergoing two-stage revision revealed that failure rate in CN PJI group (16.1%, 171/1062) was significantly lower than that in CP PJI group (20.4%, 206/1010) (OR 0.52, 95% CI 0.34-0.79, P = 0.002). CONCLUSIONS CN PJI group had similar or better survival rate when compared with CP PJI group for patients who underwent DAIR, one-stage or two-stage revision. Negative culture was not a worse prognostic factor for PJI.
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Affiliation(s)
- Feng Li
- Department of Joint Surgery, The 940th Hospital of Joint Logistic Support Force of Chinese People's Liberation Army, Gansu, Lanzhou, China.,Department of Orthopaedics, The 943rd Hospital of Joint Logistic Support Force of Chinese People's Liberation Army, Gansu, Wuwei, China
| | - Yongjie Qiao
- Department of Joint Surgery, The 940th Hospital of Joint Logistic Support Force of Chinese People's Liberation Army, Gansu, Lanzhou, China
| | - Haoqiang Zhang
- Department of Joint Surgery, The 940th Hospital of Joint Logistic Support Force of Chinese People's Liberation Army, Gansu, Lanzhou, China
| | - Guoding Cao
- Department of Orthopaedics, Lanzhou University Second Hospital, Gansu, Lanzhou, China
| | - Shenghu Zhou
- Department of Joint Surgery, The 940th Hospital of Joint Logistic Support Force of Chinese People's Liberation Army, Gansu, Lanzhou, China.
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16
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Rajgor H, Dong H, Nandra R, Parry M, Stevenson J, Jeys L. Repeat revision TKR for failed management of peri-prosthetic infection has long-term success but often require multiple operations: a case control study. Arch Orthop Trauma Surg 2023; 143:987-994. [PMID: 35980459 DOI: 10.1007/s00402-022-04594-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Accepted: 08/10/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND Prosthetic joint infection (PJI) is associated with poor outcomes and catastrophic complications. The aim of this study was to present the outcomes of re-revision surgery for PJI of the knee following previous failed two-stage exchange arthroplasty. MATERIALS AND METHODS A retrospective analysis was performed of 32 patients who underwent re-revision knee arthroplasty, having already undergone at least one previous two-stage exchange for PJI with a minimum follow-up of two-years for alive patients. Outcomes were compared to a matched control of two-stage revisions for PJI of a primary knee replacement also containing 32 patients. Outcomes investigated were eradication of infection, re-operation, mortality and limb-salvage rate. RESULTS Successful eradication of infection was achieved in 50% of patients following re-revision surgery, compared with 91% following two-stage exchange of primary knee replacement for PJI (p < 0.001). Fourteen (44%) patients required further re-operation compared with three (9%) patients in the primary group (p = 0.006). Amputation was performed in one case (3%) with thirteen patients (92%) who had infection controlled by debridement, antibiotics and implant retention (DAIR), further revision surgery or arthrodesis. Two patients died with infection (6%) and the long-term rate for infection control was 91%. The mean number of procedures following surgery for the re-revision group was 2.8 (0-9) compared with 0.13 (0-1) for the primary two-stage group (p < 0.001). Five-year patient survival was 90.6% (95% CI 77.1-100). The limb-salvage rate for the re-revision cohort was 97%. CONCLUSION Outcomes for re-revision knee arthroplasty for PJI have higher re-operation and failure rates, but no worse mortality than in revisions of primary knee replacements. Failures can successfully be managed by further operation.
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Affiliation(s)
- Harshad Rajgor
- Trauma and Orthopaedic Registrar, The Royal Orthopaedic Hospital NHS Foundation Trust, Bristol Road South, Northfield, Birmingham, B31 2AP, UK
| | - Huan Dong
- Trauma and Orthopaedic Registrar, The Royal Orthopaedic Hospital NHS Foundation Trust, Bristol Road South, Northfield, Birmingham, B31 2AP, UK
| | - Raj Nandra
- Trauma and Orthopaedic Registrar, The Royal Orthopaedic Hospital NHS Foundation Trust, Bristol Road South, Northfield, Birmingham, B31 2AP, UK
| | - Michael Parry
- Consultant Orthopaedic Oncology and Arthroplasty Surgeon, The Royal Orthopaedic Hospital NHS Foundation Trust, Bristol Road South, Northfield, Birmingham, B31 2AP, UK.,Senior Clinical Lecturer, Aston University Medical School, Aston University, Birmingham, UK
| | - Jonathan Stevenson
- Consultant Orthopaedic Oncology and Arthroplasty Surgeon, The Royal Orthopaedic Hospital NHS Foundation Trust, Bristol Road South, Northfield, Birmingham, B31 2AP, UK. .,Senior Clinical Lecturer, Aston University Medical School, Aston University, Birmingham, UK.
| | - Lee Jeys
- Consultant Orthopaedic Oncology and Arthroplasty Surgeon, The Royal Orthopaedic Hospital NHS Foundation Trust, Bristol Road South, Northfield, Birmingham, B31 2AP, UK.,Professor of Life Sciences, Aston University, Birmingham, UK
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17
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Frank BJH, Simon S, Aichmair A, Dominkus M, Hofstaetter JG. Clinical impact of microbiological results in two-stage revision arthroplasty with spacer exchange. Arch Orthop Trauma Surg 2023:10.1007/s00402-023-04770-9. [PMID: 36689002 DOI: 10.1007/s00402-023-04770-9] [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: 01/13/2022] [Accepted: 01/07/2023] [Indexed: 01/24/2023]
Abstract
INTRODUCTION Patients who require a spacer exchange as part of a two-stage procedure for the treatment of periprosthetic hip and knee joint infections (PJI) have high failure rates. Little is known about the clinical impact of microbiological results and changes in the microbiological spectrum and resistance pattern in these patients. MATERIAL AND METHODS Between 01/2011 and 12/2019, 312 patients underwent a total of 327 two-stage revision arthroplasties at our institution. A spacer exchange was required in 52/312 (16.7%) patients (27 knee/25 hip). Microbiological results, antibiotic resistance patterns, patient's host factors as well as re-revision and re-infection rates at a median follow-up of 47.8 months (range 12.2-116.7 months) were analyzed. A propensity score (PS)-matched analysis of patients who underwent spacer exchange and patients treated with standard two-stage procedure was performed. RESULTS We found a high number of microbiological spectrum changes in patients with multiple culture positive procedures between explantations and spacer exchanges (10/12 [83.3%]), spacer exchanges and reimplantations (3/4 [75%]) as well as between reimplantations and subsequent re-revision surgeries (5/6 [83.3%]). In 9/52 (17.3%) patients, same microorganisms were detected repeatedly in two different procedures. We observed changes in the antibiotic resistance patterns in 6/9 (66.7%) of these patients. High re-infection rates were found in patients with culture positive reimplantations (10/12 [83.3%]), and low re-infection rates were found in patients with culture negative reimplantations (2/40 [5%]; p < 0.001). Between patients with and without spacer exchange, no differences were found in the re-revision rates (13/52 [25%] with vs. 13/52 [25%] without; p = 1.00) as well as re-infection rates (12/52 [23.1%] with vs. 8/52 [15.4%] without; p = 0.32). CONCLUSIONS Changes in microbiological spectrum and antibiotic resistance patterns between stages are common in patients who require a spacer exchange. If eradication of the microorganism at reimplantation can be accomplished, comparable re-revision rates to standard two-stage procedures can be achieved.
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Affiliation(s)
- Bernhard J H Frank
- Michael Ogon Laboratory for Orthopaedic Research, Orthopaedic Hospital Vienna-Speising, Speisinger Strasse 109, 1130, Vienna, Austria.,2nd Department, Orthopaedic Hospital Vienna-Speising, Speisinger Strasse 109, 1130, Vienna, Austria
| | - Sebastian Simon
- Michael Ogon Laboratory for Orthopaedic Research, Orthopaedic Hospital Vienna-Speising, Speisinger Strasse 109, 1130, Vienna, Austria.,2nd Department, Orthopaedic Hospital Vienna-Speising, Speisinger Strasse 109, 1130, Vienna, Austria
| | - Alexander Aichmair
- Michael Ogon Laboratory for Orthopaedic Research, Orthopaedic Hospital Vienna-Speising, Speisinger Strasse 109, 1130, Vienna, Austria.,2nd Department, Orthopaedic Hospital Vienna-Speising, Speisinger Strasse 109, 1130, Vienna, Austria
| | - Martin Dominkus
- 2nd Department, Orthopaedic Hospital Vienna-Speising, Speisinger Strasse 109, 1130, Vienna, Austria.,School of Medicine, Sigmund Freud University Vienna, Freudplatz 1, 1020, Vienna, Austria
| | - Jochen G Hofstaetter
- Michael Ogon Laboratory for Orthopaedic Research, Orthopaedic Hospital Vienna-Speising, Speisinger Strasse 109, 1130, Vienna, Austria. .,2nd Department, Orthopaedic Hospital Vienna-Speising, Speisinger Strasse 109, 1130, Vienna, Austria.
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18
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Kloos J, Vander Linden K, Vermote S, Berger P, Vandenneucker H. Prevalence, interpretation, and management of unexpected positive cultures in revision TKA: a systematic review. Knee Surg Sports Traumatol Arthrosc 2022; 30:3998-4009. [PMID: 35031821 DOI: 10.1007/s00167-021-06856-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Accepted: 12/21/2021] [Indexed: 10/19/2022]
Abstract
PURPOSE Unexpected positive intraoperative cultures (UPIC) found in revision total knee arthroplasty (TKA) are difficult to interpret. Management goes along with risks for both over- and undertreating a potential periprosthetic joint infection (PJI). The objective of this systematic review was to determine the prevalence of UPIC in revision TKA surgery, evaluate the diagnostic workup process and the postoperative treatment, and assess outcome regarding re-revision rates. METHODS Evidence was gathered from Medline (PubMed) and Embase published from January 2000 until April 2021. Nine studies with data of UPIC in revision TKA and outcome after at least 2 years of follow-up were identified. RESULTS The calculated prevalence of UPIC in aseptic knee revision surgery was 8.32%. However, the diagnostical approach differs as well as the used criteria to confirm PJI in presumed aseptic revision surgery. The work-up generally consists of a serum C-reactive protein and Erythrocyte Sedimentation Rate, joint fluid aspiration for culture and white blood cell count and formula, and radiographic imaging. Collection of intraoperative cultures is widely used, but inconsistent in sample amount and incubation time. Once a single UPIC is found, surgeons tend to treat it in different ways. Regarding re-revision rates, the weighted arithmetic mean in the included studies was 18.45% in the unsuspected PJI group compared to 2.94% in the aseptic group. There also seems to be a trend towards higher re-revision rates when a higher number of intraoperative cultures are positive. CONCLUSION The interpretation of UPIC in revision TKA is of utmost importance since the decision whether to treat a UPIC as an unsuspected PJI has a major impact on implant survival and re-revision rate. Different criteria are used to differentiate between unsuspected PJI and contamination in true aseptic failure, and the heterogeneity amongst the included papers impedes to state a clear recommendation, integrating not only quantitative findings, but also qualitative data such as virulence of the identified microorganism. LEVEL OF EVIDENCE Systematic review, III.
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Affiliation(s)
- Johannes Kloos
- Department of Orthopaedic Surgery, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium.
| | - Koen Vander Linden
- Department of Orthopaedic Surgery, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Stijn Vermote
- Department of Orthopaedic Surgery, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Pieter Berger
- Department of Orthopaedic Surgery, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Hilde Vandenneucker
- Department of Orthopaedic Surgery, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium
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19
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Xu H, Liu L, Xie J, Huang Q, Lai Y, Zhou Z. Plasma fibrinogen: a sensitive biomarker for the screening of periprosthetic joint infection in patients undergoing re-revision arthroplasty. BMC Musculoskelet Disord 2022; 23:520. [PMID: 35650619 PMCID: PMC9158301 DOI: 10.1186/s12891-022-05476-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Accepted: 05/16/2022] [Indexed: 02/08/2023] Open
Abstract
Background Although serum C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), plasma fibrinogen and neutrophil–lymphocyte ratio (NLR) are promising biomarkers for screening PJI in patients undergoing revision arthroplasty, their efficacy with respect to re-revision arthroplasty remains unclear. Methods We included patients who underwent re-revision arthroplasty at our hospital during 2008–2020, and stratified them into two groups whether they had been diagnosed with PJI (infected) or aseptic failure (non-infected) according to the 2013 International Consensus Meeting criteria. We evaluated the diagnostic performance of CRP, ESR, fibrinogen and NLR, both individually and in combinations, based on sensitivity, specificity, and area under the receiver operating characteristic curve. Results Of the 63 included patients, 32 were diagnosed with PJI. The area under the ROC curve was 0.821 for CRP, 0.794 for ESR, 0.885 for fibrinogen and 0.702 for NLR. CRP gave a sensitivity of 87.5% and specificity of 74.2% with an optimal predictive cut-off of 8.50 mg/mL. ESR gave a sensitivity of 81.3% and specificity of 71.0% with an optimal predictive cut-off of 33 mm/h. Plasma fibrinogen gave a comparatively higher sensitivity of 93.8% and specificity of 77.4% with an optimal predictive cut-off of 3.55 g/L, while NLR gave a moderate sensitivity of 84.4% but low specificity of 54.8% with an optimal predictive cut-off of 2.30. The combination of fibrinogen and CRP gave a high AUC of 0.897, an acceptable sensitivity of 75% and a high specificity 93.5%. Conclusions Plasma fibrinogen is a cost-effective, convenient biomarker that can be used to rule out PJI in patients scheduled for re-revision arthroplasty. In combination with CRP, it may be effective in diagnosing PJI in such patients.
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Affiliation(s)
- Hong Xu
- Department of Orthopaedic Surgery, West China Hospital, Sichuan University, No.37, Guoxue Road, Wuhou District, Chengdu, 610041, Sichuan, China
| | - Li Liu
- Department of Orthopaedic Surgery, West China Hospital, Sichuan University/West China School of Nursing, Sichuan University, No.37, Guoxue Road, Wuhou district, Chengdu, 610041, Sichuan, China
| | - Jinwei Xie
- Department of Orthopaedic Surgery, West China Hospital, Sichuan University, No.37, Guoxue Road, Wuhou District, Chengdu, 610041, Sichuan, China
| | - Qiang Huang
- Department of Orthopaedic Surgery, West China Hospital, Sichuan University, No.37, Guoxue Road, Wuhou District, Chengdu, 610041, Sichuan, China
| | - Yahao Lai
- Department of Orthopaedic Surgery, West China Hospital, Sichuan University, No.37, Guoxue Road, Wuhou District, Chengdu, 610041, Sichuan, China
| | - Zongke Zhou
- Department of Orthopaedic Surgery, West China Hospital, Sichuan University, No.37, Guoxue Road, Wuhou District, Chengdu, 610041, Sichuan, China.
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20
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Nabet A, Sax OC, Shanoada R, Conway JD, Mont MA, Delanois RE, Nace J. Survival and Outcomes of 1.5-Stage vs 2-Stage Exchange Total Knee Arthroplasty Following Prosthetic Joint Infection. J Arthroplasty 2022; 37:936-941. [PMID: 35093542 DOI: 10.1016/j.arth.2022.01.043] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Revised: 01/08/2022] [Accepted: 01/18/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Traditional management of prosthetic joint infection following total knee arthroplasty (TKA) consists of a 2-stage approach. However, 1.5-stage exchange has seen preliminary success, whereby metal femoral and all-polyethylene tibia components are placed without intention for subsequent second stage. We sought to examine all patients who underwent a 1.5-stage exchange TKA at a single institution compared to historical 2-stage controls. We assessed the following: (1) infection-free survivorship and risk factors for reinfection; (2) 1-year surgical/medical outcomes; (3) patient-reported outcomes (ie, Knee Injury and Osteoarthritis Outcome Score for Joint Replacement [KOOS JR]); and (4) radiographic outcomes. METHODS We reviewed all patients undergoing a 1.5-stage (between 2015 and 2019) and 2-stage exchange TKA (between 2011 and 2016) at a single institution. A total of 162 knees were included (1.5-stage: 114; 2-stage: 48) with mean clinical follow-up of 2.6 years. KOOS JR scores and radiographic outcomes were evaluated at last clinical follow-up. RESULTS The 1.5-stage exchange TKA resulted in a 10.1% difference in infection-free survival (85.1% vs 75.0%, P = .158), compared to 2-stage exchange. Prior prosthetic joint infection was found to be an independent risk factor for reinfection (P = .030). Overall, postoperative complications were lower among 1.5-stage exchanges (8.8% vs 31.3%, P < .001). KOOS JR scores improved more from baseline among 1.5-staged (Δ24.7 vs Δ16.6, P < .001). Radiographic review did not demonstrate any progressive radiolucent lines, subsidences, or failures in either group. CONCLUSION A 1.5-stage exchange TKA is an effective alternative to the traditional 2-stage protocols with noninferior infection eradication and absence of radiographic complications at over 2 years of mean follow-up.
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Affiliation(s)
- Austin Nabet
- Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, MD
| | - Oliver C Sax
- Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, MD
| | - Roni Shanoada
- Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, MD
| | - Janet D Conway
- Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, MD
| | - Michael A Mont
- Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, MD
| | - Ronald E Delanois
- Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, MD
| | - James Nace
- Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, MD
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21
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Chuang CA, Lee SH, Chang CH, Hu CC, Shih HN, Ueng SWN, Chang Y. Application of structural allogenous bone graft in two-stage exchange arthroplasty for knee periprosthetic joint infection: a case control study. BMC Musculoskelet Disord 2022; 23:325. [PMID: 35382827 PMCID: PMC8985362 DOI: 10.1186/s12891-022-05228-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Accepted: 03/14/2022] [Indexed: 12/03/2022] Open
Abstract
Background Knee prosthetic joint infection (PJI) is a common but devastating complication after knee arthroplasty. The revision surgeries for knee PJI may become more challenging when it is associated with large bone defects. The application of structural bone allograft in knee revision surgeries with large bone defects is not a new technique. However, there is a lack of literature reporting its efficacy in PJI cases. This study aimed to investigate the outcome of structural fresh frozen allogenous bone grafts in treating patients in knee PJI with large bone defects. Methods We performed a retrospective cohort analysis of knee PJI cases treated with two-stage exchange arthroplasty at our institution from 2010 to 2016. 12 patients with structural allogenous bone graft reconstructions were identified as the study group. 24 patients without structural allograft reconstructions matched with the study group by age, gender, and Charlson comorbidity index were enrolled as the control group. The functional outcome of the study group was evaluated with the Knee Society Score (KSS). Treatment success was assessed according to the Delphi-based consensus definition. The infection relapse rate and implant survivorship were compared between groups. Results Revision knees with structural allograft presented excellent improvement in the KSS (33.1 to 75.4). There was no significant difference between infection relapse-free survival rate and prosthesis survival rate in the two groups. The 8-year prosthesis survival rate was 90.9% in the study group and 91% in the control group (p = 0.913). The 8-year infection relapse-free survival rate was 80 and 83.3% in the study group and control group, respectively (p = 0.377). Conclusion The structural fresh frozen allogenous bone graft provided an effective way for bone defect reconstruction in knee PJI with an accountable survival rate. Meanwhile, using structural allografts did not increase the relapse rate of infection.
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Affiliation(s)
- Chieh An Chuang
- Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, 5, Fu-Hsin St., Kweishan, Taoyuan, Linko, Taiwan
| | - Sheng-Hsun Lee
- Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, 5, Fu-Hsin St., Kweishan, Taoyuan, Linko, Taiwan.,Bone and Joint Research Center, Chang Gung Memorial Hospital, Linko, Taoyuan, Taiwan
| | - Chih-Hsiang Chang
- Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, 5, Fu-Hsin St., Kweishan, Taoyuan, Linko, Taiwan.,Bone and Joint Research Center, Chang Gung Memorial Hospital, Linko, Taoyuan, Taiwan
| | - Chih-Chien Hu
- Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, 5, Fu-Hsin St., Kweishan, Taoyuan, Linko, Taiwan.,Bone and Joint Research Center, Chang Gung Memorial Hospital, Linko, Taoyuan, Taiwan
| | - Hsin-Nung Shih
- Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, 5, Fu-Hsin St., Kweishan, Taoyuan, Linko, Taiwan.,Bone and Joint Research Center, Chang Gung Memorial Hospital, Linko, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Steve W N Ueng
- Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, 5, Fu-Hsin St., Kweishan, Taoyuan, Linko, Taiwan.,Bone and Joint Research Center, Chang Gung Memorial Hospital, Linko, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Yuhan Chang
- Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, 5, Fu-Hsin St., Kweishan, Taoyuan, Linko, Taiwan. .,Bone and Joint Research Center, Chang Gung Memorial Hospital, Linko, Taoyuan, Taiwan. .,College of Medicine, Chang Gung University, Taoyuan, Taiwan.
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22
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Cyphert EL, Zhang N, Learn GD, Hernandez CJ, von Recum HA. Recent Advances in the Evaluation of Antimicrobial Materials for Resolution of Orthopedic Implant-Associated Infections In Vivo. ACS Infect Dis 2021; 7:3125-3160. [PMID: 34761915 DOI: 10.1021/acsinfecdis.1c00465] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
While orthopedic implant-associated infections are rare, revision surgeries resulting from infections incur considerable healthcare costs and represent a substantial research area clinically, in academia, and in industry. In recent years, there have been numerous advances in the development of antimicrobial strategies for the prevention and treatment of orthopedic implant-associated infections which offer promise to improve the limitations of existing delivery systems through local and controlled release of antimicrobial agents. Prior to translation to in vivo orthopedic implant-associated infection models, the properties (e.g., degradation, antimicrobial activity, biocompatibility) of the antimicrobial materials can be evaluated in subcutaneous implant in vivo models. The antimicrobial materials are then incorporated into in vivo implant models to evaluate the efficacy of using the material to prevent or treat implant-associated infections. Recent technological advances such as 3D-printing, bacterial genomic sequencing, and real-time in vivo imaging of infection and inflammation have contributed to the development of preclinical implant-associated infection models that more effectively recapitulate the clinical presentation of infections and improve the evaluation of antimicrobial materials. This Review highlights the advantages and limitations of antimicrobial materials used in conjunction with orthopedic implants for the prevention and treatment of orthopedic implant-associated infections and discusses how these materials are evaluated in preclinical in vivo models. This analysis serves as a resource for biomaterial researchers in the selection of an appropriate orthopedic implant-associated infection preclinical model to evaluate novel antimicrobial materials.
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Affiliation(s)
- Erika L. Cyphert
- Department of Biomedical Engineering, Case Western Reserve University, 10900 Euclid Avenue, Cleveland, Ohio 44106, United States
| | - Ningjing Zhang
- Department of Biomedical Engineering, Case Western Reserve University, 10900 Euclid Avenue, Cleveland, Ohio 44106, United States
| | - Greg D. Learn
- Department of Biomedical Engineering, Case Western Reserve University, 10900 Euclid Avenue, Cleveland, Ohio 44106, United States
| | - Christopher J. Hernandez
- Sibley School of Mechanical and Aerospace Engineering, Cornell University, Ithaca, New York 14853, United States
- Hospital for Special Surgery, New York, New York 10021, United States
| | - Horst A. von Recum
- Department of Biomedical Engineering, Case Western Reserve University, 10900 Euclid Avenue, Cleveland, Ohio 44106, United States
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23
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[Strategic approach in periprosthetic joint infections]. Unfallchirurg 2021; 125:59-65. [PMID: 34889969 DOI: 10.1007/s00113-021-01113-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/15/2021] [Indexed: 10/19/2022]
Abstract
With rising numbers of revisions of total arthroplasty procedures of the lower extremities, the annual number of cases of implant-associated infection are also increasing. The conventional two-stage replacement strategy often leads to increased morbidity and mortality of patients; however, in the literature a one-stage exchange procedure shows equally good results if the indications are strictly defined. In addition to the correct diagnostics, the patient history, the inserted implant, the state of health and when applicable the pathogens present play an important role. If, among other factors, the pathogen is uncomplicated combined with a good bone and soft tissue situation and without a large number of previous operations, a single stage replacement of the endoprosthesis may be a suitable option. Despite existing controversies in the literature, this treatment approach seems to demonstrate a reduced hospitalization, reduced costs and improved patient satisfaction with the same re-revision rate. This review article explains the strategic approach to chronic infections of endoprostheses of the lower extremities based on clinical examples and a review of the current literature.
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24
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Jenny JY, Hamon M, Klein S, Reiter-Schatz A, Rondé-Oustau C, Boéri C, Wisniewski S, Gaudias J. Cement Loaded With High-Dose Gentamicin and Clindamycin Reduces the Risk of Subsequent Infection After One-Stage Hip or Knee Arthroplasty Exchange for Periprosthetic Infection: A Preliminary Study. J Arthroplasty 2021; 36:3973-3978. [PMID: 34511281 DOI: 10.1016/j.arth.2021.08.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 07/21/2021] [Accepted: 08/13/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND The use of antibiotic-loaded acrylic cement for treating periprosthetic joint infections remains controversial. We hypothesized that the raw rate of surgical site infection (SSI) is lower after using cement loaded with high-dose gentamicin and clindamycin than after using cement loaded with standard-dose gentamicin for implant fixation during 1-stage hip and knee revision arthroplasty for infection. METHODS One hundred seventy-one continuous patients operated by 2 experienced surgeons during a 2-year period were included in the study. All patients were followed for 24 months. The primary endpoint was the raw rate of SSI after 2 years of follow-up time. RESULTS The raw rate of SSI after 2 years of follow-up time was significantly lower in the study group (13%) than in the control group (26%) (P = .03) with an odds ratio of 0.42 (P = .03). These SSIs were new infections rather than a recurrence/persistence of the initial infection. CONCLUSION The cement used in the study group significantly reduced the risk of SSI relative to the cement used in the control group. Routine use of this high-dose dual antibiotic-loaded cement can be considered during 1-stage knee or hip revision arthroplasty for infection.
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Affiliation(s)
| | - Marie Hamon
- Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Stéphane Klein
- Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | | | | | - Cyril Boéri
- Hôpitaux Universitaires de Strasbourg, Strasbourg, France
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25
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Karachalios T, Komnos GA. Management strategies for prosthetic joint infection: long-term infection control rates, overall survival rates, functional and quality of life outcomes. EFORT Open Rev 2021; 6:727-734. [PMID: 34667643 PMCID: PMC8489477 DOI: 10.1302/2058-5241.6.210008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
DAIR (debridement, antibiotics, and implant retention), one-stage and two-stage revision surgery are the most common management strategies for prosthetic joint infection (PJI) management. Our knowledge concerning their efficacy is based on short to medium-term low-quality studies. Most studies report infection recurrence rates or infection-free time intervals. However, long-term survival rates of the infection-free joints, functional and quality of life outcome data are of paramount importance. DAIR, one-stage and two-stage revision strategies are not unique surgical techniques, presenting several variables. Infection control rates for the above strategies vary from 75% to 90%, but comparisons are difficult because different indications and patient selection criteria are used in each strategy. Recent outcome data show that DAIR and one-stage revision in selected patients (based on host, bacteriological, soft tissue and type of infection criteria) may present improved functional and quality of life outcomes and reduced costs for health systems as compared to those of two-stage revision. It is expected that health system administrators and providers will apply pressure on surgeons and departments towards the wider use of DAIR and one-stage revision strategies. It is the orthopaedic surgeon’s responsibility to conduct quality studies in order to fully clarify the indications and outcomes of the different revision strategies.
Cite this article: EFORT Open Rev 2021;6:727-734. DOI: 10.1302/2058-5241.6.210008
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Affiliation(s)
- Theofilos Karachalios
- Department of Orthopaedics and Musculoskeletal Trauma, University General Hospital of Larissa, Greece.,School of Health Sciences, Faculty of Medicine, University of Thessalia, Larissa, Greece
| | - George A Komnos
- Department of Orthopaedics and Musculoskeletal Trauma, University General Hospital of Larissa, Greece
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26
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Tuecking LR, Silligmann J, Savov P, Omar M, Windhagen H, Ettinger M. Detailed Revision Risk Analysis after Single- vs. Two-Stage Revision Total Knee Arthroplasty in Periprosthetic Joint Infection: A Retrospective Tertiary Center Analysis. Antibiotics (Basel) 2021; 10:antibiotics10101177. [PMID: 34680758 PMCID: PMC8533002 DOI: 10.3390/antibiotics10101177] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2021] [Revised: 09/13/2021] [Accepted: 09/23/2021] [Indexed: 01/03/2023] Open
Abstract
Periprosthetic joint infection (PJI) remains one of the most common causes of revision knee arthroplasty. Controversy continues to surround the proper operative technique of PJI in knee arthroplasty with single- or two-stage replacement. Significant variations are seen in the eradication rates of PJI and in implant survival rates. This detailed retrospective analysis of a single tertiary center is intended to provide further data and insight comparing single- and two-stage revision surgery. A retrospective analysis of all revision total knee arthroplasty (TKA) surgeries from 2013 to 2019 was performed and screened with respect to single- or two-stage TKA revisions. Single- and two-stage revisions were analyzed with regard to implant survival, revision rate, microbiological spectrum, and other typical demographic characteristics. A total of 63 patients were included, with 15 patients undergoing single-stage revision and 48 patients undergoing two-stage revision. The mean follow-up time was 40.7 to 43.7 months. Statistically, no difference was found between both groups in overall survival (54.4% vs. 70.1%, p = 0.68) and implant survival with respect to reinfection (71.4% vs. 82.4%, p = 0.48). Further, high reinfection rates were found for patients with difficult-to-treat organisms and low- to semi-constrained implant types, in comparison to constrained implant types. A statistically comparable revision rate for recurrence of infection could be shown for both groups, although a tendency to higher reinfection rate for single-stage change was evident. The revision rate in this single-center study was comparably high, which could be caused by the high comorbidity and high proportion of difficult-to-treat bacteria in patients at a tertiary center. In this patient population, the expectation of implant survival should be critically discussed with patients.
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Affiliation(s)
- Lars-Rene Tuecking
- Department of Orthopaedic Surgery, Hannover Medical School, Diakovere Annastift, Anna-von-Borries-Str. 1-7, 30625 Hannover, Germany; (L.-R.T.); (J.S.); (P.S.); (H.W.)
| | - Julia Silligmann
- Department of Orthopaedic Surgery, Hannover Medical School, Diakovere Annastift, Anna-von-Borries-Str. 1-7, 30625 Hannover, Germany; (L.-R.T.); (J.S.); (P.S.); (H.W.)
| | - Peter Savov
- Department of Orthopaedic Surgery, Hannover Medical School, Diakovere Annastift, Anna-von-Borries-Str. 1-7, 30625 Hannover, Germany; (L.-R.T.); (J.S.); (P.S.); (H.W.)
| | - Mohamed Omar
- Department of Trauma Surgery, Hannover Medical School, Carl-Neuberg-Strasse 1, 30625 Hanover, Germany;
| | - Henning Windhagen
- Department of Orthopaedic Surgery, Hannover Medical School, Diakovere Annastift, Anna-von-Borries-Str. 1-7, 30625 Hannover, Germany; (L.-R.T.); (J.S.); (P.S.); (H.W.)
| | - Max Ettinger
- Department of Orthopaedic Surgery, Hannover Medical School, Diakovere Annastift, Anna-von-Borries-Str. 1-7, 30625 Hannover, Germany; (L.-R.T.); (J.S.); (P.S.); (H.W.)
- Correspondence: ; Tel.: +49-511-5354-0
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Slullitel PA, Oñativia JI, Zanotti G, Comba F, Piccaluga F, Buttaro MA. One-stage exchange should be avoided in periprosthetic joint infection cases with massive femoral bone loss or with history of any failed revision to treat periprosthetic joint infection. Bone Joint J 2021; 103-B:1247-1253. [PMID: 34192931 DOI: 10.1302/0301-620x.103b7.bjj-2020-2155.r1] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AIMS There is a paucity of long-term studies analyzing risk factors for failure after single-stage revision for periprosthetic joint infection (PJI) following total hip arthroplasty (THA). We report the mid- to long-term septic and non-septic failure rate of single-stage revision for PJI after THA. METHODS We retrospectively reviewed 88 cases which met the Musculoskeletal Infection Society (MSIS) criteria for PJI. Mean follow-up was seven years (1 to 14). Septic failure was diagnosed with a Delphi-based consensus definition. Any reoperation for mechanical causes in the absence of evidence of infection was considered as non-septic failure. A competing risk regression model was used to evaluate factors associated with septic and non-septic failures. A Kaplan-Meier estimate was used to analyze mortality. RESULTS The cumulative incidence of septic failure was 8% (95% confidence interval (CI) 3.5 to 15) at one year, 13.8% (95% CI 7.6 to 22) at two years, and 19.7% (95% CI 12 to 28.6) at five and ten years of follow-up. A femoral bone defect worse than Paprosky IIIA (hazard ratio (HR) 13.58 (95% CI 4.86 to 37.93); p < 0.001) and obesity (BMI ≥ 30 kg/m2; HR 3.88 (95% CI 1.49 to 10.09); p = 0.005) were significantly associated with septic failure. Instability and periprosthetic fracture were the most common reasons for mechanical failure (5.7% and 4.5%, respectively). The cumulative incidence of aseptic failure was 2% (95% CI 0.4 to 7) at two years, 9% (95% CI 4 to 17) at five years, and 12% (95% CI 5 to 22) at ten years. A previous revision to treat PJI was significantly associated with non-septic failure (HR 9.93 (95% CI 1.77 to 55.46); p = 0.009). At the five-year timepoint, 93% of the patients were alive (95% CI 84% to 96%), which fell to 86% (95% CI 75% to 92%) at ten-year follow-up. CONCLUSION Massive femoral bone loss was associated with greater chances of developing a further septic failure. All septic failures occurred within the first five years following the one-stage exchange. Surgeons should be aware of instability and periprosthetic fracture being potential causes of further aseptic revision surgery. Cite this article: Bone Joint J 2021;103-B(7):1247-1253.
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Affiliation(s)
- Pablo A Slullitel
- Sir John Charnley Hip Surgery Unit, Institute of Orthopaedics 'Carlos E. Ottolenghi', Italian Hospital of Buenos Aires, Argentina, Buenos Aires, Argentina
| | - José I Oñativia
- Sir John Charnley Hip Surgery Unit, Institute of Orthopaedics 'Carlos E. Ottolenghi', Italian Hospital of Buenos Aires, Argentina, Buenos Aires, Argentina
| | - Gerardo Zanotti
- Sir John Charnley Hip Surgery Unit, Institute of Orthopaedics 'Carlos E. Ottolenghi', Italian Hospital of Buenos Aires, Argentina, Buenos Aires, Argentina
| | - Fernando Comba
- Sir John Charnley Hip Surgery Unit, Institute of Orthopaedics 'Carlos E. Ottolenghi', Italian Hospital of Buenos Aires, Argentina, Buenos Aires, Argentina
| | - Francisco Piccaluga
- Sir John Charnley Hip Surgery Unit, Institute of Orthopaedics 'Carlos E. Ottolenghi', Italian Hospital of Buenos Aires, Argentina, Buenos Aires, Argentina
| | - Martin A Buttaro
- Sir John Charnley Hip Surgery Unit, Institute of Orthopaedics 'Carlos E. Ottolenghi', Italian Hospital of Buenos Aires, Argentina, Buenos Aires, Argentina
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28
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Biddle M, Kennedy JW, Wright PM, Ritchie ND, Meek RMD, Rooney BP. Improving outcomes in acute and chronic periprosthetic hip and knee joint infection with a multidisciplinary approach. Bone Jt Open 2021; 2:509-514. [PMID: 34247508 PMCID: PMC8325970 DOI: 10.1302/2633-1462.27.bjo-2021-0064.r1] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
AIMS Periprosthetic hip and knee infection remains one of the most severe complications following arthroplasty, with an incidence between 0.5% to 1%. This study compares the outcomes of revision surgery for periprosthetic joint infection (PJI) following hip and knee arthroplasty prior to and after implementation of a specialist PJI multidisciplinary team (MDT). METHODS Data was retrospectively analyzed from a single centre. In all, 29 consecutive joints prior to the implementation of an infection MDT in November 2016 were compared with 29 consecutive joints subsequent to the MDT conception. All individuals who underwent a debridement antibiotics and implant retention (DAIR) procedure, a one-stage revision, or a two-stage revision for an acute or chronic PJI in this time period were included. The definition of successfully treated PJI was based on the Delphi international multidisciplinary consensus. RESULTS There were no statistically significant differences in patient demographics or comorbidities between the groups. There was also no significant difference in length of overall hospital stay (p = 0.530). The time taken for formal microbiology advice was significantly shorter in the post MDT group (p = 0.0001). There was a significant difference in failure rates between the two groups (p = 0.001), with 12 individuals (41.38%) pre-MDT requiring further revision surgery compared with one individual (6.67%) post-MDT inception. CONCLUSION Our standardized multidisciplinary approach for periprosthetic knee and hip joint infection shows a significant reduction in failure rates following revision surgery. Following implementation of our MDT, our success rate in treating PJI is 96.55%, higher than what current literature suggests. We advocate the role of a specialist infection MDT in the management of patients with a PJI to allow an individualized patient-centred approach and care plan, thereby reducing postoperative complications and failure rates. Cite this article: Bone Jt Open 2021;2(7):509-514.
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29
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Razii N, Clutton JM, Kakar R, Morgan-Jones R. Single-stage revision for the infected total knee arthroplasty : the Cardiff experience. Bone Jt Open 2021; 2:305-313. [PMID: 34003026 PMCID: PMC8168544 DOI: 10.1302/2633-1462.25.bjo-2020-0185.r1] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Aims Periprosthetic joint infection (PJI) is a devastating complication following total knee arthroplasty (TKA). Two-stage revision has traditionally been considered the gold standard of treatment for established infection, but increasing evidence is emerging in support of one-stage exchange for selected patients. The objective of this study was to determine the outcomes of single-stage revision TKA for PJI, with mid-term follow-up. Methods A total of 84 patients, with a mean age of 68 years (36 to 92), underwent single-stage revision TKA for confirmed PJI at a single institution between 2006 and 2016. In all, 37 patients (44%) were treated for an infected primary TKA, while the majority presented with infected revisions: 31 had undergone one previous revision (36.9%) and 16 had multiple prior revisions (19.1%). Contraindications to single-stage exchange included systemic sepsis, extensive bone or soft-tissue loss, extensor mechanism failure, or if primary wound closure was unlikely to be achievable. Patients were not excluded for culture-negative PJI or the presence of a sinus. Results Overall, 76 patients (90.5%) were infection-free at a mean follow-up of seven years, with eight reinfections (9.5%). Culture-negative PJI was not associated with a higher reinfection rate (p = 0.343). However, there was a significantly higher rate of recurrence in patients with polymicrobial infections (p = 0.003). The mean Oxford Knee Score (OKS) improved from 18.7 (SD 8.7) preoperatively to 33.8 (SD 9.7) at six months postoperatively (p < 0.001). The Kaplan-Meier implant survival rate for all causes of reoperation, including reinfection and aseptic failure, was 95.2% at one year (95% confidence interval (CI) 87.7 to 98.2), 83.5% at five years (95% CI 73.2 to 90.3), and 78.9% at 12 years (95% CI 66.8 to 87.2). Conclusion One-stage exchange, using a strict debridement protocol and multidisciplinary input, is an effective treatment option for the infected TKA. This is the largest single-surgeon series of consecutive cases reported to date, with broad inclusion criteria. Cite this article: Bone Jt Open 2021;2(5):305–313.
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Affiliation(s)
- Nima Razii
- Cardiff and Vale Orthopaedic Centre, University Hospital Llandough, Cardiff, UK.,Department of Trauma and Orthopaedics, Glasgow Royal Infirmary, Glasgow, UK
| | - Juliet M Clutton
- Cardiff and Vale Orthopaedic Centre, University Hospital Llandough, Cardiff, UK
| | - Rahul Kakar
- Department of Trauma and Orthopaedics, Ninewells Hospital, Dundee, UK
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Amin SJ, Patel RM, Gutowski CJ, Kim TWB. Outcomes after antibiotic megaspacer implantation in patients with severe chronic periprosthetic infections. J Orthop Res 2021; 39:308-319. [PMID: 33179324 DOI: 10.1002/jor.24911] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Revised: 10/29/2020] [Accepted: 11/08/2020] [Indexed: 02/04/2023]
Abstract
Periprosthetic joint infection (PJI) is a rare postoperative complication that is treated with antibiotic spacers. Some patients develop severe, treatment-resistant, chronic PJI despite multiple attempts at salvaging the joint. Permanent resection of the joint or amputation may be the only definitive treatment. The purpose of this study is to describe the outcomes, infection resolution rate, and complications of two-stage revision, utilizing extensive resection of the affected bone and application of antibiotic megaspacers as a modality for limb-salvage. A review of 12 patients, initially referred for amputation due to chronically failed PJI, was conducted. All patients underwent extensive resection of the bone and surgical implantation of a custom-made antibiotic megaspacer between December 2016 and June 2019. Thirteen megaspacers were placed in 13 infected joints in 12 patients with a history of chronic PJI. Six patients (50%) had a diagnosis of osteomyelitis. Eradication of the infection leading to limb-salvage was successful in nine patients. Visual Analog Scale pain scores improved by 3.5, or 50%, after two-stage revision with megaprosthesis reimplantation (p = .008), and six patients (54.5%) had improvement in ambulation. Complication rates, not including reinfection or recurrence, following megaspacer and megaprosthesis reimplantation were 58.3% and 27.3%, respectively. One patient underwent amputation due to a life-threatening infection while two other patients underwent amputation due to debilitating complications following limb-salvage surgery. Statement of Clinical Significance: In patients whose PJI becomes treatment-resistant after multiple failed attempts at traditional two-stage exchange, performing extensive boney resection with placement of an antibiotic-laden megaspacer can be an effective method of achieving limb-salvage.
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Affiliation(s)
- Sheena J Amin
- Drexel University College of Medicine, Philadelphia, Pennsylvania, USA
| | - Raj M Patel
- Cooper Medical School of Rowan University, Camden, New Jersey, USA
| | - Christina J Gutowski
- Cooper Medical School of Rowan University, Camden, New Jersey, USA
- Department of Orthopaedic Surgery, Cooper University Healthcare, Camden, New Jersey, USA
| | - Tae Won B Kim
- Cooper Medical School of Rowan University, Camden, New Jersey, USA
- Department of Orthopaedic Surgery, Cooper University Healthcare, Camden, New Jersey, USA
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Vantucci CE, Ahn H, Fulton T, Schenker ML, Pradhan P, Wood LB, Guldberg RE, Roy K, Willett NJ. Development of systemic immune dysregulation in a rat trauma model of biomaterial-associated infection. Biomaterials 2021; 264:120405. [PMID: 33069135 PMCID: PMC8117743 DOI: 10.1016/j.biomaterials.2020.120405] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Revised: 09/09/2020] [Accepted: 09/18/2020] [Indexed: 12/12/2022]
Abstract
Orthopedic biomaterial-associated infections remain a major clinical challenge, with Staphylococcus aureus being the most common pathogen. S. aureus biofilm formation enhances immune evasion and antibiotic resistance, resulting in a local, indolent infection that can persist long-term without symptoms before eventual hardware failure, bone non-union, or sepsis. Immune modulation is an emerging strategy to combat host immune evasion by S. aureus. However, most immune modulation strategies are focused on local immune responses at the site of infection, with little emphasis on understanding the infection-induced and orthopedic-related systemic immune responses of the host, and their role in local infection clearance and tissue regeneration. This study utilized a rat bone defect model to investigate how implant-associated infection affects the systemic immune response. Long-term systemic immune dysregulation was observed with a significant systemic decrease in T cells and a concomitant increase in immunosuppressive myeloid-derived suppressor cells (MDSCs) compared to non-infected controls. Further, the control group exhibited a regulated and coordinated systemic cytokine response, which was absent in the infection group. Multivariate analysis revealed high levels of MDSCs to be most correlated with the infection group, while high levels of T cells were most correlated with the control group. Locally, the infection group had attenuated macrophage infiltration and increased levels of MDSCs in the local soft tissue compared to non-infected controls. These data reveal the widespread impacts of an orthopedic infection on both the local and the systemic immune responses, uncovering promising targets for diagnostics and immunotherapies that could optimize treatment strategies and ultimately improve patient outcomes.
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Affiliation(s)
- Casey E Vantucci
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, GA, USA; Parker H. Petit Institute for Bioengineering and Bioscience, Georgia Institute of Technology, Atlanta, GA, USA
| | - Hyunhee Ahn
- The Atlanta Veterans Affairs Medical Center Atlanta, Decatur, GA, USA; Department of Orthopaedics, Emory University, Atlanta, GA, USA
| | - Travis Fulton
- The Atlanta Veterans Affairs Medical Center Atlanta, Decatur, GA, USA; Department of Orthopaedics, Emory University, Atlanta, GA, USA
| | - Mara L Schenker
- Department of Orthopaedics, Emory University, Atlanta, GA, USA; Grady Memorial Hospital, Atlanta, GA, USA
| | - Pallab Pradhan
- Parker H. Petit Institute for Bioengineering and Bioscience, Georgia Institute of Technology, Atlanta, GA, USA
| | - Levi B Wood
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, GA, USA; Parker H. Petit Institute for Bioengineering and Bioscience, Georgia Institute of Technology, Atlanta, GA, USA; George W. Woodruff School of Mechanical Engineering, Georgia Institute of Technology, Atlanta, GA, USA
| | - Robert E Guldberg
- Knight Campus for Accelerating Scientific Impact, University of Oregon, Eugene, OR, USA
| | - Krishnendu Roy
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, GA, USA; Parker H. Petit Institute for Bioengineering and Bioscience, Georgia Institute of Technology, Atlanta, GA, USA.
| | - Nick J Willett
- The Atlanta Veterans Affairs Medical Center Atlanta, Decatur, GA, USA; Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, GA, USA; Parker H. Petit Institute for Bioengineering and Bioscience, Georgia Institute of Technology, Atlanta, GA, USA; Department of Orthopaedics, Emory University, Atlanta, GA, USA.
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