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Mercurio M, Gasparini G, Cofano E, Zappia A, Familiari F, Galasso O. Knee Arthrodesis for Periprosthetic Knee Infection: Fusion Rate, Complications, and Limb Salvage-A Systematic Review. Healthcare (Basel) 2024; 12:804. [PMID: 38610226 PMCID: PMC11011444 DOI: 10.3390/healthcare12070804] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2024] [Revised: 04/01/2024] [Accepted: 04/05/2024] [Indexed: 04/14/2024] Open
Abstract
The aim of this systematic review was to investigate the outcomes of knee arthrodesis (KA) after periprosthetic joint infection (PJI) of the knee. Differences in clinical outcomes and complication rates among the intramedullary nailing (IMN), external fixation (EF), and compression plating (CP) procedures were compared. A total of 23 studies were included. Demographics, microbiological data, types of implants, surgical techniques with complications, reoperations, fusion, and amputation rates were reported. A total of 787 patients were evaluated, of whom 601 (76.4%), 166 (21%), and 19 (2.4%) underwent IMN, EF, and CP, respectively. The most common causative pathogen was coagulase-negative Staphylococcus (CNS). Fusion occurred in 71.9%, 78.8%, and 92.3% of the patients after IMN, EF, and CP, respectively, and no statistically significant difference was found. Reinfection rates were 14.6%, 15.1%, and 10.5% after IMN, EF, and CP, respectively, and no statistically significant difference was found. Conversion to amputation occurred in 4.3%, 5%, and 15.8% of patients after IMN, EF, and CP, respectively; there was a higher rate after CP than after EF. The IMN technique is the most common option used for managing PJI with KA. No differences in terms of fusion, reinfection, or conversion-to-amputation rates were reported between IMN and EF. CP is rarely used, and the high amputation rate represents an important limitation of this technique.
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Affiliation(s)
- Michele Mercurio
- Department of Orthopaedic and Trauma Surgery, Magna Graecia University, 88100 Catanzaro, Italy; (M.M.); (G.G.); (A.Z.); (F.F.); (O.G.)
- Research Center on Musculoskeletal Health, MusculoSkeletal Health@UMG, Magna Graecia University, 88100 Catanzaro, Italy
| | - Giorgio Gasparini
- Department of Orthopaedic and Trauma Surgery, Magna Graecia University, 88100 Catanzaro, Italy; (M.M.); (G.G.); (A.Z.); (F.F.); (O.G.)
- Research Center on Musculoskeletal Health, MusculoSkeletal Health@UMG, Magna Graecia University, 88100 Catanzaro, Italy
| | - Erminia Cofano
- Department of Orthopaedic and Trauma Surgery, Magna Graecia University, 88100 Catanzaro, Italy; (M.M.); (G.G.); (A.Z.); (F.F.); (O.G.)
| | - Andrea Zappia
- Department of Orthopaedic and Trauma Surgery, Magna Graecia University, 88100 Catanzaro, Italy; (M.M.); (G.G.); (A.Z.); (F.F.); (O.G.)
| | - Filippo Familiari
- Department of Orthopaedic and Trauma Surgery, Magna Graecia University, 88100 Catanzaro, Italy; (M.M.); (G.G.); (A.Z.); (F.F.); (O.G.)
- Research Center on Musculoskeletal Health, MusculoSkeletal Health@UMG, Magna Graecia University, 88100 Catanzaro, Italy
| | - Olimpio Galasso
- Department of Orthopaedic and Trauma Surgery, Magna Graecia University, 88100 Catanzaro, Italy; (M.M.); (G.G.); (A.Z.); (F.F.); (O.G.)
- Research Center on Musculoskeletal Health, MusculoSkeletal Health@UMG, Magna Graecia University, 88100 Catanzaro, Italy
- Clinica Ortopedica Department, San Giovanni di Dio e Ruggi D’Aragona University Hospital, 84100 Salerno, Italy
- Department of Medicine, Surgery and Dentistry, University of Salerno, Baronissi, 84081 Salerno, Italy
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Balato G, Dall'Anese R, Balboni F, Ascione T, Pezzati P, Bartolini G, Quercioli M, Baldini A. Synovial fluid alpha-defensin in periprosthetic knee infection workup : liquid chromatography-mass spectrometry detection of alpha-defensin in synovial fluid. Bone Joint J 2022; 104-B:1047-1051. [PMID: 36047027 DOI: 10.1302/0301-620x.104b9.bjj-2021-1672.r1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
AIMS The diagnosis of periprosthetic joint infection (PJI) continues to present a significant clinical challenge. New biomarkers have been proposed to support clinical decision-making; among them, synovial fluid alpha-defensin has gained interest. Current research methodology suggests reference methods are needed to establish solid evidence for use of the test. This prospective study aims to evaluate the diagnostic accuracy of high-performance liquid chromatography coupled with the mass spectrometry (LC-MS) method to detect alpha-defensin in synovial fluid. METHODS Between October 2017 and September 2019, we collected synovial fluid samples from patients scheduled to undergo revision surgery for painful total knee arthroplasty (TKA). The International Consensus Meeting criteria were used to classify 33 PJIs and 92 aseptic joints. LC-MS assay was performed to measure alpha-defensin in synovial fluid of all included patients. Sensitivity, specificity, positive predictive value, negative predictive value, and the area under the receiver operating characteristic curve (AUC) were calculated to define the test diagnostic accuracy. RESULTS The AUC was 0.99 (95% confidence interval (CI) 0.98 to 1.00). Receiver operating characteristic (ROC) analysis showed that the optimal cut-off value of synovial fluid alpha-defensin was 1.0 μg/l. The sensitivity of alpha-defensin was 100% (95% CI 96 to 100), the specificity was 97% (95% CI 90 to 98), the positive predictive value was 89.2% (95% CI 82 to 94), and negative predictive value was 100% (95% CI 96 to 100). ROC analysis demonstrated an AUC of 0.99 (95% CI 0.98 to 1.0). CONCLUSION The present study confirms the utility of alpha-defensin in the synovial fluid in patients with painful TKA to select cases of PJI. Since LC-MS is still a time-consuming technology and is available in highly specialized laboratories, further translational research studies are needed to take this evidence into routine procedures and promote a new diagnostic approach.Cite this article: Bone Joint J 2022;104-B(9):1047-1051.
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Affiliation(s)
- Giovanni Balato
- Department of Public Health, Orthopaedic Unit, "Federico II" University, Naples, Italy
| | | | | | - Tiziana Ascione
- Department of Infectious Diseases, Cardarelli Hospital, Naples, Italy
| | - Paola Pezzati
- SOD Sicurezza e Qualità, Azienda Ospedaliero Universitaria Careggi, Florence, Italy
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Zingg M, Kheir MM, Ziemba-Davis M, Meneghini RM. Reduced Infection Rate After Aseptic Revision Total Knee Arthroplasty With Extended Oral Antibiotic Protocol. J Arthroplasty 2022; 37:905-909. [PMID: 35077819 DOI: 10.1016/j.arth.2022.01.040] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Revised: 01/10/2022] [Accepted: 01/17/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND The optimal postoperative antibiotic duration has not been determined for aseptic revision total knee arthroplasty (R-TKA) where the risk of periprosthetic joint infection (PJI) is 3%-7.5%. This study compared PJI rates in aseptic R-TKA performed with extended oral antibiotic prophylaxis (EOAP) to published rates. METHODS Aseptic R-TKAs consecutively performed between 2013 and 2017 at a tertiary care referral center in the American Midwest were retrospectively reviewed. All patients were administered intravenous antibiotics while hospitalized and discharged on 7-day oral antibiotic prophylaxis. Infection rates and antibiotic-related complications were assessed. RESULTS Sixty-seven percent of the 176 analysis patients were female, with an average age of 64 years and body mass index of 35 kg/m2. Instability and aseptic loosening comprised 86% of revision diagnoses. Overall, 87.5% of intraoperative cultures were negative, and the remainder were single positive cultures considered contaminants. PJI rates were 0% at 90 days, 1.8% (95% confidence interval 0.4%-5.3%) at 1 year, and 2.2% (95% confidence interval 0.6%-5.7%) at mean follow-up of approximately 3 years (range, 7-65 months). CONCLUSION EOAP after aseptic R-TKA resulted in a PJI rate equivalent to primary TKA, representing a 2- to-4-fold decrease compared with published aseptic R-TKA infection rates. Further study on the benefits and costs of EOAP after aseptic R-TKA is encouraged.
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Affiliation(s)
- Matthieu Zingg
- Division of Orthopaedic and Trauma Surgery, Department of Surgery, University Hospitals of Geneva
| | - Michael M Kheir
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY
| | | | - R Michael Meneghini
- Indiana University Health Saxony Hip & Knee Center, Fishers, IN; Department of Orthopaedic Surgery, Indiana University School of Medicine, Indianapolis, IN
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Boyle KK, Kapadia M, Chiu YF, Khilnani T, Miller AO, Henry MW, Lyman S, Carli AV. The James A. Rand Young Investigator's Award: Are Intraoperative Cultures Necessary If the Aspiration Culture Is Positive? A Concordance Study in Periprosthetic Joint Infection. J Arthroplasty 2021; 36:S4-S10. [PMID: 33676815 DOI: 10.1016/j.arth.2021.01.073] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 01/14/2021] [Accepted: 01/26/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND The concordance between preoperative synovial fluid culture and multiple intraoperative tissue cultures for identifying pathogenic microorganisms in periprosthetic joint infection (PJI) remains unknown. Our aim is to determine the diagnostic performance of synovial fluid culture for early organism identification. METHODS A total of 363 patients who met Musculoskeletal Infection Society criteria for PJI following primary total joint arthroplasty were identified from a retrospective joint infection database. Inclusion criteria required a positive preoperative intra-articular synovial fluid sample within 90 days of intraoperative tissue culture(s) at revision surgery. Concordance was defined as matching organism(s) in aspirate and intraoperative specimens. RESULTS Concordance was identified in 279 (76.8%) patients with similar rates among total hip arthroplasties (77.2%) and total knee arthroplasties (76.4%, P = .86). Culture discordance occurred in 84 (23.1%) patients; 37 (10.2%) had no intraoperative culture growth and 33 (90.1%) were polymicrobial. Monomicrobial Staphylococcal PJI cases had high sensitivity (0.96, 95% confidence interval [CI] 0.92-0.98) and specificity (0.85, 95% CI 0.80-0.90). Polymicrobial infections had the lowest sensitivity (0.06, 95% CI 0.01-0.19). CONCLUSION Aspiration culture has favorable sensitivity and specificity when compared to tissue culture for identifying the majority of PJI organisms. Clinicians can guide surgical treatment and postoperative antibiotics based on monomicrobial aspiration results, but they should strongly consider collecting multiple tissue cultures to maximize the chance of identifying an underlying polymicrobial PJI. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- K Keely Boyle
- Department of Orthopaedics, Joint Replacement & Reconstruction, University at Buffalo, SUNY, Buffalo, NY
| | - Milan Kapadia
- Department of Infectious Diseases, Hospital for Special Surgery, New York, NY
| | - Yu-Fen Chiu
- Healthcare Research Institute, Hospital for Special Surgery, New York, NY
| | | | - Andy O Miller
- Department of Infectious Diseases, Hospital for Special Surgery, New York, NY
| | - Michael W Henry
- Department of Infectious Diseases, Hospital for Special Surgery, New York, NY
| | - Stephen Lyman
- Healthcare Research Institute, Hospital for Special Surgery, New York, NY; Department of Orthopedic Surgery, Adult Reconstruction and Joint Replacement, Hospital for Special Surgery, New York, NY
| | - Alberto V Carli
- Department of Orthopedic Surgery, Adult Reconstruction and Joint Replacement, Hospital for Special Surgery, New York, NY
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Abstract
BACKGROUND Periprosthetic knee infection is troublesome for Orthopedic surgeons and a catastrophy for patients. Reported rates of periprosthetic joint infection following primary total knee arthroplasty (TKA) are 0.39-2%. Two stage revision arthroplasty, which has success rates exceeding 90%, has been the gold standard for treating subacute and chronic periprosthetic infection following TKA. Antibiotic spacers, a well established means of delivering local antibiotic therapy, maintain soft tissue tension during two stage revision arthroplasty. However, controversy remains around whether static or mobile antibiotic impregnated spacers are superior for treating infection following TKA. Various mobile spacers are available, including cement-on-cement, cement-on-polyethylene and metal-on-polyethylene. In this study, the efficacy of the modified metal-on-cement spacer, consisting of reinsertion of the autoclaved femoral component and implantation of antibiotic-loaded cement in the proximal tibia, is assessed. MATERIALS AND METHODS Records of 19 patients diagnosed as periprosthetic knee infection were reviewed in this retrospective study. Among these patients, 10 patients received first stage debridement with the autoclaved metal-on-cement spacer and 8 patients with the static spacer, who eventually underwent two-stage re-implantation, were listed in the final comparison. Patient demographics, infection eradication rates, average range of motion (ROM), surgical time and blood loss during the second-stage of the surgery, and Knee Society (KS) knee scores at last followup after revision total knee replacement were clinically evaluated. RESULTS At a minimum of 2-year followup after re-implantation, infection eradication rates, surgical times, blood loss during the second-stage of the surgery, and KS knee score after re-implantation were similar for the two groups. Patients receiving autoclaved metal-on-cement spacers had superior ROM after re-implantation compared to that of patients with static spacers. CONCLUSIONS The autoclaved metal-on-cement spacer is an effective and simple method for two-stage re-implantation of a periprosthetic knee infection. Through this spacer, the good interim ROM can be achieved without the additional cost of prefabricated molds or new polyethylene tibial inserts. In addition, ROM after re-implantation is better than that with static spacers.
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Affiliation(s)
- Yu-Pin Chen
- Department of Orthopaedic Surgery, Wan Fang Hospital, School of Medicine, Taipei Medial University, Taipei, Taiwan, ROC
| | - Cheng-Chun Wu
- Department of Orthopaedic Surgery, Wan Fang Hospital, School of Medicine, Taipei Medial University, Taipei, Taiwan, ROC
| | - Wei-Pin Ho
- Department of Orthopaedic Surgery, Wan Fang Hospital, School of Medicine, Taipei Medial University, Taipei, Taiwan, ROC,Address for correspondence: Dr. Wei-Pin Ho, Department of Orthopaedics, Taipei Medial University, Wan Fang Medical Center, Taiwan No. 111, Sector 3, Xinglong Road, Wenshan District, Taipei City 116, Taiwan, ROC. E-mail:
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