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Mahnic A, Rak M, Trebše R, Rupnik M, Cőr A. Identification of prosthetic joint infections with 16S amplicon metagenomic sequencing - comparison with standard cultivation approach. Diagn Microbiol Infect Dis 2024; 109:116188. [PMID: 38340614 DOI: 10.1016/j.diagmicrobio.2024.116188] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Revised: 01/11/2024] [Accepted: 01/15/2024] [Indexed: 02/12/2024]
Abstract
Prosthetic joint infections (PJIs) are commonly diagnosed via culture-based methods, which may miss hard-to-grow pathogens. This study contrasts amplicon metagenomic sequencing (16S AS) with traditional culture techniques for enhanced clinical decision-making. We analyzed sonicate fluid from 27 patients undergoing revision arthroplasty using both methods, emphasizing the distinction between contaminants and true positives. Our findings show moderate agreement between the two methods, with a Cohen's kappa of 0.490, varying across bacterial genera (Cohen's kappa -0.059 to 1). The sensitivity of 16S AS compared to culture was 81% (95% CI, 68% to 94%). Sequencing revealed greater microbial diversity, including anaerobic genera like Anaerococcus and Citrobacter. Interestingly, several culture-negative PJI samples showed diverse bacteria via 16S AS. Despite rigorous controls and algorithms to eliminate contaminants, confirming bacteria presence with 16S AS remains a challenge. This highlights the need for improved PJI diagnostic methods, while also pointing out the limitations of next-generation sequencing (NGS) as a clinical diagnostic tool.
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Affiliation(s)
- Aleksander Mahnic
- National Laboratory of Health, Environment and Food, Department for Microbiological Research, Maribor, Slovenia.
| | - Mitja Rak
- National Laboratory of Health, Environment and Food, Medical Microbiology Department, Koper, Slovenia
| | - Rihard Trebše
- Orthopaedic Hospital Valdoltra, Ankaran, Slovenia; Faculty of Medicine, University of Ljubljana, Slovenia
| | - Maja Rupnik
- National Laboratory of Health, Environment and Food, Department for Microbiological Research, Maribor, Slovenia; Faculty of Medicine, University of Maribor, Maribor, Slovenia
| | - Andrej Cőr
- Orthopaedic Hospital Valdoltra, Ankaran, Slovenia; University of Primorska, Faculty of Health Sciences, Izola, Slovenia
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2
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Cuervo G, Quintana E, Regueiro A, Perissinotti A, Vidal B, Miro JM, Baddour LM. The Clinical Challenge of Prosthetic Valve Endocarditis: JACC Focus Seminar 3/4. J Am Coll Cardiol 2024; 83:1418-1430. [PMID: 38599718 DOI: 10.1016/j.jacc.2024.01.037] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Revised: 01/17/2024] [Accepted: 01/29/2024] [Indexed: 04/12/2024]
Abstract
During the past 6 decades, there have been numerous changes in prosthetic valve endocarditis (PVE), currently affecting an older population and increasing in incidence in patients with transcatheter-implanted valves. Significant microbiologic (molecular biology) and imaging diagnostic (fluorine-18 fluorodeoxyglucose-positron emission tomography/computed tomography) advances have been incorporated into the 2023 Duke-International Society for Cardiovascular Infectious Diseases infective endocarditis diagnostic criteria, thus increasing the diagnostic sensitivity for PVE without sacrificing specificity in validation studies. PVE is a life-threatening disease requiring management by multidisciplinary endocarditis teams in cardiac centers to improve outcomes. Novel surgical options are now available, and an increasing set of patients may avoid surgical intervention despite indication. Selected patients may complete parenteral or oral antimicrobial treatment at home. Finally, patients with prosthetic valves implanted surgically or by the transcatheter approach are candidates for antibiotic prophylaxis before invasive dental procedures.
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Affiliation(s)
- Guillermo Cuervo
- Department of Infectious Diseases, Hospital Clinic, August Pi I Sunyer Institute of Biomedical Research (IDIBAPS), University of Barcelona, Barcelona, Spain; Biomedical Network Research Center for Infectious Diseases (CIBERINFEC), Carlos III Health Institute, Madrid, Spain
| | - Eduard Quintana
- Department of Cardiovascular Surgery, Hospital Clinic, University of Barcelona, Barcelona, Spain
| | - Ander Regueiro
- Department of Cardiology, Hospital Clinic, University of Barcelona, Barcelona, Spain
| | - Andrés Perissinotti
- Department of Nuclear Medicine, Hospital Clinic, August Pi I Sunyer Institute of Biomedical Research (IDIBAPS) and Biomedical Research Networking Center of Bioengineering, Biomaterials, and Nanomedicine (CIBER-BBN), Carlos III Health Institute, Barcelona, Spain
| | - Barbara Vidal
- Department of Cardiology, Hospital Clinic, University of Barcelona, Barcelona, Spain
| | - Jose M Miro
- Department of Infectious Diseases, Hospital Clinic, August Pi I Sunyer Institute of Biomedical Research (IDIBAPS), University of Barcelona, Barcelona, Spain; Biomedical Network Research Center for Infectious Diseases (CIBERINFEC), Carlos III Health Institute, Madrid, Spain.
| | - Larry M Baddour
- Division of Public Health, Infectious Diseases, and Occupational Medicine, Departments of Medicine and Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
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Jazmati N, Liebold C, Offerhaus C, Volkenand A, Grote S, Pöpsel J, Körber-Irrgang B, Hoppe T, Wisplinghoff H. Rapid high-throughput processing of tissue samples for microbiological diagnosis of periprosthetic joint infections using bead-beating homogenization. J Clin Microbiol 2024; 62:e0148623. [PMID: 38415637 PMCID: PMC11005376 DOI: 10.1128/jcm.01486-23] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2023] [Accepted: 02/07/2024] [Indexed: 02/29/2024] Open
Abstract
Enrichment of periprosthetic tissue samples in blood culture bottles (BCBs) for microbiological diagnosis of periprosthetic joint infections (PJI) is more reliable than the use of an enrichment broth. Nevertheless, the extremely time-consuming homogenization of the samples for BCB processing has so far limited its use, especially in high-throughput settings. We aimed to establish a highly scalable homogenization process of tissue samples for long-term incubation in BCBs. A protocol for homogenization of tissue samples using bead beating was established and validated. In a second step, the use of the homogenate for enrichment in BCBs was compared to the use of thioglycolate broth (TB) in terms of diagnostic accuracy using clinical tissue samples from 150 patients with suspected PJI. Among 150 analyzed samples, 35 samples met the microbiological criteria for PJI. Using BCB, 32 of 35 (91.4%) PJI were detected compared to 30 of 35 (85.7%) by TB. The use of BCB had a lower secondary contamination rate (2/115; 1.7% vs 4/115; 3.5%) but the trend was not significant due to low numbers of samples (P = 0.39). The time to process a batch of 12 samples using the established homogenization method was 23 ± 5 min (n = 10 batches). We established and validated a homogenization workflow that achieves the highest sensitivity in the microbiological diagnostic of PJI. The enrichment of the tissue homogenate in BCBs showed equally good results as the use of enrichment broth and allows semi-automated high-throughput processing while demonstrating lower contamination rates in our study.
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Affiliation(s)
- Nathalie Jazmati
- Wisplinghoff Laboratories, Cologne, Germany
- Institute for Medical Microbiology, Immunology and Hygiene, University of Cologne, Cologne, Germany
| | | | - Christoph Offerhaus
- Department of Orthopedic Surgery and Sports Traumatology, Witten/Herdecke University, Witten, Germany
- Sana Medical Centre, Cologne, Germany
| | | | - Stefan Grote
- Department of Orthopedic, Trauma and Handsurgery, Brother of Mercy Hospital St. Elisabeth Straubing GmbH, Straubing, Germany
| | | | | | | | - Hilmar Wisplinghoff
- Wisplinghoff Laboratories, Cologne, Germany
- Institute for Virology and Microbiology, Witten/Herdecke University, Witten, Germany
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Chesdachai S, Esquer Garrigos Z, DeSimone CV, DeSimone DC, Baddour LM. Infective Endocarditis Involving Implanted Cardiac Electronic Devices: JACC Focus Seminar 1/4. J Am Coll Cardiol 2024; 83:1326-1337. [PMID: 38569763 DOI: 10.1016/j.jacc.2023.11.036] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Revised: 10/26/2023] [Accepted: 11/13/2023] [Indexed: 04/05/2024]
Abstract
Cardiac implantable electronic device-related infective endocarditis (CIED-IE) encompasses a range of clinical syndromes, including valvular, device lead, and bloodstream infections. However, accurately diagnosing CIED-IE remains challenging owing in part to diverse clinical presentations, lack of standardized definition, and variations in guideline recommendations. Furthermore, current diagnostic modalities, such as transesophageal echocardiography and [18F]-fluorodeoxyglucose positron emission tomography-computed tomography have limited sensitivity and specificity, further contributing to diagnostic uncertainty. This can potentially result in complications and unnecessary costs associated with inappropriate device extraction. Six hypothetical clinical cases that exemplify the diverse manifestations of CIED-IE are addressed herein. Through these cases, we highlight the importance of optimizing diagnostic accuracy and stewardship, understanding different pathogen-specific risks for bloodstream infections, guiding appropriate device extraction, and preventing CIED-IE, all while addressing key knowledge gaps. This review both informs clinicians and underscores crucial areas for future investigation, thereby shedding light on this complex and challenging syndrome.
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Affiliation(s)
- Supavit Chesdachai
- Division of Public Health, Infectious Diseases and Occupational Medicine, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA.
| | - Zerelda Esquer Garrigos
- Division of Public Health, Infectious Diseases and Occupational Medicine, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA; Division of Infectious Diseases, Department of Medicine, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | | | - Daniel C DeSimone
- Division of Public Health, Infectious Diseases and Occupational Medicine, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA; Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Larry M Baddour
- Division of Public Health, Infectious Diseases and Occupational Medicine, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA; Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
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Anneberg M, Kristiansen EB, Troelsen A, Gundtoft P, Sørensen HT, Pedersen AB. Enhancing the data capture of periprosthetic joint infections in the Danish Knee Arthroplasty Registry: validity assessment and incidence estimation. Acta Orthop 2024; 95:166-173. [PMID: 38595072 PMCID: PMC11004670 DOI: 10.2340/17453674.2024.40358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Accepted: 03/06/2024] [Indexed: 04/11/2024] Open
Abstract
BACKGROUND AND PURPOSE Revisions due to periprosthetic joint infection (PJI) are underestimated in national arthroplasty registries. Our primary objective was to assess the validity in the Danish Knee Arthroplasty Register (DKR) of revisions performed due to PJI against the Healthcare-Associated Infections Database (HAIBA). The secondary aim was to describe the cumulative incidences of revision due to PJI within 1 year of primary total knee arthroplasty (TKA) according to the DKR, HAIBA, and DKR/HAIBA combined. METHODS This longitudinal observational cohort study included 56,305 primary TKAs (2010-2018), reported in both the DKR and HAIBA. In the DKR, revision performed due to PJI was based on pre- and intraoperative assessment disclosed by the surgeon immediately after surgery. In HAIBA, PJI was identified from knee-related revision procedures coinciding with 2 biopsies with identical microbiological pathogens. We calculated the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of revision due to PJI in the DKR (vs. HAIBA, within 1 year of TKA) with 95% confidence intervals (CI). Cumulative incidences were calculated using the Kaplan-Meier method. RESULTS The DKR's sensitivity for PJI revision was 58% (CI 53-62) and varied by TKA year (41%-68%) and prosthetic type (31% for monoblock; 63% for modular). The specificity was 99.8% (CI 99.7-99.8), PPV 64% (CI 62-72), and NPV 99.6% (CI 99.6-99.7). 80% of PJI cases not captured by the DKR were caused by non-reporting rather than misclassification. 33% of PJI cases in the DKR or HAIBA were culture-negative. Considering potential misclassifications, the best-case sensitivity was 64%. The cumulative incidences of PJI were 0.8% in the DKR, 0.9% in HAIBA, and 1.1% when combining data. CONCLUSION The sensitivity of revision due to PJI in the DKR was 58%. The cumulative incidence of PJI within 1 year after TKA was highest (1.1%) when combining the DKR and HAIBA, showing that incorporating microbiology data into arthroplasty registries can enhance PJI validity.
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Affiliation(s)
- Marie Anneberg
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus University.
| | | | | | - Per Gundtoft
- Department of Orthopedic Surgery, Aarhus University Hospital
| | - Henrik Toft Sørensen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus University
| | - Alma B Pedersen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus University; Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
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Deans CF, Kildow BJ, Garvin KL. Recurrent Periprosthetic Joint Infections: Diagnosis, Management, and Outcomes. Orthop Clin North Am 2024; 55:193-206. [PMID: 38403366 DOI: 10.1016/j.ocl.2023.09.002] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/27/2024]
Abstract
Periprosthetic joint infection (PJI) remains one of the most common complications after total joint arthroplasty. It is challenging to manage, associated with significant morbidity and mortality, and is a financial burden on the health care system. Failure of 2-stage management for chronic PJI is not uncommon. Repeat infections are oftentimes polymicrobial, multiple drug-resistant microorganisms, or new organisms. Optimizing the success of index 2-stage revision is the greatest prevention against failure of any subsequent management options and requires a robust team-based approach.
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Affiliation(s)
- Christopher F Deans
- Department of Orthopaedic Surgery and Rehabilitation, University of Nebraska Medical Center, 985640 Nebraska Medical Center, Omaha, NE 68198, USA.
| | - Beau J Kildow
- Department of Orthopaedic Surgery and Rehabilitation, University of Nebraska Medical Center, 985640 Nebraska Medical Center, Omaha, NE 68198, USA
| | - Kevin L Garvin
- Department of Orthopaedic Surgery and Rehabilitation, University of Nebraska Medical Center, 985640 Nebraska Medical Center, Omaha, NE 68198, USA
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Klott J, Brolin TJ. Diagnostic Evaluation of Prosthetic Joint Infections of the Shoulder: What Does the Literature Say? Orthop Clin North Am 2024; 55:257-264. [PMID: 38403371 DOI: 10.1016/j.ocl.2023.09.006] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/27/2024]
Abstract
The total number of patients with a total shoulder arthroplasty (TSA) is increasing, and the number of patients experiencing a (TSA) prosthetic joint infection (PJI) also will increase. It is important that physicians know how to identify signs of infection, know the common pathogens, and know how to work up a shoulder PJI. This publication reviewed the current literature about presenting signs and symptoms, common shoulder pathogens and how they differ from total knee and hip pathogens, and what images, tests, and procedures can aid in identification of infection.
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Affiliation(s)
- Jeffrey Klott
- Department of Orthopaedic Surgery and Biomedical Engineering, University of Tennessee Health Science Center- Campbell Clinic, 1211 Union Avenue, Suite 520, Memphis, TN 38104, USA
| | - Tyler J Brolin
- Department of Orthopaedic Surgery and Biomedical Engineering, University of Tennessee Health Science Center- Campbell Clinic, 1211 Union Avenue, Suite 520, Memphis, TN 38104, USA.
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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9
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MacConnell AE, Levack AE, Brown NM. Biofilm and How It Relates to Prosthetic Joint Infection. Orthop Clin North Am 2024; 55:161-169. [PMID: 38403363 DOI: 10.1016/j.ocl.2023.10.001] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/27/2024]
Abstract
Prosthetic joint infection following total joint arthroplasty is a devastating complication, resulting in increased morbidity and mortality for the patient. The formation of a biofilm on implanted hardware contributes to the difficulty in successful identification and eradication of the infection. Antibiotic therapy and surgical intervention are necessary for addressing this condition; we present a discussion on different treatment options, including those that are not yet routinely utilized in the clinical setting or are under investigation, to highlight the present and future of PJI management.
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Affiliation(s)
- Ashley E MacConnell
- Department of Orthopaedic Surgery and Rehabilitation, Loyola University Medical Center, 2160 South First Avenue, Suite 1700, Maywood, IL 60153, USA.
| | - Ashley E Levack
- Department of Orthopaedic Surgery and Rehabilitation, Loyola University Medical Center, 2160 South First Avenue, Suite 1700, Maywood, IL 60153, USA
| | - Nicholas M Brown
- Department of Orthopaedic Surgery and Rehabilitation, Loyola University Medical Center, 2160 South First Avenue, Suite 1700, Maywood, IL 60153, USA
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Gray CF. CORR Insights®: Neutrophil Extracellular Trap-related Biomarkers Are Increased in the Synovial Fluid of Patients With Periprosthetic Joint Infections. Clin Orthop Relat Res 2024; 482:734-736. [PMID: 38231019 PMCID: PMC10936967 DOI: 10.1097/corr.0000000000002971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Accepted: 12/07/2023] [Indexed: 01/18/2024]
Affiliation(s)
- Chancellor F Gray
- Orthopaedic Surgeon, Florida Orthopaedic Institute, Gainesville, FL, USA
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Straub J, Staats K, Vertesich K, Kowalscheck L, Windhager R, Böhler C. Two-stage revision for periprosthetic joint infection after hip and knee arthroplasty. Bone Joint J 2024; 106-B:372-379. [PMID: 38555938 DOI: 10.1302/0301-620x.1064.bjj-2023-0638.r2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/02/2024]
Abstract
Aims Histology is widely used for diagnosis of persistent infection during reimplantation in two-stage revision hip and knee arthroplasty, although data on its utility remain scarce. Therefore, this study aims to assess the predictive value of permanent sections at reimplantation in relation to reinfection risk, and to compare results of permanent and frozen sections. Methods We retrospectively collected data from 226 patients (90 hips, 136 knees) with periprosthetic joint infection who underwent two-stage revision between August 2011 and September 2021, with a minimum follow-up of one year. Histology was assessed via the SLIM classification. First, we analyzed whether patients with positive permanent sections at reimplantation had higher reinfection rates than patients with negative histology. Further, we compared permanent and frozen section results, and assessed the influence of anatomical regions (knee versus hip), low- versus high-grade infections, as well as first revision versus multiple prior revisions on the histological result at reimplantation. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), chi-squared tests, and Kaplan-Meier estimates were calculated. Results Overall, the reinfection rate was 18%. A total of 14 out of 82 patients (17%) with positive permanent sections at reimplantation experienced reinfection, compared to 26 of 144 patients (18%) with negative results (p = 0.996). Neither permanent sections nor fresh frozen sections were significantly associated with reinfection, with a sensitivity of 0.35, specificity of 0.63, PPV of 0.17, NPV of 0.81, and accuracy of 58%. Histology was not significantly associated with reinfection or survival time for any of the analyzed sub-groups. Permanent and frozen section results were in agreement for 91% of cases. Conclusion Permanent and fresh frozen sections at reimplantation in two-stage revision do not serve as a reliable predictor for reinfection.
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Affiliation(s)
- Jennifer Straub
- Department of Orthopaedics and Trauma Surgery, Medical University of Vienna, Vienna, Austria
| | - Kevin Staats
- Department of Orthopaedics and Trauma Surgery, Medical University of Vienna, Vienna, Austria
| | - Klemens Vertesich
- Department of Orthopaedics and Trauma Surgery, Medical University of Vienna, Vienna, Austria
| | - Lars Kowalscheck
- Department of Pathology, Medical University of Vienna, Vienna, Austria
| | - Reinhard Windhager
- Department of Orthopaedics and Trauma Surgery, Medical University of Vienna, Vienna, Austria
| | - Christoph Böhler
- Department of Orthopaedics and Trauma Surgery, Medical University of Vienna, Vienna, Austria
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Eckmann C, Sunderkötter C, Becker K, Grabein B, Hagel S, Hanses F, Wichmann D, Thalhammer F. Left ventricular assist device-associated driveline infections as a specific form of complicated skin and soft tissue infection/acute bacterial skin and skin structure infection - issues and therapeutic options. Curr Opin Infect Dis 2024; 37:95-104. [PMID: 38085707 PMCID: PMC10911258 DOI: 10.1097/qco.0000000000000999] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2024]
Abstract
PURPOSE OF REVIEW This review comments on the current guidelines for the treatment of wound infections under definition of acute bacterial skin and skin structure infections (ABSSSI). However, wound infections around a catheter, such as driveline infections of a left ventricular assist device (LVAD) are not specifically listed under this definition in any of the existing guidelines. RECENT FINDINGS Definitions and classification of LVAD infections may vary across countries, and the existing guidelines and recommendations may not be equally interpreted among physicians, making it unclear if these infections can be considered as ABSSSI. Consequently, the use of certain antibiotics that are approved for ABSSSI may be considered as 'off-label' for LVAD infections, leading to rejection of reimbursement applications in some countries, affecting treatment strategies, and hence, patients' outcomes. However, we believe driveline exit site infections related to LVAD can be included within the ABSSSI definition. SUMMARY We argue that driveline infections meet the criteria for ABSSSI which would enlarge the 'on-label' antibiotic armamentarium for treating these severe infections, thereby improving the patients' quality of life.
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Affiliation(s)
- Christian Eckmann
- Academic Hospital of Goettingen University, Department of General, Visceral and Thoracic Surgery, Klinikum Hannoversch-Muenden, Hannoversch-Muenden
| | - Cord Sunderkötter
- Martin-Luther-University Halle-Wittenberg, University and University Hospital of Halle, Department of Dermatology and Venerology, Halle
| | - Karsten Becker
- University Medicine Greifswald, Friedrich Loeffler-Institute of Medical Microbiology, Greifswald
| | - Béatrice Grabein
- LMU Hospital, Clinical Microbiology and Hospital Hygiene, Munich
| | - Stefan Hagel
- Jena University Hospital-Friedrich Schiller University Jena, Institute for Infectious Diseases and Infection Control, Jena
| | - Frank Hanses
- University Hospital Regensburg, Department of Infection Prevention and Infectious Diseases
- University Hospital Regensburg, Emergency Department, Regensburg
| | - Dominic Wichmann
- University Medical Center Hamburg-Eppendorf, Department of Intensive Care Medicine, Hamburg
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Fenske F, Kujat B, Krause L, Meyer S, Sander AK, Repmann J, Neuhaus M, Haak R, Roth A, Lethaus B, Ziebolz D, Schmalz G. Preoperative dental screening can reduce periprosthetic infections of hip and knee endoprostheses in the first month after surgery: results of a cohort study. Infection 2024; 52:535-543. [PMID: 38060067 PMCID: PMC10954939 DOI: 10.1007/s15010-023-02128-2] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Accepted: 10/27/2023] [Indexed: 12/08/2023]
Abstract
PURPOSE The oral cavity and, in particular, potential oral foci might pose a risk of periprosthetic joint infection (PJI). The aim of this cohort study was to determine whether practical preoperative dental screening would reduce the prevalence of early PJI in the first month after surgery. METHODS Patients attending a specialized endoprosthesis implantation clinic between 2018 and 2022 were recruited. Two groups were examined. The test group consisted of patients attending the clinic between 2020 and 2022 and who were referred to their family dentist using a standardized form. The comparison group consisted of patients who were treated in the clinic between 2018 and 2020. They were not referred to their family dentist. The two groups were compared for the prevalence of PJI. Univariate analysis followed by multiple logistic regression was performed to confirm risk factors for PJI in this cohort. RESULTS 2560 individuals (test group: 1227, comparison group: 1333) were included. The prevalence of PJI was significantly lower in the test group (0.8% vs. 1.8%, p = 0.04). Multiple logistic regression with PJI as the dependent variable showed that a dental referral was a strong predictor of a lower prevalence of PJI (OR: 0.43, CI95 0.205-0.917, p = 0.03). Male gender was also strongly associated with a higher frequency of PJI (OR: 2.68, CI95 1.32-5.42, p = 0.01). Age (OR: 1.06, CI95 1.01-1.10, p = 0.01) and BMI (OR: 1.11, CI95 1.05-1.17, p < 0.01) had little effect on the risk of PJI. CONCLUSION Dental referral using a standardized form can reduce the prevalence of early PJI. Accordingly, orthopedists and dentists should collaborate in this practical way.
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Affiliation(s)
- Fabian Fenske
- Department of Oral and Maxillofacial Surgery, University of Leipzig, Liebigstr. 12, 04103, Leipzig, Germany.
| | - Benjamin Kujat
- Specialized Clinic for Orthopedics, Mediclin Waldkrankenhaus Bad Düben, 04848, Bad Düben, Germany
| | - Leah Krause
- Department of Cariology, Endodontology and Periodontology, University of Leipzig, 04103, Leipzig, Germany
| | - Stephan Meyer
- Department of Oral and Maxillofacial Surgery, University of Leipzig, Liebigstr. 12, 04103, Leipzig, Germany
| | - Anna-Katharina Sander
- Department of Oral and Maxillofacial Surgery, University of Leipzig, Liebigstr. 12, 04103, Leipzig, Germany
| | - Jaqueline Repmann
- Specialized Clinic for Orthopedics, Mediclin Waldkrankenhaus Bad Düben, 04848, Bad Düben, Germany
| | - Michael Neuhaus
- Department of Oral and Maxillofacial Surgery, University of Leipzig, Liebigstr. 12, 04103, Leipzig, Germany
| | - Rainer Haak
- Department of Cariology, Endodontology and Periodontology, University of Leipzig, 04103, Leipzig, Germany
| | - Andreas Roth
- Department of Orthopaedics, Trauma and Plastic Surgery, University Hospital Leipzig, 04103, Leipzig, Germany
| | - Bernd Lethaus
- Department of Oral and Maxillofacial Surgery, University of Leipzig, Liebigstr. 12, 04103, Leipzig, Germany
| | - Dirk Ziebolz
- Department of Cariology, Endodontology and Periodontology, University of Leipzig, 04103, Leipzig, Germany
| | - Gerhard Schmalz
- Department of Cariology, Endodontology and Periodontology, University of Leipzig, 04103, Leipzig, Germany
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de Sandes Kimura O, Mozella A, Cobra H, Maciel Saraiva AC, Carvalho de Almendra Freitas EH, Cury Fernandes MB, Matheus Guimarães JA, Defino H, Leal AC. Neutrophil Extracellular Trap-related Biomarkers Are Increased in the Synovial Fluid of Patients With Periprosthetic Joint Infections. Clin Orthop Relat Res 2024; 482:727-733. [PMID: 37882792 PMCID: PMC10937003 DOI: 10.1097/corr.0000000000002891] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Accepted: 09/15/2023] [Indexed: 10/27/2023]
Abstract
BACKGROUND The diagnosis of periprosthetic joint infection (PJI) is a major challenge in clinical practice. The role of neutrophils in fighting infection has been increasingly understood, and one mechanism of action of these cells is neutrophil extracellular traps. However, little is known about this process in PJI. QUESTIONS/PURPOSES (1) Are the biomarkers of neutrophil extracellular trap formation (citrullinated histone H3 [H3Cit], cell-free DNA [cf-DNA], and myeloperoxidase [MPO]) increased in the synovial fluid of patients with PJI? (2) What is the diagnostic accuracy of biomarkers of neutrophil extracellular trap formation for PJI? METHODS Between May 2020 and March 2021, 43 patients who underwent revision THA or TKA were enrolled in this study. Eleven patients were excluded and 32 patients were categorized into the PJI group (n = 16) or non-PJI group (n = 16) according to the 2018 Second International Consensus Meeting on Musculoskeletal Infection criteria. There were 15 men and 17 women in this study, with a median (range) age of 70 years (60 to 80 years). Twenty-seven patients had TKA and five had THA. We measured cf-DNA, MPO, and H3Cit in synovial fluid. The sensitivity, specificity, and receiver operating characteristic curve were calculated for each biomarker using the Musculoskeletal Infection Society criteria as the gold standard for diagnosis and considering a clinical surveillance of 2 years for patients in the non-PJI group. RESULTS Patients with PJI had higher levels of synovial fluid cf-DNA (median [range] 130 ng/µL [18 to 179] versus 2 ng/µL [0 to 6]; p < 0.001), MPO (1436 ng/µL [55 to 3996] versus 0 ng/µL [0 to 393]; p < 0.001), and H3Cit (2115 ng/µL [5 to 2885] versus 3 ng/µL [0 to 87]; p < 0.001) than those in the non-PJI group. In receiver operating characteristic curve analyses, we observed near-perfect performance for all biomarkers evaluated, with an area under the curve of 1 (95% CI 0.9 to 1), 0.98 (95% CI 0.9 to 1), and 0.94 (95% CI 0.8 to 0.99) for cf-DNA, MPO, and H3Cit, respectively. The sensitivity for detecting PJI using synovial fluid was 100% for cf-DNA, 94% for MPO, and 88% for H3Cit. The specificity was 100% for cf-DNA and MPO, and 88% for H3Cit. CONCLUSION Our results show that neutrophils in the periprosthetic microenvironment release neutrophil extracellular traps as part of the bactericidal arsenal to fight infection. These results allow a better understanding of the cellular and molecular processes that occur in this microenvironment, enabling the design of more assertive strategies for identifying new biomarkers and improving the available ones. Novel studies are needed to define whether and how neutrophil extracellular trap-related biomarkers can be useful for diagnosing PJI. LEVEL OF EVIDENCE Level II, diagnostic study.
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Affiliation(s)
- Osamu de Sandes Kimura
- Center for Surgery of Hip, National Institute of Traumatology and Orthopaedics, Rio de Janeiro, Brazil
| | - Alan Mozella
- Center for Surgery of Knee, National Institute of Traumatology and Orthopaedics, Rio de Janeiro, Brazil
| | - Hugo Cobra
- Center for Surgery of Knee, National Institute of Traumatology and Orthopaedics, Rio de Janeiro, Brazil
| | | | | | | | | | - Helton Defino
- Department of Orthopaedics and Anaesthesiology, Ribeirão Preto Medical School, University of São Paulo, São Paulo, Brazil
| | - Ana Carolina Leal
- Teaching and Research Division, National Institute of Traumatology and Orthopaedics, Rio de Janeiro, Brazil
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Davis JS, Dewar D, Manning L. Prosthetic joint infection diagnosis in an age of changing clinical patterns of infection and new technologies. Med J Aust 2024; 220:225-228. [PMID: 38351733 DOI: 10.5694/mja2.52228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Accepted: 01/31/2024] [Indexed: 03/18/2024]
Affiliation(s)
- Joshua S Davis
- University of Newcastle, Newcastle, NSW
- Hunter Medical Research Institute, Newcastle, NSW
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16
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Nairn L, Sivaratnam S, Bali K, Wood TJ. Neutrophil to Lymphocyte Ratio as an Indicator of Periprosthetic Joint Infection: A Retrospective Cohort Study. J Am Acad Orthop Surg 2024; 32:271-278. [PMID: 38127888 DOI: 10.5435/jaaos-d-23-00600] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Accepted: 11/02/2023] [Indexed: 12/23/2023] Open
Abstract
INTRODUCTION Periprosthetic joint infection (PJI) after total joint arthroplasty (TJA) is a serious complication posing notable clinical implications for patients and substantial economic burdens. Neutrophil to lymphocyte ratio (NLR) is an emerging biomarker of inflammation, which may better predict PJI. The objective of this review was to evaluate NLR changes in patients with confirmed PJI, to compare NLR between an aseptic revision and a revision for PJI, and to establish whether an NLR of 2.45 is an appropriate cutoff for predicting infection. METHODS A retrospective review of patients who underwent revision TJA for PJI at a single center between January 1, 2005, and December 31, 2018, was performed and compared with an aseptic cohort who underwent aseptic revision TJA. NLR was calculated from complete blood counts performed at index surgery and at the time of revision surgery. Receiver operating characteristic curves were analyzed, along with sensitivity, specificity, and positive and negative likelihood ratios. RESULTS There were 89 patients included in each cohort. Mean NLR in patients who underwent revision for PJI was 2.85 (± 1.27) at the time of index surgery and 6.89 (± 6.64) at the time of revision surgery ( P = 0.017). Mean NLR in patients undergoing revision for PJI (6.89) was significantly higher than aseptic revisions (3.17; P < 0.001). DISCUSSION In patients who underwent revision surgery for PJI, NLR was markedly elevated at time of revision compared with the time of index surgery. Because it is a cost-effective and readily available test, these findings suggest that NLR may be a useful triage test in the diagnosis of PJI. LEVEL OF EVIDENCE Level III Diagnostic Study.
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Affiliation(s)
- Leah Nairn
- From the Division of Orthopaedic Surgery, McMaster University, Hamilton, ON (Nairn, Bali, and Wood), the Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON (Sivaratnam), and the Hamilton Health Sciences Juravinski Hospital, Hamilton, ON (Bali and Wood), Canada
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17
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Tan J, Wu L, Zhan L, Sheng M, Tang Z, Xu J, Ma H. Optimal selection of specimens for metagenomic next-generation sequencing in diagnosing periprosthetic joint infections. Front Cell Infect Microbiol 2024; 14:1356804. [PMID: 38500507 PMCID: PMC10945027 DOI: 10.3389/fcimb.2024.1356804] [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] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2023] [Accepted: 02/19/2024] [Indexed: 03/20/2024] Open
Abstract
Objective This study aimed to assess the diagnostic value of metagenomic next-generation sequencing (mNGS) across synovial fluid, prosthetic sonicate fluid, and periprosthetic tissues among patients with periprosthetic joint infection (PJI), intending to optimize specimen selection for mNGS in these patients. Methods This prospective study involved 61 patients undergoing revision arthroplasty between September 2021 and September 2022 at the First Affiliated Hospital of Zhengzhou University. Among them, 43 cases were diagnosed as PJI, and 18 as aseptic loosening (AL) based on the American Musculoskeletal Infection Society (MSIS) criteria. Preoperative or intraoperative synovial fluid, periprosthetic tissues, and prosthetic sonicate fluid were collected, each divided into two portions for mNGS and culture. Comparative analyses were conducted between the microbiological results and diagnostic efficacy derived from mNGS and culture tests. Furthermore, the variability in mNGS diagnostic efficacy for PJI across different specimen types was assessed. Results The sensitivity and specificity of mNGS diagnosis was 93% and 94.4% for all types of PJI specimens; the sensitivity and specificity of culture diagnosis was 72.1% and 100%, respectively. The diagnostic sensitivity of mNGS was significantly higher than that of culture (X2 = 6.541, P=0.011), with no statistically significant difference in specificity (X2 = 1.029, P=0.310). The sensitivity of the synovial fluid was 83.7% and the specificity was 94.4%; the sensitivity of the prosthetic sonicate fluid was 90.7% and the specificity was 94.4%; and the sensitivity of the periprosthetic tissue was 81.4% and the specificity was 100%. Notably, the mNGS of prosthetic sonicate fluid displayed a superior pathogen detection rate compared to other specimen types. Conclusion mNGS can function as a precise diagnostic tool for identifying pathogens in PJI patients using three types of specimens. Due to its superior ability in pathogen identification, prosthetic sonicate fluid can replace synovial fluid and periprosthetic tissue as the optimal sample choice for mNGS.
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Affiliation(s)
- Jun Tan
- Department of Mini-invasive Spinal Surgery, The Third People’s Hospital of Henan Province, Zhengzhou, Henan, China
| | - Lingxiao Wu
- Department of Orthopedic Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Lijuan Zhan
- Department of Neurology, People’s Hospital of Zhengzhou, Zhengzhou, Henan, China
| | - Minkui Sheng
- Department of Mini-invasive Spinal Surgery, The Third People’s Hospital of Henan Province, Zhengzhou, Henan, China
| | - Zhongxin Tang
- Department of Mini-invasive Spinal Surgery, The Third People’s Hospital of Henan Province, Zhengzhou, Henan, China
- Department of Orthopedic Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Jianzhong Xu
- Department of Orthopedic Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Haijun Ma
- Department of Mini-invasive Spinal Surgery, The Third People’s Hospital of Henan Province, Zhengzhou, Henan, China
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Walther M, Krenn V, Pfahl K. Diagnosing and Managing Infection in Total Ankle Replacement. Foot Ankle Clin 2024; 29:145-156. [PMID: 38309798 DOI: 10.1016/j.fcl.2023.09.002] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2024]
Abstract
Infections after total ankle replacement (TAR) within the first 4 weeks after implantation can be managed successfully with 1 or several debridements, irrigation, and a change of polyethylene inlay. Late infections require implant removal. Low-grade infections might be an underestimated problem so far. Although single-surgery revisions are reported in the literature, the authors' experience with 2-stage revisions using an antibiotics-loaded bone cement spacer is better. Additional antibiotics are used to support the surgical treatment. After antibiotic therapy of 12 weeks, the final treatment includes ankle or tibio-talo-calcaneal fusion and, with limitations, revision TAR.
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Affiliation(s)
- Markus Walther
- Department of Foot and Ankle Surgery, Schön Klinik München Harlaching - FIFA Medical Centre, Harlachinger Straße 51, Munich 81547, Germany; Department of Orthopaedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, LMU Munich, Marchioninistraße 15, München 81377, Germany; Department of Orthopedic Surgery, University of Wuerzburg, Brettreichstrasse 11, Würzburg 97074, Germany; Paracelsus Medical University, Strubergasse 21, Salzburg 5020, Austria.
| | - Veit Krenn
- Pathologie Trier, Max-Planck-Str. 5, Trier 54296, Germany
| | - Kathrin Pfahl
- Department of Foot and Ankle Surgery, Schön Klinik München Harlaching - FIFA Medical Centre, Harlachinger Straße 51, Munich 81547, Germany; Department of Orthopaedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, LMU Munich, Marchioninistraße 15, München 81377, Germany
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Theil C, Moellenbeck B, Schwarze J, Puetzler J, Klingebiel S, Bockholt S, Gosheger G. Can the Current Thresholds for Synovial Cell Count and Neutrophil Percentage to Diagnose Prosthetic Joint Infection be Applied to Metal-on-Metal Rotating Hinge Total Knee Arthroplasty? J Arthroplasty 2024; 39:801-805. [PMID: 37648100 DOI: 10.1016/j.arth.2023.08.073] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 08/21/2023] [Accepted: 08/22/2023] [Indexed: 09/01/2023] Open
Abstract
BACKGROUND Synovial leukocyte count analysis is an important tool in the diagnosis of PJI. However, results can be poor if metallosis is present. The issue of metallosis was established for some rotating hinge knee arthroplasty designs. METHODS This was a retrospective single-center analysis that included 108 patients who had a single-design metal-on-metal rotating hinge knee arthroplasty who underwent revision surgery and had prior synovial fluid analysis performed. The diagnostic accuracy of leukocyte count and the percentage of polymorphonuclear neutrophiles (% PMN) were investigated. RESULTS Patients who had a PJI had a higher median leukocyte count and % PMN compared to aseptic revisions (7,905/μL (interquartile range (IQR) 2,419 to 37,400) and 85% (IQR 70.3 to 93.8) versus 450 (IQR 167 to 1,215) and 46% (IQR 28.5 to 67.4%), P < .001). The respective areas under the curves were 0.916 (95% confidence interval 0.862 to 0.970) for leukocyte count and 0.821 (95% confidence interval 0.739 to 0.902) for % PMN. We calculated an optimal cut-off value of 1,200 leukocytes/μL (Sensitivity 94.5%/specificity 75.5%) and 63% PMN (Sensitivity 85.5%/specificity 73.6%) to define PJI. Established thresholds were less sensitive, but more specific. The "infection likely" scenario of the European Bone and Joint Infection Society (EBJIS) definition was closest to the calculated thresholds. CONCLUSION Currently used thresholds for leukocyte cell count and %PMN to define PJI were less sensitive and specific in the diagnosis of PJI in metal-on-metal RHK knees. Surgeons must consider lower cut-off values when evaluating such implants for PJI.
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Affiliation(s)
- Christoph Theil
- Department of General Orthopedics and Tumour Orthopedics, Muenster University Hospital, Muenster, Germany
| | - Burkhard Moellenbeck
- Department of General Orthopedics and Tumour Orthopedics, Muenster University Hospital, Muenster, Germany
| | - Jan Schwarze
- Department of General Orthopedics and Tumour Orthopedics, Muenster University Hospital, Muenster, Germany
| | - Jan Puetzler
- Department of General Orthopedics and Tumour Orthopedics, Muenster University Hospital, Muenster, Germany
| | - Sebastian Klingebiel
- Department of General Orthopedics and Tumour Orthopedics, Muenster University Hospital, Muenster, Germany
| | - Sebastian Bockholt
- Department of General Orthopedics and Tumour Orthopedics, Muenster University Hospital, Muenster, Germany
| | - Georg Gosheger
- Department of General Orthopedics and Tumour Orthopedics, Muenster University Hospital, Muenster, Germany
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Salimi M, Karam JA, Willman M, Willman J, Lucke-Wold B, Khanzadeh S, Mirghaderi P, Parvizi J. Neutrophil to Lymphocyte Ratio and Periprosthetic Joint Infection: A Systematic Review and Meta-Analysis. J Arthroplasty 2024; 39:831-838. [PMID: 37633509 DOI: 10.1016/j.arth.2023.08.067] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Revised: 08/17/2023] [Accepted: 08/19/2023] [Indexed: 08/28/2023] Open
Abstract
BACKGROUND The neutrophil-to-lymphocyte ratio (NLR) has shown promising results as a diagnostic tool for periprosthetic joint infection (PJI) after total joint arthroplasty. We conducted a systematic review and meta-analysis to determine the utility of NLR in the diagnosis of PJI. METHODS We searched PubMed, Scopus, and Web of Science from inception up to 2022 and evaluated the quality of the included literature. RESULTS Based on the 12 eligible studies, NLR levels were significantly higher in patients who had PJI compared to those who had aseptic loosening (standard mean difference (SMD) = 1.05, 95% Confidence Interval (CI) = 0.71 to 1.40, P < .001). In the subgroup analysis according to type of PJI, NLR levels were significantly higher in patients who had either acute (SMD = 1.04, 95% CI = 0.05 to 2.03, P < .001) or chronic PJI (SMD = 1.08, 95% CI = 0.55 to 1.61, P < .001), compared to those who had aseptic loosening. According to type of arthroplasty, NLR levels were significantly higher in patients who had either total knee arthroplasty (SMD = 1.81, 95% CI = 1.48 to 2.13, P < .001) or total hip arthroplasty (SMD = 1.76, 95% CI = 1.54 to 1.98, P < .001) compared to aseptic loosening. The pooled sensitivity of the 12 studies was 0.73 (95% CI, 0.65 to 0.79), and the pooled specificity was 0.75 (95% CI, 0.71 to 0.78). The pooled positive likelihood ratio, negative likelihood ratio, and diagnostic odds ratio of NLR were 2.94 (95% CI = 2.44 to 3.54), 0.35 (95% CI = 0.27 to 0.46), and 8.26 (95% CI = 5.42 to 12.58), respectively. CONCLUSION In summary, this meta-analysis indicates that NLR is a reliable marker in the diagnosis of PJI.
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Affiliation(s)
- Maryam Salimi
- Bone and Joint Diseases Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Joseph Albert Karam
- Department of Orthopedic Surgery, University of Illinois at Chicago, Chicago, Illinois
| | | | | | | | - Shokoufeh Khanzadeh
- Student Research Committee, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Peyman Mirghaderi
- Students' Scientific Research Center (SSRC), Tehran University of Medical Sciences, Tehran, Iran
| | - Javad Parvizi
- Department of Orthopedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
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Maclean E, Mahtani K, Honarbakhsh S, Butcher C, Ahluwalia N, Dennis AS, Creta A, Finlay M, Elliott M, Mehta V, Wijesuriya N, Shaikh O, Zaw Y, Ogbedeh C, Gautam V, Lambiase PD, Schilling RJ, Earley MJ, Moore P, Muthumala A, Sporton SC, Hunter RJ, Rinaldi CA, Behar J, Martin C, Monkhouse C, Chow A. The BLISTER Score: A Novel, Externally Validated Tool for Predicting Cardiac Implantable Electronic Device Infections, and Its Cost-Utility Implications for Antimicrobial Envelope Use. Circ Arrhythm Electrophysiol 2024; 17:e012446. [PMID: 38258308 PMCID: PMC10949977 DOI: 10.1161/circep.123.012446] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Accepted: 01/18/2024] [Indexed: 01/24/2024]
Abstract
BACKGROUND Antimicrobial envelopes reduce the incidence of cardiac implantable electronic device infections, but their cost restricts routine use in the United Kingdom. Risk scoring could help to identify which patients would most benefit from this technology. METHODS A novel risk score (BLISTER [Blood results, Long procedure time, Immunosuppressed, Sixty years old (or younger), Type of procedure, Early re-intervention, Repeat procedure]) was derived from multivariate analysis of factors associated with cardiac implantable electronic device infection. Diagnostic utility was assessed against the existing PADIT score (Prior procedure, Age, Depressed renal function, Immunocompromised, Type of procedure) in both standard and high-risk external validation cohorts, and cost-utility models examined different BLISTER and PADIT score thresholds for TYRX (Medtronic; Minneapolis, MN) antimicrobial envelope allocation. RESULTS In a derivation cohort (n=7383), cardiac implantable electronic device infection occurred in 59 individuals within 12 months of a procedure (event rate, 0.8%). In addition to the PADIT score constituents, lead extraction (hazard ratio, 3.3 [95% CI, 1.9-6.1]; P<0.0001), C-reactive protein >50 mg/L (hazard ratio, 3.0 [95% CI, 1.4-6.4]; P=0.005), reintervention within 2 years (hazard ratio, 10.1 [95% CI, 5.6-17.9]; P<0.0001), and top-quartile procedure duration (hazard ratio, 2.6 [95% CI, 1.6-4.1]; P=0.001) were independent predictors of infection. The BLISTER score demonstrated superior discriminative performance versus PADIT in the standard risk (n=2854, event rate: 0.8%, area under the curve, 0.82 versus 0.71; P=0.001) and high-risk validation cohorts (n=1961, event rate: 2.0%, area under the curve, 0.77 versus 0.69; P=0.001), and in all patients (n=12 198, event rate: 1%, area under the curve, 0.8 versus 0.75, P=0.002). In decision-analytic modeling, the optimum scenario assigned antimicrobial envelopes to patients with BLISTER scores ≥6 (10.8%), delivering a significant reduction in infections (relative risk reduction, 30%; P=0.036) within the National Institute for Health and Care Excellence cost-utility thresholds (incremental cost-effectiveness ratio, £18 446). CONCLUSIONS The BLISTER score (https://qxmd.com/calculate/calculator_876/the-blister-score-for-cied-infection) was a valid predictor of cardiac implantable electronic device infection, and could facilitate cost-effective antimicrobial envelope allocation to high-risk patients.
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Affiliation(s)
- Edd Maclean
- Department of Cardiac Electrophysiology, Barts Heart Centre, St. Bartholomew’s Hospital, London, United Kingdom (E.M., K.M., S.H., C.B., N.A., A.S.C.D., A.C., M.F., P.D.L., R.J.S., M.J.E., P.M., A.M., S.C.E.S., R.J.H., C. Monkhouse, A.C.)
- William Harvey Research Institute, Queen Mary University of London, London, United Kingdom (E.M., S.H., N.A., R.J.S., R.J.H., A. Chow)
| | - Karishma Mahtani
- Department of Cardiac Electrophysiology, Barts Heart Centre, St. Bartholomew’s Hospital, London, United Kingdom (E.M., K.M., S.H., C.B., N.A., A.S.C.D., A.C., M.F., P.D.L., R.J.S., M.J.E., P.M., A.M., S.C.E.S., R.J.H., C. Monkhouse, A.C.)
| | - Shohreh Honarbakhsh
- Department of Cardiac Electrophysiology, Barts Heart Centre, St. Bartholomew’s Hospital, London, United Kingdom (E.M., K.M., S.H., C.B., N.A., A.S.C.D., A.C., M.F., P.D.L., R.J.S., M.J.E., P.M., A.M., S.C.E.S., R.J.H., C. Monkhouse, A.C.)
- William Harvey Research Institute, Queen Mary University of London, London, United Kingdom (E.M., S.H., N.A., R.J.S., R.J.H., A. Chow)
| | - Charles Butcher
- Department of Cardiac Electrophysiology, Barts Heart Centre, St. Bartholomew’s Hospital, London, United Kingdom (E.M., K.M., S.H., C.B., N.A., A.S.C.D., A.C., M.F., P.D.L., R.J.S., M.J.E., P.M., A.M., S.C.E.S., R.J.H., C. Monkhouse, A.C.)
| | - Nikhil Ahluwalia
- Department of Cardiac Electrophysiology, Barts Heart Centre, St. Bartholomew’s Hospital, London, United Kingdom (E.M., K.M., S.H., C.B., N.A., A.S.C.D., A.C., M.F., P.D.L., R.J.S., M.J.E., P.M., A.M., S.C.E.S., R.J.H., C. Monkhouse, A.C.)
- William Harvey Research Institute, Queen Mary University of London, London, United Kingdom (E.M., S.H., N.A., R.J.S., R.J.H., A. Chow)
| | - Adam S.C. Dennis
- Department of Cardiac Electrophysiology, Barts Heart Centre, St. Bartholomew’s Hospital, London, United Kingdom (E.M., K.M., S.H., C.B., N.A., A.S.C.D., A.C., M.F., P.D.L., R.J.S., M.J.E., P.M., A.M., S.C.E.S., R.J.H., C. Monkhouse, A.C.)
| | - Antonio Creta
- Department of Cardiac Electrophysiology, Barts Heart Centre, St. Bartholomew’s Hospital, London, United Kingdom (E.M., K.M., S.H., C.B., N.A., A.S.C.D., A.C., M.F., P.D.L., R.J.S., M.J.E., P.M., A.M., S.C.E.S., R.J.H., C. Monkhouse, A.C.)
| | - Malcolm Finlay
- Department of Cardiac Electrophysiology, Barts Heart Centre, St. Bartholomew’s Hospital, London, United Kingdom (E.M., K.M., S.H., C.B., N.A., A.S.C.D., A.C., M.F., P.D.L., R.J.S., M.J.E., P.M., A.M., S.C.E.S., R.J.H., C. Monkhouse, A.C.)
| | - Mark Elliott
- Department of Cardiac Electrophysiology, St. Thomas’ Hospital, London, United Kingdom (M.E., V.M., N.W., C.A.R., J.B.)
| | - Vishal Mehta
- Department of Cardiac Electrophysiology, St. Thomas’ Hospital, London, United Kingdom (M.E., V.M., N.W., C.A.R., J.B.)
| | - Nadeev Wijesuriya
- Department of Cardiac Electrophysiology, St. Thomas’ Hospital, London, United Kingdom (M.E., V.M., N.W., C.A.R., J.B.)
| | - Omar Shaikh
- Department of Cardiac Electrophysiology, Royal Papworth Hospital, Cambridge, United Kingdom (O.S., Y.Z., C.O., V.G., C. Martin)
| | - Yom Zaw
- Department of Cardiac Electrophysiology, Royal Papworth Hospital, Cambridge, United Kingdom (O.S., Y.Z., C.O., V.G., C. Martin)
| | - Chizute Ogbedeh
- Department of Cardiac Electrophysiology, Royal Papworth Hospital, Cambridge, United Kingdom (O.S., Y.Z., C.O., V.G., C. Martin)
| | - Vasu Gautam
- Department of Cardiac Electrophysiology, Royal Papworth Hospital, Cambridge, United Kingdom (O.S., Y.Z., C.O., V.G., C. Martin)
| | - Pier D. Lambiase
- Department of Cardiac Electrophysiology, Barts Heart Centre, St. Bartholomew’s Hospital, London, United Kingdom (E.M., K.M., S.H., C.B., N.A., A.S.C.D., A.C., M.F., P.D.L., R.J.S., M.J.E., P.M., A.M., S.C.E.S., R.J.H., C. Monkhouse, A.C.)
| | - Richard J. Schilling
- Department of Cardiac Electrophysiology, Barts Heart Centre, St. Bartholomew’s Hospital, London, United Kingdom (E.M., K.M., S.H., C.B., N.A., A.S.C.D., A.C., M.F., P.D.L., R.J.S., M.J.E., P.M., A.M., S.C.E.S., R.J.H., C. Monkhouse, A.C.)
- William Harvey Research Institute, Queen Mary University of London, London, United Kingdom (E.M., S.H., N.A., R.J.S., R.J.H., A. Chow)
| | - Mark J. Earley
- Department of Cardiac Electrophysiology, Barts Heart Centre, St. Bartholomew’s Hospital, London, United Kingdom (E.M., K.M., S.H., C.B., N.A., A.S.C.D., A.C., M.F., P.D.L., R.J.S., M.J.E., P.M., A.M., S.C.E.S., R.J.H., C. Monkhouse, A.C.)
| | - Philip Moore
- Department of Cardiac Electrophysiology, Barts Heart Centre, St. Bartholomew’s Hospital, London, United Kingdom (E.M., K.M., S.H., C.B., N.A., A.S.C.D., A.C., M.F., P.D.L., R.J.S., M.J.E., P.M., A.M., S.C.E.S., R.J.H., C. Monkhouse, A.C.)
| | - Amal Muthumala
- Department of Cardiac Electrophysiology, Barts Heart Centre, St. Bartholomew’s Hospital, London, United Kingdom (E.M., K.M., S.H., C.B., N.A., A.S.C.D., A.C., M.F., P.D.L., R.J.S., M.J.E., P.M., A.M., S.C.E.S., R.J.H., C. Monkhouse, A.C.)
| | - Simon C.E. Sporton
- Department of Cardiac Electrophysiology, Barts Heart Centre, St. Bartholomew’s Hospital, London, United Kingdom (E.M., K.M., S.H., C.B., N.A., A.S.C.D., A.C., M.F., P.D.L., R.J.S., M.J.E., P.M., A.M., S.C.E.S., R.J.H., C. Monkhouse, A.C.)
| | - Ross J. Hunter
- Department of Cardiac Electrophysiology, Barts Heart Centre, St. Bartholomew’s Hospital, London, United Kingdom (E.M., K.M., S.H., C.B., N.A., A.S.C.D., A.C., M.F., P.D.L., R.J.S., M.J.E., P.M., A.M., S.C.E.S., R.J.H., C. Monkhouse, A.C.)
- William Harvey Research Institute, Queen Mary University of London, London, United Kingdom (E.M., S.H., N.A., R.J.S., R.J.H., A. Chow)
| | - Christopher A. Rinaldi
- Department of Cardiac Electrophysiology, St. Thomas’ Hospital, London, United Kingdom (M.E., V.M., N.W., C.A.R., J.B.)
| | - Jonathan Behar
- Department of Cardiac Electrophysiology, St. Thomas’ Hospital, London, United Kingdom (M.E., V.M., N.W., C.A.R., J.B.)
| | - Claire Martin
- Department of Cardiac Electrophysiology, Royal Papworth Hospital, Cambridge, United Kingdom (O.S., Y.Z., C.O., V.G., C. Martin)
| | - Christopher Monkhouse
- Department of Cardiac Electrophysiology, Barts Heart Centre, St. Bartholomew’s Hospital, London, United Kingdom (E.M., K.M., S.H., C.B., N.A., A.S.C.D., A.C., M.F., P.D.L., R.J.S., M.J.E., P.M., A.M., S.C.E.S., R.J.H., C. Monkhouse, A.C.)
| | - Anthony Chow
- Department of Cardiac Electrophysiology, Barts Heart Centre, St. Bartholomew’s Hospital, London, United Kingdom (E.M., K.M., S.H., C.B., N.A., A.S.C.D., A.C., M.F., P.D.L., R.J.S., M.J.E., P.M., A.M., S.C.E.S., R.J.H., C. Monkhouse, A.C.)
- William Harvey Research Institute, Queen Mary University of London, London, United Kingdom (E.M., S.H., N.A., R.J.S., R.J.H., A. Chow)
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Wouthuyzen-Bakker M, Rondaan C. 'Is an isolated positive sonication fluid culture in revision arthroplasties clinically relevant?'-Author's reply. Clin Microbiol Infect 2024; 30:403-404. [PMID: 38092175 DOI: 10.1016/j.cmi.2023.12.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2023] [Accepted: 12/04/2023] [Indexed: 12/30/2023]
Affiliation(s)
- Marjan Wouthuyzen-Bakker
- Department of Medical Microbiology and Infection Prevention, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands.
| | - Christien Rondaan
- Department of Medical Microbiology and Infection Prevention, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
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23
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Rieber H. Re: 'Is an isolated positive sonication fluid culture in revision arthroplasties clinically relevant?' by Rondaan et al. Clin Microbiol Infect 2024; 30:401-402. [PMID: 38072194 DOI: 10.1016/j.cmi.2023.11.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Accepted: 11/23/2023] [Indexed: 12/29/2023]
Affiliation(s)
- Heime Rieber
- MVZ Dr. Stein and Colleagues, Division of Microbiology, Mönchengladbach, Germany.
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24
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Rossmann M, Aljawabra A, Mau H, Citak M, Gehrke T, Klatte TO, Abdelaziz H. Utility of histopathological examination in aseptic revision total hip arthroplasty: a preliminary analysis. Hip Int 2024; 34:201-206. [PMID: 37670462 DOI: 10.1177/11207000231197743] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/07/2023]
Abstract
INTRODUCTION The utility of a routine histopathological examination in aseptic revision total hip arthroplasty (THA) has not been well explored. We aim to describe the approach and present the results of histopathological examination, focusing on its clinical usefulness in the setting of aseptic revision THA. METHOD We retrospectively reviewed 285 performed aseptic revision THA with available histopathological reports between 2015 and 2017 at a single institution. We described histopathological requests by the surgical team. Preoperative diagnoses, intraoperative findings, as well as histopathology and culture results were analysed. RESULTS 13 painful THAs (4.5%) had preoperatively unknown diagnoses. In 10 of them, potential causes of pain were intraoperatively identified. Histopathology confirmed these findings in 8 THAs. 19 THAs (6.7%) revealed unexpected positive cultures (UPC). Histopathology was negative for infection in 18 of them. Among 16 consultants, 3 surgeons requested histopathology in 47% of the cases (130/285), usually to exclude infection (101/285; 35%). Documentation for tissue sample location was lacking in 51% (145/285), and for question asked by the surgeon in 47% (135/285). CONCLUSIONS Histopathology is deemed a useful confirmatory tool in the context of ruling out infection in UPCs, and in documenting intraoperative findings in painful THAs with unknown preoperative diagnoses. Importantly, the approach to requesting histopathology should be optimised. Further large-scale studies, including cost analyses, are warranted to explore the usefulness of histopathology in routine utility.
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Affiliation(s)
- Markus Rossmann
- Department of Joint Replacement Surgery, Helios ENDO-Klinik Hamburg, Hamburg, Germany
| | - Alaa Aljawabra
- Department of Joint Replacement Surgery, Helios ENDO-Klinik Hamburg, Hamburg, Germany
| | - Hans Mau
- Department of Joint Replacement Surgery, Helios ENDO-Klinik Hamburg, Hamburg, Germany
| | - Mustafa Citak
- Department of Joint Replacement Surgery, Helios ENDO-Klinik Hamburg, Hamburg, Germany
| | - Thorsten Gehrke
- Department of Joint Replacement Surgery, Helios ENDO-Klinik Hamburg, Hamburg, Germany
| | - Till Orla Klatte
- Department of Trauma, Hand, and Reconstructive Surgery, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Hussein Abdelaziz
- Department of Joint Replacement Surgery, Helios ENDO-Klinik Hamburg, Hamburg, Germany
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25
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Lee WS, Park KK, Cho BW, Park JY, Kim I, Kwon HM. Risk factors for early septic failure after two-stage exchange total knee arthroplasty for treatment of periprosthetic joint infection. J Orthop Traumatol 2024; 25:6. [PMID: 38347255 PMCID: PMC10861422 DOI: 10.1186/s10195-024-00750-w] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 01/18/2024] [Indexed: 02/15/2024] Open
Abstract
BACKGROUND The cause of early septic failure after two-stage exchange revision total knee arthroplasty (TKA) for chronic periprosthetic joint infection (PJI) and the factors affecting it are not well known. The purpose of this study was to determine the surgical outcomes and the risk factors for early septic failure after two-stage revision TKA for chronic PJI. METHODS We identified a total of 246 adult patients who met the Musculoskeletal Infection Society (MSIS) diagnostic criteria for chronic PJI at two academic tertiary hospitals from March 2012 to December 2018. Finally, 151 patients who consecutively received two-stage exchange revision TKA for chronic PJI and who had a minimum 3-year follow-up were enrolled and retrospectively reviewed. Successful surgical treatment was evaluated for two-stage revision TKA and risk factors for early septic failure were identified. RESULTS Early septic failures occurred within 3 years after reimplantation in 48 patients (31.8%). After accounting for potentially confounding variables, we found that male patient [odds ratio (OR): 2.753, 95% confidence interval (CI) 1.099-6.893, p = 0.031], fungus or mycobacterial infection (OR: 5.224, 95% CI 1.481-18.433, p = 0.01), and positive culture at reimplantation (OR: 4.407, 95% CI 1.255-15.480, p = 0.021) were independently associated with early septic failure after two-stage exchange revision TKA. CONCLUSION Male patients, fungus or mycobacterial infection, and positive culture at reimplantation were independently associated with an increased risk of early septic failure after two-stage exchange revision TKA despite normal C-reactive protein values prior to reimplantation. Further prospective and high-quality studies are needed to determine the risk factors of two-stage exchange revision TKA for chronic PJI. LEVEL OF EVIDENCE level IV; retrospective comparison; treatment study.
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Affiliation(s)
- Woo-Suk Lee
- Department of Orthopaedic Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Kwan Kyu Park
- Department of Orthopaedic Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Byung-Woo Cho
- Department of Orthopaedic Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jun Young Park
- Department of Orthopaedic Surgery, Yongin Severance Hospital, Yonsei University College of Medicine, Gyeonggi-do, Republic of Korea
| | - Inuk Kim
- Department of Orthopaedic Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Hyuck Min Kwon
- Department of Orthopaedic Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea.
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26
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Surroca M, Massons M, Nuñez JH. Letter to the Editor on "The Albumin to Globulin Ratio Performs Well for Diagnosing Periprosthetic Joint Infection: A Single-Center Retrospective Study". J Arthroplasty 2024; 39:e10-e11. [PMID: 38182324 DOI: 10.1016/j.arth.2023.10.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2023] [Revised: 10/15/2023] [Accepted: 10/21/2023] [Indexed: 01/07/2024] Open
Affiliation(s)
- Maria Surroca
- Department of Orthopedic Surgery, University Hospital of Mutua Terrasa, Universitat de Barcelona, Terrassa, Barcelona, Spain
| | - Miriam Massons
- Department of Orthopedic Surgery, University Hospital of Mutua Terrasa, Universitat de Barcelona, Terrassa, Barcelona, Spain
| | - Jorge H Nuñez
- Department of Orthopedic Surgery, University Hospital of Mutua Terrasa, Universitat de Barcelona, Terrassa, Barcelona, Spain; Artro-Esport, Centro Médico Teknon, Barcelona, Spain
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27
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Lara-Taranchenko Y, Moreira T, Sandiford NA, Guerra-Farfán E, Gehrke T, Citak M. Unexpected positive cultures in patients with arthrofibrosis following total hip and total knee arthroplasty. Int Orthop 2024; 48:345-350. [PMID: 37755469 DOI: 10.1007/s00264-023-05990-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Accepted: 09/14/2023] [Indexed: 09/28/2023]
Abstract
PURPOSE It has been suggested that low-grade infections could be the cause of arthrofibrosis. However, this hypothesis has not been conclusively proven. The aim of this study is to assess the incidence of unexpected positive cultures (UPC) in patients undergoing revision total joint arthroplasty for a diagnosis of arthrofibrosis. METHODS A retrospective single-centre review was performed. All patients who underwent an aseptic revision due to histologically confirmed arthrofibrosis (based on the synovial-like interface membrane (SLIM) criteria) were included. The incidence of UPC was then calculated. RESULTS A total of 147 patients were included. Of these, 100 underwent a total knee arthroplasty (TKA) procedure and 46 a total hip arthroplasty (THA) surgery. One patient had a periprosthetic joint infection and was therefore excluded. Of the 146 included patients, 6 had confirmed UPC (4.08%). The following bacteria were identified: Anaerococcus octavius, Staphylococcus epidermidis, Enterobacter cloacae, Staphylococcus hominis, Streptococcus pluranimalium, Staphylococcus pettenkoferi. CONCLUSIONS Our results suggest that the incidence of UPC in patients with arthrofibrosis is low. It is lower than that of UPC in patients that undergo a revision for other causes. There is no proven relationship between histologically confirmed arthrofibrosis following total joint arthroplasty and prosthetic joint infection.
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Affiliation(s)
- Yuri Lara-Taranchenko
- Orthopaedic Surgery Department, Vall d'Hebron University Hospital, Universitat Autonoma de Barcelona, Pg. Vall d'Hebron 119-129, 08035, Barcelona, Spain
- Helios ENDO-Klinik, Holstenstraße 2, 22767, Hamburg, Germany
| | - Tiago Moreira
- Helios ENDO-Klinik, Holstenstraße 2, 22767, Hamburg, Germany
- Hospital Ortopedico de Goiânia, Goiania, Brazil
| | - N Amir Sandiford
- Joint Reconstruction Unit, Southland Hospital, Kew Road, Kew, Invercargill, 9812, New Zealand
| | - Ernesto Guerra-Farfán
- Orthopaedic Surgery Department, Vall d'Hebron University Hospital, Universitat Autonoma de Barcelona, Pg. Vall d'Hebron 119-129, 08035, Barcelona, Spain
| | - Thorsten Gehrke
- Helios ENDO-Klinik, Holstenstraße 2, 22767, Hamburg, Germany
| | - Mustafa Citak
- Helios ENDO-Klinik, Holstenstraße 2, 22767, Hamburg, Germany.
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28
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Kew ME, Mathew JI, Wimberly AC, Fu MC, Taylor SA, Blaine TA, Carli AV, Dines JS, Dines DM, Gulotta LV. Outcomes after débridement, antibiotics, and implant retention for prosthetic joint infection in shoulder arthroplasty. J Shoulder Elbow Surg 2024; 33:e68-e78. [PMID: 37468030 DOI: 10.1016/j.jse.2023.06.012] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2023] [Revised: 05/29/2023] [Accepted: 06/05/2023] [Indexed: 07/21/2023]
Abstract
BACKGROUND Patients who undergo total shoulder arthroplasty usually have excellent long-term outcomes. However, a subset of patients is diagnosed with a prosthetic joint infection (PJI) requiring revision procedures and prolonged recovery. The purpose of this study was to evaluate rates of recurrent shoulder PJI in patients undergoing débridement, antibiotics, and implant retention (DAIR), single-stage revision, and 2-stage revision. We also sought to compare outcomes and complications across procedures. METHODS Retrospective chart review was conducted for patients diagnosed with PJI after primary shoulder arthroplasty between January 2010 and August 2021. Patients were included if they underwent treatment with DAIR, single-stage revision, or 2-stage revision. Demographic information, surgical details, complications, laboratory data, postoperative antibiotic regimen, and infectious pathogen were collected. Postoperative patient-reported outcomes were collected: American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form, Single Assessment Numeric Evaluation, Shoulder Activity Scale, and PROMIS Upper Extremity. Chi-square, t test, and 1-way analysis of variance were used as appropriate to evaluate each factor. RESULTS Sixty-five patients were included in the study, 26% treated with DAIR, 9% treated with single-stage revision, and 65% treated with 2-stage revision. There were no significant differences in patient comorbidities. Patients undergoing DAIR were diagnosed significantly earlier than those undergoing single- and 2-stage revision procedures (12.6 ± 22.9 months vs. 49.6 ± 48.4 vs. 25.0 ± 26.6, P = .010). Recurrent PJI was noted in 23.1% of patients: 29.4% of DAIR patients, no single-stage patients, and 23.8% of 2-stage patients (P = .330). Patients undergoing 2-stage revision with treatment failure had a significantly higher Elixhauser Comorbidity Index (0.2 ± 3.7 vs. 3.7 ± 3.9, P = .027). There was no significant difference in patient-reported outcomes across groups. CONCLUSION Patients undergoing treatment of shoulder PJI with DAIR did not have an increased rate of reinfection compared with single-stage and 2-stage revision procedures. Patients treated with DAIR were diagnosed with PJI significantly earlier than those undergoing single-stage and 2-stage revision procedures. There was no difference in complication rates between groups. This information adds to the body of work detailing outcomes after DAIR for shoulder PJI and provides encouraging data for use in this patient population. Future studies with a larger sample size may be conducted to further investigate specific pathogens, infection timelines, and antibiotic regimens that reduce the risk of treatment failure.
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Affiliation(s)
- Michelle E Kew
- Sports Medicine and Shoulder Service, Hospital for Special Surgery, New York, NY, USA
| | | | - Audrey C Wimberly
- Sports Medicine and Shoulder Service, Hospital for Special Surgery, New York, NY, USA
| | - Michael C Fu
- Sports Medicine and Shoulder Service, Hospital for Special Surgery, New York, NY, USA
| | - Samuel A Taylor
- Sports Medicine and Shoulder Service, Hospital for Special Surgery, New York, NY, USA
| | - Theodore A Blaine
- Sports Medicine and Shoulder Service, Hospital for Special Surgery, New York, NY, USA
| | - Alberto V Carli
- Adult Reconstruction and Joint Replacement, Hospital for Special Surgery, New York, NY, USA
| | - Joshua S Dines
- Sports Medicine and Shoulder Service, Hospital for Special Surgery, New York, NY, USA
| | - David M Dines
- Sports Medicine and Shoulder Service, Hospital for Special Surgery, New York, NY, USA
| | - Lawrence V Gulotta
- Sports Medicine and Shoulder Service, Hospital for Special Surgery, New York, NY, USA.
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29
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Longo UG, De Salvatore S, Bandini B, Lalli A, Barillà B, Budhiparama NC, Lustig S. Debridement, antibiotics, and implant retention (DAIR) for the early prosthetic joint infection of total knee and hip arthroplasties: a systematic review. J ISAKOS 2024; 9:62-70. [PMID: 37714518 DOI: 10.1016/j.jisako.2023.09.003] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2023] [Revised: 08/21/2023] [Accepted: 09/07/2023] [Indexed: 09/17/2023]
Abstract
PURPOSE Early periprosthetic joint infection (PJI) represents one of the most fearsome complications of joint replacement. No international consensus has been reached regarding the best approach for early prosthetic knee and hip infections. The aim of this updated systematic review is to assess whether debridement, antibiotics, and implant retention (DAIR) is an effective choice of treatment in early postoperative and acute hematogenous PJI. METHODS This systematic review was performed using the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. The diagnostic criteria defining a PJI, the most present pathogen, and the days between the index procedure and the onset of the PJI were extracted from the selected articles. Additionally, the mean follow-up, antibiotic regimen, and success rate of the treatment were also reported. RESULTS The articles included provided a cohort of 970 patients. Ten studies specified the joint of their cohort in PJIs regarding either hip prostheses or knee prostheses, resulting in 454 total knees and 460 total hips. The age of the patients ranged from 18 to 92 years old. Success rates for the DAIR treatments in the following cohort ranged from 55.5% up to a maximum of 90% (mean value of 71%). CONCLUSION Even though the DAIR procedure is quite limited, it is still considered an effective option for patients developing an early post-operative or acute hematogenous PJI. However, there is a lack of studies, in particular randomized control trials (RCTs), comparing DAIR with one-stage and two-stage revision protocols in the setting of early PJIs, reflecting the necessity to conduct further high-quality studies to face the burden of early PJI.
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Affiliation(s)
- Umile Giuseppe Longo
- Research Unit of Orthopaedic and Trauma Surgery, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, 00128 Roma, Italy; Research Unit of Orthopaedic and Trauma Surgery, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo, 21, 00128 Roma, Italy.
| | - Sergio De Salvatore
- Research Unit of Orthopaedic and Trauma Surgery, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, 00128 Roma, Italy; Research Unit of Orthopaedic and Trauma Surgery, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo, 21, 00128 Roma, Italy.
| | - Benedetta Bandini
- Research Unit of Orthopaedic and Trauma Surgery, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, 00128 Roma, Italy; Research Unit of Orthopaedic and Trauma Surgery, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo, 21, 00128 Roma, Italy.
| | - Alberto Lalli
- Research Unit of Orthopaedic and Trauma Surgery, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, 00128 Roma, Italy; Research Unit of Orthopaedic and Trauma Surgery, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo, 21, 00128 Roma, Italy.
| | - Bruno Barillà
- Research Unit of Orthopaedic and Trauma Surgery, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, 00128 Roma, Italy; Research Unit of Orthopaedic and Trauma Surgery, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo, 21, 00128 Roma, Italy.
| | | | - Sebastien Lustig
- Orthopaedic Department, Lyon North University Hospital, Hôpital de La Croix Rousse, Hospices Civils de Lyon, 103 Grande Rue de la Croix Rousse, 69004 Lyon, France.
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30
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Jia-Wei H, Jing W, Li C, Xiao-Gang Z, Guo-Qing L, Bo-Yong X, Bao-Chao J, Jun-Jie H, Jun Z. Two-dimensional liquid chromatography measurement of meropenem concentration in synovial fluid of patients with periprosthetic joint infection. Biomed Chromatogr 2024; 38:e5778. [PMID: 38073142 DOI: 10.1002/bmc.5778] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Revised: 10/23/2023] [Accepted: 10/25/2023] [Indexed: 01/26/2024]
Abstract
Periprosthetic joint infection (PJI) is a catastrophic complication following joint replacement surgery. One potential treatment approach for PJI could be the combination of one-stage revision and intra-articular infusion of antibiotics. Meropenem is one of the commonly used intra-articular antibiotics in our institution. Determining the concentration of meropenem in the joint cavity could be crucial for optimizing its local application, effectively eradicating biofilm infection, and improving PJI treatment outcomes. In this study, we developed a simple, precise, and accurate method of two-dimensional liquid chromatography (2D-LC) for determining the concentration of meropenem in human synovial fluid. The method was then validated based on the guidelines of the Food and Drug Administration and the Chinese Pharmacopoeia. Meropenem showed good linearity in the range of 0.31-25.01 μg/mL (r ≥ .999). Selectivity, intra-day and inter-day precision and accuracy, extraction recovery, and stability validation results were all within the acceptance range. This method has been successfully applied to the determination of synovial fluid samples from PJI patients, providing a useful detection method for meropenem therapeutic drug monitoring (TDM) in PJI patients.
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Affiliation(s)
- He Jia-Wei
- Department of Pharmacy, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang, China
| | - Wang Jing
- Department of Pharmacy, The Eighth Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang, China
| | - Cao Li
- Department of Orthopaedics, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang, China
| | - Zhang Xiao-Gang
- Department of Orthopaedics, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang, China
| | - Li Guo-Qing
- Department of Orthopaedics, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang, China
| | - Xu Bo-Yong
- Department of Orthopaedics, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang, China
| | - Ji Bao-Chao
- Department of Orthopaedics, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang, China
| | - Huang Jun-Jie
- College of Pharmacy, Xinjiang Medical University, Urumqi, Xinjiang, China
| | - Zhao Jun
- Department of Pharmacy, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang, China
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Dong M, Feng Y. Reply to Letter to the Editor on "The Albumin to Globulin Ratio Performs Well for Diagnosing Periprosthetic Joint Infection: A Single-Center Retrospective Study". J Arthroplasty 2024; 39:e12-e13. [PMID: 38182325 DOI: 10.1016/j.arth.2023.10.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Revised: 10/15/2023] [Accepted: 10/17/2023] [Indexed: 01/07/2024] Open
Affiliation(s)
- Mingjie Dong
- Department of Orthopaedics, The Second Hospital of Shanxi Medical University, Taiyuan, China; Shanxi Key Laboratory of Bone and Soft Tissue Injury Repair, Taiyuan, China
| | - Yi Feng
- Department of Orthopaedics, The Second Hospital of Shanxi Medical University, Taiyuan, China
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Lutro O, Mo S, Tjørhom MB, Fenstad AM, Leta TH, Bruun T, Hallan G, Furnes O, Dale H. How good are surgeons at disclosing periprosthetic joint infection at the time of revision, based on pre- and intra-operative assessment? A study on 16,922 primary total hip arthroplasties reported to the Norwegian Arthroplasty Register. Acta Orthop 2024; 95:67-72. [PMID: 38288989 PMCID: PMC10826841 DOI: 10.2340/17453674.2024.39914] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Accepted: 12/14/2023] [Indexed: 02/01/2024] Open
Abstract
BACKGROUND AND PURPOSE Revision due to infection, as reported to the Norwegian Arthroplasty Register (NAR), is a surrogate endpoint to periprosthetic joint infection (PJI). We aimed to find the accuracy of the reported causes of revision after primary total hip arthroplasty (THA) compared with PJI to see how good surgeons were at disclosing infection, based on pre- and intraoperative assessment. PATIENTS AND METHODS We investigated the reasons for revision potentially caused by PJI following primary THA: infection, aseptic loosening, prolonged wound drainage, and pain only, reported to the NAR from surgeons in the region of Western Norway during the period 2010-2020. The electronic patient charts were investigated for information on clinical assessment, treatment, biochemistry, and microbiological findings. PJI was defined in accordance with the Musculoskeletal Infection Society (MSIS) definition. Sensitivity, specificity, and accuracy were calculated. RESULTS 363 revisions in the NAR were eligible for analyses. Causes of revision were (reported/validated): infection (153/177), aseptic loosening (139/133), prolonged wound drainage (37/13), and pain only (34/40). The sensitivity for reported revision due to infection compared with PJI was 80%, specificity was 94%, and accuracy-the surgeons' ability to disclose PJI or non-septic revision at time of revision-was 87%. The accuracy for the specific revision causes was highest for revision due to aseptic loosening (95%) and pain only (95%), and lowest for revision due to prolonged wound drainage (86%). CONCLUSION The accuracy of surgeon-reported revisions due to infection as representing PJI was 87% in the NAR. Our study shows the importance of systematic correction of the reported cause of revision in arthroplasty registers, after results from adequately taken bacterial samples.
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Affiliation(s)
- Olav Lutro
- Department of Medicine, Stavanger University Hospital, Stavanger.
| | - Synnøve Mo
- The Norwegian Arthroplasty Register, Department of Orthopaedic Surgery, Haukeland University Hospital, Bergen
| | | | - Anne Marie Fenstad
- The Norwegian Arthroplasty Register, Department of Orthopaedic Surgery, Haukeland University Hospital, Bergen
| | - Tesfaye Hordofa Leta
- The Norwegian Arthroplasty Register, Department of Orthopaedic Surgery, Haukeland University Hospital, Bergen; VID Specialized University, Bergen, Norway
| | - Trond Bruun
- Department of Medicine, Haukeland University Hospital, Bergen
| | - Geir Hallan
- The Norwegian Arthroplasty Register, Department of Orthopaedic Surgery, Haukeland University Hospital, Bergen; Department of Medicine, Haukeland University Hospital, Bergen
| | - Ove Furnes
- The Norwegian Arthroplasty Register, Department of Orthopaedic Surgery, Haukeland University Hospital, Bergen; Department of Clinical Medicine, University of Bergen, Bergen
| | - Håvard Dale
- The Norwegian Arthroplasty Register, Department of Orthopaedic Surgery, Haukeland University Hospital, Bergen; Department of Clinical Medicine, University of Bergen, Bergen
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Mittal A, Blackburn AZ, Katakam A, Bedair HS, Melnic CM. Dual Surgical Setup Associated with Reduced Infection Recurrence for Hip and Knee Arthroplasty After Two-Stage Exchange. J Am Acad Orthop Surg 2024; 32:68-74. [PMID: 37793169 DOI: 10.5435/jaaos-d-23-00317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2023] [Accepted: 07/20/2023] [Indexed: 10/06/2023] Open
Abstract
INTRODUCTION Two-stage exchange (TSE) is the gold standard for the treatment of chronic periprosthetic joint infection (PJI) after total joint arthroplasty of the hip and knee in the United States. Failure of treatment can have devastating consequences for the patient, including poor functional outcomes, multiple further surgeries, and increased mortality. Several factors associated with infection recurrence have previously been identified in the literature. The purpose of this study was to evaluate whether the use of a dual surgical setup was associated with reduced risk of recurrence after TSE for PJI. METHODS A retrospective study was conducted between January 2000 and December 2021 to isolate patients who underwent TSE after total joint arthroplasty of the hip and knee. Failure was defined as infection recurrence requiring surgical intervention. Demographic factors (age, sex, body mass index, smoking status, American Society of Anesthesiologists status), preoperative comorbidities (hypertension, cardiac disease, diabetes status, depression diagnosis, pulmonary disease), operating surgeon, single versus dual setup, hospital setting, use of long-term antibiotics postoperatively after TSE, aspiration data, and infecting organism were compared between cohorts using multivariate regression analysis. RESULTS A total of 134 patients were identified who underwent TSE after diagnosis of PJI. The mean follow-up was 67.84 (range, 13 to 236) months. Dual setup (odds ratio, 0.13; confidence interval, 0.02 to 0.52; P = 0.0122) was found to be an independent predictive variable associated with a lower risk of infection recurrence. CONCLUSION Utilization of a dual surgical setup is a low-cost modifiable risk factor associated with a lower risk of recurrence of after TSE of the hip and knee for PJI.
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Affiliation(s)
- Ashish Mittal
- From the Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA (Mittal, Blackburn, Katakam, Bedair, and Melnic), and the Department of Orthopaedic Surgery, Newton-Wellesley Hospital, Newton, MA (Bedair, and Melnic)
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Tsai ML, Herng-Shouh Hsu A, Wu CT, Lin PC, Tan TL, Kuo FC. Optimal reimplantation timing in two-stage exchange for periprosthetic joint infection: an observative cohort study in Asian population. BMC Musculoskelet Disord 2024; 25:28. [PMID: 38166999 PMCID: PMC10763399 DOI: 10.1186/s12891-023-07129-8] [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] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Accepted: 12/18/2023] [Indexed: 01/05/2024] Open
Abstract
BACKGROUND The optimal timing for reimplantation for periprosthetic joint infection (PJI) has not been established and varies from a few weeks to several months. The aim of this study was to assess the commendable time between implant removal and reimplantation in patients who underwent two-stage exchange arthroplasty for PJI. METHODS We retrospectively reviewed 361 patients who were treated with two-stage exchange arthroplasty for hip and knee chronic PJI at our institution between January 2000 and December 2018. Patient characteristics, comorbidities, surgical variables, microbiology data, and time to reimplantation were recorded. All patients were followed for a minimum of one year. Treatment failure was defined by Delphi criteria. Logistic regression analyses were used to calculate survival rates and adjusted odds ratios (ORs) of treatment failure. RESULTS In final analysis, 27 (7.5%) had treatment failure. Factors related to treatment failure including interim spacer exchange (OR, 3.13; confidence interval (CI), 1.04-9.09, p = 0.036), higher ESR level at reimplantation (OR, 1.85; CI, 1.05-3.57; p = 0.04), and time to reimplantation (OR, 1.00; CI, 1.003-1.005, p = 0.04). Performing revision arthroplasty surgery from 16 to 20 weeks had highest successful rate. The reimplantation over 24 weeks had a lower successful rate. However, no statistical significance in comparing each interval group. CONCLUSION Our study emphasized the importance of timely reimplantation in achieving successful outcomes. Factors such as ESR levels, spacer exchange, and the duration of time to reimplantation influenced the likelihood of treatment failure in two-stage exchange arthroplasty for hip and knee PJI.
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Affiliation(s)
- Meng-Lun Tsai
- Department of Orthopaedic Surgery, Kaohsiung Chang Gung Memorial Hospital, No. 123, Dapi Road, Niaosong District, 833, Kaohsiung, Taiwan
| | - Allen Herng-Shouh Hsu
- Department of Orthopaedic Surgery, Kaohsiung Chang Gung Memorial Hospital, No. 123, Dapi Road, Niaosong District, 833, Kaohsiung, Taiwan
| | - Cheng-Ta Wu
- Department of Orthopaedic Surgery, Kaohsiung Chang Gung Memorial Hospital, No. 123, Dapi Road, Niaosong District, 833, Kaohsiung, Taiwan
| | - Po-Chun Lin
- Department of Orthopaedic Surgery, Kaohsiung Chang Gung Memorial Hospital, No. 123, Dapi Road, Niaosong District, 833, Kaohsiung, Taiwan
| | - Timothy L Tan
- Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco, CA, USA
| | - Feng-Chih Kuo
- Department of Orthopaedic Surgery, Kaohsiung Chang Gung Memorial Hospital, No. 123, Dapi Road, Niaosong District, 833, Kaohsiung, Taiwan.
- College of Medicine, Chang Gung University, Kaohsiung, Taiwan.
- Center for General Education, Cheng Shiu University, Kaohsiung, Taiwan.
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Garrigues GE, Lin A, Hodakowski AJ, Karimi A, Quinlan NJ, Pottinger PS, Hsu JE. Infection in Shoulder Arthroplasty: Prevention, Diagnosis, and Treatment. Instr Course Lect 2024; 73:513-526. [PMID: 38090921] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
Prosthetic joint infection is a devastating complication following shoulder arthroplasty that can lead to pain, poor function, and poor quality of life. With the increasing number of shoulder arthroplasties performed annually, recognition of prosthetic infection and treatment is necessary. The skin surrounding the shoulder has a unique microbiome, and Cutibacterium acnes is the most commonly encountered bacteria causing prosthetic joint infection. C acnes is a low-virulence organism that resides in the subcutaneous layer of the skin. As a result, the clinical presentation is typically less obvious than prosthetic infections seen in other joints such as the hip and knee. Therefore, diagnosis is not always straightforward, and optimal treatment strategy is unclear. Guidance on prevention, diagnosis, and treatment of shoulder prosthetic joint infection with special emphasis on the consensus definition established at the 2018 International Consensus Meeting is provided.
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Zardi EM, de Sanctis EG, Franceschi F. Performance of classical serum inflammatory markers in healed and unhealed treated patients with joint and prosthetic joint infections. Am J Med Sci 2024; 367:28-34. [PMID: 37797825 DOI: 10.1016/j.amjms.2023.09.026] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 09/20/2023] [Indexed: 10/07/2023]
Abstract
BACKGROUND Serum markers, such as erythrocyte sedimentation rate (ESR), C-reactive protein (CRP) and D-dimer, are currently used by clinicians and orthopedic surgeons in diagnosing and managing joint infections (JI), although conflicting results exist on their performance. The aim of this study was to evaluate their performance in assessing healing or unhealing of patients with JI or with prosthetic joint infection (PJI). METHODS ESR, CRP and D-dimer serum levels were evaluated before, during and after antibiotic treatment in 61 patients (65.1 ± 12.6 years): 49 affected by PJI and 12 by JI, between 2020 and 2022. These patients had undergone orthopedic surgery and were treated with antibiotics. RESULTS ESR, CRP and D-dimer were significantly lower after treatment than before (p value: 0.001, 0.001 and 0.003, respectively) in healed and unhealed patients. A moderate correlation was found between the three inflammatory markers. CONCLUSIONS Using a cut off value of 25 mm/h for ESR, 0.5 mg/L for CRP, and 700 ng/ml for D-dimer, it might be possible to discriminate healed from unhealed patients (PPV and NPV: ESR 65.5% and 68.8%, CRP 71.9% and 79.3%, D-dimer 76.9% and 81.8%). The combined use of these three inflammatory markers might be useful in the management of joint infections.
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Affiliation(s)
- Enrico Maria Zardi
- Internistic Ultrasound Service, Department of Medicine and Surgery, Fondazione Policlinico Universitario Campus Bio-Medico, Rome, Italy.
| | | | - Francesco Franceschi
- Department of Orthopaedic and Trauma Surgery, San Pietro Fatebenefratelli Hospital, Rome, Italy; UniCamillus-Saint Camillus International University of Health Sciences, Rome, Italy
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Moore RA, Witten JC, Lowry AM, Shrestha NK, Blackstone EH, Unai S, Pettersson GB, Wierup P. Isolated mitral valve endocarditis: Patient, disease, and surgical factors that influence outcomes. J Thorac Cardiovasc Surg 2024; 167:127-140.e15. [PMID: 35927083 PMCID: PMC9532471 DOI: 10.1016/j.jtcvs.2022.01.058] [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] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Revised: 12/21/2021] [Accepted: 01/23/2022] [Indexed: 10/18/2022]
Abstract
OBJECTIVE The objectives of this study were to investigate patient characteristics, valve pathology, bacteriology, and surgical techniques related to outcome of patients who underwent surgery for isolated native (NVE) or prosthetic (PVE) mitral valve endocarditis. METHODS From January 2002 to January 2020, 447 isolated mitral endocarditis operations were performed, 326 for NVE and 121 for PVE. Multivariable analysis of time-related outcomes used random forest machine learning. RESULTS Staphylococcus aureus was the most common causative organism. Of 326 patients with NVE, 88 (27%) underwent standard mitral valve repair, 43 (13%) extended repair, and 195 (60%) valve replacement. Compared with NVE with standard repair, patients who underwent all other operations were older, had more comorbidities, worse cardiac function, and more invasive disease. Hospital mortality was 3.8% (n = 17); 0 (0%) after standard valve repair, 3 (7.0%) after extended repair, 8 (4.1%) after NVE replacement, and 6 (5.0%) after PVE re-replacement. Survival at 1, 5, and 10 years was 91%, 75%, and 62% after any repair and 86%, 62%, and 44% after replacement, respectively. The most important risk factor for mortality was renal failure. Risk-adjusted outcomes, including survival, were similar in all groups. Unadjusted extended repair outcomes, particularly early, were similar or worse than replacement in terms of reinfection, reintervention, regurgitation, gradient, and survival. CONCLUSIONS A patient- and pathology-tailored approach to surgery for isolated mitral valve endocarditis has low mortality and excellent results. Apparent superiority of standard valve repair is related to patient characteristics and pathology. Renal failure is the most powerful risk factor. In case of extensive destruction, extended repair shows no benefit over replacement.
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Affiliation(s)
- Ryan A Moore
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - James C Witten
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Ashley M Lowry
- Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Nabin K Shrestha
- Department of Infectious Disease, Respiratory Institute, Cleveland Clinic, Cleveland, Ohio
| | - Eugene H Blackstone
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio; Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio.
| | - Shinya Unai
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Gösta B Pettersson
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Per Wierup
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
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Burchette DT, Dasci MF, Fernandez Maza B, Linke P, Gehrke T, Citak M. Neutrophil-Lymphocyte Ratio and Lymphocyte-Monocyte Ratio correlate with Chronic Prosthetic Joint Infection but are not useful markers for diagnosis. Arch Orthop Trauma Surg 2024; 144:297-305. [PMID: 37874358 DOI: 10.1007/s00402-023-05052-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Accepted: 09/02/2023] [Indexed: 10/25/2023]
Abstract
PURPOSE To investigate reported correlations between Neutrophil-to-Lymphocyte (NLR) and Lymphocyte-to-Monocyte (LMR) ratios and their value in diagnosis of chronic prosthetic joint infection (PJI) in a large cohort of patients from a single specialist hospital. METHODS Diagnostic aspirations of 362 patients under investigation for PJI were identified. Of the included patients 185 patients received a final diagnosis of PJI and 177 were classed as aseptic. Established criteria (ICM 2018) were employed to define PJI. Included in the analysis are differential white cell counts, C-Reactive Protein (CRP), Synovial Leukocyte Count, Synovial Alpha-defensin ELISA and Synovial Leukocyte esterase activity. Receiver-operator characteristic (ROC) curves were calculated for each of the available diagnostic tests together with the corresponding area under the curve values (AUC). Youden's index was utilized to identify the optimal diagnostic threshold point for the NLR and LMR. Other diagnostic tests were evaluated as per the threshold values previously defined in the literature and specified in the ICM criteria. RESULTS Using Youden's Index to identify the optimal NLR cut-off within our cohort we established a value of 2.93. This yielded a sensitivity of 0.60 and specificity of 0.64. The area under the curve (AUC) of a receiving operator characteristics (ROC) curve was 0.625. Regarding the LMR the results demonstrate similar findings; a positive correlation with a diagnosis of infection but poor sensitivity and specificity. The AUC for LMR was 0.633 and was not superior to NLR (P = 0.753). CONCLUSIONS There is a significant correlation between higher Neutrophil-Lymphocyte and Lymphocyte-Monocyte ratios, and a diagnosis of PJI. The sensitivity and specificity of this calculation is poor and the does not add value to the diagnostic algorithm for PJI. LEVEL OF EVIDENCE Level III Retrospective Cohort analysis.
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Affiliation(s)
- Daniel Timothy Burchette
- ENDO-Klinik Hamburg, Holstenstr. 2, 22767, Hamburg, Germany.
- Royal National Orthopaedic Hospital, Brockley Hill, Stanmore, HA7 4LP, UK.
| | - Mustafa Fatih Dasci
- ENDO-Klinik Hamburg, Holstenstr. 2, 22767, Hamburg, Germany
- Department of Orthopaedics and Traumatology, Istanbul Bagcilar Training and Research Hospital, Health Sciences University, Istanbul, Turkey
| | - Beatriz Fernandez Maza
- ENDO-Klinik Hamburg, Holstenstr. 2, 22767, Hamburg, Germany
- Puerta de Hierro University Hospital, Calle de Joaquín Rodrigo, Madrid, Spain
| | - Philip Linke
- ENDO-Klinik Hamburg, Holstenstr. 2, 22767, Hamburg, Germany
| | | | - Mustafa Citak
- ENDO-Klinik Hamburg, Holstenstr. 2, 22767, Hamburg, Germany
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Klemt C, Yeo I, Harvey M, Burns JC, Melnic C, Uzosike AC, Kwon YM. The Use of Artificial Intelligence for the Prediction of Periprosthetic Joint Infection Following Aseptic Revision Total Knee Arthroplasty. J Knee Surg 2024; 37:158-166. [PMID: 36731501 DOI: 10.1055/s-0043-1761259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Periprosthetic joint infection (PJI) following revision total knee arthroplasty (TKA) for aseptic failure is associated with poor outcomes, patient morbidity, and high health care expenditures. The aim of this study was to develop novel machine learning algorithms for the prediction of PJI following revision TKA for patients with aseptic indications for revision surgery. A single-institution database consisting of 1,432 consecutive revision TKA patients with aseptic etiologies was retrospectively identified. The patient cohort included 208 patients (14.5%) who underwent re-revision surgery for PJI. Three machine learning algorithms (artificial neural networks, support vector machines, k-nearest neighbors) were developed to predict this outcome and these models were assessed by discrimination, calibration, and decision curve analysis. This is a retrospective study. Among the three machine learning models, the neural network model achieved the best performance across discrimination (area under the receiver operating characteristic curve = 0.78), calibration, and decision curve analysis. The strongest predictors for PJI following revision TKA for aseptic reasons were prior open procedure prior to revision surgery, drug abuse, obesity, and diabetes. This study utilized machine learning as a tool for the prediction of PJI following revision TKA for aseptic failure with excellent performance. The validated machine learning models can aid surgeons in patient-specific risk stratifying to assist in preoperative counseling and clinical decision making for patients undergoing aseptic revision TKA.
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Affiliation(s)
- Christian Klemt
- Bioengineering Laboratory, Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Ingwon Yeo
- Bioengineering Laboratory, Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Michael Harvey
- Bioengineering Laboratory, Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Jillian C Burns
- Bioengineering Laboratory, Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Christopher Melnic
- Bioengineering Laboratory, Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Akachimere Cosmas Uzosike
- Bioengineering Laboratory, Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Young-Min Kwon
- Bioengineering Laboratory, Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
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Richter A, Altemeier A, Hold M, Lenhof S, Stauss R, Ettinger M, Omar M. Drain fluid cultures can rule in but cannot rule out infection persistence after surgical treatment of periprosthetic joint infections. J Orthop Sci 2024; 29:177-182. [PMID: 36462996 DOI: 10.1016/j.jos.2022.11.014] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2022] [Revised: 09/28/2022] [Accepted: 11/16/2022] [Indexed: 12/03/2022]
Abstract
BACKGROUND Periprosthetic joint infection (PJI) is one of the most common reason for implant failure in arthroplasty. Surgical therapy is essential but there is no standardized guideline to determine infection eradication in multiple-step revision surgery. To date, clinical and laboratory inflammation markers and preoperative arthrocentesis are controversial to evaluate the infection status before reimplantation and therefore are often combined. Drain fluid cultures enable a microbiological analysis without need for further invasive procedure after revision surgery. This retrospective study evaluates the diagnostic performance of drain fluid cultures in diagnosing infection persistence according to the MSIS definition of PJI. METHODS Drain samples have been taken after every revision surgery for microbiological testing. Afterwards, the results have been assigned to the infection status according to the diagnostic criteria of the MSIS definition of PJI. RESULTS 1084 revision surgeries in 183 patients have been included, resulting in a total sample size of 1552 drain fluid cultures. Overall sensitivity was 36.0%, specificity was 90.7% and ROC-AUC was 0.63. CONCLUSION Due to a high specificity and a low sensitivity drain fluid cultures can rule in but cannot rule out infection persistence in PJI.
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Affiliation(s)
- Alena Richter
- Orthopaedic Department - DIAKOVERE Annastift, Hannover Medical School, Anna-von-Borries-Str. 1-7, 30625 Hannover, Germany.
| | - Anna Altemeier
- Orthopaedic Department - DIAKOVERE Annastift, Hannover Medical School, Anna-von-Borries-Str. 1-7, 30625 Hannover, Germany.
| | - Mara Hold
- Orthopaedic Department - DIAKOVERE Annastift, Hannover Medical School, Anna-von-Borries-Str. 1-7, 30625 Hannover, Germany.
| | - Stefan Lenhof
- Trauma Department - Hannover Medical School, Carl-Neuberg-Str 130625 Hannover, Germany.
| | - Ricarda Stauss
- Trauma Department - Hannover Medical School, Carl-Neuberg-Str 130625 Hannover, Germany.
| | - Max Ettinger
- Orthopaedic Department - DIAKOVERE Annastift, Hannover Medical School, Anna-von-Borries-Str. 1-7, 30625 Hannover, Germany.
| | - Mohamed Omar
- Trauma Department - Hannover Medical School, Carl-Neuberg-Str 130625 Hannover, Germany.
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Sathyamurthy I, Elangovan I. 18F- FDG PET/CT in reclassifying the probable diagnosis of IE - A review. Indian Heart J 2024; 76:10-15. [PMID: 38185328 PMCID: PMC10943555 DOI: 10.1016/j.ihj.2024.01.003] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2023] [Revised: 12/30/2023] [Accepted: 01/04/2024] [Indexed: 01/09/2024] Open
Abstract
In the diagnosis of infective endocarditis (IE), Modified Duke's criteria, coupled with clinical suspicion, serve as the guiding framework. For cases involving prosthetic valve endocarditis and infections affecting implantable devices, the use of metabolic imaging with 18 F-FDG PET/CT scans has gained prominence, as per the recommendations of the European Society of Cardiology guidelines. This imaging modality enhances sensitivity and specificity by identifying infective foci within the heart and extracardiac locations. Early utilization of these scans is crucial for confirming or ruling out IE, although caution is required to mitigate false positive responses, especially in the presence of ongoing inflammatory activity. A standardized ratio of ≥2.0 between FDG uptake around infected tissues and the blood pool has demonstrated a sensitivity of 100 % and specificity of 91 %. It is noteworthy that the sensitivity of FDG PET/CT varies, being lower for native valve and lead infections but considerably higher for prosthetic valve and pulse generator infections. This review provides a comprehensive overview of the advantages offered by FDG PET/CT in achieving a definitive diagnosis of IE.
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Affiliation(s)
- I Sathyamurthy
- Dept of Cardiology, Apollo Main Hospitals, Chennai 600006, India.
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Fraval A, Zappley NR, Brown SA. Methylene Blue Infiltration As a Method for Distinguishing Superficial and Deep Infections. J Arthroplasty 2024; 39:224-228. [PMID: 37531982 DOI: 10.1016/j.arth.2023.07.020] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Revised: 07/19/2023] [Accepted: 07/25/2023] [Indexed: 08/04/2023] Open
Abstract
BACKGROUND There are no established objective methods to reliably differentiate between superficial and deep infection in the setting of total hip arthroplasty. We employed a technique of distinguishing superficial and deep infections by infiltrating methylene blue to a prosthetic hip during infection workup to determine its effectiveness and to characterize its utility in defining the joint cavity where deep debridement is required. METHODS An analysis was conducted on 35 patients who preoperatively received an injection of methylene blue under radiological guidance to their total hip arthroplasty. Where established periprosthetic joint infection (PJI) criteria were not met, without signs of methylene blue beyond the deep fascia, the infection was considered superficial, and debridement remained superficial to the deep fascia. Where diagnosis of PJI was confirmed preoperatively or the presence of methylene blue in the wound cavity confirmed deep contamination, the prosthesis was addressed with methylene blue staining defining the joint cavity as a guide for debridement. RESULTS There were 11 patients who had no methylene blue extrusion into the superficial compartment and did not meet PJI criteria. Eight patients failed to meet PJI criteria preoperatively, but had extrusion of methylene blue, confirming a deep infection intraoperatively. There were 16 patients who met PJI criteria preoperatively with methylene blue acting as a visual guide to the joint space. CONCLUSION Infiltrating methylene blue in a prosthetic hip is useful in differentiating between superficial or deep infections where PJI workup is indeterminate. Where deep infection is present, its utility in defining the joint cavity may be advantageous.
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Affiliation(s)
- Andrew Fraval
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Nicolina R Zappley
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Scot A Brown
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
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Xu H, Zhou J, Huang Q, Huang Z, Xie J, Zhou Z. Unreliability of Serum- or Plasma-based Assays of D-dimer or Fibrin (Fibrinogen) Degradation Product for Diagnosing Periprosthetic Joint Infection: A Prospective Parallel Study. Orthop Surg 2024; 16:29-37. [PMID: 37975182 PMCID: PMC10782268 DOI: 10.1111/os.13935] [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] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2023] [Revised: 09/23/2023] [Accepted: 09/26/2023] [Indexed: 11/19/2023] Open
Abstract
OBJECTIVE The ability of D-dimer to diagnose periprosthetic joint infection (PJI) before revision hip or knee arthroplasty is still controversial, and the differences in diagnostic ability between serum- or plasma-based assays of D-dimer and fibrin (fibrinogen) degradation product (FDP) are uncertain. The prospective parallel study was performed to determine the ability of D-dimer to diagnose PJI before revision hip or knee arthroplasty, and the differences in diagnostic ability between serum- or plasma-based assays of D-dimer and FDP. METHODS Patients undergoing knee or hip arthroplasty at our institution were prospectively enrolled into the following groups: those without inflammatory diseases who were undergoing primary arthroplasty ("Prim" group), those with inflammatory arthritis who were undergoing primary arthroplasty ("Prim/Inflam"), those undergoing revision arthroplasty because of aseptic failure ("Rev/Asept"), or those undergoing revision arthroplasty because of PJI ("Rev/PJI"). The ability of preoperative levels of D-dimer or FDP in serum or plasma to diagnose PJI in each group was assessed using areas under receiver operating characteristic curves (AUCs) and other diagnostic performance indicators. The diagnostic performance of these assays was compared with that of C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR). RESULTS In the final analysis, Prim included 42 patients; Prim/Inflam, 40; Rev./Asept, 62; and Rev./PJI, 47. D-dimer assays led to AUCs of 0.635 in serum and 0.573 in plasma, compared to 0.593 and 0.607 for FDP. Even in combination with CRP or ESR, these assays failed to perform as well as the combination of CRP and ESR for diagnosing PJI. CONCLUSION Levels of D-dimer or FDP in serum or plasma, whether used alone or together with CRP or ESR, are unreliable for diagnosing PJI before revision arthroplasty.
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Affiliation(s)
- Hong Xu
- Department of Orthopedic surgery and Orthopedic Research Institute, West China HospitalSichuan UniversityChengduChina
| | - Jing Zhou
- Department of Laboratory Medicine, West China HospitalSichuan UniversityChengduChina
| | - Qiang Huang
- Department of Orthopedic surgery and Orthopedic Research Institute, West China HospitalSichuan UniversityChengduChina
| | - Zeyu Huang
- Department of Orthopedic surgery and Orthopedic Research Institute, West China HospitalSichuan UniversityChengduChina
| | - Jinwei Xie
- Department of Orthopedic surgery and Orthopedic Research Institute, West China HospitalSichuan UniversityChengduChina
| | - Zongke Zhou
- Department of Orthopedic surgery and Orthopedic Research Institute, West China HospitalSichuan UniversityChengduChina
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Dong M, Wang Y, Fan H, Yang D, Wang R, Feng Y. The Albumin to Globulin Ratio Performs Well for Diagnosing Periprosthetic Joint Infection: A Single-Center Retrospective Study. J Arthroplasty 2024; 39:229-235.e4. [PMID: 37557968 DOI: 10.1016/j.arth.2023.08.002] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Revised: 07/29/2023] [Accepted: 08/01/2023] [Indexed: 08/11/2023] Open
Abstract
BACKGROUND Accurate diagnosis of the periprosthetic joint infection (PJI) remains a challenge for surgeons. The purpose of this study was to assess the value of albumin to globulin ratio (AGR) and globulin (GLB) for diagnosing PJI. METHODS A total of 182 patients undergoing revision after arthroplasty were included and divided into 2 groups, 61 in knee group (PJI: 38; non-PJI: 23) and 121 in hip group (PJI: 26; non-PJI: 95). We used receiver operating characteristic curves to determine the diagnostic value of AGR, GLB, inflammatory markers (erythrocyte sedimentation rate [ESR] and C-reactive protein [CRP]). RESULTS The receiver operating characteristic curves showed the areas under the curve of AGR, GLB, ESR, and CRP in the knee group were 0.940, 0.928, 0.867, and 0.848, respectively, and they were 0.855, 0.831, 0.886, and 0.912 in the hip group. The optimal predictive cut-off values for AGR in knee and hip groups were 1.375 and 1.295, respectively. The sensitivity and specificity of AGR, respectively, were 94.7% and 87.0% (knee group) and 84.6% and 75.8% (hip group) for diagnosing PJI. The sensitivity of "AGR or ESR" and specificity of "AGR and GLB" in the knee group were 99.6% and 98.9%, respectively. CONCLUSION For knee or hip groups, the AGR exhibits good value for the diagnosis of PJI comparable with ESR and CRP. The AGR and GLB, together with CRP and ESR, should be used as the preferred indicators for diagnosing PJI. The "AGR or ESR" and "AGR and GLB" in the knee group have an excellent diagnostic value in sensitivity and specificity, respectively.
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Affiliation(s)
- Mingjie Dong
- Department of Orthopaedics, The Second Clinical Medical College of Shanxi Medical University, TaiYuan, China
| | - Yushan Wang
- Department of Orthopaedics, The Second Clinical Medical College of Shanxi Medical University, TaiYuan, China
| | - Hao Fan
- Department of Orthopaedics, The Second Clinical Medical College of Shanxi Medical University, TaiYuan, China
| | - Dinglong Yang
- Department of Orthopaedics, The Second Clinical Medical College of Shanxi Medical University, TaiYuan, China
| | - Renwei Wang
- Department of Orthopaedics, The Second Clinical Medical College of Shanxi Medical University, TaiYuan, China
| | - Yi Feng
- Department of Orthopaedics, The Second Hospital of Shanxi Medical University, TaiYuan, China
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Miller AO, Carli AV, Chin A, Chee D, Simon S, MacLean CH. Development of Diagnostic Quality Metrics for Prosthetic Joint Infection. J Healthc Qual 2024; 46:31-39. [PMID: 38166164 PMCID: PMC10802978 DOI: 10.1097/jhq.0000000000000405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2024]
Abstract
ABSTRACT Although well-accepted clinical practice guidelines exist for the diagnosis of prosthetic joint infection (PJI), little is known about the quality of diagnosis for PJI. The identification of quality gaps in the diagnosis of PJI would facilitate the development of care structures and processes to shorten time to diagnosis and reduce the significant morbidity, mortality, and economic burden associated with this condition. Hence, we sought to develop valid clinical quality measures to improve the timeliness and accuracy of PJI diagnosis. We convened a nine-member multidisciplinary national panel of PJI experts including orthopedic surgeons, infectious disease specialists, an emergency medicine physician, and a patient previously treated for PJI to review, discuss, and rate the validity of proposed measures using a modification of the RAND-UCLA appropriateness method. In total, 57 permutations of six proposed measures were rated. Populations considered to be at high enough risk for PJI that certain care processes should always be performed were identified by the panel. Among the proposed quality measures, the panel rated five as valid. These novel clinical quality measures could provide insight into care gaps in the diagnosis of PJI.
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Iwamoto K, Yamamoto N, Saiga K, Maruo A, Noda T, Kawasaki K, Ozaki T. Prosthetic joint infection after total talar replacement: An implant-retained case treated with combined continuous local antibiotic perfusion (CLAP). J Orthop Sci 2024; 29:349-353. [PMID: 35067408 DOI: 10.1016/j.jos.2022.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Revised: 11/24/2021] [Accepted: 01/03/2022] [Indexed: 02/09/2023]
Affiliation(s)
- Kohei Iwamoto
- Department of Emergency Medical Center, Kagawa Prefectural Central Hospital, 1-2-1, Asahi-machi, Takamatsu, Kagawa 760-8557, Japan
| | - Norio Yamamoto
- Department of Orthopaedic Surgery, Kagawa Prefectural Central Hospital, 1-2-1, Asahi-machi, Takamatsu, Kagawa 760-8557, Japan; Systematic Review Workshop Peer Support Group (SRWS-PSG), Osaka, Japan.
| | - Kenta Saiga
- Department of Orthopaedic Surgery, Okayama University Hospital, 2-5-1 Shikatacho, Kitaku, Okayama 700-8558, Japan
| | - Akihiro Maruo
- Department of Orthopaedic Surgery, Steel Memorial Hirohata Hospital, Yumesaki-cho 3-1, Hirohata-ku, Himeji, Hyogo, 671-1122, Japan
| | - Tomoyuki Noda
- Department of Orthopaedic Surgery and Traumatology, Kawasaki Medical School, General Medical Center, 2-6-1, Nakasange, Kitaku, Okayama, 700-8505, Japan
| | - Keisuke Kawasaki
- Department of Orthopaedic Surgery, Kagawa Prefectural Central Hospital, 1-2-1, Asahi-machi, Takamatsu, Kagawa 760-8557, Japan
| | - Toshifumi Ozaki
- Department of Orthopaedic Surgery, Okayama University Hospital, 2-5-1 Shikatacho, Kitaku, Okayama 700-8558, Japan
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Berli MC. A New Aid in Diagnosing Periprosthetic Joint Infection with a Tool Already in Use?: Commentary on an article by Andreas G. Tsantes, MD, et al.: "A Pilot Observational Study Evaluating the Diagnostic Capacity of Rotational Thromboelastometry in Periprosthetic Joint Infections". J Bone Joint Surg Am 2023; 105:e58. [PMID: 38117269 DOI: 10.2106/jbjs.23.01098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2023]
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Cichos KH, Ruark RJ, Ghanem ES. Isothermal microcalorimetry improves accuracy and time to bacterial detection of periprosthetic joint infection after total joint arthroplasty. J Clin Microbiol 2023; 61:e0089323. [PMID: 37947408 PMCID: PMC10729692 DOI: 10.1128/jcm.00893-23] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Accepted: 10/16/2023] [Indexed: 11/12/2023] Open
Abstract
Isothermal microcalorimetry (IMC) was evaluated compared to conventional cultures to determine the clinical performance for diagnosing periprosthetic joint infection (PJI) of hip/knee replacements. We prospectively collected three to five deep tissue samples per patient from 152 patients undergoing conversion or revision hip/knee arthroplasty from July 2020 to November 2022. Cultures and IMC for each sample were compared for concordance, median time to detection (TTD), and diagnostic performance based on 2013 Musculoskeletal Infection Society criteria. Secondary analyses involved patients on antibiotics at sampling. The 152 total patients had 592 tissue samples (mean 3.9 ± 0.3) with sample concordance between cultures and IMC of 90%. IMC demonstrated a sensitivity of 83%, specificity of 100%, negative predictive value (NPV) of 89%, and positive predictive value (PPV) of 100% for PJI. Cultures resulted in 69% sensitivity, 100% specificity, 81% NPV, and 100% PPV. The accuracy of IMC was 93% compared to 87% for cultures (P < 0.001). The median TTD of PJI by cultures was 51 (21-410) hours compared to 10 (0.5-148) hours for IMC (P < 0.001). For 39 patients on chronic antibiotics, sensitivity in PJI detection was 93%, specificity 100%, NPV 85%, and PPV 100% by IMC compared to 79% sensitivity, 100% specificity, 65% NPV, and 100% PPV for cultures. The accuracy was 95% for IMC compared to 85% for cultures (P < 0.001) with median TTD of 12 (0.5-127) hours compared to 52 (21-174) hours (P < 0.001). Utilizing IMC for PJI detection improves TTD by nearly 2 days while improving diagnostic accuracy compared to cultures, particularly in patients on chronic antibiotics.
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Affiliation(s)
- Kyle H. Cichos
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
- Hughston Foundation, Columbus, Georgia, USA
- Hughston Clinic, Columbus, Georgia, USA
| | | | - Elie S. Ghanem
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri, USA
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Ji W, Liu Z, Lin T. Diagnostic value of albumin/fibrinogen ratio and C-reactive protein/albumin/globulin ratio for periprosthetic joint infection: a retrospective study. PeerJ 2023; 11:e16662. [PMID: 38111666 PMCID: PMC10726739 DOI: 10.7717/peerj.16662] [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] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Accepted: 11/21/2023] [Indexed: 12/20/2023] Open
Abstract
Background The study aims to explore diagnostic value of albumin/fibrinogen ratio (AFR) and C-reactive protein (CRP)/albumin (ALB)/globulin (GLO) ratio (CAGR) for periprosthetic joint infection (PJI). Methods A retrospective analysis was conducted on clinical data collected from 190 patients who had joint replacement surgery in Qilu Hospital of Shandong University (Qingdao), from January 2017 to December 2022. Based on the occurrence of PJI after surgery, patients were divided as an infection group (10 cases) and non-infection group (180 cases). Diagnostic indicators were analyzed, univariate and multivariate logistic regression analyses were further performed to identify factors related to PJI. Sensitivity and specificity of AFR and CAGR, both individually and in combination, were calculated using ROC curves, and their diagnostic performance was compared based on the area under the curve (AUC). Results Levels of CRP, ESR, FIB, GLO, and CAGR were significantly higher in the infection group than in non-infection group (P < 0.05). Levels of ALB and AFR were significantly lower in infection group (P < 0.05). Multivariate logistic regression analysis reviewed that CRP (OR = 3.324), ESR (OR = 2.118), FIB (OR = 3.142), ALB (OR = 0.449), GLO (OR = 1.985), AFR (OR = 0.587), and CAGR (OR = 2.469) were factors influencing PJI (P < 0.05). The AUC for AFR and CAGR in diagnosing PJI were 0.739 and 0.780, while AUC for their combined detection was 0.858. Conclusion Abnormal levels of AFR and CAGR are associated with PJI, and their combined use has certain diagnostic value for PJI.
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Affiliation(s)
- Wei Ji
- Department of Joint Surgery, Qilu Hospital of Shandong University (Qingdao), Qingdao, China
| | - Zemiao Liu
- Department of Joint Surgery, Qilu Hospital of Shandong University (Qingdao), Qingdao, China
| | - Tao Lin
- Department of Joint Surgery, Qilu Hospital of Shandong University (Qingdao), Qingdao, China
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Kwon S, Lee E, Choi EK, Lee SR, Oh S, Choi YS. Long-term outcomes of abandoned leads of cardiac implantable electronic devices. Heart Rhythm 2023; 20:1639-1646. [PMID: 37543304 DOI: 10.1016/j.hrthm.2023.07.068] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Revised: 07/25/2023] [Accepted: 07/27/2023] [Indexed: 08/07/2023]
Abstract
BACKGROUND Evidence of the long-term outcomes of abandoned leads (ALs) in patients with cardiac implantable electronic devices (CIEDs) is scarce. OBJECTIVE This study aimed to investigate the long-term outcomes of ALs. METHODS This retrospective cohort study reviewed a single-center CIED registry of 2962 procedures performed from 1984-2018 and identified 130 patients with AL (AL group). We matched 2 controls without AL (by age, sex, device type, and device revision/removal date) to each patient with AL (n = 260) and compared CIED-related infection, venous thrombosis/stenosis, and all-cause mortality between groups using a Cox proportional hazard model analysis. RESULTS For a mean follow-up period of 11.2 ± 8.2 years, 14 (3.6%), 7 (1.8%), and 143 (36.7%) patients had a CIED-related infection, venous thrombosis/stenosis, or experienced all-cause mortality, respectively. The AL group had more comorbidities than the control group. Lead malfunction was the most common cause of abandonment (64.6%). After adjustment for covariates, no significant intergroup differences were noted in the risks of infection, venous thrombosis/stenosis, or all-cause mortality (adjusted hazard ratio [aHR] 2.52; 95% confidence interval [CI] 0.77-8.25; aHR 1.18; 95% CI 0.25-5.64; aHR 1.26; 95% CI 0.89-1.80, respectively). Patients with multiple ALs had increased risks of infection and all-cause mortality vs controls (aHR 8.61; 95% CI 2.13-34.84; aHR 2.42; 95% CI 1.17-5.00, respectively). CONCLUSION Patients with a single AL showed similar risks of CIED-related infections, venous thrombosis/stenosis, and all-cause mortality as those without ALs, whereas those with multiple ALs showed increased risks of infection and all-cause mortality.
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Affiliation(s)
- Soonil Kwon
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Euijae Lee
- Department of Cardiovascular Medicine, Bucheon Sejong Hospital, Bucheon, Republic of Korea
| | - Eue-Keun Choi
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea; Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea.
| | - So-Ryoung Lee
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Seil Oh
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea; Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Yun-Shik Choi
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea; Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
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