Role of bariatric surgery in reducing periprosthetic joint infections in total knee arthroplasty. A systematic review and meta-analysis

BACKGROUND

Obesity represents an epidemic of rising numbers worldwide year after year. In the Orthopedic field, obesity is one of the major causes leading to osteoarthritis needing Total Joint Arthroplasty (TJA). Still, contextually, it represents one of the most significant risk factors for joint replacement complications and failures. So, bariatric Surgery (BS) is becoming a valuable option for weight control and mitigating obesity-related risk factors. This review of the literature and meta-analysis aims to evaluate periprosthetic joint infections (PJI) and surgical site infections (SSI) rates in patients who underwent TKA after BS compared to obese patients without BS.

METHODS

Systematic review was performed according to Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines up to October 2023. We included longitudinal studies comparing obese patients who underwent total knee arthroplasty after bariatric surgery (study group) and obese patients who underwent TKA (control group). The surgical site infection and Periprosthetic joint infection rate were compared among groups using a meta-analytical approach.

RESULTS

The online database and references investigation identified one hundred and twenty-five studies. PJI rate differed significantly among groups, (z = -21.8928, p < 0.0001), with a lower risk in the BS group (z = -10.3114, p < 0.0001), for SSI, instead, not statistically significance were recorded (z = -0.6784, p = 0.4975).

CONCLUSIONS

The current Literature suggests that Bariatric Surgery can reduce infectious complications in TKA, leading to better outcomes and less related costs treating of knee osteoarthritis in obese patients.

Articulating spacers in elderly patients affected by periprosthetic knee infection: clinical findings and outcome

OBJECTIVE

Although the two-stage technique is a validated strategy in periprosthetic joint infections, there is a lack of data on the patients' clinical outcomes after the spacer placement. This study aims at evaluating the quality of life, joint function, and pain in patients over 70 years affected by periprosthetic joint infection treated with a two-stage exchange using metal on polyethylene spacers.

PATIENTS AND METHODS

We conducted a follow-up study to evaluate the quality of life and functionality of consecutive patients over 70 years treated for PJI at our institution using a validated assessment set including the Western Ontario and Mac Master University (WOMAC) score, Knee Society Score (KSS), numerical rating scale (NRS). Knee Range of Movement (ROM) before and after the surgery was also analyzed.

RESULTS

Forty-five patients with a mean age of 76 ± 5.3 years were included. Coagulase-negative staphylococci were the most isolated microorganisms. In the preoperative study group, the WOMAC score was 48.4 ± 18.9, and the KSS objective and functional scores were 37.6 ± 17.3 and 27.6 ± 22.3, respectively. NRS was 7.3 ± 1.8. After three months of follow-up, we found better results than preoperative clinical evaluation. We retrieved similar results comparing our post-operative PROMS (WOMAC and KSS scores) with published thresholds for treatment success two months after primary total knee arthroplasty. The infection eradication rate was 87%.

CONCLUSIONS

The two-stage technique confirmed its efficacy in the treatment of PJI. Patients over 70 years who had undergone the first stage of the two-stage technique for PJI showed a good quality of life and knee function.

A training ground Lay out improves rehabilitation after trauma surgery: A Fast Track Policy

 

Fracture patients are frail and have high mortality. We investigated whether introducing a fast-track strategy during post-surgery care and including early rehabilitation protocols may shorten the length of hospital stay (LOS) while improving the overall clinical effectiveness. A training ground was built inside the inpatient area dedicated to trauma settings. Usual postoperative care consists of immobilization during the first day, but patients may start rehabilitation earlier, 24 hours after the surgical procedure, with a fast-track strategy. In general, gait speed, step length, and self-assessment in terms of mobility improve significantly in the first six postoperative weeks in fracture patients. As delayed postoperative mobility during hospitalization was observed, the established training ground may help with this concern. The expert physiotherapist may contribute to ameliorating the indicators showing great potential in postoperative rehabilitation regardless of fracture pattern. The primary outcome was postoperative physical functioning. Secondary outcomes included the patient’s assessment of therapeutic effect (overall improvement), perceived pain intensity, health services utilization, treatment side effects, and adverse events. Data were analyzed by univariate analysis and binary logistic regression showing a reduction of LOS of almost three days. Further, the optimized hip fracture program reduced the rate of in-hospital postoperative complications and mortality. Adding to the schedule, some PROMPTS (Patient-reported outcome measures) could further integrate the patient empowerment perspective into the quality set of values. For this reason, ‘fast track’ may define a crucial policy able to guarantee rapid rehabilitation, becoming a key factor to achieving a good clinical effect. Fast-track rehabilitation facilitates a shortened hospital stay and cost-saving and can be used to optimize the patient’s condition before admission to a rehabilitation facility

Key messages

• Early rehabilitation protocols may shorten the length of hospital stay (LOS) while improving the overall clinical effectiveness.

• Human factors and patients empowerments may help.

Prevention and treatment of peri-prosthetic joint infection using surgical wound irrigation

Over the past decade, the incidence of revision arthroplasty due to infection has increased substantially, often resulting in multiple surgical interventions with variable success rates and poor clinical outcome. Intraoperative wound irrigation has been proposed to reduce bacterial bioburden and contamination, but currently there is no widely accepted recommendation for the use of topical antiseptics, whether as separate molecules or as a mixed solution. We reviewed studies regarding the use of intraoperative topical antiseptics, their security profile and efficacy in preventing and treating infections of orthopedic implants and introduced a possible combination that may prove valuable in the future.

Post-arthroscopic septic arthritis of the knee. Analysis of the outcome after treatment in a case series and systematic literature review

OBJECTIVE

The aim of this study was to review the characteristics of patients with septic arthritis after ACL reconstruction comparing our results with those deriving from the literature review.

PATIENTS AND METHODS

Patients with suspected post arthroscopic septic arthritis of the knee occurring within 6 months after surgery were evaluated to be included in the investigation. Septic arthritis was defined by i) clinical evidence; ii) laboratory investigations; iii) synovial fluid leukocyte count of more than 2,5 x 104/μL or positive cultures obtained by synovial fluid aspirate.

RESULTS

Thirty-nine patients (median age 25 years, range 17-42) with septic arthritis following ACL reconstruction were enrolled. Staphylococci were the main bacteria identified. Resolution within 4 weeks of local signs was observed more frequently in those receiving arthroscopic debridement and synovectomy coupled with antibiotic therapy (18/21 vs. 9/18, p<0.05). Fever was present in 33 (85%) cases. Fever disappearance and CRP normalization within 4 weeks were reported more frequently in patients receiving intravenous antibiotics (17/20 vs. 9/19, p<0.05). Similar findings were retrieved by literature analysis.

CONCLUSIONS

An intravenous antibiotic therapy with surgical debridement is the first-line treatment for septic arthritis. Staphylococci are the main causative agents, justifying an empiric therapeutic approach with an anti-MRSA agent and cephalosporin.

Clinical and prognostic features of prosthetic joint infections caused by Enterococcus spp

OBJECTIVE

Pathogens colonizing the intestinal or urinary tract such as enterococci or Gram-negative bacilli can cause prosthetic joint infection (PJI).

PATIENTS AND METHODS

PJI undergoing 2-stage exchange, referred to the Department of Infectious Diseases of the Cotugno Hospital of Naples and the Fondazione Policlinico Gemelli of Rome over a 7-year period (2009-2015) for Infectious Diseases (ID) consultation were included. Demographic data, detailed information about previous or underlying diseases, findings of the clinical examination, and results of laboratory investigations were analyzed. The cure was defined by the disappearance of clinical, laboratory, and radiological evidence of PJI 96 week after the discontinuation of antibiotic treatment.

RESULTS

Thirty-one cases of PJI sustained by Enterococci were included (16 early infections, 13 delayed infections, and 2 late infections). Median age was 73 years (range 39-83), 39% were males. Comorbidities related to an increased risk of infection were reported in 17 (55%) cases. Joint pain interfering with daily living was reported in 27 (87%) cases, fever in 7 with early infection and in no case with delayed or late infection (7/17 vs. 0/14, Odds ratio undefined, p=0.01). Local inflammation and joint effusion were reported in 29 (93%) cases, sinus tract in 25 (81%). Enterococcus faecalis was the etiologic agent in 28 (90%) cases, E. faecium in 2 (6%), E. casseliflavus in 1 (3%). Eleven cases were polymicrobial. Favourable outcome was reported in 20 (65%) cases. Patients with comorbidities reported more frequently an unfavourable outcome (9/17 vs. 2/14, Odds ratio 6.7, 95% CI 1.1-39.8; p=0.06).

CONCLUSIONS

Comorbidities should arise the suspect of infection by enterococci. Associative protocols, considering drugs active against biofilm should be considered in the cases with enterococcal infection.

Volar distal radius vascularized bone graft vs non-vascularized bone graft: a prospective comparative study

The pseudoarthrosis (PSA) of scaphoid leads to alteration in load transfer in the wrist joint. Its treatment aims to achieve consolidation to improve clinical complaints and prevent post-traumatic arthritis. The indication for using vascularized bone grafts is still controversial. This prospective comparative study aimed to compare consolidation rate and time to healing of scaphoid PSA treated by volar distal radius vascularized bone graft vs non-vascularized iliac bone graft. Nine patients underwent vascularized grafting of scaphoid PSA. These patients were compared to a control group consisting of twelve patients treated with iliac crest-free bone graft. PSA consolidation was obtained in 8 of 9 patients (88%) and 9 of 12 patients (75%) in the study and control group, respectively. The difference in consolidation rate was not significant. Two of three patients with AVN of the proximal pole in the study group (66%) went to consolidation. In the control group no patient with AVN obtained bone consolidation. This difference almost reached statistical significance (p = 0.083). The mean time to consolidation was 8.6 weeks (range 8-11) and 11.7 weeks (range 10-16), respectively, in the study and control group. This difference was significant (p < 0.05). In conclusion, the distal radius vascularized graft led to satisfactory consolidation rate of PSA in the current study, even in cases of AVN of the proximal pole. Moreover, the vascularized bone graft resulted in shorter healing time compared to the non-vascularized graft.

Blood loss and transfusion rate in patients undergoing two-stage exchange in infected total knee arthroplasty

Two-stage exchange in infected total knee arthroplasty is a reliable technique, but it has a high rate of blood loss. The study aims to compare the pre-operative and post-operative haemoglobin levels, the rate of transfusion, and the blood loss in two-stage exchange. From July 2018 to July 2019, eighteen patients underwent two-stage exchange of their infected total knee arthroplasty. Local and systemic tranexamic acid was administered in both surgical stages. Calculated blood loss was 2246 mL (range 1528 - 2850) in the first stage and 2388 mL (1873 - 2829) during reimplantation, respectively. The corresponding transfusion rate was 55 % and 67%, respectively. With the numbers available, these differences were not significant. In conclusion, this study shows that the blood loss and transfusion rate are similar during the two stages of exchange knee arthroplasty for infection.

Use of synthetic cartilage implant (Cartiva®) for degeneration of the first and second metatarsophalangeal joint: what is the current evidence?

Polyvinyl alcohol hydrogel implants (also known as Synthetic Cartilage Implant or Cartiva® have been described in the treatment of degeneration of the first and second metatarsophalangeal joint (MTPJ). We reviewed literature to report characteristics of devices on the market and investigate their efficacy and safety. Following the PRISMA checklist, the Medline and Scopus databases were searched, including studies reporting use of Cartiva® for treating joint degeneration of the first and second MPTJ. Studies were searched for surgical technique, postoperative protocol, clinical scores, complications and reoperations. We found that, although some studies suggest that the use of Synthetic Cartilage Implant (Cartiva® is effective in the treatment of hallux rigidus in providing symptoms relief without sacrifice of joint motion, the redundancy of cohorts reported in studies and the frequency of conflict of interest reported by authors weaken the strength of evidence available and warrant further studies. Regarding the treatment of the second MTPJ ailments, no recommendation can be formulated to date due to the lack of primary studies.

Foot and ankle measurements on cone beam weightbearing computed tomography

Over the last years, an increased number of studies have reported the use of cone beam weightbearing computed tomography (WBCT) in the assessment of foot and ankle pathology. This new technology has enabled to overcome the limits inherently related to two-dimensional radiographs (superimposition bias, operator-related bias, rotation bias) and to obtain images reproducing the bones and joints anatomy during physiological standing with a low radiation dose. We performed a review of the current literature to summarize the evidence about the use of 2D or 3D measurements on WBCT images in various foot and ankle conditions. Our aims were to describe measurements proposed so far and to report data on reliability and validity from primary authors.

Tantalum monoblock cups in total hip arthroplasty: clinical results and outcome predictors

This study aims to report the minimum 2-year follow-up results of the tantalum monoblock cup in primary THA and to identify possible outcome predictors. Eighty-eight porous tantalum monoblock acetabular cup in primary THA were reviewed. The Harris Hip Score (HHS) and the Short Form-36 Health Survey (SF-36) were used for the evaluation of outcomes. Radiographic evaluation included acetabular component orientation, presence of bone gaps, radiolucent lines, new bone formation and heterotopic ossifications. After a mean follow-up of 55.4±19.5 months, no component revision was noted. The HHS improved from 43.6±14.6 to 88.3±8.4 (P less than 0.001). The mean physical domain of the SF-36 did not significantly differ from that of age-matched, healthy subjects (P=0.072); the mean mental component of the SF-36 was significantly higher than that of age-matched, healthy subjects (P less than 0.001). Negative determinants of postoperative HHS (total adjusted R2=0.328) using tantalum monoblock cups were age at surgery (R2=0.164, P less than 0.001), female sex (R2=0.103, P less than 0.001), and acetabular inclination (R2=0.084, P equals 0.003).

Knee Septic Arthritis after Arthroscopy: Incidence, Risk Factors, Functional Outcome, and Infection Eradication Rate

Purpose  Septic knee arthritis following arthroscopy is a rare but dreaded complication. Definition and management of knee deep infections are quite discussed in literature. In this review, literature regarding infections after knee arthroscopy is analyzed highlighting the incidence, causative bacteria, risk factors as well as clinical outcomes.

Methods  We performed a review of the literature matching the following key words: “septic arthritis” OR “infection” AND “arthroscopy” AND “knee.” Knee arthroscopic procedures, such as debridement, meniscectomy, meniscus repair, synovectomy, microfracture, and lateral release, were considered. Complex procedures, such as ligament reconstruction, fractures, or complex cartilage repair techniques, were not included.

Results  Thirteen studies were included in this review. Incidence of infection ranged from 0.009 to 1.1% in patients undergoing simple arthroscopic procedures. Staphylococci are the most commonly isolated organisms from postarthroscopy infection. Use of intraoperative intra-articular steroids, smoking, obesity, male sex, diabetes, number of procedures performed during surgery, time of surgery, and tourniquet time of more than 60 minutes have been certified as risk factors for knee infection.

Conclusion  Postarthroscopy septic arthritis of the knee causes significant morbidity, usually requiring readmission to the hospital, at least one additional operation, and prolonged antibiotic therapy, both intravenous and oral. Prompt diagnosis and treatment are associated with a high success rate.

Level of Evidence  Level IV, systematic review of I-IV studies.

Preliminary focus on the mechanical and antibacterial activity of a PMMA-based bone cement loaded with gold nanoparticles

In total knee arthroplasty (TKA) and total hip replacement (THR) the restoration of the normal joint function represents a fundamental feature. A prosthetic joint must be able to provide motions and to transmit functional loads.

As reported in the literature, the stress distribution may be altered in bones after the implantation of a total joint prosthesis. Some scientific works have also correlated uncemented TKA to a progressive decrease of bone density below the tibial component. Antibiotic-loaded bone cements are commonly employed in conjunction with systemic antibiotics to treat infections. Furthermore, nanoparticles with antimicrobial activity have been widely analysed. Accordingly, the current research was focused on a preliminary analysis of the mechanical and antibacterial activity of a PMMA-based bone cement loaded with gold nanoparticles. The obtained results demonstrated that nanocomposite cements with a specific concentration of gold nanoparticles improved the punching performance and antibacterial activity. However, critical aspects were found in the optimization of the nanocomposite bone cement.

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Evaluation of the in vitro effects of bacterial adhesion and proliferation on modified bone cement samples.

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Assessment of anti-bacterial and anti-biofilm activities of the nanocomposite bone cement.

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Analysis of the effect of the inclusion of gold nanoparticles on mechanical performances of a PMMA-based bone cement.

The difficult primary total knee arthroplasty: a review

Primary total knee arthroplasty (TKA) is a reliable procedure with reproducible long-term results. Nevertheless, there are conditions related to the type of patient or local conditions of the knee that can make it a difficult procedure. The most common scenarios that make it difficult are discussed in this review. These include patients with many previous operations and incisions, and those with severe coronal deformities, genu recurvatum, a stiff knee, extra-articular deformities and those who have previously undergone osteotomy around the knee and those with chronic dislocation of the patella. Each condition is analysed according to the characteristics of the patient, the pre-operative planning and the reported outcomes. When approaching the difficult primary TKA surgeons should use a systematic approach, which begins with the review of the existing literature for each specific clinical situation.

RELEASE OF GENTAMICIN FROM CEMENT SPACERS IN TWO-STAGE PROCEDURES FOR HIP AND KNEE PROSTHETIC INFECTION: AN IN VIVO PHARMACOKINETIC STUDY WITH CLINICAL FOLLOW-UP

Eighteen patients undergoing two-stage exchange arthroplasty for infected total hip or knee arthroplasty using gentamicin-loaded bone cement spacers (80g bone cement, 2 g gentamicin and 2 g clindamycin) were studied. The concentration of gentamicin eluted from the spacers was assessed on samples of blood, urine, and drainage fluid that were collected from each patient at set intervals during the 48 hours following the first-stage surgery. The hip and knee cement spacers showed similar curve of release over the first postoperative hours (early peak followed by slow release), but the mean gentamicin concentration in the drainage fluid was higher in patients with hip spacers compared to patients with knee spacers (30.61±19.47 mg/L vs 17.43±13,63 mg/L, p less than 0.05). In patients with hip spacers, the mean, maximum, and minimum concentration of gentamicin was higher with respect to the minimum inhibitory concentration (MIC) break point for Staphylococcus spp, Pseudomonas Aeruginosa and Enterobacteriaceae throughout the first postoperative 48 h. Conversely, in 25% of patients with a knee spacer a drug concentration below the MIC break point for Gram negative bacteria was found in the drainage fluid after 12 h. Gentamicin levels in the blood samples were negligible over the entire time interval and were steadily well below the renal toxicity reference. The highest urinary concentration of gentamicin was observed between 4 and 9 h postoperatively. Subsequently, it gradually declined until 48 h. Clinically, the rate of cure was 100% at a mean follow-up of 113 weeks (range 90-182). Gentamicin-loaded cement spacers offer the advantage of achieving early high concentrations of the antibiotic directly at the site of infection but especially in the knee a systemic antibiotic therapy must be given as a complement to the spacer implantation to eradicate periprosthetic joint infection (PJI).

Treatment of Proximal Scaphoid Non-union by Resection of the Proximal Pole and Palmaris Longus Interposition Arthroplasty

BACKGROUND

The purpose of this study was to determine the long-term clinical and radiographic outcome in a group of patients treated with resection of the proximal pole and tendon ball arthroplasty because of a scaphoid non-union.

PATIENTS AND METHODS

15 patients affected by scaphoid non-union and treated with resection arthroplasty were studied at a mean follow-up of 9.1 years. The assessment included a visual analogue scale (VAS) to evaluate pain, the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire, and the measurement of grip and pinch strength. We also evaluated pre-operative and follow-up radiographs to determine the stage of SNAC wrist.

RESULTS

We obtained a good subjective clinical result in 11 patients and a poor result in 4. Mean VAS and DASH score at follow-up was 1.2±1.2 and 12±12,1, respectively. Grip and key pinch strength in the surgically treated hand were 89% of the contralateral hand. There was significant increase in the SNAC stage at follow-up with respect to the preoperative evaluation in the operated wrist.

CONCLUSION

Resection of the proximal pole and tendon ball arthroplasty provided long-term relief of pain and good functional results in most patients affected by scaphoid non-union. This technique did not affect the natural history of SNAC wrist with its clinical and functional consequences.

Trapeziometacarpal arthrodesis: is bone union necessary for a good outcome?

We present a retrospective study of 107 cases of thumb carpometacarpl joint arthrodesis. The aim of our study was to analyse our population and to compare the outcomes of patients who obtained bone union with the patients who did not. There were no statistical differences in most of the clinical outcomes (DASH score, visual analogue scale, Kapandji test, grip, and key pinch) between the two groups of patients; there were fewer cases of scaphotrapeziotrapezoid arthritis in the group that did not obtain bone union. We conclude that the bone union is not necessary for a good outcome. Level IV of evidence.

Factors related to outcome of early and delayed prosthetic joint infections

In this prospective study, we evaluate the impact of adherence to a diagnostic and therapeutic protocol on prosthetic joint infections (PJI) diagnostic accuracy and outcome.

PATIENTS AND METHODS

Patients with early or delayed PJI referred over a 5-year period were included. Diagnosis was based on characteristic clinical signs, radiographic findings and microbiological evidence. Antibiotics were chosen on the basis of microbiological findings, and drugs active against methicillin-resistant staphylococci were administered if no microbiological evidence had been obtained.

RESULTS

Inclusion criteria were met in 159 cases (median age 64 years, males 45%). 56 were early infections and 103 delayed infections. Comorbidities were reported in 99 (62%) cases. Positive cultures were obtained in 122/159 (77%), coagulase-negative staphylococci were cultured in 20%, Staphylococcus aureus in 28%, and Pseudomonas aeruginosa in 7%. In early infections, cure rate after debridement and antibiotic therapy was 80%. In delayed infections, cure rate after two-stage exchange was 85%. Of 28 patients with delayed infection treated with antibiotics without surgery, only 8 (29%) infections were suppressed 48 weeks after treatment discontinuation. Rifampin afforded a better outcome.

CONCLUSION

Appropriate diagnostic and surgical procedures and microbiologically driven antibiotic therapy including rifampin are recommended to improve diagnostic accuracy and outcome.

Long-term clinical results and MRI changes after tendon ball arthroplasty for advanced Kienbock's disease

The purpose of this study was to assess the long-term clinical results and morphological changes after tendon ball arthroplasty for advanced Kienböck's disease. Twenty-six patients were reviewed, with a mean follow-up interval of 125 months (range 50-226). At follow-up, mean score on the Disabilities of the Arm, Shoulder, and Hand questionnaire was 7.7 and mean visual analogue scale score for pain was 1. Mean carpal height ratio was significantly reduced with respect to the pre-operative value. On magnetic resonance imaging scans, cartilage damage, synovitis, and erosive or oedematous changes in the bones were detected in most patients. Calcification in the defect filled by the tendon ball was seen in all patients. Narrowing of the radioscaphoid joint and the presence of intercarpal synovitis were negatively associated with clinical outcome. Tendon ball arthroplasty in advanced Kienböck's disease results in long-term satisfactory clinical outcomes, despite widespread changes in the bones and joints within the wrist.

Reactivity to euro coins and sensitization thresholds in nickel-sensitive subjects

BACKGROUND

The 1- and the 2-euro coins consist of nickel alloys, which release nickel. The nickel released by far exceeds the amount allowed by the European Union Nickel Directive referring to products intended to come into direct and prolonged contact with the skin. As there is only temporary contact with the skin, the clinical relevance of nickel-containing coins with regard to nickel dermatitis is a matter of debate, although there is evidence that the nickel released from the coins affects some nickel-sensitive subjects through occupational exposure.

OBJECTIVES

Our aim was to study skin reactivity to euro coins, and to correlate the frequency and intensity of coin patch test responses to sensitization thresholds to nickel.

PATIENTS AND METHODS

Sixty-four nickel-sensitized and 30 non-nickel-sensitized subjects were patch tested with serial dilutions of nickel sulfate (5, 1, 0.5, 0.1, 0.05, 0.01 and 0.005% in distilled water) and with coins. Italian coins (500, 200, 100 and 50 lira) and euro coins (2 and 1 euros, 20 and 5 euro cents) were used for patch testing and compared.

RESULTS

The application of 1- and 2-euro coins to the skin induced eczematous reactions, being more frequent and intense in comparison with those provoked by other coins. A correlation between intensity of responses to coin patch tests and sensitization threshold to nickel was observed. Patients with the strongest reactions to 1- and 2-euro coins showed positive responses to the lowest nickel concentrations.

CONCLUSIONS

The nickel content in euro coins represents a possible health hazard, especially for highly nickel-sensitive subjects. We recommend that nickel sulfate patch tests should be performed at different concentrations to determine sensitization thresholds at least in individuals with occupational exposure to coins.