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Lin Y, Chen W, Peng S, Chang C, Lee S, Lin S. Impact of unplanned second debridement, antibiotics and implant retention on long-term outcomes in knee exchange arthroplasty: Elevated risk of failure and reinfection. J Exp Orthop 2024; 11:e12024. [PMID: 38694767 PMCID: PMC11058667 DOI: 10.1002/jeo2.12024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2023] [Revised: 02/02/2024] [Accepted: 03/26/2024] [Indexed: 05/04/2024] Open
Abstract
Purpose This study investigates the outcomes of two-stage exchange arthroplasty (EA) for periprosthetic joint infection (PJI) following initial or unplanned repeat debridement antibiotics, and implant retention (DAIR). Methods We retrospectively reviewed cases of knee arthroplasty infection treated with two-stage EA after DAIR, spanning from January 1994 to December 2010. A total of 138 patients were included, comprising 112 with initial DAIR and 26 with an unplanned second DAIR. Data on demographics, comorbidities, infection characteristics and causative organisms were analyzed. The primary outcome was implant failure or reinfection, observed over a minimum follow-up of 10 years. Results The overall success rate for two-stage EA was 87% (119/138 patients). Factors identified for treatment failure included reinfection with the same pathogen for unplanned second DAIR (hazard ratio [HR] = 3.41; 95% confidence interval [CI] = 1.35-4.38; p = 0.004), higher reinfection rates in patients undergoing EA after an unplanned second DAIR, especially with a prior history of PJI within 2 years (HR = 4.23; 95% CI = 2.39-5.31; p = 0.002), pre-first DAIR C-reactive protein (CRP) levels over 100 mg/dL (HR = 2.52; 95% CI = 1.98-3.42; p = 0.003) and recurrence with the same pathogen (HR = 2.35; 95% CI = 1.32-4.24; p = 0.007). Additional factors such as male gender (HR = 3.92; 95% CI = 1.21-5.25; p = 0.007) and osteoporosis (T score < -2.5; HR = 3.27; 95% CI = 1.23-5.28; p = 0.005) were identified as risk factors for implant failure in all EA cases. Conclusions This study identifies key risk factors for worse knee EA outcomes following DAIR, including a pre-first DAIR CRP level over 100 mg/L, same pathogen recurrence, and PJI history within 2 years. It shows implant failure rates remain constant across EA cases, regardless of DAIR sequence, particularly with risk factors like male gender and severe osteoporosis (T score < -2.5). These results underscore the need for careful evaluation before an unplanned second DAIR, given its significant impact on EA success. Level of Evidence Level III.
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Affiliation(s)
- Yu‐Chih Lin
- Department of Orthopaedic SurgeryChang Gung Memorial Hospital (CGMH)KweishanTaoyuanTaiwan
- Bone and Joint Research CenterChang Gung Memorial Hospital (CGMH)KweishanTaoyuanTaiwan
- College of MedicineChang Gung University (CGU)KweishanTaoyuanTaiwan
| | - Wei‐Cheng Chen
- Department of Orthopaedic SurgeryChang Gung Memorial Hospital (CGMH)KweishanTaoyuanTaiwan
- Bone and Joint Research CenterChang Gung Memorial Hospital (CGMH)KweishanTaoyuanTaiwan
- College of MedicineChang Gung University (CGU)KweishanTaoyuanTaiwan
| | - Shih‐Hui Peng
- Department of Orthopaedic SurgeryChang Gung Memorial Hospital (CGMH)KweishanTaoyuanTaiwan
- Bone and Joint Research CenterChang Gung Memorial Hospital (CGMH)KweishanTaoyuanTaiwan
- College of MedicineChang Gung University (CGU)KweishanTaoyuanTaiwan
| | - Chih‐Hsiang Chang
- Department of Orthopaedic SurgeryChang Gung Memorial Hospital (CGMH)KweishanTaoyuanTaiwan
- Bone and Joint Research CenterChang Gung Memorial Hospital (CGMH)KweishanTaoyuanTaiwan
- College of MedicineChang Gung University (CGU)KweishanTaoyuanTaiwan
| | - Sheng‐Hsun Lee
- Department of Orthopaedic SurgeryChang Gung Memorial Hospital (CGMH)KweishanTaoyuanTaiwan
- Bone and Joint Research CenterChang Gung Memorial Hospital (CGMH)KweishanTaoyuanTaiwan
- College of MedicineChang Gung University (CGU)KweishanTaoyuanTaiwan
| | - Sheng‐Hsuan Lin
- Institute of StatisticsNational Yang Ming Chiao Tung UniversityHsinchuTaiwan
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Hawellek T, von Lewinski G, Lehmann W, Kühn KD. [Cement in revision arthroplasty-what about the "glacier effect"? : Case studies viewed from different perspectives]. ORTHOPADIE (HEIDELBERG, GERMANY) 2024; 53:185-194. [PMID: 37861705 DOI: 10.1007/s00132-023-04452-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 09/22/2023] [Indexed: 10/21/2023]
Abstract
BACKGROUND The number of operations concerning revision arthroplasty has been increasing continuously in recent years, and it can be assumed that they will continue to increase in the future. If an arthroplasty implant becomes loose, it must be changed. The question often arises as to how the new implant should be fixed in the bone. ADVANTAGES Revision implants can be inserted into the bone without cement. In the subsequent period, a secondary osseointegration of the implant takes place. Another possibility is to anchor the implant by using bone cement. The advantage of cemented anchorage is that the implant is firmly fixed in the bone, in principle, immediately, and it is possible to fully load the implant directly. Direct postoperative full weight bearing is helpful, especially for older and multimorbid patients, in order to achieve rapid mobilization. PREREQUISITES AND CHALLENGES When using cement in revision cases, however, there are a few prerequisites and challenges that the surgeon should definitely take into account. In the case of revision, the bone in the former implant bed is often deficient and appears thinned and sclerosed. It is, therefore, important to analyze the bone quality preoperatively on radiographic images and to include it in the planning of the anchoring strategy. In addition, the individual bone quality of the patient must also be taken into account intraoperatively. In any case, it must be clarified whether the basic prerequisites for the sufficient bond strength of the cement with the bone to be formed can still be met. Furthermore, the principles of cementing technique must be strictly observed, and the goal of a perfect cement mantle must be aimed for. If the indication for this is overstated, early loosening of the cemented revision arthroplasty is very likely.
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Affiliation(s)
- Thelonius Hawellek
- Klinik für Unfallchirurgie, Orthopädie und Plastische Chirurgie, Universitätsmedizin Göttingen, Robert-Koch-Str. 40, 37075, Göttingen, Deutschland.
| | - Gabriela von Lewinski
- Klinik für Unfallchirurgie, Orthopädie und Plastische Chirurgie, Universitätsmedizin Göttingen, Robert-Koch-Str. 40, 37075, Göttingen, Deutschland
| | - Wolfgang Lehmann
- Klinik für Unfallchirurgie, Orthopädie und Plastische Chirurgie, Universitätsmedizin Göttingen, Robert-Koch-Str. 40, 37075, Göttingen, Deutschland
| | - Klaus-Dieter Kühn
- Universitätsklinik für Orthopädie und Orthopädische Chirurgie, Medizinische Universität Graz, Graz, Österreich
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Wilczyński M, Bieniek M, Krakowski P, Karpiński R. Cemented vs. Cementless Fixation in Primary Knee Replacement: A Narrative Review. MATERIALS (BASEL, SWITZERLAND) 2024; 17:1136. [PMID: 38473607 DOI: 10.3390/ma17051136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/20/2024] [Revised: 02/13/2024] [Accepted: 02/26/2024] [Indexed: 03/14/2024]
Abstract
Knee osteoarthritis (OA) is one of the leading causes of disability around the globe. Osteoarthritis is mainly considered a disease affecting the elderly. However, more and more studies show that sports overuse, obesity, or congenital disorders can initiate a pathologic cascade that leads to OA changes in the younger population. Nevertheless, OA mostly affects the elderly, and with increasing life expectancy, the disease will develop in more and more individuals. To date, the golden standard in the treatment of the end-stage of the disease is total joint replacement (TJR), which restores painless knee motion and function. One of the weakest elements in TJR is its bonding with the bone, which can be achieved by bonding material, such as poly methyl-methacrylate (PMMA), or by cementless fixation supported by bone ingrowth onto the endoprosthesis surface. Each technique has its advantages; however, the most important factor is the revision rate and survivor time. In the past, numerous articles were published regarding TJR revision rate, but no consensus has been established yet. In this review, we focused on a comparison of cemented and cementless total knee replacement surgeries. We introduced PICO rules, including population, intervention, comparison and outcomes of TJR in a PubMed search. We identified 783 articles published between 2010 and 2023, out of which we included 14 in our review. Our review reveals that there is no universally prescribed approach to fixate knee prostheses. The determination of the most suitable method necessitates an individualized decision-making process involving the active participation and informed consent of each patient.
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Affiliation(s)
- Mikołaj Wilczyński
- Orthopaedic and Sports Traumatology Department, Carolina Medical Center, Pory 78, 02-757 Warsaw, Poland
| | - Michał Bieniek
- Orthopaedic and Sports Traumatology Department, Carolina Medical Center, Pory 78, 02-757 Warsaw, Poland
| | - Przemysław Krakowski
- Orthopaedic and Sports Traumatology Department, Carolina Medical Center, Pory 78, 02-757 Warsaw, Poland
- Department of Trauma Surgery and Emergency Medicine, Medical University of Lublin, Staszica 11, 20-081 Lublin, Poland
| | - Robert Karpiński
- Department of Machine Design and Mechatronics, Faculty of Mechanical Engineering, Lublin University of Technology, Nadbystrzycka 36, 20-618 Lublin, Poland
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Anderson PM, Heinz T, Weißenberger M, Winter P, Rudert M, Jakuscheit A. Zirconium as a Promising Synovial Biomarker for Loose Cemented Knee Prosthesis. J Arthroplasty 2024:S0883-5403(24)00019-6. [PMID: 38244639 DOI: 10.1016/j.arth.2024.01.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Revised: 12/21/2023] [Accepted: 01/09/2024] [Indexed: 01/22/2024] Open
Abstract
BACKGROUND Aseptic loosening is the most common mode of failure after total knee arthroplasty. Despite this, the diagnosis often remains challenging and mainly relies on imaging modalities. Until today, no biomarker exists to aid in diagnosing loosening of the implants. As zirconium (Zr) is often found in bone cement, where it serves as radiopacifier, this study aimed to establish Zr as a synovial biomarker for loosened cemented knee prostheses. METHODS A total of 31 patients scheduled for revision of a cemented knee prostheses were included. In all patients, the initial used cement contained Zr. After arthrotomy, specimens of synovial fluid were taken and levels of Zr were measured by inductively coupled plasma mass spectrometry. Depending on the necessary amount of force for explantation, the implants were graded "loose" or "well-fixed". Preoperative radiographs were evaluated by 2 independent physicians. RESULTS The concentration of Zr in the synovial fluid differed significantly (P < .001) between the "loose" (mean 170.9 μg/L, range 0 to 1941 μg/L) and the "well-fixed" (mean 0.6 μg/L, range 0 to 6 μg/L) implants. The receiver operating characteristic analysis revealed 0.25 μg/l as an optimal cutoff value leading to a sensitivity of 0.84, a specificity of 0.92, a positive predictive value of 0.94, and a negative predictive value of 0.79. There was no significant difference in the diagnostic performance compared to radiographs (P = .66). CONCLUSIONS Zirconium proved to be a reliable novel synovial biomarker for diagnosing aseptic loosening of knee prothesis fixed with cement containing Zr. This biomarker should not be interpreted in isolation, but in combination with existing diagnostic tools.
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Affiliation(s)
- Philip M Anderson
- Department of Orthopedics, Orthopädische Klinik König-Ludwig-Haus, University of Wuerzburg, Würzburg, Germany
| | - Tizian Heinz
- Department of Orthopedics, Orthopädische Klinik König-Ludwig-Haus, University of Wuerzburg, Würzburg, Germany
| | - Manuel Weißenberger
- Department of Orthopedics, Orthopädische Klinik König-Ludwig-Haus, University of Wuerzburg, Würzburg, Germany
| | - Philipp Winter
- Department of Orthopaedic Surgery, University of Saarland, Homburg, Germany
| | - Maximilian Rudert
- Department of Orthopedics, Orthopädische Klinik König-Ludwig-Haus, University of Wuerzburg, Würzburg, Germany
| | - Axel Jakuscheit
- Department of Orthopedics, Orthopädische Klinik König-Ludwig-Haus, University of Wuerzburg, Würzburg, Germany
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Iddir SP, Phelan KC, Lee CS. Revision Medial Patellofemoral Ligament Reconstruction for Recurrent Instability After Patellofemoral Arthroplasty. Arthrosc Tech 2023; 12:e2247-e2250. [PMID: 38196887 PMCID: PMC10772993 DOI: 10.1016/j.eats.2023.07.053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Accepted: 07/30/2023] [Indexed: 01/11/2024] Open
Abstract
Recurrent patellar instability is a rare complication after patellofemoral arthroplasty (PFA) and usually involves a traumatic injury. Medial patellofemoral ligament (MPFL) reconstruction after arthroplasty is a complicated and technically challenging surgical procedure because the lack of patellar bone stock due to resurfacing significantly increases the risk of patellar fracture. We present our surgical technique for revision MPFL reconstruction for recurrent instability after PFA. This technical note describes the use of 1.8-mm all-suture anchors for revision MPFL reconstruction in patients with decreased patellar bone stock after PFA. This technique reduces the risk of patellar fracture without compromising the integrity of the MPFL graft.
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Affiliation(s)
- Sabrina P. Iddir
- University of Illinois College of Medicine at Chicago, Chicago, Illinois, U.S.A
| | - Kelly C. Phelan
- University of Rochester School of Medicine and Dentistry, Rochester, New York, U.S.A
| | - Christopher S. Lee
- Stetson Lee Orthopaedics and Sports Medicine, Burbank, California, U.S.A
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Yan S, Zhang X, Lyu Z, Liu J. Decreased serum superoxide dismutase concentration has a high value for the diagnosis of periprosthetic joint infection-a single-center, retrospective study. BMC Musculoskelet Disord 2022; 23:1000. [PMID: 36411448 PMCID: PMC9677697 DOI: 10.1186/s12891-022-05965-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Accepted: 11/08/2022] [Indexed: 11/22/2022] Open
Abstract
PURPOSE As the most serious complication of total knee arthroplasty (TKA), periprosthetic joint infection (PJI) often leads to disastrous consequences. An accurate preoperative diagnosis plays a significant role in saving prostheses and optimizing treatment outcomes. Through this retrospective case-control study, we aimed to investigate the potential of superoxide dismutase (SOD) as a novel serum biomarker in the diagnosis of PJI. METHODS We conducted a retrospective review of all patients who underwent TKA and received adequate follow-ups in our hospital from June 2015 to December 2021. A total of 50 patients were enrolled in the PJI group based on the 2018 International Consensus Meeting (ICM) criteria. Besides that, we enrolled 100 patients who underwent TKA in the same period and had a good postoperative course in the control group. Patient characteristics, comorbidities, laboratory results (serum, synovial, and microbial), and intraoperative findings (purulence and histopathology) were documented and compared by univariate analysis. Receiver operating characteristic (ROC) analysis was used to determine the sensitivity, specificity, and diagnostic performance. RESULTS The median serum SOD level in the PJI and control group was 135.95 ± 24.47 U/ml (IQR, 111.85-158.30 U/ml) and 173.83 ± 13.9 U/ml (IQR,162.83-183.5 U/ml) (p < 0.05), respectively. With the calculated cutoff of SOD at 149.5U/L, the area under the ROC curve (AUC), sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV), were 0.919, 0.72, 0.97, 0.923, and 0.874, respectively. In subgroup analysis, the specificity of SOD in diagnosing culture-negative PJI remained extremely high (0.98). Combined diagnosis of serum SOD and C-reactive protein (CRP) made AUC increase to 0.972. CONCLUSION Serum SOD showed great potential in the diagnosis of PJI.
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Affiliation(s)
- Shuo Yan
- grid.417028.80000 0004 1799 2608Department of Joints, Tianjin Hospital, No. 406 Jiefang South Rd, Tianjin, 300211 Hexi District China ,grid.265021.20000 0000 9792 1228Graduate School of Tianjin Medical University, 22 Qixiang Tai Road, Tianjin, 300203 Heping District China
| | - Xiaofei Zhang
- grid.417028.80000 0004 1799 2608Department of Joints, Tianjin Hospital, No. 406 Jiefang South Rd, Tianjin, 300211 Hexi District China ,grid.412645.00000 0004 1757 9434Department of Orthopaedics, Tianjin Medical University General Hospital, Anshan Road 154, Tianjin, 300052 Heping District China
| | - Zhen Lyu
- grid.417028.80000 0004 1799 2608Department of Joints, Tianjin Hospital, No. 406 Jiefang South Rd, Tianjin, 300211 Hexi District China
| | - Jun Liu
- grid.417028.80000 0004 1799 2608Department of Joints, Tianjin Hospital, No. 406 Jiefang South Rd, Tianjin, 300211 Hexi District China
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