1
|
Aboona F, Bou-Akl T, Miller AJ, Fry M, Wu B, Pawlitz P, Ren W, Markel DC. Effects of Vancomycin/Tobramycin-Doped Ceramic Composite (Polyvinyl Alcohol Composite-Vancomycin/Tobramycin-Polymeric Dicalcium Phosphate Dihydrate) in a Rat Femur Model Implanted With Contaminated Porous Titanium Cylinders. J Arthroplasty 2024:S0883-5403(24)00424-8. [PMID: 38718912 DOI: 10.1016/j.arth.2024.04.076] [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: 11/10/2023] [Revised: 04/26/2024] [Accepted: 04/27/2024] [Indexed: 06/06/2024] Open
Abstract
BACKGROUND Periprosthetic joint infection (PJI) remains common and problematic. We hypothesized that using a bioceramic that provided rapid release of the antibiotics (vancomycin [VAN] or VAN and tobramycin [VAN and TOB]) from a polyvinyl-alcohol-composite (PVA) combined with a delayed and sustained antibiotic release from polymeric-dicalcium-phosphate-dihydrate (PDCPD) ceramic would inhibit S. aureus-associated implant infections. METHODS A total of 50 male Sprague Dawley rats were randomly divided into 5 groups-I: negative control; II: bacteria only; III: bacteria + saline wash; IV: bacteria + PVA-VAN-PDCPD, and V: bacteria + PVA-VAN-TOB-PDCPD. A porous titanium (Ti) implant was press-fit into the rat knee. S. aureus-containing broth was added into the joint space creating a PJI. After 1 week, the joints from groups III to V were washed with saline and the fluid collected for bacterial quantification. This was followed by saline irrigation treatment (groups III to V) and application of the antibiotic-loaded PVA-PDCPD bioceramic (groups IV and V). On day 21, joint fluid was collected, and the implants harvested for bacterial quantification. RESULTS No bacteria were isolated from the negative control (group I). The positive control (group II) was positive on both days 7 and 21. Bacteria were still present on day 21 in the fluid and implant in group III. Groups (IV and V) showed a decrease in the bacterial burden in the fluid and implant on day 21. There were significant differences in bacteria levels in the collected wash fluid and on the implant at day 21 between the saline wash (group III) and treatment groups (IV and V). CONCLUSIONS In this animal model of acute periprosthetic infection, treatment with PVA-VAN-PDCPD and PVA-VAN/TOB-PDCPD reduced bacterial load in the infected joint and the infected Ti implant. Application of PVA-VAN-PDCPD and/or PVA-VAN/TOB-PDCPD after saline irrigation could be used as an addition to the treatment of PJI.
Collapse
Affiliation(s)
- Fadi Aboona
- Section of Orthopaedic Surgery, Ascension-Providence Hospital, Southfield, Michigan
| | - Therese Bou-Akl
- Section of Orthopaedic Surgery, Ascension-Providence Hospital, Southfield, Michigan
| | - Adam J Miller
- Section of Orthopaedic Surgery, Ascension-Providence Hospital, Southfield, Michigan
| | - Mike Fry
- Section of Orthopaedic Surgery, Ascension-Providence Hospital, Southfield, Michigan
| | - Bin Wu
- Section of Orthopaedic Surgery, Ascension-Providence Hospital, Southfield, Michigan
| | - Paula Pawlitz
- Section of Orthopaedic Surgery, Ascension-Providence Hospital, Southfield, Michigan
| | - Weiping Ren
- Section of Orthopaedic Surgery, Ascension-Providence Hospital, Southfield, Michigan; Virotech Co., Inc., Troy, Michigan
| | - David C Markel
- Section of Orthopaedic Surgery, Ascension-Providence Hospital, Southfield, Michigan; The Core Institute, Novi, Michigan
| |
Collapse
|
2
|
Wu X, Chen W, Rong R, Pan B, Hu X, Zheng L, Alimu A, Chu C, Tu Y, Zhang Z, Ye Y, Gu M, Sheng P. Application of the New Irrigation Protocol to Reduce Recurrence Rate in the Management Of Periprosthetic Joint Infection. Orthop Surg 2024; 16:577-584. [PMID: 38238252 PMCID: PMC10925507 DOI: 10.1111/os.13948] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2023] [Revised: 10/24/2023] [Accepted: 10/24/2023] [Indexed: 02/15/2024] Open
Abstract
OBJECTIVE Irrigation is a conventional treatment for acute and chronic periprosthetic joint infections (PJI). However, there has been no unified standard for irrigation during surgery for PJI in the past, and the efficacy is uncertain. The purpose of this study is to create a new irrigation protocol to enhance the infection control rate and reduce the postoperative recurrence rate of PJI patients. METHODS We conducted a single-institution retrospective review with a total of 56 patients who underwent revision total hip or knee arthroplasties due to PJI from January 2011 to January 2022. Conventional irrigation (CI) was used in 32 cases, and standard operating procedure of irrigation (SOPI) was used in 24. The CI protocol carries out an empirical irrigation after debridement, which is quite random. Our SOPI protocol clearly stipulates the soaking concentration and time of hydrogen peroxide and povidone-iodine. The irrigation is carried out three times, and tissue samples are taken from multiple parts before and after irrigation, which are sent for microbial culture. The important statistical indicators were the rate of positive microbiological culture and postoperative recurrence rate with an average follow-up of 24 average months. RESULTS The drainage volume was lower in the SOPI group than in the CI group on postoperative day 3 (p < 0.01) and 7 (p = 0.016). In addition, the percentage of positive microbiological cultures after the third irrigation was less than that before (p < 0.01) and after (p < 0.01) the first irrigation. The most common causative organism was Staphylococcus aureus, which was detected in 25.0% and 12.5% of the SOPI and CI groups, respectively. The failure rate at the final follow-up was 8.3% and 31.3% (p = 0.039) for the SOPI and CI groups, respectively. CONCLUSION Compared with the traditional CI method, SOPI standardized the soaking time of hydrogen peroxide and povidone-iodine, increased the frequency of and irrigation, and proved that microorganisms were almost completely removed through the microbial culture of multiple tissues. SOPI has the potential to become a standardized irrigation process worthy of promotion, effectively reducing the postoperative recurrence rate of PJI patients.
Collapse
Affiliation(s)
- Xiaoyu Wu
- Department of Joint SurgeryThe First Affiliated Hospital of Sun Yat‐Sen UniversityGuangzhouChina
- Guangdong Provincial Key Laboratory of Orthopaedics and TraumatologyThe First Affiliated Hospital of Sun Yat‐sen UniversityGuangzhouChina
| | - Weishen Chen
- Department of Joint SurgeryThe First Affiliated Hospital of Sun Yat‐Sen UniversityGuangzhouChina
- Guangdong Provincial Key Laboratory of Orthopaedics and TraumatologyThe First Affiliated Hospital of Sun Yat‐sen UniversityGuangzhouChina
| | - Rong Rong
- Department of Nosocomial InfectionThe First Affiliated Hospital of Sun Yat‐Sen UniversityGuangzhouChina
| | - Baiqi Pan
- Department of Joint SurgeryThe First Affiliated Hospital of Sun Yat‐Sen UniversityGuangzhouChina
- Guangdong Provincial Key Laboratory of Orthopaedics and TraumatologyThe First Affiliated Hospital of Sun Yat‐sen UniversityGuangzhouChina
| | - Xuantao Hu
- Department of Joint SurgeryThe First Affiliated Hospital of Sun Yat‐Sen UniversityGuangzhouChina
- Guangdong Provincial Key Laboratory of Orthopaedics and TraumatologyThe First Affiliated Hospital of Sun Yat‐sen UniversityGuangzhouChina
| | - Linli Zheng
- Department of Joint SurgeryThe First Affiliated Hospital of Sun Yat‐Sen UniversityGuangzhouChina
- Guangdong Provincial Key Laboratory of Orthopaedics and TraumatologyThe First Affiliated Hospital of Sun Yat‐sen UniversityGuangzhouChina
| | - Aerman Alimu
- Department of Joint SurgeryThe First Affiliated Hospital of Sun Yat‐Sen UniversityGuangzhouChina
- Guangdong Provincial Key Laboratory of Orthopaedics and TraumatologyThe First Affiliated Hospital of Sun Yat‐sen UniversityGuangzhouChina
| | - Chenghan Chu
- Department of Joint SurgeryThe First Affiliated Hospital of Sun Yat‐Sen UniversityGuangzhouChina
- Guangdong Provincial Key Laboratory of Orthopaedics and TraumatologyThe First Affiliated Hospital of Sun Yat‐sen UniversityGuangzhouChina
| | - Yucheng Tu
- Department of Joint SurgeryThe First Affiliated Hospital of Sun Yat‐Sen UniversityGuangzhouChina
- Guangdong Provincial Key Laboratory of Orthopaedics and TraumatologyThe First Affiliated Hospital of Sun Yat‐sen UniversityGuangzhouChina
| | - Ziji Zhang
- Department of Joint SurgeryThe First Affiliated Hospital of Sun Yat‐Sen UniversityGuangzhouChina
- Guangdong Provincial Key Laboratory of Orthopaedics and TraumatologyThe First Affiliated Hospital of Sun Yat‐sen UniversityGuangzhouChina
| | - Yongyu Ye
- Department of Spinal SurgeryGuangdong Provincial People's HospitalGuangzhouChina
| | - Minghui Gu
- Department of Joint SurgeryThe First Affiliated Hospital of Sun Yat‐Sen UniversityGuangzhouChina
- Guangdong Provincial Key Laboratory of Orthopaedics and TraumatologyThe First Affiliated Hospital of Sun Yat‐sen UniversityGuangzhouChina
| | - Puyi Sheng
- Department of Joint SurgeryThe First Affiliated Hospital of Sun Yat‐Sen UniversityGuangzhouChina
- Guangdong Provincial Key Laboratory of Orthopaedics and TraumatologyThe First Affiliated Hospital of Sun Yat‐sen UniversityGuangzhouChina
| |
Collapse
|
3
|
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: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [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.
Collapse
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.
| |
Collapse
|
4
|
Gao J, Shu L, Jiang K, Muheremu A. Prophylactic use of vancomycin powder on postoperative infection after total joint arthroplasty. BMC Musculoskelet Disord 2024; 25:68. [PMID: 38229109 DOI: 10.1186/s12891-023-07024-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Accepted: 11/07/2023] [Indexed: 01/18/2024] Open
Abstract
OBJECTIVE By reviewing the literature analyzing vancomycin powder for preventive surgery, the effect of this method on reducing the infection rate after TJA was systematically evaluated to provide a basis for future clinical work. METHODS Using PubMed, Medline, Elsevier, and CNKI, with the following mesh words: "vancomycin", "local / intraoperative / topical / intrawound", "TJA", "TKA", "THA", "total joint arthroplasty", "total knee arthroplasty", "total hip arthroplasty", "infection", and "SSI", to search for case-control research papers on the impact of prophylactic application of vancomycin powder on the incidence of postoperative infection, we compared the overall infection rate in the literature by using RevMan 5.3 meta-analysis software and analyzed the impact of vancomycin on the infection rate of different parts and types of TJA according to different subgroups. RESULTS A total of 22 qualified studies were selected; twenty-five studies compared the effect of prophylactic use of vancomycin powder on infection rates after TJA. There were 23,363 cases in total, including 9545 cases in the vancomycin group and 13,818 cases in the control group. The results of the meta-analysis showed that the possibility of postoperative infection after prophylactic use of vancomycin powder was significantly lower than that without vancomycin risk ratio: 0.38 [0.23,0.59], P < 0.01). However, a meta-analysis of randomized controlled trials (RCTs) showed no significant effect of vancomycin on postoperative infection (P = 0.52). CONCLUSION Based on the retrospective studies, local prophylactic use of vancomycin powder in TJA can significantly reduce the incidence of postoperative infection. High-quality RCTs should be carried out to further evaluate these results.
Collapse
Affiliation(s)
- Jian Gao
- Orthopedic Research Center, Sixth Affiliated Hospital of Xinjiang Medical University, 39, Wuxing Nan Rd, Tianshan District, 86830001, 86830001, Urumqi, Xinjiang, China
| | - Li Shu
- Orthopedic Research Center, Sixth Affiliated Hospital of Xinjiang Medical University, 39, Wuxing Nan Rd, Tianshan District, 86830001, 86830001, Urumqi, Xinjiang, China
| | - Kan Jiang
- Orthopedic Research Center, Sixth Affiliated Hospital of Xinjiang Medical University, 39, Wuxing Nan Rd, Tianshan District, 86830001, 86830001, Urumqi, Xinjiang, China.
| | - Aikeremujiang Muheremu
- Orthopedic Research Center, Sixth Affiliated Hospital of Xinjiang Medical University, 39, Wuxing Nan Rd, Tianshan District, 86830001, 86830001, Urumqi, Xinjiang, China.
| |
Collapse
|
5
|
Martin VT, Zhang Y, Wang Z, Liu QL, Yu B. A systematic review and meta-analysis comparing intrawound vancomycin powder and povidone iodine lavage in the prevention of periprosthetic joint infection of hip and knee arthroplasties. J Orthop Sci 2024; 29:165-176. [PMID: 36470703 DOI: 10.1016/j.jos.2022.11.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Revised: 11/14/2022] [Accepted: 11/16/2022] [Indexed: 12/03/2022]
Abstract
BACKGROUND Focus on reviewing a vigorous research effort to improve the safety profile of vancomycin powder (VP) and its optimal dose in reducing periprosthetic joint infection (PJI) is the need of the hour. This systematic review and meta-analysis attempt to explore the ongoing use of VP and VP + povidone iodine (PI) lavage to prevent PJI of hip/knee arthroplasties and highlights its challenges among the orthopedic community about the existence of the major organism and its frequency in total joint arthroplasty (TJA) patients. METHODS We searched PubMed/MEDLINE, EMBASE databases regarding the outcomes of vancomycin powder (VP) and VP + povidone iodine (PI) combination in preventing periprosthetic joint infection of hip and knee arthroplasties. RESULTS In 5 of 7 studies, the combination of vancomycin powder (VP) and povidone iodine (PI) lavage have shown a lower risk of periprosthetic joint infection (PJI) in acute and high-risk hip and knee arthroplasties patients, with less or without serious adverse events and readmissions; while four of seven studies using VP-only found increasing rates of PJI in primary total knee arthroplasty and partial hip replacement in elderly patients with comorbidities, and significantly causes aseptic wound complications compared to the control group. CONCLUSIONS Intra-articular vancomycin powder (VP) and povidone iodine (PI) lavage showed a significant reduction of periprosthetic joint infection in primary and revision total joint arthroplasty. Before its widespread use in clinical settings, prospective randomized studies and, most importantly, its long-term efficacy and safety are recommended.
Collapse
Affiliation(s)
- Vidmi Taolam Martin
- Department of Orthopaedics and Traumatology, Zhujiang Hospital, Southern Medical University, Guangzhou 510282, China.
| | - Yan Zhang
- Department of Orthopaedics, Leping People's Hospital, Jiangxi Province 333300, China
| | - Zhaozhen Wang
- Department of Bone and Joint Surgery and Sports Medicine Center, The First Affiliated Hospital, Jinan University, Institute of Biological and Medical Engineering, Guangdong Academy of Sciences, Guangzhou 510632, PR China
| | - Qiao-Lan Liu
- Department of Orthopaedics and Traumatology, Zhujiang Hospital, Southern Medical University, Guangzhou 510282, China
| | - Bo Yu
- Department of Orthopaedics and Traumatology, Zhujiang Hospital, Southern Medical University, Guangzhou 510282, China.
| |
Collapse
|
6
|
Chambers MM, Namdari S. A Review of Surgical Irrigation Solutions for Infection Prevention in Orthopaedic Surgery. JBJS Rev 2023; 11:01874474-202312000-00003. [PMID: 38079492 DOI: 10.2106/jbjs.rvw.23.00158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
» Intraoperative surgical irrigation is a common practice in orthopaedic procedures, although there is no universally established standard of care due to a lack of concrete data supporting an optimal irrigation agent.» Isotonic normal saline has long been considered a safe and cost effective solution for wound irrigation as compared with other antibiotic and antiseptic irrigation solutions.» Currently, the only adjunct to saline that is formally supported by American Academy of Orthopaedic Surgeons, the Centers for Disease Control and Prevention, and World Health Organization is povidone-iodine.» Further in vivo clinical studies are needed to identify the ideal irrigation solution that carries low cytotoxic effects while also exerting optimal antimicrobial properties.
Collapse
|
7
|
Taha M, Arulanandam R, Chen A, Diallo JS, Abdelbary H. Combining povidone-iodine with vancomycin can be beneficial in reducing early biofilm formation of methicillin-resistant Staphylococcus aureus and methicillin-sensitive S. aureus on titanium surface. J Biomed Mater Res B Appl Biomater 2023; 111:1133-1141. [PMID: 36632686 DOI: 10.1002/jbm.b.35220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Revised: 12/09/2022] [Accepted: 12/23/2022] [Indexed: 01/13/2023]
Abstract
There is controversial clinical evidence regarding the added antibacterial benefit of locally administering antiseptic solutions or antibiotics to the infected joint space. The objectives of this in vitro study were to test the efficacy of povidone-iodine (PVP-I) and vancomycin in treating premature and developed Staphylococcus aureus biofilms grown on titanium implant surfaces. PVP-I and vancomycin were used to treat immature and developed biofilms formed by two clinical strains of S. aureus (BP043-MRSA, PB011-MSSA). S. aureus strains were grown as immature (3 h-old) or developed (24 h-old) biofilm. These biofilms were grown on titanium plasma sprayed discs. The treatment regimens tested were: 0.8% PVP-I, 500 μg/ml vancomycin as well as a combination of vancomycin and PVP-I. PVP-I was tested at 3 min, as per current clinical practice, versus 1 min treatment times. In addition, the cytotoxicity of the PVP-I and vancomycin was tested using fresh skeletal muscle tissue cores harvested from the rat's abdominal muscles using alamarBlue assay. The combination of PVP-I (3 min) and vancomycin (24 h.) showed synergistic interaction and the best efficacy against immature biofilms formed by both clinical strains. This degree of eradication was statistically significant compared to the untreated control, p < .0001. However, this combination therapy had limited efficiency against developed biofilms. Also, PVP-I alone was more effective when exposure time was 3 min instead of 1 min against immature biofilm for MRSA, p = .02, and MSSA, p = .01. PVP-I and vancomycin were not effective against developed biofilm regardless of exposure time. Also, combining PVP-I and vancomycin was not cytotoxic to muscle tissue. Combining PVP-I with vancomycin is superior in reducing viable S. aureus cells in immature biofilms grown on titanium surface without causing significant cytotoxicity to muscle tissue. Exposure times and biofilm maturity play a role in dictating the efficacy of using local antiseptics and antibiotics to treat biofilms on implant surfaces.
Collapse
Affiliation(s)
- Mariam Taha
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,The Ottawa Hospital, Division of Orthopedic Surgery Ottawa, Ottawa, Ontario, Canada
| | - Rozanne Arulanandam
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,Centre for Innovative Cancer Research, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Andrew Chen
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,Centre for Innovative Cancer Research, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Jean-Simon Diallo
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,Centre for Innovative Cancer Research, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,Department of Biochemistry, Microbiology and Immunology, University of Ottawa, Ottawa, Ontario, Canada
| | - Hesham Abdelbary
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,The Ottawa Hospital, Division of Orthopedic Surgery Ottawa, Ottawa, Ontario, Canada.,Centre for Innovative Cancer Research, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| |
Collapse
|
8
|
Ma T, Lyu J, Ma J, Huang X, Chen K, Wang S, Wei Y, Shi J, Xia J, Zhao G, Huang G. Comparative analysis of pathogen distribution in patients with fracture-related infection and periprosthetic joint infection: a retrospective study. BMC Musculoskelet Disord 2023; 24:123. [PMID: 36782133 PMCID: PMC9926857 DOI: 10.1186/s12891-023-06210-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2022] [Accepted: 01/30/2023] [Indexed: 02/15/2023] Open
Abstract
BACKGROUND The purpose of this study is to investigate the microbial patterns of periprosthetic joint infection (PJI) and fracture-related infection (FRI), and guide for the formulation of more accurate empirical antimicrobial regimens based on the differences in pathogen distribution. METHODS A comparative analysis of pathogen distribution was conducted between 153 patients (76 with PJI and 77 with FRI). Predicted analyses against isolated pathogens from two cohorts were conducted to evaluate the best expected efficacy of empirical antimicrobial regimens (imipenem + vancomycin, ciprofloxacin + vancomycin, and piperacillin/tazobactam + vancomycin). RESULTS Our study found significant differences in pathogen distribution between the PJI and FRI cohorts. Staphylococci (61.3% vs. 31.9%, p = 0.001) and Gram-negative bacilli (GNB, 26.7% vs. 56.4%, p < 0.001) were responsible for the majority of infections both in the PJI and FRI cohorts, and their distribution in the two cohorts showed a significant difference (p < 0.001). Multi-drug resistant organisms (MDRO) were more frequently detected in the FRI cohort (29.3% vs. 44.7%, p = 0.041), while methicillin-resistant coagulase-negative Staphylococci (MRCoNS, 26.7% vs. 8.5%, p = 0.002) and Canidia albicans (8.0% vs. 1.1%, p = 0.045) were more frequently detected in the PJI cohort. Enterobacter spp. and Acinetobacter baumannii were detected only in the FRI cohort (11.7% and 8.5%, respectively). CONCLUSIONS Staphylococci and GNB were responsible for the majority of infections in both PJI and FRI. Empirical antimicrobial therapy should focus on the coverage of Staphylococci in PJI and GNB in FRI, and infections caused by MDROs should be more vigilant in FRI, while the high incidence of MRCoNS in PJI should be noted, which could guide for the formulation of more accurate empirical antimicrobial regimens. Targeted therapy for FRI caused by A. baumannii and PJI caused by C. albicans needs to be further investigated. Our study reports significant differences in pathogen distribution between the two infections and provides clinical evidence for studies on the mechanism of implant-associated infection.
Collapse
Affiliation(s)
- Tiancong Ma
- grid.411405.50000 0004 1757 8861Department of Orthopaedic Surgery Huashan Hospital Fudan University, 12Th Wulumuqi Middle Road, Jing’an District, Shanghai, China ,grid.8547.e0000 0001 0125 2443Fudan University, 220Th Handan Road, Yang’pu District, Shanghai, China
| | - Jinyang Lyu
- grid.411405.50000 0004 1757 8861Department of Orthopaedic Surgery Huashan Hospital Fudan University, 12Th Wulumuqi Middle Road, Jing’an District, Shanghai, China ,grid.8547.e0000 0001 0125 2443Fudan University, 220Th Handan Road, Yang’pu District, Shanghai, China
| | - Jingchun Ma
- grid.411405.50000 0004 1757 8861Department of Orthopaedic Surgery Huashan Hospital Fudan University, 12Th Wulumuqi Middle Road, Jing’an District, Shanghai, China
| | - Xin Huang
- grid.411405.50000 0004 1757 8861Department of Orthopaedic Surgery Huashan Hospital Fudan University, 12Th Wulumuqi Middle Road, Jing’an District, Shanghai, China ,grid.8547.e0000 0001 0125 2443Fudan University, 220Th Handan Road, Yang’pu District, Shanghai, China
| | - Kangming Chen
- grid.411405.50000 0004 1757 8861Department of Orthopaedic Surgery Huashan Hospital Fudan University, 12Th Wulumuqi Middle Road, Jing’an District, Shanghai, China ,grid.8547.e0000 0001 0125 2443Fudan University, 220Th Handan Road, Yang’pu District, Shanghai, China
| | - Siqun Wang
- grid.411405.50000 0004 1757 8861Department of Orthopaedic Surgery Huashan Hospital Fudan University, 12Th Wulumuqi Middle Road, Jing’an District, Shanghai, China ,grid.8547.e0000 0001 0125 2443Fudan University, 220Th Handan Road, Yang’pu District, Shanghai, China
| | - Yibing Wei
- grid.411405.50000 0004 1757 8861Department of Orthopaedic Surgery Huashan Hospital Fudan University, 12Th Wulumuqi Middle Road, Jing’an District, Shanghai, China ,grid.8547.e0000 0001 0125 2443Fudan University, 220Th Handan Road, Yang’pu District, Shanghai, China
| | - Jingsheng Shi
- grid.411405.50000 0004 1757 8861Department of Orthopaedic Surgery Huashan Hospital Fudan University, 12Th Wulumuqi Middle Road, Jing’an District, Shanghai, China ,grid.8547.e0000 0001 0125 2443Fudan University, 220Th Handan Road, Yang’pu District, Shanghai, China
| | - Jun Xia
- Department of Orthopaedic Surgery Huashan Hospital Fudan University, 12Th Wulumuqi Middle Road, Jing'an District, Shanghai, China. .,Fudan University, 220Th Handan Road, Yang'pu District, Shanghai, China.
| | - Guanglei Zhao
- Department of Orthopaedic Surgery Huashan Hospital Fudan University, 12Th Wulumuqi Middle Road, Jing'an District, Shanghai, China. .,Fudan University, 220Th Handan Road, Yang'pu District, Shanghai, China.
| | - Gangyong Huang
- Department of Orthopaedic Surgery Huashan Hospital Fudan University, 12Th Wulumuqi Middle Road, Jing'an District, Shanghai, China. .,Fudan University, 220Th Handan Road, Yang'pu District, Shanghai, China. .,Department of Orthopaedic Surgery North Branch of Huashan Hospital Fudan University, 518Th Jingpohu Road, Bao'shan District, Shanghai, China.
| |
Collapse
|
9
|
Bourget-Murray J, Azad M, Gofton W, Abdelbary H, Garceau S, Grammatopoulos G. Is the routine use of local antibiotics in the management of periprosthetic joint infections justified? Hip Int 2023; 33:4-16. [PMID: 36447342 DOI: 10.1177/11207000221139467] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/05/2022]
Abstract
Periprosthetic joint infection (PJI) following total hip and total knee arthroplasty continues to be a leading cause of re-operation and revision arthroplasty. Not only is the treatment of PJI notoriously challenging, but success rates are variable. Regardless of the surgical strategy used, successful management of PJI requires a comprehensive surgical debridement focused at eradicating the underlying biofilm followed by appropriate antimicrobial therapy. Although systemic antimicrobial delivery continues to be a cornerstone in the treatment of PJI, many surgeons have started using local antibiotics to deliver higher concentrations of antibiotics directly into the vulnerable joint and adjacent soft tissues, which often have compromised vascularity. Available evidence on the use of topical powder, bone cement, and calcium sulphate carriers for local delivery of antibiotics during the initial treatment of PJI is limited to studies that are extremely heterogeneous. There is currently no level-1 evidence to support routinely using these products. Further, appropriately powered, prospective studies are needed to quantify the safety and efficacy of antibiotic-located calcium-sulphate carriers to justify their added costs. These products should not encourage surgeons to deviate from best practice guidelines, such as those recommended during the International Consensus Meeting on Musculoskeletal Infections.
Collapse
Affiliation(s)
| | - Marisa Azad
- Division of Infectious Diseases, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Wade Gofton
- Division of Orthopaedic Surgery, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Hesham Abdelbary
- Division of Orthopaedic Surgery, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Simon Garceau
- Division of Orthopaedic Surgery, The Ottawa Hospital, Ottawa, Ontario, Canada
| | | |
Collapse
|
10
|
Liao S, Yang Z, Li X, Chen J, Liu JG. Effects of different doses of vancomycin powder in total knee and hip arthroplasty on the periprosthetic joint infection rate: a systematic review and meta-analysis. J Orthop Surg Res 2022; 17:546. [PMID: 36527075 PMCID: PMC9758814 DOI: 10.1186/s13018-022-03445-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Accepted: 12/09/2022] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Periprosthetic joint infection (PJI) following total joint arthroplasty (TJA) is a serious complication for patients. Some joint surgeons have tried to use vancomycin powder (VP) in total knee and total hip arthroplasty to prevent postoperative PJI, but its effect is still not clear. At present, there is no meta-analysis that specifically analyses the effect of different doses of vancomycin powder on the incidence of PJI. METHODS We carried out a search based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and identified the studies we needed. Review Manager (RevMan) 5.3 software was employed for statistical analysis. RESULTS The analysis of primary TKA (PTKA) showed that using 1 g (RR 0.38, 95% CI 0.22-0.67 [P = 0.0008]) and 2 g (RR 0.48, 95% CI 0.31-0.74 [P = 0.0008]) of vancomycin powder in primary TKA (PTKA) could all significantly prevent PJI. The analysis of primary THA (PTHA) showed that using 1 g (RR 0.37, 95% CI 0.17-0.80 [P = 0.01]) of vancomycin powder effectively decreased the incidence of PJI, while using 2 g (RR 1.02, 95% CI 0.53-1.97 [P = 0.94]) of vancomycin powder had no significant effect on preventing PJI. Because the data were abnormal, we believed the conclusion that using 2 g of vancomycin powder in primary THA had no effect on preventing PJI was doubtful. Using vancomycin powder in revision TKA (RTKA) significantly reduced the PJI rate (RR 0.33, 95% CI 0.14-0.77 [P = 0.01]), similar to revision THA (RTHA) (RR 0.37, 95% CI 0.14-0.96 [P = 0.04]). CONCLUSIONS In primary TKA, both 1 g and 2 g of vancomycin powder can effectively prevent PJI. In primary THA, using 1 g of vancomycin powder is a better choice, while the effect of using 2 g of vancomycin powder is not clear, and a more prospective randomized controlled trial should be done to verify it. In revision TKA and revision THA, vancomycin powder is a good choice to prevent PJI.
Collapse
Affiliation(s)
- Shiyu Liao
- grid.430605.40000 0004 1758 4110Department of Orthopaedics, The First Hospital of Jilin University, No. 71, Xinmin Street, Chaoyang District, Changchun, 130000 Jilin China
| | - Zhize Yang
- grid.430605.40000 0004 1758 4110Department of Orthopaedics, The First Hospital of Jilin University, No. 71, Xinmin Street, Chaoyang District, Changchun, 130000 Jilin China
| | - Xiao Li
- grid.430605.40000 0004 1758 4110Department of Orthopaedics, The First Hospital of Jilin University, No. 71, Xinmin Street, Chaoyang District, Changchun, 130000 Jilin China
| | - Jintian Chen
- grid.430605.40000 0004 1758 4110Department of Orthopaedics, The First Hospital of Jilin University, No. 71, Xinmin Street, Chaoyang District, Changchun, 130000 Jilin China
| | - Jian-guo Liu
- grid.430605.40000 0004 1758 4110Department of Orthopaedics, The First Hospital of Jilin University, No. 71, Xinmin Street, Chaoyang District, Changchun, 130000 Jilin China
| |
Collapse
|
11
|
Muacevic A, Adler JR, Albqami SN, Barri A, Albatly M, Arafah O. Use of Antibiotic Lavage in Total Knee Replacement to Prevent Postoperative Infection. Cureus 2022; 14:e32727. [PMID: 36686072 PMCID: PMC9850443 DOI: 10.7759/cureus.32727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/19/2022] [Indexed: 12/24/2022] Open
Abstract
Purpose To determine the effectiveness of using antibiotic lavage in preventing postoperative infections in total knee replacement (TKR) patients. Methods Data on all patients who underwent TKR, either primary or secondary, during the period from May 2015 to April 2019 were collected. Many factors (both patient-related and surgery-related) that can increase the risk of surgical site infection (SSI) were taken into consideration to eliminate confounding factors. Results A total of 685 patients were identified; out of those, 232 patients received intraoperative antibiotic lavage and 453 did not. We noted that out of all 13 patients who developed SSI, only one patient (7.7%) had received antibiotic lavage, while the other 12 (92.3%) patients did not receive antibiotic lavage. However, the difference was not statistically significant (p=0.078). Conclusion Using intraoperative vancomycin lavage was associated with a decrease in the incidence of SSI post-TKR, but the difference was not statistically significant. However, more studies are needed in this area.
Collapse
|
12
|
Li Y, Wuermanbieke S, Zhang X, Mu W, Ma H, Qi F, Sun X, Amat A, Cao L. Effects of intra-articular D-amino acids combined with systemic vancomycin on an experimental Staphylococcus aureus-induced periprosthetic joint infection. JOURNAL OF MICROBIOLOGY, IMMUNOLOGY, AND INFECTION = WEI MIAN YU GAN RAN ZA ZHI 2022; 55:716-727. [PMID: 35346597 DOI: 10.1016/j.jmii.2022.01.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Revised: 12/25/2021] [Accepted: 01/20/2022] [Indexed: 06/14/2023]
Abstract
BACKGROUND The D-isoforms of amino acids (D-AAs) exhibit anti-biofilm potential against a diverse range of bacterial species in vitro, while its role in vivo remains unclear. The aim of this study was to investigate the effects of a combination of D-AAs and vancomycin on a PJI rat model. METHODS Eight-week-old male SD rats were randomized to the control group, sham group, vancomycin group, D-AAs-vancomycin group. After treatment for 6 weeks, we analysed the levels of inflammatory factors in serum, behavioural change, imaging manifestations. The anti-biofilm ability of D-AAs was detected by crystal violet staining and scanning electron microscope observation, and its ability to assist antibiotics in killing bacteria was assessed by culture of bacteria. Additionally, micro-CT and histological analysis were used to evaluate the impact of D-AAs combined with vancomycin on the bone remodelling around the prosthesis. RESULTS The group treated with a D-AAs-vancomycin combination sustained normal weight gain and exhibited reduced the serum levels of α2M, IL-1β, IL-6, IL-10, TNF-α and PGE2. Moreover, treated with D-AAs in combination with vancomycin improved the weight-bearing activity performance, increased the sizes and widths of distal femurs, and improved Rissing scale scoring. In particular, treatment using D-AAs enhanced the ability of vancomycin to eradicate Staphylococcus aureus, as demonstrated by the dispersion of existing biofilms and the inhibition of biofilm formation that occurred in a concentration-dependent manner. This treatment combination also resulted in a reduction in bacterial burden with in the soft tissues, bones, and implants. Furthermore, D-AAs-vancomycin combination treatment attenuated abnormal bone remodelling around the implant, as evidenced by an observed increase in BMD, BV/TV, and Tb.Th and the presence of reduced Trap+ osteoclasts and elevated osterix+ osteo-progenitors. CONCLUSIONS Combining D-AAs with vancomycin provides an effective therapeutic strategy for the treatment of PJI by promoting biofilm dispersion to enhance antimicrobial activity.
Collapse
Affiliation(s)
- Yicheng Li
- Department of Orthopaedics, First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | | | - Xiaogang Zhang
- Department of Orthopaedics, First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | - Wenbo Mu
- Department of Orthopaedics, First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | - Hairong Ma
- Department of Orthopaedics, First Affiliated Hospital of Xinjiang Medical University, Urumqi, China; Xinjiang Uygur Autonomous Region Clinical Research Center for Orthopedic Diseases, Urumqi, China
| | - Fei Qi
- Department of Orthopaedics, First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | - Xiaoyue Sun
- Department of Orthopaedics, First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | - Abdusami Amat
- Department of Orthopaedics, First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | - Li Cao
- Department of Orthopaedics, First Affiliated Hospital of Xinjiang Medical University, Urumqi, China.
| |
Collapse
|
13
|
Springer BD. Irrigation Solutions and Antibiotic Powders: Should I Use Them in Primary and Revision Total Joint Arthroplasty? J Arthroplasty 2022; 37:1438-1440. [PMID: 35247486 DOI: 10.1016/j.arth.2022.02.096] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Revised: 02/18/2022] [Accepted: 02/22/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND The prevention and treatment of periprosthetic joint infection is of utmost importance to orthopedic surgeons. Irrigation solutions have become a popular additive to the prevention and treatment armamentarium. METHODS This symposium summarizes the mechanism of action, basic science, and clinical research to date on the use of irrigation solutions. The four most commonly used irrigation solutions, povidone iodine, chlorhexidine, hydrogen peroxide, and acetic acid, are discussed. In addition, the role of antibiotic powers is reviewed. RESULTS Each solution has its risks and benefits that must be weighed by the surgeon. There is no clear irrigation solution that is superior. The role of additive antibiotic powder (vancomycin) remains controversial. CONCLUSION More rigorous prospective clinical trials are needed to determine the optimal irrigation solution for the prevention and treatment of periprosthetic joint infection.
Collapse
Affiliation(s)
- Bryan D Springer
- OrthoCarolina Hip and Knee Center, Atrium Musculoskeletal Institute, Charlotte, NC
| |
Collapse
|
14
|
Systematic Review and Meta-Analysis of Intrawound Vancomycin in Total Hip and Total Knee Arthroplasty: A Continued Call for a Prospective Randomized Trial. J Arthroplasty 2022; 37:1405-1415.e1. [PMID: 35314283 DOI: 10.1016/j.arth.2022.03.047] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Accepted: 03/12/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Periprosthetic joint injection (PJI) is a rare, but life-altering complication of total joint arthroplasty (TJA). Though intrawound vancomycin powder (IVP) has been studied in other orthopedic subspecialties, its efficacy and safety in TJA has not been established. METHODS PubMed and MEDLINE databases were used to identify studies utilizing IVP in primary and revision total hip (THA) and knee arthroplasty (TKA). Postoperative PJI data were pooled using random effect models with results reported as odds ratios (ORs) and 95% confidence intervals (CIs). Studies were weighted by the inverse variance of their effect estimates. RESULTS Overall, 16 of the 1871 studies identified were pooled for final analysis, yielding 33,731 patients totally. Of these, 17 164 received IVP. In aggregate, patients who received IVP had a decreased rate of PJI (OR 0.46, P < .05). Separately, TKA and THA patients who received IVP had lower rates of PJI (OR 0.41, P < .05 and OR 0.45, P < .05, respectively). Aggregate analysis of primary TKA and THA patients also revealed a decreased PJI rate (OR 0.44, P < .05). Pooled revision TKA and THA patients had a similar decrease in PJI rates (OR 0.30, P < .05). Although no publication bias was appreciated, these findings are limited by the low-quality evidence available. CONCLUSION While IVP may reduce the risk of PJI in primary and revision TJA, its widespread use cannot be recommended until higher-quality data, such as that obtained from randomized control trials, are available. This study underscores the continued need for more rigorous studies before general adoption of this practice by arthroplasty surgeons.
Collapse
|
15
|
Masters EA, Ricciardi BF, Bentley KLDM, Moriarty TF, Schwarz EM, Muthukrishnan G. Skeletal infections: microbial pathogenesis, immunity and clinical management. Nat Rev Microbiol 2022; 20:385-400. [PMID: 35169289 PMCID: PMC8852989 DOI: 10.1038/s41579-022-00686-0] [Citation(s) in RCA: 140] [Impact Index Per Article: 70.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/07/2022] [Indexed: 12/13/2022]
Abstract
Osteomyelitis remains one of the greatest risks in orthopaedic surgery. Although many organisms are linked to skeletal infections, Staphylococcus aureus remains the most prevalent and devastating causative pathogen. Important discoveries have uncovered novel mechanisms of S. aureus pathogenesis and persistence within bone tissue, including implant-associated biofilms, abscesses and invasion of the osteocyte lacuno-canalicular network. However, little clinical progress has been made in the prevention and eradication of skeletal infection as treatment algorithms and outcomes have only incrementally changed over the past half century. In this Review, we discuss the mechanisms of persistence and immune evasion in S. aureus infection of the skeletal system as well as features of other osteomyelitis-causing pathogens in implant-associated and native bone infections. We also describe how the host fails to eradicate bacterial bone infections, and how this new information may lead to the development of novel interventions. Finally, we discuss the clinical management of skeletal infection, including osteomyelitis classification and strategies to treat skeletal infections with emerging technologies that could translate to the clinic in the future.
Collapse
Affiliation(s)
- Elysia A Masters
- Center for Musculoskeletal Research, University of Rochester Medical Center, Rochester, NY, USA
- Department of Biomedical Engineering, University of Rochester Medical Center, Rochester, NY, USA
| | - Benjamin F Ricciardi
- Center for Musculoskeletal Research, University of Rochester Medical Center, Rochester, NY, USA
- Department of Orthopaedics and Rehabilitation, University of Rochester Medical Center, Rochester, NY, USA
| | - Karen L de Mesy Bentley
- Center for Musculoskeletal Research, University of Rochester Medical Center, Rochester, NY, USA
- Department of Orthopaedics and Rehabilitation, University of Rochester Medical Center, Rochester, NY, USA
- Department of Pathology and Laboratory Medicine, University of Rochester Medical Center, Rochester, NY, USA
| | | | - Edward M Schwarz
- Center for Musculoskeletal Research, University of Rochester Medical Center, Rochester, NY, USA.
- Department of Biomedical Engineering, University of Rochester Medical Center, Rochester, NY, USA.
- Department of Orthopaedics and Rehabilitation, University of Rochester Medical Center, Rochester, NY, USA.
| | - Gowrishankar Muthukrishnan
- Center for Musculoskeletal Research, University of Rochester Medical Center, Rochester, NY, USA
- Department of Orthopaedics and Rehabilitation, University of Rochester Medical Center, Rochester, NY, USA
| |
Collapse
|
16
|
Markel DC, Todd SW, Provenzano G, Bou-Akl T, Dietz PR, Ren W. Mark Coventry Award: Efficacy of Saline Wash Plus Antibiotics Doped Polyvinyl Alcohol (PVA) Composite (PVA-VAN/TOB-P) in a Mouse Pouch Infection Model. J Arthroplasty 2022; 37:S4-S11. [PMID: 35248751 DOI: 10.1016/j.arth.2022.02.098] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Revised: 02/21/2022] [Accepted: 02/22/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND The efficacy of saline irrigation for treatment of periprosthetic infection (PJI) is limited by the presence of contaminated medical devices. This study evaluated treatment efficacy of locally placed polyvinyl alcohol (PVA)/bioceramic composite doped with vancomycin (PVA-VAN-P) or vancomycin and tobramycin (PVA-VAN/TOB-P) after saline irrigation in a mouse pouch infection model. METHODS Sutures were implanted into air pouches of BALB/cJ mice, then inoculated with Staphylococcus aureus. Mice were randomized into 6 groups (n = 6 each): (1) no bacteria; (2) bacteria without saline wash; (3) saline wash only; (4) saline wash + PVA-P; (5) saline wash + PVA-VAN-P, and (6) saline wash + PVA-VAN/TOB-P. After 7 days, pouches were washed with saline alone or with additional injection of 0.2 mL of the composites. Sacrifice occurred 14 days after the washout. Histology was performed on the pouch tissues and bacteria cultures on the washout fluid. RESULTS Bacterial culture (optical density) showed that infection persisted after saline irrigation (0.10 ± 0.14) but was effectively eradicated by the addition of PVA-VAN-P (0.05 ± 0.09) and PVA-VAN/TOB-P (0.002 ± 0.003, P < .05). These effects were confirmed by histology. Importantly, no residues of the PVA-P were detected in either the pouch washouts or pouch tissues. CONCLUSION PJI is common and problematic, and few innovations have changed clinical practice and/or outcome. Our data confirmed that the effect of saline irrigation was very limited in the presence of contaminated sutures. PVA-VAN/TOB-P was biodegradable, biocompatible, and effective in eradicating bacterial retention after saline irrigation. Application of PVA-VAN/TOB-P after saline irrigation could be an option for treatment of PJI and should be evaluated in future PJI animal models.
Collapse
Affiliation(s)
- David C Markel
- The CORE Institute, Novi, MI; Department of Biomedical Engineering, Wayne State University, Detroit, MI; Ascension Providence Hospital Orthopedic Research Laboratory, Southfield, MI
| | - Samuel W Todd
- Ascension Providence Hospital Orthopedic Research Laboratory, Southfield, MI
| | - Gina Provenzano
- Ascension Providence Hospital Orthopedic Research Laboratory, Southfield, MI
| | - Therese Bou-Akl
- Department of Biomedical Engineering, Wayne State University, Detroit, MI; Ascension Providence Hospital Orthopedic Research Laboratory, Southfield, MI
| | - Paula R Dietz
- Ascension Providence Hospital Orthopedic Research Laboratory, Southfield, MI
| | - Weiping Ren
- Ascension Providence Hospital Orthopedic Research Laboratory, Southfield, MI; Virotech Co., Inc., Troy, MI
| |
Collapse
|
17
|
Ortiz D, Teo GM, Lygrisse K, Aggarwal VK, Long WJ. Increased Rate of Early Periprosthetic Joint Infection in Total Hip Arthroplasty With the Use of Alternatives to Cefazolin Despite Additional Gram-Negative Coverage. Arthroplast Today 2022; 14:183-188. [PMID: 35342780 PMCID: PMC8943215 DOI: 10.1016/j.artd.2022.02.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Revised: 01/28/2022] [Accepted: 02/14/2022] [Indexed: 11/16/2022] Open
Affiliation(s)
- Dionisio Ortiz
- Department of Orthopedics, NYU Langone Health, New York, NY, USA
- Capital Region Orthopedic Associates, Albany, NY, USA
- Corresponding author. Capital Region Orthopedic Associates, 1367 Washington Ave, Suite 300, Albany, NY 12206, USA. Tel.: +1 518 261 7237.
| | - Greg M. Teo
- Department of Orthopedics, NYU Langone Health, New York, NY, USA
| | | | | | - William J. Long
- Department of Orthopedics, NYU Langone Health, New York, NY, USA
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY, USA
| |
Collapse
|
18
|
Tarity TD, Xiang W, Jones CW, Gkiatas I, Nocon A, Selemon NA, Carli A, Sculco PK. Do Antibiotic-Loaded Calcium Sulfate Beads Improve Outcomes After Debridement, Antibiotics, and Implant Retention? A Matched Cohort Study. Arthroplast Today 2022; 14:90-95. [PMID: 35252512 PMCID: PMC8891996 DOI: 10.1016/j.artd.2022.01.023] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2021] [Accepted: 01/13/2022] [Indexed: 12/23/2022] Open
Abstract
Background Dissolvable antibiotic-loaded calcium sulfate beads are used as an intraoperative adjunct during debridement with antibiotics and implant retention (DAIR) for periprosthetic joint infections (PJI) to reduce the historically higher failure rates than one- or two-stage exchange. This study evaluated clinical outcomes after DAIRs performed with and without these antibiotic beads. The primary outcome was post-DAIR failure secondary to recurrent PJI at 2 years. The secondary outcome was early failure secondary to recurrent PJI within 90 days. Material and methods DAIRs performed for acute or acute hematogenous PJI at a single institution were retrospectively identified between 2013 and 2018. All DAIRs with adjunctive antibiotic beads (cases) were then exactly matched to a cohort of DAIRs without beads (controls) based on Charlson Comorbidity Index. The McNemar’s test and Wilcoxon signed-rank test were used to evaluate differences in outcomes and patient characteristics. Results Twenty DAIR cases (with antibiotic beads) were matched with 20 DAIR controls. There was no difference in age, sex, body mass index, joint, erythrocyte sedimentation rate, C-reactive protein, microbiology profile, antibiotic-resistance profile, or intraoperative lavage adjuncts between groups. There were no statistically significant differences between cases and controls for either overall infection-related failure at 2 years (P = .21) or early infection-related failure at 90 days (P = 1.00). Conclusion Adjunctive dissolvable antibiotic-loaded calcium sulfate beads did not reduce the incidence of recurrent PJIs at 2 years or 90 days postoperatively after DAIR. Given the added cost of these antibiotic dissolvable beads without clinical benefits, we cannot recommend their use as an adjunct treatment during DAIRs.
Collapse
Affiliation(s)
- T David Tarity
- Stavros Niarchos Foundation Complex Joint Reconstruction Center, Hospital for Special Surgery, New York, NY, USA
| | - William Xiang
- Stavros Niarchos Foundation Complex Joint Reconstruction Center, Hospital for Special Surgery, New York, NY, USA
| | - Christopher W Jones
- Stavros Niarchos Foundation Complex Joint Reconstruction Center, Hospital for Special Surgery, New York, NY, USA
| | - Ioannis Gkiatas
- Stavros Niarchos Foundation Complex Joint Reconstruction Center, Hospital for Special Surgery, New York, NY, USA
| | - Allina Nocon
- Stavros Niarchos Foundation Complex Joint Reconstruction Center, Hospital for Special Surgery, New York, NY, USA
| | - Nicolas A Selemon
- Stavros Niarchos Foundation Complex Joint Reconstruction Center, Hospital for Special Surgery, New York, NY, USA
| | - Alberto Carli
- Stavros Niarchos Foundation Complex Joint Reconstruction Center, Hospital for Special Surgery, New York, NY, USA.,Adult Reconstruction and Joint Replacement, Hospital for Special Surgery, New York, NY, USA
| | - Peter K Sculco
- Stavros Niarchos Foundation Complex Joint Reconstruction Center, Hospital for Special Surgery, New York, NY, USA.,Adult Reconstruction and Joint Replacement, Hospital for Special Surgery, New York, NY, USA
| |
Collapse
|
19
|
Ashley BS, Parvizi J. Current Insights in the Evaluation and Treatment of Infected Total Knee Arthroplasty. J Knee Surg 2021; 34:1388-1395. [PMID: 34600438 DOI: 10.1055/s-0041-1737030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Total knee arthroplasty is a widely successful procedure, but a small percentage of patients have a postoperative course complicated by periprosthetic joint infection (PJI). PJI is a difficult problem to diagnose and to treat, and the management of PJI differs, depending on the acuity of the infection. This paper discusses the established and newer technologies developed for the diagnosis of PJI as well as different treatment considerations and surgical solutions currently available.
Collapse
Affiliation(s)
- Blair S Ashley
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute, Philadelphia, Pennsylvania
| | - Javad Parvizi
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute, Philadelphia, Pennsylvania
| |
Collapse
|
20
|
Siddiqi A, Abdo ZE, Rossman SR, Kelly MA, Piuzzi NS, Higuera CA, Schwarzkopf R, Springer BD, Chen AF, Parvizi J. What Is the Optimal Irrigation Solution in the Management of Periprosthetic Hip and Knee Joint Infections? J Arthroplasty 2021; 36:3570-3583. [PMID: 34127346 DOI: 10.1016/j.arth.2021.05.032] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 05/16/2021] [Accepted: 05/19/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Thorough irrigation and debridement using an irrigation solution is a well-established treatment for both acute and chronic periprosthetic joint infections (PJIs). In the absence of concrete data, identifying the optimal irrigation agent and protocol remains challenging. METHODS A thorough review of the current literature on the various forms of irrigations and their additives was performed to evaluate the efficacy and limitations of each solution as pertaining to pathogen eradication in the treatment of PJI. As there is an overall paucity of high-quality literature comparing irrigation additives to each other and to any control, no meta-analyses could be performed. The literature was therefore summarized in this review article to give readers concise information on current irrigation options and their known risks and benefits. RESULTS Antiseptic solutions include povidone-iodine, chlorhexidine gluconate, acetic acid, hydrogen peroxide, sodium hypochlorite, hypochlorous acid, and preformulated commercially available combination solutions. The current literature suggests that intraoperative use of antiseptic irrigants may play a role in treating PJI, but definitive clinical studies comparing antiseptic to no antiseptic irrigation are lacking. Furthermore, no clinical head-to-head comparisons of different antiseptic irrigants have identified an optimal irrigation solution. CONCLUSION Further high-quality studies on the optimal irrigation additive and protocol for the management of PJI are warranted to guide future evidence-based decisions.
Collapse
Affiliation(s)
- Ahmed Siddiqi
- A Division of Ortho Alliance NJ, Orthopaedic Institute of Central Jersey, Manasquan, NJ; Department of Orthopedic Surgery, Hackensack Meridian Health, Hackensack Meridian School of Medicine, Hackensack, NJ; Department of Orthopedic Surgery, Jersey Shore University Medical Center, Neptune, NJ
| | - Zuhdi E Abdo
- Department of Orthopedics, Rutgers New Jersey Medical School, Newark, NJ
| | - Stephen R Rossman
- Department of Orthopedic Surgery, Hackensack Meridian Health, Hackensack Meridian School of Medicine, Hackensack, NJ
| | - Michael A Kelly
- Department of Orthopedic Surgery, Hackensack Meridian Health, Hackensack Meridian School of Medicine, Hackensack, NJ
| | - Nicolas S Piuzzi
- Department of Orthopedic Surgery, Cleveland Clinic Foundation, Cleveland, OH
| | - Carlos A Higuera
- Department of Orthopedic Surgery, Cleveland Clinic Florida, Weston, FL
| | - Ran Schwarzkopf
- Department of Orthopedics, New York University Langone Medical Center, New York, NY
| | - Bryan D Springer
- Department of Orthopedics, Atrium Musculoskeletal Institute, OrthoCarolina Hip and Knee Center, Charlotte, NC
| | - Antonia F Chen
- Department of Orthopedic Surgery, Brigham and Women's Hospital, Boston, MA
| | - Javad Parvizi
- Department of Orthopedics, Rothman Orthopedics, Philadelphia, PA
| |
Collapse
|
21
|
Wong MT, Sridharan SS, Davison EM, Ng R, Desy NM. Can Topical Vancomycin Prevent Periprosthetic Joint Infection in Hip and Knee Arthroplasty? A Systematic Review. Clin Orthop Relat Res 2021; 479:1655-1664. [PMID: 33929342 PMCID: PMC8277283 DOI: 10.1097/corr.0000000000001777] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 03/24/2021] [Indexed: 02/06/2023]
Abstract
BACKGROUND Periprosthetic joint infection (PJI) after hip and knee arthroplasty is a leading cause of revision surgery, inferior function, complications, and death. The administration of topical, intrawound vancomycin (vancomycin powder) has appeared promising in some studies, but others have found it ineffective in reducing infection risk; for that reason, a high-quality systematic review of the best-available evidence is needed. QUESTIONS/PURPOSES In this systematic review, we asked: (1) Does topical vancomycin (vancomycin powder) reduce PJI risk in hip and knee arthroplasty? (2) Does topical vancomycin lead to an increased risk of complications after hip and knee arthroplasty? METHODS A search of Embase, MEDLINE, and PubMed databases as of June 2020 was performed according to Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. Studies comparing topical vancomycin in addition to standard infection prevention regimens (such as routine perioperative intravenous antibiotics) with standard regimens only in primary hip and knee arthroplasty were identified. Patients 18 years or older with a minimum follow-up of 3 months were included. No restrictions on maximal loss to follow-up or PJI definition were imposed. Studies were excluded if they included patients with a history of septic arthritis, used an antibiotic other than vancomycin or a different route of administration for the intervention, performed additional interventions that differed between groups, or omitted a control group. A total of 2408 studies were screened, resulting in nine eligible studies reviewing 3371 patients who received topical vancomycin (vancomycin powder) during a primary THA or TKA and 2884 patients who did not receive it. Groups were comparable with respect to duration of follow-up and loss to follow-up when reported. Study quality was assessed using the Newcastle-Ottawa scale, showing moderate-to-high quality for the included studies. The risks of PJI and overall complications in the topical vancomycin group were compared with those in the control group. RESULTS One of nine studies found a lower risk of PJI after primary THA or TKA, while eight did not, with odds ratios that broadly bracketed the line of no difference (range of odds ratios across the nine studies 0.09 to 1.97). In the six studies where overall complications could be compared between topical vancomycin and control groups in primary THA or TKA, there was no difference in overall complication risks with vancomycin (range of ORs across the six studies 0.48 to 0.94); however, we caution that these studies were underpowered to detect differences in the types of uncommon complications associated with vancomycin use (such as allergy, ototoxicity, and nephrotoxicity). CONCLUSION In the absence of clear evidence of efficacy, and without a sufficiently large evidence base reporting on safety-related endpoints, topical vancomycin (vancomycin powder) should not be used in routine primary THA and TKA. Adequately powered, multicenter, prospective trials demonstrating clear reductions in infection risk and large registry-driven audits of safety-related endpoints are required before the widespread use of topical vancomycin can be recommended. LEVEL OF EVIDENCE Level III, therapeutic study.
Collapse
Affiliation(s)
| | | | | | - Richard Ng
- University of Calgary, Calgary, AB, Canada
| | | |
Collapse
|
22
|
Rupp M, Baertl S, Walter N, Hitzenbichler F, Ehrenschwender M, Alt V. Is There a Difference in Microbiological Epidemiology and Effective Empiric Antimicrobial Therapy Comparing Fracture-Related Infection and Periprosthetic Joint Infection? A Retrospective Comparative Study. Antibiotics (Basel) 2021; 10:antibiotics10080921. [PMID: 34438971 PMCID: PMC8388716 DOI: 10.3390/antibiotics10080921] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Revised: 07/14/2021] [Accepted: 07/27/2021] [Indexed: 11/16/2022] Open
Abstract
This study aims to investigate (1) microbial patterns in fracture-related infections (FRIs) in comparison to microbiological patterns of periprosthetic joint infections (PJIs), (2) the identification of effective empiric antibiotic therapy for FRIs and PJIs and (3) analysis of difficult-to-treat (DTT) pathogens. Patients treated for FRIs or PJIs from 2017 to 2020 were evaluated for pathogens detected during treatment. Antibiotic susceptibility profiles were examined with respect to broadly used antibiotics and antibiotic combinations. Resistance rates to rifampicin or fluoroquinolone were determined. A total of 81 patients with PJI and 86 with FRI were included in the study. For FRIs Staphylococcus aureus was the most common infection-causing pathogen (37.4% vs. 27.9% for PJI). Overall, there was no statistical difference in pathogen distribution (p = 0.254). For FRIs, combinations of gentamicin + vancomycin (93.2%), co-amoxiclav + glycopeptide and meropenem + vancomycin (91.9% each) would have been effective for empiric therapy, similar to PJIs. Difficult to treat pathogens were more frequently detectable in PJIs (11.6% vs. 2.3%). Empiric therapy combinations such as gentamicin + vancomycin, co-amoxiclav + glycopeptide or meropenem + vancomycin, are effective antibiotic strategies for both FRI and PJI patients. More DTT pathogens were detectable in PJIs compared to FRIs.
Collapse
Affiliation(s)
- Markus Rupp
- Department for Trauma Surgery, University Medical Center Regensburg, 93053 Regensburg, Germany; (S.B.); (N.W.); (V.A.)
- Correspondence: ; Tel.: +49-941944-6799
| | - Susanne Baertl
- Department for Trauma Surgery, University Medical Center Regensburg, 93053 Regensburg, Germany; (S.B.); (N.W.); (V.A.)
| | - Nike Walter
- Department for Trauma Surgery, University Medical Center Regensburg, 93053 Regensburg, Germany; (S.B.); (N.W.); (V.A.)
| | - Florian Hitzenbichler
- Department of Infection Prevention and Infectious Diseases, University Medical Center Regensburg, 93053 Regensburg, Germany;
| | - Martin Ehrenschwender
- Institute of Clinical Microbiology and Hygiene, University Medical Center Regensburg, 93053 Regensburg, Germany;
| | - Volker Alt
- Department for Trauma Surgery, University Medical Center Regensburg, 93053 Regensburg, Germany; (S.B.); (N.W.); (V.A.)
| |
Collapse
|
23
|
Buchalter DB, Teo GM, Kirby DJ, Schwarzkopf R, Aggarwal VK, Long WJ. Does the Organism Profile of Periprosthetic Joint Infections Change With a Topical Vancomycin Powder and Dilute Povidone-Iodine Lavage Protocol? J Arthroplasty 2021; 36:S314-S319. [PMID: 33526397 DOI: 10.1016/j.arth.2020.12.036] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2020] [Revised: 12/14/2020] [Accepted: 12/22/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND While vancomycin powder and dilute povidone-iodine (VIP) is associated with fewer total joint arthroplasty (TJA) periprosthetic joint infections (PJI), its effect on PJI organism profiles is unclear. This study evaluates primary TJA PJI organism profiles before and after the implementation of a VIP protocol. METHODS In total, 18,299 primary TJAs performed at a university-affiliated, not-for-profit orthopedic hospital from before (1/2012-12/2013) and after (1/2016-12/2019) a VIP protocol was initiated were reviewed to identify deep PJIs that occurred within 90 days of the index arthroplasty as defined by the Musculoskeletal Infection Society guidelines. Demographics, overall organism incidence (n/TJAs), and relative organism incidence (n/PJIs) from the two cohorts were compared. RESULTS In total, 103 TJA PJIs were identified (pre-VIP: 32/3982; VIP: 71/14,317). Following the introduction of VIP, the overall and relative incidence of coagulase-negative staphylococcal TJA PJIs significantly decreased (overall: 0.20% to 0.04%, P = .004; relative: 25.00% to 8.45%, P = .031). In response, the relative incidence of MSSA TJA PJIs significantly increased (18.75% to 40.85%, P = .042). Broken down by arthroplasty type, VIP was associated with a significantly lower overall incidence of coagulase-negative staphylococcal total knee arthroplasty (TKA) PJIs (0.27% to 0.06%, P = .015), a significantly lower overall incidence of MRSA TKA PJIs (0.18% to 0.03%, P = .031), and a nonsignificant decrease in the overall incidence of gram-negative TKA PJIs (0.18% to 0.04%, P = .059). No organism profile changes were found in total hip arthroplasty PJIs. CONCLUSION VIP is not associated with more difficult to treat primary TJA PJIs. While promising, these findings require a prospective randomized controlled trial for confirmation. LEVEL OF EVIDENCE Level III, Retrospective cohort study.
Collapse
Affiliation(s)
| | - Greg M Teo
- Department of Orthopedic Surgery, NYU Langone Health, New York, NY
| | - David J Kirby
- Department of Orthopedic Surgery, NYU Langone Health, New York, NY
| | - Ran Schwarzkopf
- Department of Orthopedic Surgery, NYU Langone Health, New York, NY
| | - Vinay K Aggarwal
- Department of Orthopedic Surgery, NYU Langone Health, New York, NY
| | - William J Long
- Department of Orthopedic Surgery, NYU Langone Health, New York, NY
| |
Collapse
|
24
|
Kildow BJ, Patel SP, Otero JE, Fehring KA, Curtin BM, Springer BD, Fehring TK. Results of debridement, antibiotics, and implant retention for periprosthetic knee joint infection supplemented with the use of intraosseous antibiotics. Bone Joint J 2021; 103-B:185-190. [PMID: 34053280 DOI: 10.1302/0301-620x.103b6.bjj-2020-2278.r1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AIMS Debridement, antibiotics, and implant retention (DAIR) remains one option for the treatment of acute periprosthetic joint infection (PJI) despite imperfect success rates. Intraosseous (IO) administration of vancomycin results in significantly increased local bone and tissue concentrations compared to systemic antibiotics alone. The purpose of this study was to evaluate if the addition of a single dose of IO regional antibiotics to our protocol at the time of DAIR would improve outcomes. METHODS A retrospective case series of 35 PJI TKA patients, with a median age of 67 years (interquartile range (IQR) 61 to 75), who underwent DAIR combined with IO vancomycin (500 mg), was performed with minimum 12 months' follow-up. A total of 26 patients with primary implants were treated for acute perioperative or acute haematogenous infections. Additionally, nine patients were treated for chronic infections with components that were considered unresectable. Primary outcome was defined by no reoperations for infection, nor clinical signs or symptoms of PJI. RESULTS Mean follow-up for acute infection was 16.5 months (12.1 to 24.2) and 15.8 months (12 to 24.8) for chronic infections with unresectable components. Overall non-recurrence rates for acute infection was 92.3% (24/26) but only 44.4% (4/9) for chronic infections with unresectable components. The majority of patients remained on suppressive oral antibiotics. Musculoskeletal Infection Society (MSIS) host grade was a significant indicator of failure (p < 0.001). CONCLUSION The addition of IO vancomycin at the time of DAIR was shown to be safe with improved results compared to current literature using standard DAIR without IO antibiotic administration. Use of this technique in chronic infections should be applied with caution. While these results are encouraging, this technique requires longer follow-up before widespread adoption. Cite this article: Bone Joint J 2021;103-B(6 Supple A):185-190.
Collapse
Affiliation(s)
- Beau J Kildow
- OrthoCarolina Hip and Knee Center, OrthoCarolina, Charlotte, North Carolina, USA
| | - Shaun P Patel
- Kaiser Permanente Orange County - Irvine Medical Center, Irvine, California, USA
| | - Jesse E Otero
- OrthoCarolina Hip and Knee Center, OrthoCarolina, Charlotte, North Carolina, USA.,Department of Orthopaedic Surgery, Atrium Health/Atrium Musculoskeletal Institute, Charlotte, North Carolina, USA
| | - Keith A Fehring
- OrthoCarolina Hip and Knee Center, OrthoCarolina, Charlotte, North Carolina, USA
| | - Brian M Curtin
- OrthoCarolina Hip and Knee Center, OrthoCarolina, Charlotte, North Carolina, USA
| | - Bryan D Springer
- OrthoCarolina Hip and Knee Center, OrthoCarolina, Charlotte, North Carolina, USA.,Department of Orthopaedic Surgery, Atrium Health/Atrium Musculoskeletal Institute, Charlotte, North Carolina, USA
| | - Thomas K Fehring
- OrthoCarolina Hip and Knee Center, OrthoCarolina, Charlotte, North Carolina, USA.,Department of Orthopaedic Surgery, Atrium Health/Atrium Musculoskeletal Institute, Charlotte, North Carolina, USA
| |
Collapse
|
25
|
Siddiqi A, Abdo ZE, Springer BD, Chen AF. Pursuit of the ideal antiseptic irrigation solution in the management of periprosthetic joint infections. J Bone Jt Infect 2021; 6:189-198. [PMID: 34109103 PMCID: PMC8182666 DOI: 10.5194/jbji-6-189-2021] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Accepted: 05/07/2021] [Indexed: 12/23/2022] Open
Abstract
Irrigation and debridement in the treatment of periprosthetic joint infection
(PJI) serve an integral role in the eradication of bacterial burden and
subsequent re-infection rates. Identifying the optimal irrigation agent,
however, remains challenging, as there is limited data on superiority.
Direct comparison of different irrigation solutions remains difficult
because of variability in treatment protocols. While basic science studies
assist in the selection of irrigation fluids, in vitro results do not directly
translate into clinical significance once implemented in vivo. Dilute
povidone iodine, hydrogen peroxide, chlorhexidine gluconate, acetic acid,
sodium hypochlorite, hypochlorous acid, and preformed combination solutions
all have potential against a broad spectrum of PJI pathogens with their own
unique advantages and disadvantages. Future clinical studies are needed to
identify ideal irrigation solutions with optimal bactericidal properties and
low cytotoxicity for PJI treatment.
Collapse
Affiliation(s)
- Ahmed Siddiqi
- Orthopaedic Institute of Central Jersey, a division of Ortho Alliance NJ, 2315 Route 34 South Manasquan, NJ 08736, USA.,Hackensack Meridian School of Medicine, Department of Orthopedic Surgery, Hackensack, NJ, USA.,Jersey Shore University Medical Center, Department of Orthopedic Surgery, Neptune, NJ, USA
| | - Zuhdi E Abdo
- Rutgers New Jersey Medical School, Department of Orthopedics, Newark, NJ, 07103, USA
| | - Bryan D Springer
- OrthoCarolina Hip and Knee Center, Department of Orthopedics Atrium Musculoskeletal Institute, Charlotte, NC, 28207, USA
| | - Antonia F Chen
- Brigham & Women's Hospital, Department of Orthopedics, Boston, MA, 02115, USA
| |
Collapse
|
26
|
The bactericidal effect of vancomycin is not altered by tranexamic acid, adrenalin, dexamethasone, or lidocaine in vitro. Sci Rep 2021; 11:10739. [PMID: 34031481 PMCID: PMC8144205 DOI: 10.1038/s41598-021-90302-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Accepted: 05/06/2021] [Indexed: 11/29/2022] Open
Abstract
One of the most challenging complications of total knee arthroplasty (TKA) is periprosthetic joint infection (PJI). There is growing evidence of a good anti-infective effect of intrawound vancomycin powder in total joint arthroplasty. At the same time, various different locally applied substances have become popular in total joint arthroplasty. The objective of this study was therefore to investigate a possible inhibition of the bactericidal effect of vancomycin by tranexamic acid, adrenalin, lidocaine, or dexamethasone. The bactericidal effect of vancomycin was quantified using the established method of the agar diffusion test. The plates were incubated with Staphylococcus aureus or Staphylococcus epidermidis and four wells were stamped out. The wells were filled with vancomycin alone, the tested substance alone or a mixture of the two. The fourth well remained empty as a control. The plates were incubated overnight at 37 °C and the zone of inhibition in each field was measured on the next day. All tests were run three times for each pathogen and mean values and standard deviations of the measurements were calculated. Differences between the substances were tested using the t-test at a level of significance of 0.05. The bacterial growth was homogeneous on all plates. The baseline value for the zone of inhibition of vancomycin was on average 6.2 ± 0.4 mm for Staphylococcus aureus and 12 ± 0.3 mm for Staphylococcus epidermidis. In all other substances, no inhibition was detected around the well. The combination of vancomycin and each other substance did not show any different result compared to vancomycin alone. The bactericidal effect of vancomycin on staphylococci is not altered by tranexamic acid, adrenalin, dexamethasone, or lidocaine in vitro.
Collapse
|
27
|
Mu W, Xu B, Guo W, Ji B, Wahafu T, Cao L. Outcome of Irrigation and Debridement With Topical Antibiotics Delivery for the Management of Periprosthetic Joint Infection Occurring Within 3 Months Since the Primary Total Joint Arthroplasty. J Arthroplasty 2021; 36:1765-1771. [PMID: 33358609 DOI: 10.1016/j.arth.2020.11.033] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2020] [Revised: 11/21/2020] [Accepted: 11/23/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Irrigation and debridement with modular component exchange is appealing for surgeons to treat early-stage periprosthetic joint infection (PJI). However, the indication, perioperative protocol, and success rate remain controversial. This study is the first one to present results of debridement, antibiotics, and implant retention (DAIR) with integrated MIT (modular component exchange, povidone-iodine and topical antibiotics delivery) protocol for treating PJI occurring within 3 months since the primary total joint arthroplasty. METHODS We retrospectively analyzed patients who received DAIR with MIT protocol in our department between January 2011 and May 2018. Topical antibiotics were delivered in all cases. Topical antibiotics infusion was applied for those infected with multidrug-resistant bacteria, fungus, polymicrobial infection, and culture negative one. Failure was defined as additional surgical intervention for infection after DAIR; persistent sinus tract, drainage or excessive joint pain; need for suppressive antibiotics therapy due to the infection; infection relapse with the same pathogen; reinfection with different microorganism; and infection-related death. RESULTS A total of 73 patients with a mean age of 63.30 ± 10.97 years were included in this study, including 43 men and 30 women. There are 41 knees and 32 hips. Thirty patients had sinus tract. With a mean follow-up of 63.79 ± 18.57 months, there were 9 failures in total with an overall success rate of 87.67%. The success rate was 88.57% and 86.84% for those receiving topical antibiotics infusion postoperatively and those without. CONCLUSIONS DAIR with a standard MIT protocol is a viable and safe option for PJI occurring within 3 months since the primary total joint arthroplasty. LEVEL OF EVIDENCE Level 4, therapeutic study.
Collapse
Affiliation(s)
- Wenbo Mu
- Department of Orthopaedics, First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang, China
| | - Boyong Xu
- Department of Orthopaedics, First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang, China
| | - Wentao Guo
- Department of Orthopaedics, First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang, China
| | - Baochao Ji
- Department of Orthopaedics, First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang, China
| | - Tuerhongjiang Wahafu
- Department of Orthopaedics, First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang, China
| | - Li Cao
- Department of Orthopaedics, First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang, China
| |
Collapse
|
28
|
Buchalter DB, Kirby DJ, Teo GM, Iorio R, Aggarwal VK, Long WJ. Topical Vancomycin Powder and Dilute Povidone-Iodine Lavage Reduce the Rate of Early Periprosthetic Joint Infection After Primary Total Knee Arthroplasty. J Arthroplasty 2021; 36:286-290.e1. [PMID: 32919848 DOI: 10.1016/j.arth.2020.07.064] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Revised: 07/16/2020] [Accepted: 07/27/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Vancomycin powder and dilute povidone-iodine lavage (VIP) was introduced to reduce the incidence of periprosthetic joint infection (PJI) in high-risk total knee arthroplasty (TKA) patients. We hypothesize that VIP can reduce the incidence of early PJI in all primary TKA patients, regardless of preoperative risk. METHODS An infection database of primary TKAs performed before a VIP protocol was implemented (January 2012-December 2013), during a time when only high-risk TKAs received VIP (January 2014-December 2015), and when all TKAs received VIP (January 2016-September 2019) at an urban, university-affiliated, not-for-profit orthopedic hospital was retrospectively reviewed to identify patients with PJI. Criteria used for diagnosis of PJI were the National Healthcare Safety Network and Musculoskeletal Infection Society guidelines. RESULTS VIP reduced early primary TKA PJI incidence in both the high-risk and all-risk cohorts compared with the pre-VIP cohort by 44.6% and 56.4%, respectively (1.01% vs 0.56% vs 0.44%, P = .0088). In addition, after introducing VIP to all-risk TKA patients, compared with high-risk TKA patients, the relative risk of PJI dropped an additional 21.4%, but this finding did not reach statistical significance (0.56% vs 0.44%, P = .4212). There were no demographic differences between the 3 VIP PJI cohorts. CONCLUSION VIP is associated with a reduced early PJI incidence after primary TKA, regardless of preoperative risk. With the literature supporting its safety and cost-effectiveness, VIP is a value-based intervention, but given the nature of this historical cohort study, a multicenter randomized controlled trial is underway to definitively confirm its efficacy.
Collapse
Affiliation(s)
| | - David J Kirby
- Department of Orthopedic Surgery, NYU Langone Health, New York, NY
| | - Greg M Teo
- Department of Orthopedic Surgery, NYU Langone Health, New York, NY
| | - Richard Iorio
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, MA
| | - Vinay K Aggarwal
- Department of Orthopedic Surgery, NYU Langone Health, New York, NY
| | - William J Long
- Department of Orthopedic Surgery, NYU Langone Health, New York, NY
| |
Collapse
|
29
|
Budge MD, Koch JA, Mandell JB, Cappellini AJ, Orr S, Patel S, Ma D, Nourie O, Brothers KM, Urish KL. The In Vitro Efficacy of Doxycycline over Vancomycin and Penicillin in the Elimination of Cutibacterium Acnes Biofilm. ANTIMICROBIAL COMBINATION DEVICES 2020; STP1630:53-64. [PMID: 35529525 PMCID: PMC9070841 DOI: 10.1520/stp163020200019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
Cutibacterium acnes (formerly Propionibacterium acnes) is a significant pathogen in periprosthetic joint infections (PJIs) in total shoulder arthroplasty. Poor outcomes seen in PJIs are due to the established C. acnes bacterial biofilms. The prolonged nature of C. acnes infections makes them difficult to treat with antibiotics. The goal of this study was to determine the relative efficacy of vancomycin compared with penicillin and doxycycline against planktonic and mature biofilms. Clinical isolates from PJI patients as well as a laboratory strain of C. acnes were tested. Planktonic minimum inhibitory concentrations (MICs) and minimum bactericidal concentrations (MBCs) were obtained using modified clinical laboratory standard index assays. Biofilm MICs and MBCs were also obtained. The MIC was determined for both using the PrestoBlue viability stain. The MBC was determined using differential reinforced clostridial medium agar plates for colony-forming unit analysis. Using the PrestoBlue viability reagent, the planktonic MIC values for vancomycin were significantly higher than doxycycline. Across 10 strains of C. acnes, all three antibiotics had decreased efficacy when comparing planktonic and biofilm cultures. Although effective antibiotic doses ranged from 1 to 1,000 μg/mL, only doxycycline achieved inhibitory and bactericidal concentrations in all tested strains. Penicillin failed to achieve the minimum biofilm inhibitory concentration (MBIC) in 60% of tested strains, whereas vancomycin failed in 80% of tested strains. Penicillin, doxycycline, and vancomycin have similar abilities in inhibiting C. acnes growth planktonically. The MBIC for doxycycline was within the clinical dosing range, suggesting C. acnes biofilm offers minimal tolerance to these antibiotics. The MBIC for penicillin was within clinical dosing ranges in only 60% of trials, suggesting the relative tolerance of C. acnes to penicillin. The minimum biofilm bactericidal concentration (MBBC) of doxycycline showed efficacy in 90% of trials, whereas penicillin and vancomycin achieved MBBC in 15% of samples.
Collapse
Affiliation(s)
- Matthew D Budge
- NW Perrnanente, 5125 Skyline Rd. S., Salem, OR 97306-9427, USA
| | - John A Koch
- NW Perrnanente, 5125 Skyline Rd. S., Salem, OR 97306-9427, USA
- Arthritis and Arthroplasty Design Group, Dept. of Orthopaedic Surgery, 100 Technology Dr., Pittsburgh, PA 15219, USA
| | - Jonathan B Mandell
- Arthritis and Arthroplasty Design Group, Dept. of Orthopaedic Surgery, 100 Technology Dr., Pittsburgh, PA 15219, USA
| | - Alex J Cappellini
- Arthritis and Arthroplasty Design Group, Dept. of Orthopaedic Surgery, 100 Technology Dr., Pittsburgh, PA 15219, USA
| | - Sara Orr
- Arthritis and Arthroplasty Design Group, Dept. of Orthopaedic Surgery, 100 Technology Dr., Pittsburgh, PA 15219, USA
| | - Samik Patel
- Arthritis and Arthroplasty Design Group, Dept. of Orthopaedic Surgery, 100 Technology Dr., Pittsburgh, PA 15219, USA
| | - Dongzhu Ma
- Arthritis and Arthroplasty Design Group, Dept. of Orthopaedic Surgery, 100 Technology Dr., Pittsburgh, PA 15219, USA
| | - Olivia Nourie
- NW Perrnanente, 5125 Skyline Rd. S., Salem, OR 97306-9427, USA
| | - Kimberly M Brothers
- Arthritis and Arthroplasty Design Group, Dept. of Orthopaedic Surgery, 100 Technology Dr., Pittsburgh, PA 15219, USA
| | - Kenneth L Urish
- Arthritis and Arthroplasty Design Group, The Bone and Joint Center, MageeWomens Hospital of the University of Pittsburgh Medical Center, 300 Halket St., Pittsburgh, PA 15213, USA; and Dept. of Orthopaedic Surgery, Dept. of Bioengineering, and Clinical and Translational Science Institute, University of Pittsburgh, 100 Technology Dr., Pittsburgh, PA 15219, USA
| |
Collapse
|
30
|
Abstract
Projections indicate an increase in primary and revision total joint arthroplasties (TJAs). Periprosthetic joint infections (PJIs) are one of the most common and devastating causes of failure after TJA. Perioperative administration of systemic and/or local antibiotics is used for both prophylaxis and treatment of PJI. Antibiotic stewardship is a term that has been met with clinical acceptance and success in other specialties of medicine. Identifying antibiotic best practice use in the fight against PJI is limited by studies that are extremely heterogeneous in their design. Variations in studies include antibiotic selection and duration, surgical débridement steps, type of antibiotic delivery (intra-articular, local, intravenous, and prolonged oral), mix of primary and revision surgery cohorts, both hip and knee cohorts, infecting organisms, and definitions of treatment success/failure. This review highlights the current challenges of antibiotic stewardship in TJA.
Collapse
|
31
|
Yavuz IA, Oken OF, Yildirim AO, Inci F, Ceyhan E, Gurhan U. No effect of vancomycin powder to prevent infection in primary total knee arthroplasty: a retrospective review of 976 cases. Knee Surg Sports Traumatol Arthrosc 2020; 28:3055-3060. [PMID: 31728604 DOI: 10.1007/s00167-019-05778-8] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Accepted: 10/28/2019] [Indexed: 02/07/2023]
Abstract
PURPOSE Vancomycin powder (VP) has been used to prevent periprosthetic joint infection (PJI). However, studies investigating the efficacy of VP to prevent infection in primary total knee arthroplasty (TKA) are very rare. The purpose of this study was to investigate the efficacy of VP application to prevent PJI in TKA. METHODS Between 2012 and 2016, 976 consecutive patients who underwent primary TKA were included in the present study. Patients were divided into two groups. There were 474 patients (48.6%) in the VP group and 502 patients in the control group (51.4%). Except for VP, all procedures were the same in both groups. In the VP group, 2 g of VP was poured into the joint just before the fascia was closed. Average follow-up was 53.2 months (24-84 months). RESULTS Infection was found in 4 (0.84%) of 474 patients in the VP group and 5 (0.99%) of 502 patients in the control group. There was no statistically significant difference between groups in terms of infection rates (p = 0.535). Staphylococcus aureus was found in 2 patients in the VP group. Two patients had S. aureus and 1 patient had Pseudomonas aeruginosa in the control group. There was no statistically significant difference between groups in terms of demographic parameters (p > 0.05). CONCLUSION Intrawound VP administration doesn't change the infection rates in primary TKA. The VP administration for preventing PJI is not recommended in primary TKA. LEVEL OF EVIDENCE III.
Collapse
Affiliation(s)
- Ibrahim Alper Yavuz
- Department of Orthopaedics and Traumatology, University of Health Science, Ankara Numune Training and Research Hospital, Ankara, Turkey.
| | - Ozdamar Fuad Oken
- Department of Orthopaedics and Traumatology, University of Health Science, Ankara Numune Training and Research Hospital, Ankara, Turkey
| | - Ahmet Ozgur Yildirim
- Department of Orthopaedics and Traumatology, University of Health Science, Ankara Numune Training and Research Hospital, Ankara, Turkey
| | - Fatih Inci
- Department of Orthopaedics and Traumatology, University of Health Science, Ankara Numune Training and Research Hospital, Ankara, Turkey
| | - Erman Ceyhan
- Department of Orthopaedics and Traumatology, University of Health Science, Ankara Numune Training and Research Hospital, Ankara, Turkey
| | - Utku Gurhan
- Department of Orthopaedics and Traumatology, University of Health Science, Ankara Numune Training and Research Hospital, Ankara, Turkey
| |
Collapse
|
32
|
Intraarticular vancomycin powder is effective in preventing infections following total hip and knee arthroplasty. Sci Rep 2020; 10:13053. [PMID: 32747743 PMCID: PMC7400548 DOI: 10.1038/s41598-020-69958-0] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Accepted: 07/09/2020] [Indexed: 11/08/2022] Open
Abstract
Locally applied vancomycin is increasingly being used in primary hip and knee arthroplasty to reduce the risk of infection. Despite encouraging initial results, considerable debate remains on the basis of the data currently available. In particular, it has been unclear up to now whether local vancomycin is suitable to further reduce the risk of infection even if the rate of infection is already low (< 1%). In this monocentric retrospective cohort study, all primary total hip and knee arthroplasties performed between 2013 and 2018 were included. After a change in procedure at the hospital, 1 g vancomycin powder was applied intraarticularly before wound closure. The remaining perioperative procedure was constant over the investigation period. The follow-up was one year. The presence of an infection according to the currently valid MSIS criteria was defined as the endpoint. In patients with TKA two infections (0.3%) were observed under vancomycin prophylaxis in contrast to 44 infections (1.3%) in the control group (p = 0.033). In patients with THA two infections (0.5%) were observed under vancomycin prophylaxis and 48 infections (1.1%) in the control group without local vancomycin but this difference was statistically not significant. No wound complications requiring revision were observed as a result of the vancomycin. On the basis of the results of this study, intraarticular application of vancomycin powder in total hip and knee arthroplasty may be considered. Prospective randomized studies have to confirm this promising results prior a common recommendation.Level of Evidence III Retrospective cohort study.
Collapse
|
33
|
Iorio R, Yu S, Anoushiravani AA, Riesgo AM, Park B, Vigdorchik J, Slover J, Long WJ, Schwarzkopf R. Vancomycin Powder and Dilute Povidone-Iodine Lavage for Infection Prophylaxis in High-Risk Total Joint Arthroplasty. J Arthroplasty 2020; 35:1933-1936. [PMID: 32247676 DOI: 10.1016/j.arth.2020.02.060] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2020] [Revised: 02/18/2020] [Accepted: 02/25/2020] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Dilute povidone-iodine lavage has been shown to be safe and effective in decreasing acute periprosthetic joint infection (PJI) following total joint arthroplasty (TJA). Vancomycin powder is reported to be effective in preventing infection in spine surgery. We hypothesize that a "vanco-povidone protocol" (VIP) for TJA patients at high risk for infection is safe and will decrease the rate of PJI. METHODS High-risk TJA patients (body mass index >40, active smokers, American Society of Anesthesiologists ≥3, immunosuppression/diabetes, methicillin-resistant Staphylococcus aureus colonization, revision surgery) utilizing VIP were compared to a high-risk historical cohort not treated with VIP, at a single institution. VIP consisted of dilute povidone-iodine lavage followed by application of vancomycin powder prior to wound closure. Primary endpoint was PJI within 3 months postoperatively. RESULTS The historical, high-risk control cohort consisted of 3251 patients with a PJI incidence of 1.8%. A total of 1413 subjects received the VIP protocol with a PJI incidence of 1.3%. There was a 27.8% risk reduction when compared to the control group of high-risk subjects not treated with the VIP. There were no medical complications secondary to the use of VIP, no increase in vancomycin-resistant enterococcus or vancomycin-resistant Staph aureus, and no cases of acute renal impairment secondary to application of the local vancomycin. CONCLUSIONS PJI remains a common complication of TJA, especially in high-risk populations. This study indicates that a protocol of dilute povidone-iodine lavage combined with topical vancomycin powder is safe and may reduce PJI incidence in high-risk TJA patients. Due to low, current PJI rates, a multi-institutional randomized controlled trial is necessary to assess interventions that minimize the risk of PJI. LEVEL OF EVIDENCE Retrospective Observational Cohort.
Collapse
Affiliation(s)
- Richard Iorio
- Department of Orthpaedic Surgery, Brigham Health, Brigham and Women's Hospital, Boston, MA
| | - Stephen Yu
- Department of Orthopaedic Surgery, NYU Langone Health, NYU Langone Orthopaedic Hospital, New York, NY
| | - Afshin A Anoushiravani
- Department of Orthopaedic Surgery, NYU Langone Health, NYU Langone Orthopaedic Hospital, New York, NY
| | - Aldo M Riesgo
- Department of Orthopaedic Surgery, NYU Langone Health, NYU Langone Orthopaedic Hospital, New York, NY
| | - Brian Park
- Department of Orthopaedic Surgery, NYU Langone Health, NYU Langone Orthopaedic Hospital, New York, NY
| | - Jonathan Vigdorchik
- Department of Orthopaedic Surgery, NYU Langone Health, NYU Langone Orthopaedic Hospital, New York, NY
| | - James Slover
- Department of Orthopaedic Surgery, NYU Langone Health, NYU Langone Orthopaedic Hospital, New York, NY
| | - William J Long
- Department of Orthopaedic Surgery, NYU Langone Health, NYU Langone Orthopaedic Hospital, New York, NY
| | - Ran Schwarzkopf
- Department of Orthopaedic Surgery, NYU Langone Health, NYU Langone Orthopaedic Hospital, New York, NY
| |
Collapse
|
34
|
Pan S, Rodriguez D, Thirumavalavan N, Gross MS, Eid JF, Mulcahy J, Munarriz R. The Use of Antiseptic Solutions in the Prevention and Management of Penile Prosthesis Infections: A Review of the Cytotoxic and Microbiological Effects of Common Irrigation Solutions. J Sex Med 2020; 16:781-790. [PMID: 31146926 DOI: 10.1016/j.jsxm.2019.03.271] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Revised: 03/19/2019] [Accepted: 03/22/2019] [Indexed: 12/12/2022]
Abstract
INTRODUCTION The Mulcahy salvage fundamentally altered the management of penile prosthesis infections (PPI). Central to this procedure is a sequence of antiseptic irrigations that aims to remove and eradicate pathogenic microflora from the infected field, thus preparing for immediate reimplantation. The antiseptic solutions and their respective concentrations, however, have never been evaluated for efficacy. AIM This review critically examines 3 commonly used antiseptic irrigation solutions (povidone-iodine [PVI], hydrogen peroxide [H2O2], and chlorhexidine gluconate [CHG]) in terms of their antimicrobial activity, cytotoxicity, and clinical use. METHODS A PubMed literature review was performed on articles published between 2003 and 2018. Both preclinical as well as clinical studies from various surgical disciplines were included in this review. MAIN OUTCOME MEASURE The original salvage protocol selected for irrigation solutions at concentrations that are likely detrimental to native tissue. RESULTS All 3 agents demonstrate in vitro cytotoxic effects at subclinical concentrations, but H2O2 is associated with the most significant deleterious properties. It does not seem to broaden antimicrobial coverage beyond what is covered by PVI. Dilute PVI (0.35-3.5% with exposure time of at least 3 minutes) possesses the most robust clinical evidence as an intraoperative adjunct, reducing the incidence of postoperative infectious complications. chlorhexidine gluconate is a promising new agent but lacks clinical data. CLINICAL IMPLICATION Improvements in the salvage protocol are warranted based on current evidence. Careful selection of lavage solution and usage of the lowest necessary concentration will help achieve desired antimicrobial activity while avoiding native tissue cytotoxicity. Strength and limitation: The study is limited by its retrospective nature, and the heterogeneity of literature reviewed precluded a formal meta-analysis. Furthermore, future studies will need to address the roles of normal saline and antibiotic irrigations as intraoperative adjuncts for infection prevention. CONCLUSION Diluted PVI (0.35-3.5% for 3 minutes) may be beneficial in the prevention of PPI. Evidence supports its use both in the setting of primary implantation as well as salvage of infected hardware. An improved, evidence-based protocol may increase positive outcomes of urologic prosthetic surgery. Pan S, Rodriguez D, Thirumavalavan N, et al. The Use of Antiseptic Solutions in the Prevention and Management of Penile Prosthesis Infections: A Review of the Cytotoxic and Microbiological Effects of Common Irrigation Solutions. J Sex Med 2019;16:781-790.
Collapse
Affiliation(s)
- Shu Pan
- Department of Urology, Boston University School of Medicine, Boston, MA, USA
| | - Dayron Rodriguez
- Department of Urology, Boston University School of Medicine, Boston, MA, USA
| | | | - Martin S Gross
- Section of Urology, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - J Francois Eid
- Lenox Hill Hospital Northwell Health System, New York, NY, USA
| | - John Mulcahy
- Department of Urology, University of Alabama Madison, Madison, AL, USA
| | - Ricardo Munarriz
- Department of Urology, Boston University School of Medicine, Boston, MA, USA.
| |
Collapse
|
35
|
Abstract
STUDY DESIGN Case control series. OBJECTIVE The aim of this study was to evaluate and compare the effectiveness of methods to decrease surgical site infections (SSIs) following spine tumor surgery. SUMMARY OF BACKGROUND DATA With the aging population of the United States, the prevalence of cancer and associated metastatic spine disease is increasing. The most common complication of spine tumor surgery is SSI. METHODS This a single-institution case-control series of patients undergoing spine tumor surgery from June 2003 to October 2018. Patients were grouped into the following groups: Betadine irrigation and intrawound vancomycin powder (BIVP), intrawound vancomycin powder only (IVP), and patients receiving neither (NONE). The primary outcome was SSIs/wound complications. RESULTS One hundred fifty-one spine tumor patients undergoing 174 procedures meeting our inclusion criteria were identified. The BIVP group had 60 patients (73 procedures); the IVP group had 46 patients (47 procedures); and the NONE group had 45 patients (54 procedures). The overall infection rate was 8.6% of all procedures (15/174) and 9.9% (15/151) of all patients. Bivariate analysis comparing patients with and without infections noted the patients with SSIs had significantly higher rates of preoperative radiation treatment (53.3% in infection group vs. 25.5% in noninfection group), P = 0.02. Patients undergoing procedures in the BIVP group had a significantly lower rate of infections (2.7%) than the patients in the IVP (12.8%) and NONE (13%) groups, P = 0.04. Stepwise regression analysis was used to evaluate further factors associated with SSIs. Elevated BMI was significantly associated with SSIs in the model [P = 0.02, odds ratio (OR) 1.14]. BIVP was also protective against infections as compared to the IVP and NONE groups, P = 0.02, OR 0.02. CONCLUSION BIVP led to a significant decrease in SSI rates following spine tumor surgery. Administration of BIVP is not time consuming and decreased SSI rates. LEVEL OF EVIDENCE 3.
Collapse
|
36
|
Qu GX, Zhang CH, Yan SG, Cai XZ. Debridement, antibiotics, and implant retention for periprosthetic knee infections: a pooling analysis of 1266 cases. J Orthop Surg Res 2019; 14:358. [PMID: 31718644 PMCID: PMC6852904 DOI: 10.1186/s13018-019-1378-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Accepted: 09/13/2019] [Indexed: 01/10/2023] Open
Abstract
Background The debridement, antibiotics, and implant retention (DAIR) procedure is an established therapeutic option for periprosthetic knee infections (PKI). However, the efficacy and the indication for this procedure are still controversial. Methods All the relevant literatures were systematically reviewed and analyzed. The present study aimed to assess the success rate of DAIR in the management of PKI, identify the factors associated with prognosis of DAIR, and establish a simple algorithm for predicting a high success rate of DAIR. Results Totally, 33 studies with 1266 cases were included. The overall success rate following DAIR in the management of PKI was 57.11%. In the subgroup analyses, the factors of “the time from symptoms to debridement was < 3 weeks” and “the bacterial species other than methicillin-resistant Staphylococcus aureus” significantly improved the success rate of DAIR and thus were defined as the major criteria. The statistically insignificant factors of “the open debridement and liner exchange” and “the comorbidity of rheumatoid arthritis” were set as the minor criteria. The success rate of DAIR for PKI meeting all the major criteria and no less than one minor criterion was 80.98%, which was significantly higher than the overall success rate of DAIR (p < 0.05). Conclusion PKI cases meeting two major criteria and no less than one minor criterion may confer a high success rate of DAIR. This simple algorithm may contribute to identifying the appropriate PKI patient for DAIR treatment and predicting the prognosis of DAIR.
Collapse
Affiliation(s)
- Guo-Xin Qu
- Department of Orthopaedic Surgery, Second Affiliated Hospital of Zhejiang University School of Medicine, Jiefang Road 88, Hangzhou, 310009, China.,The affiliated Cancer Hospital of Zhengzhou University, Dongming Road 127, Zhengzhou, China
| | - Cai-Hua Zhang
- Department of Orthopaedic Surgery, Second Affiliated Hospital of Zhejiang University School of Medicine, Jiefang Road 88, Hangzhou, 310009, China.,Orthopaedic Research Laboratory, Zhejiang University, Jiefang Road 88, Hangzhou, China
| | - Shi-Gui Yan
- Department of Orthopaedic Surgery, Second Affiliated Hospital of Zhejiang University School of Medicine, Jiefang Road 88, Hangzhou, 310009, China.,Orthopaedic Research Laboratory, Zhejiang University, Jiefang Road 88, Hangzhou, China
| | - Xun-Zi Cai
- Department of Orthopaedic Surgery, Second Affiliated Hospital of Zhejiang University School of Medicine, Jiefang Road 88, Hangzhou, 310009, China. .,Orthopaedic Research Laboratory, Zhejiang University, Jiefang Road 88, Hangzhou, China.
| |
Collapse
|
37
|
Wouthuyzen-Bakker M, Löwik CAM, Knobben BAS, Zijlstra WP, Ploegmakers JJW, Mithoe G, Al Moujahid A, Kampinga GA, Jutte PC. Use of gentamicin-impregnated beads or sponges in the treatment of early acute periprosthetic joint infection: a propensity score analysis. J Antimicrob Chemother 2019; 73:3454-3459. [PMID: 30189006 DOI: 10.1093/jac/dky354] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Accepted: 08/07/2018] [Indexed: 01/15/2023] Open
Abstract
Objectives Early acute periprosthetic joint infections (PJIs) treated with debridement, antibiotics and implant retention (DAIR) have failure rates ranging from 10% to 60%. We determined the efficacy of applying local gentamicin-impregnated beads and/or sponges during debridement in early PJI. Methods Patients with early acute PJI, defined as less than 21 days of symptoms and treated with DAIR within 90 days after index surgery, were retrospectively evaluated. Early failure was defined as PJI-related death, the need for implant removal or a second DAIR or antibiotic suppressive therapy owing to persistent signs of infection, all within 60 days after initial debridement. Overall failure was defined as implant removal at any timepoint during follow-up. A 1:1 propensity score matching was performed to correct for confounding factors. Results A total of 386 patients were included. Local gentamicin was applied in 293 patients (75.9%) and was withheld in 93 patients (24.1%). Multivariate analysis demonstrated that the use of local gentamicin was independently associated with early failure (OR = 1.97, 95% CI = 1.12-3.48). After propensity matching, early failure was 40.3% in the gentamicin group versus 26.0% in the control group (P = 0.06) and overall failure was 5.2% in the gentamicin group versus 2.6% in the control group (P = 0.40). These numbers remained when solely analysing the application of gentamicin-impregnated sponges. Conclusions Even after propensity score matching, failure rates remained higher if local gentamicin-impregnated beads and/or sponges were administered in early acute PJI. Based on these results, their use should be discouraged.
Collapse
Affiliation(s)
- Marjan Wouthuyzen-Bakker
- Department of Medical Microbiology and Infection Prevention, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Claudia A M Löwik
- Department of Orthopaedic Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Bas A S Knobben
- Department of Orthopaedic Surgery, Martini Ziekenhuis, Groningen, The Netherlands
| | - Wierd P Zijlstra
- Department of Orthopaedic Surgery, Medisch Centrum Leeuwarden, Leeuwarden, The Netherlands
| | - Joris J W Ploegmakers
- Department of Orthopaedic Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Glen Mithoe
- Department of Medical Microbiology, Certe Medical Diagnostics & Advice, Groningen, The Netherlands
| | - Aziz Al Moujahid
- Center for Infectious Diseases Friesland, Izore, Leeuwarden, The Netherlands
| | - Greetje A Kampinga
- Department of Medical Microbiology and Infection Prevention, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Paul C Jutte
- Department of Orthopaedic Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| |
Collapse
|
38
|
Heckmann ND, Mayfield CK, Culvern CN, Oakes DA, Lieberman JR, Della Valle CJ. Systematic Review and Meta-Analysis of Intrawound Vancomycin in Total Hip and Total Knee Arthroplasty: A Call for a Prospective Randomized Trial. J Arthroplasty 2019; 34:1815-1822. [PMID: 31005433 DOI: 10.1016/j.arth.2019.03.071] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Revised: 03/25/2019] [Accepted: 03/26/2019] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Topical intrawound vancomycin has been used extensively in spine surgery to decrease surgical site infections. However, the efficacy of intrawound vancomycin in total hip (THA) and total knee arthroplasty (TKA) to prevent periprosthetic joint infection (PJI) has not been established. METHODS The PubMed and MEDLINE databases were searched to identify studies utilizing intrawound vancomycin in primary and revision THA and TKA. Data for postoperative infection were pooled using random effect models with results reported as odds ratios (ORs) and 95% confidence intervals. Studies were weighted by the inverse variance of their effect estimates. RESULTS Of the 91 studies identified, 6 low-quality retrospective studies (level III) were pooled for further analysis. A total of 3298 patients were assessed, 1801 of which were treated with intrawound vancomycin. Overall, patients who received vancomycin had a decreased rate of PJI (OR 0.2530, P < .0001). When analyzed separately, TKA patients and THA patients who received intrawound vancomycin had lower rates of PJI (OR 0.3467, P = .0005 and OR 0.3672, P = .0072, respectively). Pooled primary TKA and THA patients receiving vancomycin saw the rate of PJI decrease (OR 0.4435, P = .0046). Pooled revision TKA and THA patients saw a similar decrease in infection rates (OR 0.2818, P = .0013). No apparent publication bias was observed; however, the results from this analysis are limited by the low quality of evidence and inherent potential for bias. CONCLUSION Intrawound vancomycin may reduce the risk of PJI in primary and revision TKA and THA. However, only low-quality evidence exists, highlighting the need for randomized controlled trials before broad adoption of this practice can be recommended given the potential implications of widespread use of vancomycin in hip and knee arthroplasty.
Collapse
Affiliation(s)
| | - Cory K Mayfield
- Keck School of Medicine of the University of Southern California, Los Angeles, CA
| | - Chris N Culvern
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL
| | - Daniel A Oakes
- Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA
| | - Jay R Lieberman
- Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA
| | - Craig J Della Valle
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL
| |
Collapse
|
39
|
Hart A, Hernandez NM, Abdel MP, Mabry TM, Hanssen AD, Perry KI. Povidone-Iodine Wound Lavage to Prevent Infection After Revision Total Hip and Knee Arthroplasty: An Analysis of 2,884 Cases. J Bone Joint Surg Am 2019; 101:1151-1159. [PMID: 31274716 DOI: 10.2106/jbjs.18.01152] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Postoperative infection remains a major challenge in revision total hip arthroplasty (THA) and revision total knee arthroplasty (TKA). Wound irrigation with dilute povidone-iodine (PI) solution has emerged as a simple, inexpensive, and potentially successful means of reducing postoperative infections. The aim of this study was to assess its effectiveness in reducing infection following revision THA and TKA in, to our knowledge, the largest revision cohort to date. METHODS Using our institution's total joint registry, we identified 1,402 revision THAs and 1,482 revision TKAs performed during the study period (2013, when the PI irrigation protocol was first implemented, to 2017). The PI lavage protocol was employed in 27% of the revision THA cases and 34% of the revision TKA cases; in the remaining cases, the protocol was not used. Demographics, comorbid conditions, underlying surgical diagnoses, and whether the revision was for a septic or an aseptic etiology were compared between the groups (use or no use of PI irrigation). Any reoperation due to infection, as assessed at 3 and 12 months following revision arthroplasty, was compared between the groups and propensity scores were calculated to account for differences in baseline characteristics between the groups. RESULTS After adjusting for baseline differences between the groups using the propensity-score weighted models, we found no significant difference in the rate of reoperation for infection at 3 months (p = 0.58 for revision THA, and p = 0.06 for revision TKA) and at 12 months (p = 0.78 for revision THA, and p = 0.06 for revision TKA). Nonetheless, the hazard ratios from the propensity-score model trended higher for patients who received PI lavage: 1.6 and 1.3 for revision THA at 3 and 12 months, respectively, and 2.9 at both 3 and 12 months for revision TKA. CONCLUSIONS PI wound lavage demonstrated no benefit in reducing any reoperation for infection following revision THA and TKA. Moreover, the trend toward higher rates for reoperation for infection among patients who received PI irrigation merit further consideration. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
Collapse
Affiliation(s)
- Adam Hart
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | | | - Matthew P Abdel
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Tad M Mabry
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Arlen D Hanssen
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Kevin I Perry
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| |
Collapse
|
40
|
Hernandez NM, Hart A, Taunton MJ, Osmon DR, Mabry TM, Abdel MP, Perry KI. Use of Povidone-Iodine Irrigation Prior to Wound Closure in Primary Total Hip and Knee Arthroplasty: An Analysis of 11,738 Cases. J Bone Joint Surg Am 2019; 101:1144-1150. [PMID: 31274715 DOI: 10.2106/jbjs.18.01285] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Povidone-iodine (PI) irrigation is often used prior to wound closure in total joint arthroplasty, but there are limited reports evaluating its efficacy in decreasing joint infections. The goal of this study was to compare the rate of any reoperation for infection (both superficial and deep) in primary total hip arthroplasty (THA) and primary total knee arthroplasty (TKA) among patients who did and did not receive PI irrigation prior to wound closure. METHODS Using our institution's total joint registry, we identified 5,534 primary THA and 6,204 primary TKA procedures performed from 2013 to 2017. Cases were grouped on the basis of whether or not the wound was irrigated with 1 L of 0.25% PI prior to closure. PI irrigation was used in 1,322 (24%) of the THA cases and in 2,410 (39%) of the TKA cases. The rates of reoperation for infection at 3 months and 1 year were compared between the 2 groups. The same comparisons were then performed using propensity scores to account for differences in baseline characteristics. RESULTS The rate of reoperation for infection as assessed at 3 months following THA was similar between those who received dilute PI irrigation (0.9%) and who did not (0.7%) (p = 0.7). At 1 year, the rate of reoperation for infection was similar between those who received dilute PI irrigation (0.7%) and those who did not (0.9%) (p = 0.6). After using the propensity score, there was no difference between the groups in the risk of septic reoperations. For TKA, the rate of reoperation as assessed at 3 months was similar between those who received dilute PI irrigation (0.8%) and those who did not (0.3%) (p = 0.06). At 1 year, there was a greater rate of reoperations for infection among those who received dilute PI irrigation (1.2%) compared with those who did not (0.6%) (p = 0.03). However, there was no difference in the risk of septic reoperations between the groups after using the propensity score. CONCLUSIONS Despite enthusiasm for and progressive adoption of the use of dilute PI irrigation at our institution, there was not a significant reduction in the risk of reoperation for infection as assessed at 3 months and 1 year following primary THA and TKA. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
Collapse
Affiliation(s)
- Nicholas M Hernandez
- Departments of Orthopedic Surgery (N.M.H., A.H., M.J.T., T.M.M., M.P.A., and K.I.P.) and Infectious Disease (D.R.O.), Mayo Clinic, Rochester, Minnesota
| | - Adam Hart
- Departments of Orthopedic Surgery (N.M.H., A.H., M.J.T., T.M.M., M.P.A., and K.I.P.) and Infectious Disease (D.R.O.), Mayo Clinic, Rochester, Minnesota
| | - Michael J Taunton
- Departments of Orthopedic Surgery (N.M.H., A.H., M.J.T., T.M.M., M.P.A., and K.I.P.) and Infectious Disease (D.R.O.), Mayo Clinic, Rochester, Minnesota
| | - Douglas R Osmon
- Departments of Orthopedic Surgery (N.M.H., A.H., M.J.T., T.M.M., M.P.A., and K.I.P.) and Infectious Disease (D.R.O.), Mayo Clinic, Rochester, Minnesota
| | - Tad M Mabry
- Departments of Orthopedic Surgery (N.M.H., A.H., M.J.T., T.M.M., M.P.A., and K.I.P.) and Infectious Disease (D.R.O.), Mayo Clinic, Rochester, Minnesota
| | - Matthew P Abdel
- Departments of Orthopedic Surgery (N.M.H., A.H., M.J.T., T.M.M., M.P.A., and K.I.P.) and Infectious Disease (D.R.O.), Mayo Clinic, Rochester, Minnesota
| | - Kevin I Perry
- Departments of Orthopedic Surgery (N.M.H., A.H., M.J.T., T.M.M., M.P.A., and K.I.P.) and Infectious Disease (D.R.O.), Mayo Clinic, Rochester, Minnesota
| |
Collapse
|
41
|
Aggarwal VK, Weintraub S, Klock J, Stachel A, Phillips M, Schwarzkopf R, Iorio R, Bosco J, Zuckerman JD, Vigdorchik JM, Long WJ. 2019 Frank Stinchfield Award: A comparison of prosthetic joint infection rates between direct anterior and non-anterior approach total hip arthroplasty. Bone Joint J 2019; 101-B:2-8. [PMID: 31146560 DOI: 10.1302/0301-620x.101b6.bjj-2018-0786.r1] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
AIMS We studied the impact of direct anterior (DA) versus non-anterior (NA) surgical approaches on prosthetic joint infection (PJI), and examined the impact of new perioperative protocols on PJI rates following all surgical approaches at a single institution. PATIENTS AND METHODS A total of 6086 consecutive patients undergoing primary total hip arthroplasty (THA) at a single institution between 2013 and 2016 were retrospectively evaluated. Data obtained from electronic patient medical records included age, sex, body mass index (BMI), medical comorbidities, surgical approach, and presence of deep PJI. There were 3053 male patients (50.1%) and 3033 female patients (49.9%). The mean age and BMI of the entire cohort was 62.7 years (18 to 102, sd 12.3) and 28.8 kg/m2 (13.3 to 57.6, sd 6.1), respectively. Infection rates were calculated yearly for the DA and NA approach groups. Covariates were assessed and used in multivariate analysis to calculate adjusted odds ratios (ORs) for risk of development of PJI with DA compared with NA approaches. In order to determine the effect of adopting a set of infection prevention protocols on PJI, we calculated ORs for PJI comparing patients undergoing THA for two distinct time periods: 2013 to 2014 and 2015 to 2016. These periods corresponded to before and after we implemented a set of perioperative infection protocols. RESULTS There were 1985 patients in the DA group and 4101 patients in the NA group. The overall rate of PJI at our institution during the study period was 0.82% (50/6086) and decreased from 0.96% (12/1245) in 2013 to 0.53% (10/1870) in 2016. There were 24 deep PJIs in the DA group (1.22%) and 26 deep PJIs in the NA group (0.63%; p = 0.023). After multivariate analysis, the DA approach was 2.2 times more likely to result in PJI than the NA approach (OR 2.2 (95% confidence interval 1.1 to 3.9); p = 0.006) for the overall study period. CONCLUSION We found a higher rate of PJI in DA versus NA approaches. Infection prevention protocols such as use of aspirin, dilute povidone-iodine lavage, vancomycin powder, and Gram-negative coverage may have been positively associated with diminished PJI rates observed for all approaches over time. Cite this article: Bone Joint J 2019;101-B(6 Supple B):2-8.
Collapse
Affiliation(s)
- Vinay K Aggarwal
- Department of Orthopaedic Surgery, NYU Langone Medical Center, New York, New York, USA
| | - S Weintraub
- Infection Prevention and Control, Department of Infectious Diseases, NYU Langone Medical Center, New York, New York, USA
| | - J Klock
- Infection Prevention and Control, Department of Infectious Diseases, NYU Langone Medical Center, New York, New York, USA
| | - A Stachel
- Infection Prevention and Control, Department of Infectious Diseases, NYU Langone Medical Center, New York, New York, USA
| | - M Phillips
- Infection Prevention and Control, Department of Infectious Diseases, NYU Langone Medical Center, New York, New York, USA
| | - Ran Schwarzkopf
- Department of Orthopaedic Surgery, NYU Hospital for Joint Diseases, New York, New York, USA
| | - R Iorio
- Department of Orthopaedic Surgery, NYU Hospital for Joint Diseases, New York, New York, USA
| | - J Bosco
- Department of Orthopaedic Surgery, NYU Hospital for Joint Diseases, New York, New York, USA
| | - J D Zuckerman
- Department of Orthopaedic Surgery, NYU Hospital for Joint Diseases, New York, New York, USA
| | - J M Vigdorchik
- Department of Orthopaedic Surgery, NYU Hospital for Joint Diseases, New York, New York, USA
| | - W J Long
- Department of Orthopaedic Surgery, NYU Hospital for Joint Diseases, New York, New York, USA
| |
Collapse
|
42
|
Garrigues GE, Zmistowski B, Cooper AM, Green A. Proceedings from the 2018 International Consensus Meeting on Orthopedic Infections: prevention of periprosthetic shoulder infection. J Shoulder Elbow Surg 2019; 28:S13-S31. [PMID: 31196506 DOI: 10.1016/j.jse.2019.04.017] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Accepted: 04/20/2019] [Indexed: 02/01/2023]
Abstract
The Second International Consensus Meeting on Orthopedic Infections was held in Philadelphia, Pennsylvania, in July 2018. Over 800 international experts from all 9 subspecialties of orthopedic surgery and allied fields of infectious disease, microbiology, and epidemiology were assembled to form a consensus workgroup. The following proceedings on the prevention of periprosthetic shoulder infection come from 16 questions evaluated by delegates from the shoulder section.
Collapse
Affiliation(s)
- Grant E Garrigues
- Division of Sports Medicine, Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, IL, USA.
| | - Benjamin Zmistowski
- Department of Orthopaedic Surgery, Rothman Institute at Thomas Jefferson University, Philadelphia, PA, USA
| | - Alexus M Cooper
- Department of Orthopaedic Surgery, Rothman Institute at Thomas Jefferson University, Philadelphia, PA, USA
| | - Andrew Green
- Division of Shoulder and Elbow Surgery, Department of Orthopaedic Surgery, Warren Alpert Medical School, Brown University, Providence, RI, USA
| |
Collapse
|
43
|
Does Suture Type Influence Bacterial Retention and Biofilm Formation After Irrigation in a Mouse Model? Clin Orthop Relat Res 2019; 477:116-126. [PMID: 30794234 PMCID: PMC6345317 DOI: 10.1097/corr.0000000000000391] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Irrigation and débridement are frequently utilized in the management of surgical infections, but even with aggressive débridement, it is difficult to remove all the suture material from the tissues and retained suture material may harbor bacteria and/or biofilm. The degree to which barbed or braided sutures may differentially influence the risk of infection has not been defined in a well-controlled animal model. QUESTIONS/PURPOSES We compared braided and barbed monofilament sutures after irrigation of an infected mouse air pouch model to determine whether the suture type influenced the effectiveness of the irrigation. After irrigation of infected pouches, sutures were compared for (1) bacterial adherence and bacterial retention; (2) qualitative and quantitative pouch thickness and cellular density; and (3) quantitative biofilm formation. METHODS Soft tissue air pouches were created on the backs of 60 female, mature 10-week-old BALB/cJ mice by sequentially introducing air into the subcutaneous tissue and allowing the pouch to mature. The pouches were inoculated with Staphylococcus aureus and braided or barbed monofilament sutures were implanted. Pouch irrigation was performed Day 7 after suture implantation. Suture segments were collected before and after irrigation. After euthanasia on Day 14, pouch tissues with residual suture segments were collected for analysis: microbiologic analysis done using optical density as a measure of the concentration of bacteria in the culture (the larger concentration indicates higher number of bacteria) and histologic evaluation of the pouch tissues were semiquantitative, whereas environmental scanning electron microscopy (ESEM) and confocal analyses of the biofilm and bacteria on the sutures were qualitative. RESULTS Histologic evaluation of pouch tissue showed all groups had inflammatory responses. Quantitatively microbiology showed no difference in bacterial number calculated from the optical density (OD) values between the two suture materials at any time point in the irrigation group. In the no-irrigation group, for the Day 7 time point, mean (± SD) OD was greater in the barbed than the OD in the braided sutures (0.52 ± 0.12 versus 0.37 ± 0.16, mean difference 0.43 [95% confidence interval, 0.08-0.13]; p = 0.007). Qualitatively, ESEM showed more bacterial retention by braided sutures before and after irrigation. Confocal imaging of the sutures demonstrated penetration of biofilm into the interstices of braided sutures and less adhesion in barbed monofilament sutures. The quantification of the biomass showed no differences between groups at all time points (before-irrigation biomass was 11.2 ± 9.3 for braided versus 5.2 ± 4.7 for barbed sutures, p = 0.196; and after-irrigation biomass was 7.2 ± 7.5 for braided versus 3.3 ± 4.3 for barbed suture, p = 0.259). CONCLUSIONS All sutures can retain bacteria and biofilm, but it is rarely possible to remove all suture material at the time of irrigation to treat infection. After an irrigation procedure, qualitatively braided sutures appeared to harbor more bacteria and to retain more biofilm than barbed monofilaments. CLINICAL RELEVANCE When saline irrigation was used to simulate infection treatment in an infected mouse air pouch model, bacteria/biofilm was not completely eliminated from either braided or barbed monofilament sutures. The irrigation appeared to clear more bacteria and biofilm from the monofilament despite having barbs. Unfortunately, current technologies do not allow direct quantitative comparisons of biofilm retention. Clinicians should be aware that in the face of infection, any retained sutures may harbor bacteria despite irrigation.
Collapse
|
44
|
Koerner JC, George MJ, Kissam EA, Rosco MG. Povidone-iodine concentration and in vitro killing time of bacterial corneal ulcer isolates. Digit J Ophthalmol 2018; 24:24-26. [PMID: 30800010 DOI: 10.5693/djo.01.2018.06.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Background The concentration and dosing of povidone-iodine (PI) solution used in surgical site prophylaxis are variable. Prior in vitro work has demonstrated that dilute PI solutions (<1%) had greater bactericidal activity than stock solutions (10%). Studies using pathologic clinical isolates from the eye have yielded mixed results. The purpose of the current study was to evaluate the efficacy of different concentrations of PI on pathologic ocular surface isolates. Methods We conducted an in vitro microbiology study using clinical isolates from corneal ulcers. Bacteria were recovered from trypticase soy agar with 5% sheep erythrocytes, chocolate agar, and thioglycollate broth media. A standardized concentration of each bacterial sample (1 × 108 cfu/ml) was exposed to various dilutions of PI. Quantitative cultures were performed to determine the number of organisms surviving PI exposure. Results None of the isolates survived exposure to the PI 0.25% solution for 30 seconds. Micrococcus luteus and Staphylococcus aureus survived both 30-second and 1-minute exposure to PI 5% and 10%. The exposure time required to produce no growth was variable with concentrations of <0.25%. In some isolates, the 10% solution was faster than the more dilute solutions (0.1%, 0.05%). Conclusions Our results are consistent with prior in vitro studies of PI, from nonocular sources, and suggest that PI has similar bactericidal action on pathologic bacteria from the ocular surface. In vitro exposure to dilute PI (0.25%) resulted in no growth after 30 seconds, whereas 10% and 5% solutions took longer to kill several of the isolates. Future investigations of PI use in ophthalmology as an antimicrobial agent should include the study of low-concentration PI (0.25%).
Collapse
Affiliation(s)
- Jagger C Koerner
- Department of Ophthalmology, Albany Medical College, Albany, New York
| | - Mary J George
- Department of Microbiology, Albany Medical College, Albany, New York
| | | | | |
Collapse
|
45
|
Taha M, Abdelbary H, Ross FP, Carli AV. New Innovations in the Treatment of PJI and Biofilms-Clinical and Preclinical Topics. Curr Rev Musculoskelet Med 2018; 11:380-388. [PMID: 29926287 PMCID: PMC6105481 DOI: 10.1007/s12178-018-9500-5] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
PURPOSE OF REVIEW Periprosthetic joint infection (PJI) is a devastating complication after total joint replacement. A main source for antibiotic tolerance and treatment failure is bacterial production of biofilm-a resilient barrier against antibiotics, immune system, and mechanical debridement. The purpose of this review is to explore some novel approaches to treat PJI and biofilm-related infections. RECENT FINDINGS Innovative treatment strategies of bacterial and biofilm infections revolve around (a) augmenting current therapies, such as improving the delivery and efficiency of conventional antibiotics and enhancing the efficacy of antiseptics and (b) administrating completely new therapeutic modalities, such as using immunotherapy, nanoparticles, lytic bacteriophages, photodynamic therapy, novel antibiotics, and antimicrobial peptides. Several promising treatment strategies for PJI are available to be tested further. The next requirement for most of the novel treatments is reproducing their effects in clinically representative animal models of PJI against clinical isolates of relevant bacteria.
Collapse
Affiliation(s)
- Mariam Taha
- Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Division of Orthopedic Surgery Ottawa, The Ottawa Hospital, Ottawa, ON, Canada
| | - Hesham Abdelbary
- Division of Orthopedic Surgery Ottawa, The Ottawa Hospital, Ottawa, ON, Canada
| | - F Patrick Ross
- Hospital for Special Surgery, 535 E 70th St, New York, NY, 10021, USA
| | - Alberto V Carli
- Division of Orthopedic Surgery Ottawa, The Ottawa Hospital, Ottawa, ON, Canada.
- Hospital for Special Surgery, 535 E 70th St, New York, NY, 10021, USA.
| |
Collapse
|
46
|
Zaruta DA, Qiu B, Liu AY, Ricciardi BF. Indications and Guidelines for Debridement and Implant Retention for Periprosthetic Hip and Knee Infection. Curr Rev Musculoskelet Med 2018; 11:347-356. [PMID: 29869769 PMCID: PMC6105472 DOI: 10.1007/s12178-018-9497-9] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
PURPOSE OF REVIEW Prosthetic joint infection is one the most common causes of revision surgery after hip or knee replacement. Debridement and implant retention (DAIR) is one method of treating these infections; however, significant controversy exists. The purpose of our review was to describe current knowledge about indications, intraoperative/postoperative patient management, and outcomes of DAIR. RECENT FINDINGS Patient selection affects the success of DAIR. Medical comorbidities, duration of symptoms, and nature of infectious organism all influence outcomes. Intraoperative techniques such as open arthrotomy, extensive debridement, copious irrigation, and exchange of modular parts remain current standards for DAIR. Postoperative administration of antibiotics tailored to operative cultures remains critical. Antibiotic suppression may increase the success of DAIR. DAIR provides reasonable infection eradication between 50 and 80% with improved outcomes in appropriately selected patients. More research is needed on the use of adjuvant therapies intraoperatively and the role of postoperative antibiotic suppression.
Collapse
Affiliation(s)
- Douglas A Zaruta
- Department of Orthopedic Surgery, University of Rochester School of Medicine, Highland Hospital, 1000 South Avenue, Rochester, NY, 14620, USA
| | - Bowen Qiu
- Department of Orthopedic Surgery, University of Rochester School of Medicine, Highland Hospital, 1000 South Avenue, Rochester, NY, 14620, USA
| | - Andrew Y Liu
- Department of Orthopedic Surgery, University of Rochester School of Medicine, Highland Hospital, 1000 South Avenue, Rochester, NY, 14620, USA
| | - Benjamin F Ricciardi
- Department of Orthopedic Surgery, University of Rochester School of Medicine, Highland Hospital, 1000 South Avenue, Rochester, NY, 14620, USA.
| |
Collapse
|