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Yendluri A, Gonzalez C, Cordero JK, Hayden BL, Moucha CS, Parisien RL. Statistical Outcomes Guiding Periprosthetic Joint Infection Prevention and Revision Are Fragile: A Systematic Review of Randomized Controlled Trials. J Arthroplasty 2024; 39:1869-1875. [PMID: 38331358 DOI: 10.1016/j.arth.2024.01.059] [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: 06/18/2023] [Revised: 01/26/2024] [Accepted: 01/29/2024] [Indexed: 02/10/2024] Open
Abstract
BACKGROUND Dichotomous outcomes are frequently reported in orthopaedic research and have substantial clinical implications. This study utilizes the fragility index (FI) and fragility quotient (FQ) metrics to determine the statistical stability of outcomes reported in total joint arthroplasty randomized controlled trials (RCTs) relating to periprosthetic joint infection (PJI). METHODS The RCTs that reported dichotomous data related to PJI published between January 1, 2010, and December 31, 2022, were evaluated. The FI and reverse FI (RFI) were defined as the number of outcome event reversals required to reverse the significance of significant and nonsignificant outcomes, respectively. The FQ was determined by dividing the FI or RFI by the respective sample size. There were 108 RCTs screened, and 17 studies included for analysis. RESULTS A total of 58 outcome events were identified, with a median FI of 4 (interquartile range [IQR] 2 to 5) and associated FQ of 0.0417 (IQR 0.0145 to 0.0602). The 13 statistically significant outcomes had a median FI of 1 (IQR 1 to 2) and FQ of 0.00935 (IQR 0.00629 to 0.01410). The 45 nonsignificant outcomes had a median RFI of 4 (IQR 3 to 5) and FQ of 0.05 (IQR 0.0361 to 0.0723). The number of patients lost to follow-up was greater than or equal to the FI in 46.6% of outcomes. CONCLUSIONS Statistical outcomes in RCTs analyzing PJI are fragile and may lack statistical integrity. We recommend a comprehensive fragility analysis, with the reporting of FI and FQ metrics, to aid in the interpretation of outcomes in the total joint arthroplasty literature.
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Affiliation(s)
- Avanish Yendluri
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Christopher Gonzalez
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - John K Cordero
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Brett L Hayden
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Calin S Moucha
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Robert L Parisien
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, New York
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Plesniar J, Breit HC, Clauss M, Donners R. Diagnosing periprosthetic hip joint infection with new-generation 0.55T MRI. Eur J Radiol 2024; 176:111524. [PMID: 38851014 DOI: 10.1016/j.ejrad.2024.111524] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2024] [Revised: 05/06/2024] [Accepted: 05/21/2024] [Indexed: 06/10/2024]
Abstract
PURPOSE To assess the accuracy of 0.55 T MRI in diagnosing periprosthetic joint infection (PJI) in patients with symptomatic total hip arthroplasty (THA). MATERIAL AND METHODS 0.55 T MRI of patients with THA PJI (Group A) and noninfected THA (Group B), including aseptic loosening (Group C, subgroup of B) performed between May 2021 and July 2023 were analysed retrospectively. Two musculoskeletal fellowship-trained radiologists independently identified MRI bone and soft tissue changes including: marrow oedema, periosteal reaction, osteolysis, joint effusion, capsule oedema and thickening, fluid collections, muscle oedema, bursitis, inguinal adenopathy, and muscle tears. The diagnostic performance of MRI discriminators of PJI was evaluated using Fisher's exact test (p < 0.05) and interrater reliability was determined. 61 MRI scans from 60 THA patients (34 female, median age 68, range 41-93 years) in Group A (n = 9; female 4; median age 69, range 56-82 years), B (n = 51; 30; 67.5, 41-93 years), and C (10; 6; 67; 41-82 years) were included. RESULTS Capsule oedema (sensitivity 89 %, specificity 92 %,), intramuscular oedema (89 %, 82 %) and joint effusion (89 %, 73 %) were the best performing discriminators for PJI diagnosis (p ≤ 0.001), when viewed individually and had combined 70 % sensitivity and 100 % specificity for PJI diagnosis in parallel testing. For the differentiation between PJI and aseptic loosening, intramuscular oedema (89 %, 80 %) and capsule oedema (89 %, 80 %) were significant discriminators (p ≤ 0.001) with combined 64 % sensitivity and 96 % specificity for PJI. CONCLUSIONS New generation 0.55 T MRI may aid in the detection of PJI in symptomatic patients. Oedema of the joint capsule, adjacent muscles as well as joint effusion were indicative of the presence of PJI.
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Affiliation(s)
- Jan Plesniar
- Department of Radiology, University Hospital Basel, Basel, Switzerland; University of Basel, Basel, Switzerland.
| | | | - Martin Clauss
- Department for Orthopaedics and Trauma Surgery, University Hospital Basel, Basel, Switzerland; Center For Muskuloskeletal Infections (ZMSI), University Hospital Basel, Basel, Switzerland
| | - Ricardo Donners
- Department of Radiology, University Hospital Basel, Basel, Switzerland; University of Basel, Basel, Switzerland
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Verheul M, Mulder AA, van Dun SCJ, Merabishvili M, Nelissen RGHH, de Boer MGJ, Pijls BG, Nibbering PH. Bacteriophage ISP eliminates Staphylococcus aureus in planktonic phase, but not in the various stages of the biofilm cycle. Sci Rep 2024; 14:14374. [PMID: 38909125 DOI: 10.1038/s41598-024-65143-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Accepted: 06/17/2024] [Indexed: 06/24/2024] Open
Abstract
Metal-implant associated bacterial infections are a major clinical problem due to antibiotic treatment failure. As an alternative, we determined the effects of bacteriophage ISP on clinical isolates of Staphylococcus aureus in various stages of its life cycle in relation to biofilm formation and maturation. ISP effectively eliminated all planktonic phase bacteria, whereas its efficacy was reduced against bacteria attached to the metal implant and bacteria embedded within biofilms. The biofilm architecture hampered the bactericidal effects of ISP, as mechanical disruption of biofilms improved the efficacy of ISP against the bacteria. Phages penetrated the biofilm and interacted with the bacteria throughout the biofilm. However, most of the biofilm-embedded bacteria were phage-tolerant. In agreement, bacteria dispersed from mature biofilms of all clinical isolates, except for LUH15394, tolerated the lytic activity of ISP. Lastly, persisters within mature biofilms tolerated ISP and proliferated in its presence. Based on these findings, we conclude that ISP eliminates planktonic phase Staphylococcus aureus while its efficacy is limited against bacteria attached to the metal implant, embedded within (persister-enriched) biofilms, and dispersed from biofilms.
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Affiliation(s)
- Mariëlle Verheul
- Department of Infectious Diseases, Leiden University Medical Center, 2300RC, Leiden, The Netherlands.
- Department of Orthopedics, Leiden University Medical Center, 2300RC, Leiden, The Netherlands.
| | - Aat A Mulder
- Department of Cell and Chemical Biology, Electron Microscopy Facility, Leiden University Medical Center, 2300RC, Leiden, The Netherlands
| | - Sven C J van Dun
- Department of Infectious Diseases, Leiden University Medical Center, 2300RC, Leiden, The Netherlands
- Department of Orthopedics, Leiden University Medical Center, 2300RC, Leiden, The Netherlands
| | - Maia Merabishvili
- Laboratory for Molecular and Cellular Technology, Queen Astrid Military Hospital, Brussels, Belgium
| | - Rob G H H Nelissen
- Department of Orthopedics, Leiden University Medical Center, 2300RC, Leiden, The Netherlands
| | - Mark G J de Boer
- Department of Infectious Diseases, Leiden University Medical Center, 2300RC, Leiden, The Netherlands
| | - Bart G Pijls
- Department of Orthopedics, Leiden University Medical Center, 2300RC, Leiden, The Netherlands
| | - Peter H Nibbering
- Department of Infectious Diseases, Leiden University Medical Center, 2300RC, Leiden, The Netherlands
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Russo A, Camacho Uribe A, Abuljadail S, Bokhari A, Gehrke T, Citak M. Excellent Survival Rate of Cemented Modular Stems in One-Stage Revision for Periprosthetic Hip Infections With Massive Femoral Bone Loss: A Retrospective Single-Center Analysis of 150 Cases. J Arthroplasty 2024; 39:1577-1582. [PMID: 38072095 DOI: 10.1016/j.arth.2023.12.006] [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: 08/18/2023] [Revised: 12/02/2023] [Accepted: 12/04/2023] [Indexed: 12/30/2023] Open
Abstract
BACKGROUND With the increasing incidence of total hip arthroplasty (THA), there is also an expected concurrent increase in revision THA (rTHA), which is known to have a high complication and re-revision rate. In the setting of infection, radical debridement is essential and options for femoral bone loss are limited. One viable solution is cemented modular stems, but limited evidence exists on their use in septic revision. This study aimed to analyze survival and complication related to the use of cemented modular stems in one-stage septic rTHA with severe femoral bone loss. METHODS The institutional database of patients who underwent rTHA for septic one-stage revision with cemented modular stems was reviewed. Exclusion criteria were patients aged less than 18 years and nonseptic or 2 stage revisions. Outcomes measured were complication, re-infection, re-operation, and survivorship of the implant. A total of 150 patients were included. The mean age was 68 years (range, 30 to 91), and the mean follow-up was 105 months (range, 1 to 150). RESULTS Treatment was considered successful in 81.3% of cases. Patients who underwent multiple prior surgeries demonstrated a lower rate of treatment success (P < .001). The main cause of failure was re-infection (11 of 28). Among cases failed for aseptic reasons (17 of 28), loosening of the cemented modular stem was the cause of re-revision in 2 patients (1.3%). CONCLUSIONS The use of modular cemented stems is a viable option in case of septic one-stage rTHA associated with severe femoral bone loss. However, surgeons and patients should be aware that this treatment is still characterized by a high rate of complications, which may lead to further surgeries. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Antonio Russo
- Helios ENDO-Klinik, Holsenstraße 2, Hamburg, Germany; Department of Surgical Sciences, University of Turin, Turin, Italy
| | - Abelardo Camacho Uribe
- Helios ENDO-Klinik, Holsenstraße 2, Hamburg, Germany; Universidad del Rosario, Bogotá, Colombia; Departamento de Ortopedia y Traumatología Hospital, Universitario Fundación Santa Fe de Bogotá, Bogotá, Colombia
| | - Salahulddin Abuljadail
- Helios ENDO-Klinik, Holsenstraße 2, Hamburg, Germany; King Faisal University, College of Medicine, Hofuf, Ahsa, Saudi Arabia
| | - Ali Bokhari
- Helios ENDO-Klinik, Holsenstraße 2, Hamburg, Germany
| | | | - Mustafa Citak
- Helios ENDO-Klinik, Holsenstraße 2, Hamburg, Germany
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Strassburg A, Weber AT, Kluba T. Implementation of Outpatient Parenteral Antimicrobial Therapy (OPAT) in Patients with Complicated Periprosthetic Joint Infections. ZEITSCHRIFT FUR ORTHOPADIE UND UNFALLCHIRURGIE 2024. [PMID: 38802072 DOI: 10.1055/a-2288-7187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/29/2024]
Abstract
Periprosthetic joint infections (PJI) are a serious complication of arthroplasty with high morbidity. With growing bacterial resistance and limited disposability of oral antibiotics with sufficient bioavailability, the need for intravenous antibiotic application is raising. This causes long-term hospital stays and rising costs. In the course of transferring procedures into an outpatient setting as well as coping with pressures on hospital capacity, outpatient parenteral antimicrobial therapy (OPAT) can build a bridge for the treatment of such infections.In a single centre analysis, 47 cases treated with OPAT were studied in relation to pathogen, antimicrobial resistance, indication for OPAT and follow up. Furthermore, the patients received an anonymised questionnaire with 4 clusters of interest in terms of internal quality assessment on the success and evaluation of this therapeutic procedure. Special attention was paid to the descriptive analysis of patients with periprosthetic joint infections (n = 30).Between May 2021 and October 2022 out of 47 patients with OPAT, 30 cases with periprosthetic joint infections were identified. For infected hip- and knee arthroplasties, a remarkable spectrum of pathogens was found. In hip infections highly resistant strains of Staphylococcus epidermidis and Enterococci were detected. In knee infections, the pathogens were more susceptible, but however highly virulent Staphylococcus aureus and Streptococci. Difficult to treat, mixed infections were found in both locations. The indication for OPAT was based in half of the cases on the high level of antimicrobial resistance, with availability of only parenteral applicable antibiotics. Further indications were mixed infections and difficult to treat pathogens, with flucloxacillin therapy as well as OPAT as the last therapeutic option. The questionnaire showed 96% patient satisfaction in terms of organisation and acceptance of this kind of therapy. Complications or unexpected outpatient/ hospital treatments were very rare in connection with OPAT. Two thirds of patients reported completion of the treatment. In the clinical follow up (average of 5.7 months), 96.6% of cases were declared free of infection. In one patient the infection persisted.OPAT is a safe and reliable therapeutic option for outpatients to continue parenteral antimicrobial treatment in joint infections. Due to increasing pressure on hospitals in terms of costs and capacity, this therapy offers an alternative to inpatient treatment. The indication for OPAT should be set individually, risk adjusted and not generalised for all patients. The outpatient sector needs financial and structural support for comprehensive roll-out of this treatment in Germany. A further focus should be on the prevention of periprosthetic joint infections. With the knowledge of the expected pathogens and the surgical resources, the standards should be adapted. The choice of the antibiotic should be specified and the intervals of application be shortened, according to the surgical course, in order to yield high levels of agent concentration in the surgical area. Further investigations are required to test the superiority of OPAT versus the oral administration of antibiotics in long-term observations as well as to define the necessary duration of OPAT.
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Affiliation(s)
- Anne Strassburg
- Klinik für Orthopädie und Orthopädische Chirurgie, Städtisches Klinikum Dresden Friedrichstadt, Dresden, Deutschland
| | - Andreas T Weber
- Klinik für Orthopädie und Orthopädische Chirurgie, Städtisches Klinikum Dresden Friedrichstadt, Dresden, Deutschland
| | - Torsten Kluba
- Klinik für Orthopädie und Orthopädische Chirurgie, Städtisches Klinikum Dresden Friedrichstadt, Dresden, Deutschland
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Karau MJ, Alarcon Perico D, Guarin Perez SF, Koscianski C, Abdel MP, Patel R, Bedard NA. Duration of cefazolin prophylaxis did not impact infection risk in a murine model of joint arthroplasty. J Orthop Res 2024. [PMID: 38796743 DOI: 10.1002/jor.25903] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2024] [Revised: 04/22/2024] [Accepted: 05/10/2024] [Indexed: 05/28/2024]
Abstract
To minimize periprosthetic joint infection (PJI) risk, some clinicians prescribe extended antibiotic prophylaxis (EAP) following total joint arthroplasty (TJA). Given the limited evidence supporting EAP, we sought to evaluate impact of prophylactic antibiotic duration on PJI risk in a murine TJA model. A titanium prosthesis was implanted into the proximal tibia of 89 mice and inoculated with 102 colony forming units (cfu) of Staphylococcus aureus Xen36. Control mice (n = 20) did not receive antibiotics. Treated mice received either 24 h (n = 35) or 4 days (n = 34) of cefazolin prophylaxis. Cultures were obtained from the prostheses, tibia, femur, and knee tissues 3 weeks after surgery. All mice in the control group developed PJI. Both prophylaxis regimens reduced the rate of PJI relative to the control, with only 2/35 mice in the 24-h cohort (p < 0.0001) and 1/34 in 4-day cohort developing PJI (p < 0.0001). CFU counts from the prostheses, bone and knee tissues were reduced for the 24-h and 4-day prophylaxis cohorts relative to the control (p < 0.0001 for both). There was no difference in rates of PJI or CFU counts between the two prophylaxis cohorts (p = 0.58). Prophylactic cefazolin profoundly reduced rates of PJI in a murine model of TJA in which all control animals developed PJI. Extending cefazolin prophylaxis duration from 24 h to 4 days did not result in improved PJI rates or decreased bacterial loads in infected cases. While these results strongly support use of antibiotic prophylaxis for TJA, EAP did not appear to add benefit in the described mouse model.
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Affiliation(s)
- Melissa J Karau
- Department of Laboratory Medicine and Pathology, Division of Clinical Microbiology, Rochester, Minnesota, USA
| | | | | | - Christina Koscianski
- Department of Laboratory Medicine and Pathology, Division of Clinical Microbiology, Rochester, Minnesota, USA
| | - Matthew P Abdel
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Robin Patel
- Department of Laboratory Medicine and Pathology, Division of Clinical Microbiology, Rochester, Minnesota, USA
- Department of Medicine, Division of Public Health, Infectious Diseases, and Occupational Medicine, Rochester, Minnesota, USA
| | - Nicholas A Bedard
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
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Schaffler BC, Longwell M, Byers B, Kreft R, Ramot R, Ramot Y, Schwarzkopf R. Nanoparticle ultrasonication outperforms conventional irrigation solutions in eradicating Staphylococcus aureus biofilm from titanium surfaces: an in vitro study. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2024:10.1007/s00590-024-03982-y. [PMID: 38761198 DOI: 10.1007/s00590-024-03982-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/15/2024] [Accepted: 04/29/2024] [Indexed: 05/20/2024]
Abstract
PURPOSE Bacterial biofilms create a challenge in the treatment of prosthetic joint infection (PJI), and failure to eradicate biofilms is often implicated in the high rates of recurrence. In this study, we aimed to compare the effectiveness of a novel nanoparticle ultrasonication technology on Staphylococcus aureus biofilm eradication compared to commonly used orthopedic irrigation solutions. METHODS Twenty-four sterile, titanium alloy discs were inoculated with a standardized concentration of methicillin-resistant S. aureus and cultured for seven days to allow for biofilm formation. Discs were then treated with either ultrasonicated nanoparticle therapy or irrigation with chlorhexidine gluconate, povidone-iodine or normal saline. The remaining bacteria on each surface was subsequently plated for colony-forming units of S. aureus. Bacterial eradication was reported as a decrease in CFUs relative to the control group. Mann-Whitney U tests were used to compare between groups. RESULTS Treatment with ultrasonicated nanoparticles resulted in a significant mean decrease in CFUs of 99.3% compared to controls (p < 0.0001). Irrigation with povidone-iodine also resulted in a significant 77.5% reduction in CFUs compared to controls (p < 0.0001). Comparisons between ultrasonicated nanoparticles and povidone-iodine demonstrated a significantly higher reduction in bacterial CFUs in the nanoparticle group (p < 0.0001). CONCLUSION Ultrasonicated nanoparticle were superior to commonly used bactericidal irrigation solutions in the eradication of S. aureus from a titanium surface. Future clinical studies are warranted to evaluate this ultrsonication technology in the treatment of PJI.
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Affiliation(s)
- Benjamin C Schaffler
- Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, 301 East 17Th Street, New York, NY, 10003, USA
| | - Mark Longwell
- Center for Excellence in Biofilm Research, Allegheny Health Network Research Institute, Pittsburgh, PA, USA
| | - Barbara Byers
- Center for Excellence in Biofilm Research, Allegheny Health Network Research Institute, Pittsburgh, PA, USA
| | - Rachel Kreft
- Center for Excellence in Biofilm Research, Allegheny Health Network Research Institute, Pittsburgh, PA, USA
| | - Roi Ramot
- Center for Excellence in Biofilm Research, Allegheny Health Network Research Institute, Pittsburgh, PA, USA
| | - Yair Ramot
- Center for Excellence in Biofilm Research, Allegheny Health Network Research Institute, Pittsburgh, PA, USA
| | - Ran Schwarzkopf
- Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, 301 East 17Th Street, New York, NY, 10003, USA.
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Appleton L, Barnes J, Ray H, Thompson J, Zychowicz M. Nicotine Screening and Cessation Education Among Patients Awaiting Total Joint Arthroplasty: A Quality Improvement Project. Orthop Nurs 2024; 43:141-150. [PMID: 38861744 DOI: 10.1097/nor.0000000000001027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/13/2024] Open
Abstract
Orthopedic surgical patients who use nicotine are at a high risk for postoperative complications including infection, respiratory failure, cardiac arrest, and death. Periprosthetic joint infections may result from nicotine-induced immunosuppression and microvascular changes, increasing perioperative morbidity and mortality. These complications result in higher health care costs, increased length of stay, and loss of reimbursement due to readmissions. Four weeks of nicotine cessation prior to arthroplasty decreases these risks; however, perioperative teams may lack reliable nicotine screening and cessation education methods. This project identified inconsistencies in nicotine screening and cessation counseling in the preoperative setting, which contributed to surgery cancellations among patients who required to demonstrate nicotine cessation preoperatively. Standardization of preoperative nicotine screening and patient cessation education resources can improve the identification of orthopedic patients who use nicotine and provide concrete, proven methods of achieving nicotine cessation prior to elective primary arthroplasty. Investment from perioperative staff is essential to ensure success.
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Affiliation(s)
- Lindsay Appleton
- Lindsay Appleton, DNP, AGACNP-BC, RN-BC, CEN, Nurse Practitioner, Novant Health Inpatient Care Services, Charlotte, North Carolina
- Joshua Barnes, DNP, APRN, FNP-BC, NP-C, CCRN, CNEn, Nurse Practitioner, Novant Health Inpatient Care Services, Charlotte, North Carolina
- Hollis Ray, MD, DFPM, FHM, Clinical Physician Executive, Novant Health Surgical Institute, Charlotte, North Carolina
- Julie Thompson, PhD, Research Scientist and Consulting Associate, at Duke University School of Nursing, Durham, North Carolina
- Michael Zychowicz, DNP, ANP, ONP, FAAN, FAANP, Clinical Professor, at Duke University School of Nursing, Durham, North Carolina
| | - Joshua Barnes
- Lindsay Appleton, DNP, AGACNP-BC, RN-BC, CEN, Nurse Practitioner, Novant Health Inpatient Care Services, Charlotte, North Carolina
- Joshua Barnes, DNP, APRN, FNP-BC, NP-C, CCRN, CNEn, Nurse Practitioner, Novant Health Inpatient Care Services, Charlotte, North Carolina
- Hollis Ray, MD, DFPM, FHM, Clinical Physician Executive, Novant Health Surgical Institute, Charlotte, North Carolina
- Julie Thompson, PhD, Research Scientist and Consulting Associate, at Duke University School of Nursing, Durham, North Carolina
- Michael Zychowicz, DNP, ANP, ONP, FAAN, FAANP, Clinical Professor, at Duke University School of Nursing, Durham, North Carolina
| | - Hollis Ray
- Lindsay Appleton, DNP, AGACNP-BC, RN-BC, CEN, Nurse Practitioner, Novant Health Inpatient Care Services, Charlotte, North Carolina
- Joshua Barnes, DNP, APRN, FNP-BC, NP-C, CCRN, CNEn, Nurse Practitioner, Novant Health Inpatient Care Services, Charlotte, North Carolina
- Hollis Ray, MD, DFPM, FHM, Clinical Physician Executive, Novant Health Surgical Institute, Charlotte, North Carolina
- Julie Thompson, PhD, Research Scientist and Consulting Associate, at Duke University School of Nursing, Durham, North Carolina
- Michael Zychowicz, DNP, ANP, ONP, FAAN, FAANP, Clinical Professor, at Duke University School of Nursing, Durham, North Carolina
| | - Julie Thompson
- Lindsay Appleton, DNP, AGACNP-BC, RN-BC, CEN, Nurse Practitioner, Novant Health Inpatient Care Services, Charlotte, North Carolina
- Joshua Barnes, DNP, APRN, FNP-BC, NP-C, CCRN, CNEn, Nurse Practitioner, Novant Health Inpatient Care Services, Charlotte, North Carolina
- Hollis Ray, MD, DFPM, FHM, Clinical Physician Executive, Novant Health Surgical Institute, Charlotte, North Carolina
- Julie Thompson, PhD, Research Scientist and Consulting Associate, at Duke University School of Nursing, Durham, North Carolina
- Michael Zychowicz, DNP, ANP, ONP, FAAN, FAANP, Clinical Professor, at Duke University School of Nursing, Durham, North Carolina
| | - Michael Zychowicz
- Lindsay Appleton, DNP, AGACNP-BC, RN-BC, CEN, Nurse Practitioner, Novant Health Inpatient Care Services, Charlotte, North Carolina
- Joshua Barnes, DNP, APRN, FNP-BC, NP-C, CCRN, CNEn, Nurse Practitioner, Novant Health Inpatient Care Services, Charlotte, North Carolina
- Hollis Ray, MD, DFPM, FHM, Clinical Physician Executive, Novant Health Surgical Institute, Charlotte, North Carolina
- Julie Thompson, PhD, Research Scientist and Consulting Associate, at Duke University School of Nursing, Durham, North Carolina
- Michael Zychowicz, DNP, ANP, ONP, FAAN, FAANP, Clinical Professor, at Duke University School of Nursing, Durham, North Carolina
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Wildeman P, Rolfson O, Wretenberg P, Nåtman J, Gordon M, Söderquist B, Lindgren V. Effect of a national infection control programme in Sweden on prosthetic joint infection incidence following primary total hip arthroplasty: a cohort study. BMJ Open 2024; 14:e076576. [PMID: 38684253 PMCID: PMC11086449 DOI: 10.1136/bmjopen-2023-076576] [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: 06/15/2023] [Accepted: 03/01/2024] [Indexed: 05/02/2024] Open
Abstract
OBJECTIVES Prosthetic joint infection (PJI) is a serious complication following total hip arthroplasty (THA) entailing increased mortality, decreased quality of life and high healthcare costs.The primary aim was to investigate whether the national project: Prosthesis Related Infections Shall be Stopped (PRISS) reduced PJI incidence after primary THA; the secondary aim was to evaluate other possible benefits of PRISS, such as shorter time to diagnosis. DESIGN Cohort study. SETTING In 2009, a nationwide, multidisciplinary infection control programme was launched in Sweden, PRISS, which aimed to reduce the PJI burden by 50%. PARTICIPANTS We obtained data on patients undergoing primary THA from the Swedish Arthroplasty Registry 2012-2014, (n=45 723 patients, 49 946 THAs). Using personal identity numbers, this cohort was matched with the Swedish Prescribed Drug Registry. Medical records of patients with ≥4 weeks' antibiotic consumption were reviewed to verify PJI diagnosis (n=2240, 2569 THAs). RESULTS The cumulative incidence of PJI following the PRISS Project was 1.2% (95% CI 1.1% to 1.3%) as compared with 0.9% (95% CI 0.8% to 1.0%) before. Cox regression models for the PJI incidence post-PRISS indicates there was no statistical significance difference versus pre-PRISS (HR 1.1 (95% CI 0.9 to 1.3)). There was similar time to PJI diagnosis after the PRISS Project 24 vs 23 days (p=0.5). CONCLUSIONS Despite the comprehensive nationwide PRISS Project, Swedish PJI incidence was higher after the project and time to diagnosis remained unchanged. Factors contributing to PJI, such as increasing obesity, higher American Society of Anesthesiology class and more fractures as indications, explain the PJI increase among primary THA patients.
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Affiliation(s)
- Peter Wildeman
- Department of Orthopedics, Faculty of Medicine and Health, Orebro University, Orebro, Sweden
| | - Ola Rolfson
- Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Swedish Arthroplasty Register, Registercentrum Vastra Gotaland, Gothenburg, Sweden
| | - Per Wretenberg
- Department of Orthopedics, Faculty of Medicine and Health, Orebro University, Orebro, Sweden
| | - Jonatan Nåtman
- Swedish Arthroplasty Register, Registercentrum Vastra Gotaland, Gothenburg, Sweden
| | - Max Gordon
- Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Bo Söderquist
- School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Orebro, Sweden
- Department of Infectious Diseases, Faculty of Medicine and Health, Orebro University, Orebro, Sweden
| | - Viktor Lindgren
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
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Reinhard J, Lang S, Walter N, Schindler M, Bärtl S, Szymski D, Alt V, Rupp M. In-hospital mortality of patients with periprosthetic joint infection. Bone Jt Open 2024; 5:367-373. [PMID: 38663864 PMCID: PMC11045279 DOI: 10.1302/2633-1462.54.bjo-2023-0162.r1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/29/2024] Open
Abstract
Aims Periprosthetic joint infection (PJI) demonstrates the most feared complication after total joint replacement (TJR). The current work analyzes the demographic, comorbidity, and complication profiles of all patients who had in-hospital treatment due to PJI. Furthermore, it aims to evaluate the in-hospital mortality of patients with PJI and analyze possible risk factors in terms of secondary diagnosis, diagnostic procedures, and complications. Methods In a retrospective, cross-sectional study design, we gathered all patients with PJI (International Classification of Diseases (ICD)-10 code: T84.5) and resulting in-hospital treatment in Germany between 1 January 2019 and 31 December 2022. Data were provided by the Institute for the Hospital Remuneration System in Germany. Demographic data, in-hospital deaths, need for intensive care therapy, secondary diagnosis, complications, and use of diagnostic instruments were assessed. Odds ratios (ORs) with 95% confidence intervals (CIs) for in-hospital mortality were calculated. Results A total of 52,286 patients were included, of whom 1,804 (3.5%) died. Hypertension, diabetes mellitus, and obesity, the most frequent comorbidities, were not associated with higher in-hospital mortality. Cardiac diseases as atrial fibrillation, cardiac pacemaker, or three-vessel coronary heart disease showed the highest risk for in-hospital mortality. Postoperative anaemia occurred in two-thirds of patients and showed an increased in-hospital mortality (OR 1.72; p < 0.001). Severe complications, such as organ failure, systemic inflammatory response syndrome (SIRS), or septic shock syndrome showed by far the highest association with in-hospital mortality (OR 39.20; 95% CI 33.07 to 46.46; p < 0.001). Conclusion These findings highlight the menace coming from PJI. It can culminate in multi-organ failure, SIRS, or septic shock syndrome, along with very high rates of in-hospital mortality, thereby highlighting the vulnerability of these patients. Particular attention should be paid to patients with cardiac comorbidities such as atrial fibrillation or three-vessel coronary heart disease. Risk factors should be optimized preoperatively, anticoagulant therapy stopped and restarted on time, and sufficient patient blood management should be emphasized.
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Affiliation(s)
- Jan Reinhard
- Department of Orthopaedic Surgery, University Medical Center Regensburg, Regensburg, Germany
- Department of Trauma Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Siegmund Lang
- Department of Trauma Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Nike Walter
- Department of Trauma Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Melanie Schindler
- Department of Trauma Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Susanne Bärtl
- Department of Trauma Surgery, University Medical Center Regensburg, Regensburg, Germany
- Center for Musculoskeletal Surgery, Charité – University Medicine Berlin, Berlin, Germany
| | - Dominik Szymski
- Department of Trauma Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Volker Alt
- Department of Trauma Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Markus Rupp
- Department of Trauma Surgery, University Medical Center Regensburg, Regensburg, Germany
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11
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Bhanushali A, Tran L, Nairne-Nagy J, Bereza S, Callary SA, Atkins G, Ramasamy B, Solomon LB. Patient-Related Predictors of Treatment Failure After Two-Stage Total Hip Arthroplasty Revision for Periprosthetic Joint Infection: A Systematic Review and Meta-Analysis. J Arthroplasty 2024:S0883-5403(24)00376-0. [PMID: 38677343 DOI: 10.1016/j.arth.2024.04.053] [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: 11/05/2023] [Revised: 04/16/2024] [Accepted: 04/18/2024] [Indexed: 04/29/2024] Open
Abstract
BACKGROUND Periprosthetic joint infection (PJI) treatment has high failure rates even after 2-stage revision. Risk factors for treatment failure (TF) after staged revision for PJI are not well defined, nor is it well established how they correlate with the risks of developing an index PJI. Identifying modifiable risk factors may allow preoperative optimization, while identifying nonmodifiable risk factors can influence surgical options or advise against further surgery. We performed a systematic review and meta-analysis to better define predictors of TF in 2-stage revision for PJI. METHODS The PubMed, Embase, and Scopus databases were searched from their inception in December 1976 to April 15, 2023. Studies comparing patient-related variables between patients successfully treated who had 2-staged revision total hip arthroplasty (THA) and patients with persistent infections were included. Studies were screened, and 2 independent reviewers extracted data, while a third resolved discrepancies. Meta-analysis was performed on these data. There were 10,052 unique studies screened, and 21 studies met the inclusion criteria for data extraction. RESULTS There was good-quality evidence that obesity, liver cirrhosis, and previous failed revisions for PJI are nonmodifiable risk factors, while intravenous drug use (IVDU) and smoking are modifiable risk factors for TF after 2-stage revision for hip PJI. Reoperation between revision stages was also significantly associated with an increased risk of TF. Interestingly, other risk factors for an index PJI including male gender, American Society of Anesthesiology score, diabetes mellitus, and inflammatory arthropathy did not predict TF. Evidence on Charlson Comorbidity Index was limited. CONCLUSIONS Patients with a smoking history, obesity, IVDU, previous failed revision for PJI, reoperation between stages, and liver cirrhosis are more likely to experience TF after 2-stage revision THA for PJI. Modifiable risk factors include smoking and IVDU and these patients should be referred to services for cessation as early as possible before 2-stage revision THA.
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Affiliation(s)
- Ameya Bhanushali
- Department of Orthopaedics and Trauma, Royal Adelaide Hospital, Adelaide, South Australia, Australia; The University of Adelaide, Faculty of Health and Medical Sciences, Adelaide, South Australia, Australia
| | - Liem Tran
- Department of Orthopaedics and Trauma, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Jaiden Nairne-Nagy
- Department of Orthopaedics and Trauma, Royal Adelaide Hospital, Adelaide, South Australia, Australia; The University of Adelaide, Faculty of Health and Medical Sciences, Adelaide, South Australia, Australia
| | - Samuel Bereza
- Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Stuart A Callary
- Department of Orthopaedics and Trauma, Royal Adelaide Hospital, Adelaide, South Australia, Australia; The University of Adelaide, Faculty of Health and Medical Sciences, Adelaide, South Australia, Australia
| | - Gerald Atkins
- Department of Orthopaedics and Trauma, Royal Adelaide Hospital, Adelaide, South Australia, Australia; The University of Adelaide, Faculty of Health and Medical Sciences, Adelaide, South Australia, Australia
| | - Boopalan Ramasamy
- Department of Orthopaedics and Trauma, Royal Adelaide Hospital, Adelaide, South Australia, Australia; The University of Adelaide, Faculty of Health and Medical Sciences, Adelaide, South Australia, Australia
| | - Lucian B Solomon
- Department of Orthopaedics and Trauma, Royal Adelaide Hospital, Adelaide, South Australia, Australia; The University of Adelaide, Faculty of Health and Medical Sciences, Adelaide, South Australia, Australia
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Suardi V, Baroni D, Shahein AHA, Morena V, Logoluso N, Mangiavini L, Pellegrini AV. Microbiology of Prosthetic Joint Infections: A Retrospective Study of an Italian Orthopaedic Hospital. Antibiotics (Basel) 2024; 13:399. [PMID: 38786128 PMCID: PMC11117340 DOI: 10.3390/antibiotics13050399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2024] [Revised: 04/22/2024] [Accepted: 04/25/2024] [Indexed: 05/25/2024] Open
Abstract
The most frequent cause of periprosthetic infections (PJIs) is intraoperative contamination; hence, antibiotic prophylaxis plays a crucial role in prevention. Modifications to standard prophylaxis can be considered if there is a high incidence of microorganisms resistant to current protocols. To date, very few studies regarding microbial etiology have been published in Italy. In this single-center, retrospective study conducted at IRCCS Ospedale Galeazzi-Sant'Ambrogio in Milan, we analyzed hip, knee, and shoulder PJIs in patients undergoing first implantation between 1 January 17 and 31 December 2021. The primary aim was to derive a local microbiological case history. The secondary aim was to evaluate the adequacy of preoperative antibiotic prophylaxis in relation to the identified bacteria. A total of 57 PJIs and 65 pathogens were identified: 16 S. aureus, 15 S. epidermidis, and 10 other coagulase-negative staphylococci (CoNS), which accounted for 63% of the isolations. A total of 86.7% of S. epidermidis were methicillin-resistant (MRSE). In line with other case reports, we found a predominance of staphylococcal infections, with a lower percentage of MRSA than the Italian average, while we found a high percentage of MRSE. We estimated that 44.6% of the bacteria isolated were resistant to cefazolin, our standard prophylaxis. These PJIs could be prevented by using glycopeptide alone or in combination with cefazolin, but the literature reports conflicting results regarding the adequacy of such prophylaxis. In conclusion, our study showed that in our local hospital, our standard antibiotic prophylaxis is ineffective for almost half of the cases, highlighting the importance of defining specific antibiotic guidelines based on the local bacterial prevalence of each institution.
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Affiliation(s)
- Virginia Suardi
- IRCCS Ospedale Galeazzi–Sant’Ambrogio, 20157 Milan, Italy; (V.S.); (N.L.); (A.V.P.)
| | - Daniele Baroni
- Department of Orthopedics and Traumatology, Alessandro Manzoni Hospital, 23900 Lecco, Italy;
| | | | - Valentina Morena
- Infectious Disease Unit, Alessandro Manzoni Hospital, 23900 Lecco, Italy;
| | - Nicola Logoluso
- IRCCS Ospedale Galeazzi–Sant’Ambrogio, 20157 Milan, Italy; (V.S.); (N.L.); (A.V.P.)
| | - Laura Mangiavini
- IRCCS Ospedale Galeazzi–Sant’Ambrogio, 20157 Milan, Italy; (V.S.); (N.L.); (A.V.P.)
- Department of Biomedical Sciences for Health, University of Milan, 20133 Milan, Italy
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13
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Lum ZC, O’Connor DT, Holland CT, Gharib-Parsa A, Barragan-Trejo A, Park JY, Giordani M, Meehan JP. Natural History of Opioid Use in Naive and Tolerant Patients in Revision Total Hip Arthroplasty. J Am Acad Orthop Surg Glob Res Rev 2024; 8:01979360-202404000-00017. [PMID: 38648392 PMCID: PMC11037732 DOI: 10.5435/jaaosglobal-d-23-00165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Revised: 01/26/2024] [Accepted: 02/06/2024] [Indexed: 04/25/2024]
Abstract
BACKGROUND Opioid use after revision total hip arthroplasty (rTHA) has not been well characterized. The purpose of this study was to characterize preoperative, perioperative, and postoperative opioid use during rTHA. METHODS Patients undergoing revision THA from 2010 to 2018 were screened for opioid use 3 months before revision surgery and tracked 24 months postoperatively. Patients were categorized as naïve or tolerant. Opioid prescriptions and average morphine milligram equivalents (MME) were compared between the two groups. RESULTS One hundred twenty-four of 247 patients (50%) in the tolerant group averaged a preoperative MME of 23.7 mg/day. Postoperatively, tolerant patients received significantly higher daily MME at all time points, including at 3 months 31.4 versus 18.1 mg/day (P < 0.001), 6 months 19.9 versus 2.95 mg/day (P < 0.001), 12 months 14.3 versus 3.5 mg/day (P < 0.001), and 24 months 10.7 versus 2.17 mg/day (P < 0.001). Tolerant patients were more likely to have a prescription at 6 months (44% versus 22%), 12 months (41.4% versus 24%), and 24 months (38% versus 19.3%) (P < 0.001, P = 0.002, P < 0.001, respectively). DISCUSSION Opioid-tolerant patients had higher postoperative MME requirements for longer recovery duration. Both groups reduced opioid use at 3 months and plateaued at 6 months. These findings can help the revision surgeon counsel patients and expectations.
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Affiliation(s)
- Zachary C. Lum
- From the UC Davis Health System, University of California, Davis, Sacramento, CA
| | - Daniel T. O’Connor
- From the UC Davis Health System, University of California, Davis, Sacramento, CA
| | | | - Arta Gharib-Parsa
- From the UC Davis Health System, University of California, Davis, Sacramento, CA
| | | | - Jeannie Y. Park
- From the UC Davis Health System, University of California, Davis, Sacramento, CA
| | - Mauro Giordani
- From the UC Davis Health System, University of California, Davis, Sacramento, CA
| | - John P. Meehan
- From the UC Davis Health System, University of California, Davis, Sacramento, CA
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14
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Villa JM, Rajschmir K, Lin S, Higuera-Rueda CA. What Is the True Impact of Periprosthetic Joint Infection Diagnosis on Mortality? J Arthroplasty 2024:S0883-5403(24)00269-9. [PMID: 38548238 DOI: 10.1016/j.arth.2024.03.052] [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: 12/15/2023] [Revised: 03/04/2024] [Accepted: 03/18/2024] [Indexed: 04/15/2024] Open
Abstract
BACKGROUND Mortality is a quality indicator that may affect expenditures. Revisions for periprosthetic joint infection (PJI) are, on average, more expensive and exhibit higher morbidity than aseptic revisions, although reimbursement is similar. Therefore, we sought to determine (1) impact on mortality rates of revision total hip and/or knee arthroplasty performed for PJI diagnosis (septic) versus aseptic revisions, at any point in time, and (2) mortality predictors among PJI patients. METHODS Retrospective chart review of 978 consecutive patients who underwent revision at a single institution (January 2015 to November 2020). All revisions were evaluated, and it was determined whether patients had a revision for PJI at any point in time or not. Two groups were compared: (1) patients with septic revision(s) (n = 350) and (2) patients who only underwent aseptic revision(s) (n = 628). Demographics and mortality status at latest follow-up (mean 3 years, range: 0 to 18 years, from first revision ever) were assessed. Mortality status was also separately assessed among patients who exclusively had hip revision(s), or solely knee revision(s), or both. Multivariate regression analysis (Cox) was used to determine whether PJI diagnosis was an independent mortality predictor. Among PJI patients, potential mortality predictors were evaluated. RESULTS Overall, 65 patients died (6.6%). The septic cohort had significantly more men and American Society of Anesthesiologists (ASA) class-IV patients. Mortality rates were 10.9% and 4.3% (P < .0001) for septic and aseptic revision groups, respectively. After controlling for sex, ASA, and number of revisions, PJI diagnosis was a significant mortality predictor (hazard ratio [HR]: 2.69, 95% confidence interval [CI]: 1.5 to 4.7, P = .001). Among PJI patients, age (HR: 1.05, 95% CI: 1.01 to 1.08, P = .009) and ASA (HR: 4.02, 95% CI: 1.67 to 9.67, P = .002) were independent predictors. CONCLUSIONS Having a revision due to PJI diagnosis was associated with 2.5 times increased mortality. Therefore, more accurate coding capturing the complexity and morbidity of revisions for PJI diagnosis is needed.
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Affiliation(s)
- Jesus M Villa
- Levitetz Department of Orthopaedic Surgery, Cleveland Clinic Florida, Weston, Florida
| | - Katherine Rajschmir
- Levitetz Department of Orthopaedic Surgery, Cleveland Clinic Florida, Weston, Florida
| | - Shu Lin
- Levitetz Department of Orthopaedic Surgery, Cleveland Clinic Florida, Weston, Florida
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15
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Liukkonen R, Honkanen M, Skyttä E, Eskelinen A, Karppelin M, Reito A. Clinical Outcomes After Revision Hip Arthroplasty due to Prosthetic Joint Infection-A Single-Center Study of 369 Hips at a High-Volume Center With a Minimum of One Year Follow-Up. J Arthroplasty 2024; 39:806-812.e3. [PMID: 37661070 DOI: 10.1016/j.arth.2023.08.078] [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: 07/08/2023] [Revised: 08/22/2023] [Accepted: 08/27/2023] [Indexed: 09/05/2023] Open
Abstract
BACKGROUND Prosthetic joint infection (PJI) treatment decisions are traditionally based on treatment algorithms. There is, however, a lack of evidence to support the choice of these treatment algorithms. Therefore, we aimed to assess the one-year survival after PJI revision and compared different surgical strategies in a single-center setting. METHODS Revisions of the hip due to PJI performed at our institution between January 2008 and September 2021 with at least one-year of follow-up were identified. In total, 134 debridement, antibiotics, and implant retentions (DAIRs), 114 one-stage revisions, and 121 two-stage revisions were performed. Infections were classified as early, acute hematogenous, and chronic. Survival was calculated using the Kaplan-Meier method and cumulative incidence function. Predictors of outcomes were examined with Fine-Gray regressions and Cox proportional hazards regressions. Subdistribution hazard ratios and hazard ratios (HRs) with 95% confidence intervals (CIs) were calculated. RESULTS At one-year follow-up, 26.6% (CI 22.2 to 31.2%) of the patients had undergone reoperation and 7.9% (CI 5.4 to 10.9%) had died. The risk for reoperation was highest after DAIR (36.6%, CI 28.5 to 44.7%) and lowest after one-stage revision (20.2%, CI 13.4 to 28%). Within the early infections, the one-stage revision almost halved the risk of reoperation (HR 0.51, CI 0.31 to 0.84) with no added mortality risk (HR 1.05, CI 0.5 to 2.2), when compared to DAIR. CONCLUSION By utilizing 1-stage revision over DAIR in early infections, it might be possible to improve the prognosis by decreasing the risk of reoperation without increasing mortality. However, as the patient selection is undeniably difficult, more research is warranted.
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Affiliation(s)
- Rasmus Liukkonen
- Coxa Hospital for Joint Replacement, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Meeri Honkanen
- Department of Internal Medicine, Tampere University Hospital, Tampere, Finland
| | - Eerik Skyttä
- Coxa Hospital for Joint Replacement, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Antti Eskelinen
- Coxa Hospital for Joint Replacement, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Matti Karppelin
- Department of Internal Medicine, Tampere University Hospital, Tampere, Finland
| | - Aleksi Reito
- Coxa Hospital for Joint Replacement, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
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16
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Wier J, Liu KC, Richardson MK, Gettleman BS, Kistler NM, Heckmann ND, Lieberman JR. Higher Blood Glucose Levels on the Day of Surgery Are Associated with an Increased Risk of Periprosthetic Joint Infection After Total Hip Arthroplasty. J Bone Joint Surg Am 2024; 106:276-287. [PMID: 38127864 DOI: 10.2106/jbjs.23.00546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2023]
Abstract
BACKGROUND Hyperglycemia has been identified as a risk factor for periprosthetic joint infection (PJI) after total hip arthroplasty (THA). However, there is no consensus with regard to the preoperative blood glucose level (BGL) on the day of the surgical procedure associated with increased risk. We sought to identify preoperative BGL thresholds associated with an increased risk of PJI. METHODS The Premier Healthcare Database was retrospectively queried for adult patients who underwent primary, elective THA and had a measurement of the preoperative BGL recorded on the day of the surgical procedure (preoperative BGL) from January 1, 2016, to December 31, 2021. The association between preoperative BGL and 90-day PJI risk was modeled using multivariable logistic regression with restricted cubic splines. Patients with and without diabetes with a preoperative BGL associated with 1.5 times greater odds of PJI (high preoperative BGL) were then compared with patients with a normal preoperative BGL. RESULTS In this study, 90,830 patients who underwent THA and had a recorded preoperative BGL were identified. The preoperative BGL associated with 1.5 times greater odds of PJI was found to be 277 mg/dL in patients with diabetes and 193 mg/dL in patients without diabetes. Compared with the normal preoperative BGL cohort, those with high preoperative BGL had increased odds of PJI (adjusted odds ratio [OR], 2.60 [95% confidence interval (CI), 1.45 to 4.67] for patients with diabetes and 1.66 [95% CI, 1.10 to 2.51] for patients without diabetes) and 90-day readmissions (adjusted OR, 1.92 [95% CI, 1.45 to 2.53] for patients with diabetes and 1.66 [95% CI, 1.37 to 2.00] for patients without diabetes). CONCLUSIONS Increased preoperative BGL was found to be associated with an increased risk of PJI following primary THA. Surgeons should be aware of patients with diabetes and a preoperative BGL of >277 mg/dL and patients without diabetes but with a preoperative BGL of >193 mg/dL. LEVEL OF EVIDENCE Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Julian Wier
- Department of Orthopaedic Surgery, University of Southern California Keck School of Medicine, Los Angeles, California
| | - Kevin C Liu
- Department of Orthopaedic Surgery, University of Southern California Keck School of Medicine, Los Angeles, California
| | - Mary K Richardson
- Department of Orthopaedic Surgery, University of Southern California Keck School of Medicine, Los Angeles, California
| | | | - Natalie M Kistler
- Department of Orthopaedic Surgery, University of Southern California Keck School of Medicine, Los Angeles, California
| | - Nathanael D Heckmann
- Department of Orthopaedic Surgery, University of Southern California Keck School of Medicine, Los Angeles, California
| | - Jay R Lieberman
- Department of Orthopaedic Surgery, University of Southern California Keck School of Medicine, Los Angeles, California
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Youssef Y, Roschke E, Dietze N, Dahse AJ, Chaberny IF, Ranft D, Pempe C, Goralski S, Ghanem M, Kluge R, Lübbert C, Rodloff AC, Roth A. Early-Outcome Differences between Acute and Chronic Periprosthetic Joint Infections-A Retrospective Single-Center Study. Antibiotics (Basel) 2024; 13:198. [PMID: 38534633 DOI: 10.3390/antibiotics13030198] [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: 01/28/2024] [Revised: 02/14/2024] [Accepted: 02/17/2024] [Indexed: 03/28/2024] Open
Abstract
Periprosthetic joint infections (PJI) are serious complications after arthroplasty, associated with high morbidity, mortality, and complex treatment processes. The outcomes of different PJI entities are largely unknown. The aim of this study was to access the early outcomes of different PJI entities. A retrospective, single-center study was conducted. The characteristics and outcomes of patients with PJI treated between 2018 and 2019 were evaluated 12 months after the completion of treatment. Primary endpoints were mortality, relapse free survival (RFS) and postoperative complications (kidney failure, sepsis, admission to ICU). A total of 115 cases were included [19.1% early (EI), 33.0% acute late (ALI), and 47.8% chronic infections (CI)]. Patients with ALI were older (p = 0.023), had higher ASA scores (p = 0.031), preoperative CRP concentrations (p = 0.011), incidence of kidney failure (p = 0.002) and sepsis (p = 0.026). They also tended towards higher in-house mortality (ALI 21.1%, 13.6% EI, 5.5% CI) and admission to ICU (ALI 50.0%, 22.7% EI, 30.9% CI). At 12 months, 15.4% of patients with EI had a relapse, compared to 38.1% in ALI and 36.4% in CI. There are differences in patient characteristics and early outcomes between PJI entities. Patients with EI have better early clinical outcomes. Patients with ALI require special attention during follow-up because they have higher occurrences of relapses and postoperative complications than patients with EI and CI.
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Affiliation(s)
- Yasmin Youssef
- Department of Orthopedics, Traumatology and Plastic Surgery, University Hospital Leipzig, Liebigstraße 20, 04103 Leipzig, Germany
| | - Elisabeth Roschke
- Department of Orthopedics, Traumatology and Plastic Surgery, University Hospital Leipzig, Liebigstraße 20, 04103 Leipzig, Germany
| | - Nadine Dietze
- Institute of Medical Microbiology and Virology, University Hospital Leipzig, Liebigstraße 21, 04103 Leipzig, Germany
| | - Anna-Judith Dahse
- Hospital Pharmacy, University Hospital Leipzig, Liebigstraße 20, 04103 Leipzig, Germany
| | - Iris F Chaberny
- Institute of Hygiene, Hospital Epidemiology and Environmental Health, University Hospital Leipzig, Liebigstraße 22, 04103 Leipzig, Germany
- Institute of Hospital Epidemiology and Environmental Hygiene, University Medical Center Schleswig-Holstein, Arnold-Heller-Str. 3, 24105 Kiel, Germany
| | - Donald Ranft
- Hospital Pharmacy, University Hospital Leipzig, Liebigstraße 20, 04103 Leipzig, Germany
| | - Christina Pempe
- Department of Orthopedics, Traumatology and Plastic Surgery, University Hospital Leipzig, Liebigstraße 20, 04103 Leipzig, Germany
| | - Szymon Goralski
- Department of Orthopedics, Traumatology and Plastic Surgery, University Hospital Leipzig, Liebigstraße 20, 04103 Leipzig, Germany
| | - Mohamed Ghanem
- Department of Orthopedics, Traumatology and Plastic Surgery, University Hospital Leipzig, Liebigstraße 20, 04103 Leipzig, Germany
| | - Regine Kluge
- Department of Nuclear Medicine, University Hospital Leipzig, Liebigstraße 18, 04103 Leipzig, Germany
| | - Christoph Lübbert
- Division of Infectious Diseases and Tropical Medicine, Department of Medicine I, University Hospital Leipzig, Liebigstraße 20, 04103 Leipzig, Germany
- Interdisciplinary Center for Infectious Diseases, University Hospital Leipzig, Liebigstraße 20, 04103 Leipzig, Germany
| | - Arne C Rodloff
- Institute of Medical Microbiology and Virology, University Hospital Leipzig, Liebigstraße 21, 04103 Leipzig, Germany
| | - Andreas Roth
- Department of Orthopedics, Traumatology and Plastic Surgery, University Hospital Leipzig, Liebigstraße 20, 04103 Leipzig, Germany
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Devi NR, Khandelwal S, Subramaniyan M, Pappu S. Extraction, characterization, and therapeutic potential of Omega-3 fatty acids from Belone belone skin. 3 Biotech 2024; 14:42. [PMID: 38261852 PMCID: PMC10796888 DOI: 10.1007/s13205-023-03885-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Accepted: 12/08/2023] [Indexed: 01/25/2024] Open
Abstract
This study provides the fatty acid profile, presence of Omega 3 fatty acids (ω3FAs) and therapeutic potential of the skin of Garfish (Belone belone), a highly nutritious fish. The ω3FAs were obtained using the urea crystallization method and confirmed by UV VIS spectroscopy, HPLC, FT-IR, and NMR. Additionally, the therapeutic potential of the ω3FAs was assessed through antioxidant, antimicrobial, antibiofilm, and toxicity assays. The oil extracted from Garfish skin (GS) predominantly contains ω3FAs, palmitic acids, and oleic acids. The ω3FAs exhibit high anti-free radical activity and ferric reducing activity. It reduces nitric oxide production as well as lipid peroxidation under certain time. They also demonstrate effective antibacterial activity against Escherichia coli, Pseudomonas aeruginosa, Staphylococcus aureus and Streptococcus pneumoniae. The biofilm formation is efficiently reduced by ω3FAs and eradication effects on biofilm are higher at 4000 µg/mL of concentration. When tested against brine shrimp larvae, ω3FAs were found to be non-toxic. The study indicates that GS skin oil contains a significant amount of omega-3 fatty acids and has potential therapeutic benefits due to its antioxidant and antibacterial properties, without causing any toxic effects. Omega-3 fatty acids have the potential to enhance the treatment of infections caused by harmful bacteria and their biofilm formation. Further research is needed to understand how omega-3 fatty acids work to kill bacteria and how they affect bacterial gene expression.
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Affiliation(s)
- Naorem Rojita Devi
- Department of Animal Health and Management, Alagappa University, Karaikudi, Tamil Nadu 630003 India
| | - Sital Khandelwal
- Department of Animal Health and Management, Alagappa University, Karaikudi, Tamil Nadu 630003 India
| | - Muthumari Subramaniyan
- Department of Animal Health and Management, Alagappa University, Karaikudi, Tamil Nadu 630003 India
| | - Srinivasan Pappu
- Department of Animal Health and Management, Alagappa University, Karaikudi, Tamil Nadu 630003 India
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Doub JB, Heil EL, Manson T. Adjuvant intra-articular vancomycin for recalcitrant Staphylococcal prosthetic joint infections of the knee. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2024; 34:1031-1036. [PMID: 37864658 DOI: 10.1007/s00590-023-03764-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Accepted: 10/09/2023] [Indexed: 10/23/2023]
Abstract
OBJECTIVE Chronic prosthetic joint infection patients who fail conventional two-stage revision surgery are an especially difficult to treat patient population. Consequently, the objective of this study was to investigate the safety and long-term effectiveness of adjuvant intra-articular vancomycin therapy in conjunction with two-stage revision knee arthroplasties for recalcitrant Staphylococcal prosthetic joint infections. METHODS This was an observational cohort study of twelve patients with recalcitrant Staphylococcal prosthetic joint infections of the knee which had failed previous revision surgeries. Each patient subsequently underwent two-stage revision with placement of Hickman catheters to deliver intra-articular vancomycin therapy. In addition, systemic antibiotic therapy was administered for 6 weeks, and long-term follow-up was evaluated then for 5 years. RESULTS Seventy-five percent of the cohort have had no recurrence of their infections at 5 years. Two patients formed fistulas requiring above the knee amputations, and three patients had acute kidney injury. All patients had maximum measurable serum vancomycin trough levels that ranged from 6.1 to 93.6 mcg/mL. CONCLUSION The aggressive protocol used in this cohort with repeat two-stage revision surgery, intra-articular vancomycin and systemic antibiotics was able to prevent recurrence of infection in most patients, but higher than expected rates of acute kidney injury were observed in this study. Therefore, while intra-articular vancomycin therapy may have some effectiveness in treating recalcitrant prosthetic joint infections, its ability to eradicate all bacterial niduses is unproven, and clinicians should be cognizant of potential adverse events that can occur with this therapy.
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Affiliation(s)
- James B Doub
- Division of Infectious Diseases, University of Maryland School of Medicine, 725 West Lombard Street, BaltimoreMaryland, MD, 21201, USA.
| | - Emily L Heil
- Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, MD, 21201, USA
| | - Theodore Manson
- Department of Orthopedic Surgery, University of Maryland School of Medicine, Baltimore, MD, 21201, USA
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20
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Yu G, Doub JB, Mao Y, Kjellerup BV. Do bacteriophages have activity in synovial fluid and against synovial fluid induced bacterial aggregates? J Orthop Res 2024; 42:484-490. [PMID: 37728962 DOI: 10.1002/jor.25692] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 08/11/2023] [Accepted: 09/14/2023] [Indexed: 09/22/2023]
Abstract
Bacteriophage therapy is a promising adjuvant therapy for the treatment of periprosthetic joint infections. However, there is a paucity of knowledge about the activity of bacteriophages in synovial fluid. Therefore, this study evaluated the activity of a clinically used bacteriophage in synovial fluid as well as the ability of that bacteriophage to prevent the formation of and eradicate bacteria in synovial fluid induced aggregates. The results of this study reinforce that synovial fluid induced aggregates form rapidly in numerous synovial fluid concentrations. More importantly, there was a statistically significant reduction in bacteriophage activity in synovial fluid compared to tryptic soy broth (p < 0.05) and the bacteriophage could not prevent the formation synovial fluid induced aggregates. Also the bacteriophage could not significantly reduce the amount of bacteria in the synovial fluid induced aggregates when compared to controls, and this was not secondary to resistance. Rather the reduced activity seems to be caused by bacteriophages being hindered in the ability to attach to bacterial receptors. We hypothesize this occurred because the viscosity of synovial fluid slowed bacteriophage interactions with planktonic bacteria and the synovial fluid polymers obstructed the bacteriophage attachment receptors thereby preventing attachment to bacteria in the aggregates. These findings have clinical ramifications, supporting the use of bacteriophage therapy as an adjunct to surgical interventions and not in isolation, at the nascent stage. While these findings show a shortcoming of bacteriophage therapy in periprosthetic joint infections, the knowledge gained should spearhead further research to ultimately devise effective and reproducible bacteriophage therapeutics.
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Affiliation(s)
- Guangchao Yu
- Clinical Laboratory Center, First Affiliated Hospital of Jinan University, Guangzhou, China
- The Kjellerup Biofilm Laboratory, Department of Civil and Environmental Engineering, University of Maryland, College Park, Maryland, USA
| | - James B Doub
- The Doub Laboratory of Translational Bacterial Research, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Yuzhu Mao
- The Kjellerup Biofilm Laboratory, Department of Civil and Environmental Engineering, University of Maryland, College Park, Maryland, USA
| | - Birthe V Kjellerup
- The Kjellerup Biofilm Laboratory, Department of Civil and Environmental Engineering, University of Maryland, College Park, Maryland, USA
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21
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Jones IA, Wier J, Liu KC, Richardson MK, Yoshida B, Palmer R, Lieberman JR, Heckmann ND. Dexamethasone-Associated Hyperglycemia is Not Associated With Infectious Complications After Total Joint Arthroplasty in Diabetic Patients. J Arthroplasty 2024:S0883-5403(24)00025-1. [PMID: 38220028 DOI: 10.1016/j.arth.2024.01.025] [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: 10/25/2023] [Revised: 12/26/2023] [Accepted: 01/09/2024] [Indexed: 01/16/2024] Open
Abstract
BACKGROUND Postoperative infection is a devastating complication of total joint arthroplasty (TJA). Perioperative use of dexamethasone in patients who have diabetes mellitus (DM) remains controversial due to concern for increased infection risk. This study aimed to evaluate the association between dexamethasone and infection risk among patients who have DM undergoing TJA. METHODS This was a retrospective cohort study conducted on adult patients who underwent primary, elective total knee arthroplasty (TKA) or total hip arthroplasty (THA) between January 2016 and December 2021 using a large national database. We identified 110,568 TJA patients (TKA: 66.6%; THA: 33.4%), 31.0% (34,298) of which had DM. Patients who received perioperative dexamethasone were compared to those who did not. The primary end points were the 90-day risk of postoperative periprosthetic joint infection, surgical site infection (SSI), and other non-SSI (urinary tract infection, pneumonia, sepsis). RESULTS When modeling the association between dexamethasone exposure and study outcomes while accounting for the interaction between dexamethasone and morning blood glucose levels, dexamethasone administration conferred no increased odds of postoperative periprosthetic joint infection nor SSI in diabetics. However, dexamethasone significantly lowered the adjusted odds of other postoperative infections in diabetic patients (TKA: adjusted odds ratio = 09, 95% confidence interval = 0.8 to 1.0, P = .030; THA: adjusted odds ratio = 0.7, 95% confidence interval = 0.6 to 0.9, P = .001); specifically in patients with morning blood glucose levels between 110 to 248 mg/dL in TKA and ≤ 172 mg/dL in THA. CONCLUSIONS This study provides strong evidence against withholding dexamethasone in diabetic patients undergoing TJA based on concern for infection. Instead, short-course perioperative dexamethasone reduced infection risk in select patients. The narrative surrounding dexamethasone should shift away from questions about whether dexamethasone is appropriate for diabetic patients, and instead focus on how best to optimize its use.
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Affiliation(s)
- Ian A Jones
- Department of Anaesthesiology & Pain Medicine, University of Washington, Seattle, Washington
| | - Julian Wier
- Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Kevin C Liu
- Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Mary K Richardson
- Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Brandon Yoshida
- Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Ryan Palmer
- Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Jay R Lieberman
- Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Nathanael D Heckmann
- Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
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22
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Bundschuh KE, Muffly BT, Ayeni AM, Heo KY, Khawaja SR, Tocio AJ, Karzon AL, Premkumar A, Guild GN. Should All Patients Receive Extended Oral Antibiotic Prophylaxis? Defining Its Role in Patients Undergoing Primary and Aseptic Revision Total Joint Arthroplasty. J Arthroplasty 2024:S0883-5403(24)00012-3. [PMID: 38218558 DOI: 10.1016/j.arth.2024.01.012] [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: 07/01/2023] [Revised: 12/28/2023] [Accepted: 01/07/2024] [Indexed: 01/15/2024] Open
Abstract
BACKGROUND Prior studies have demonstrated reduced periprosthetic joint infection (PJI) rates following extended oral antibiotics (EOAs) for high-risk patients undergoing primary total joint arthroplasty (TJA). This study compared 3-month PJI rates in all patients undergoing primary or aseptic revision TJA with or without EOA prophylaxis. METHODS In total, 2,982 consecutive primary (n = 2,677) and aseptic revision (n = 305) TJAs were performed by a single, fellowship-trained arthroplasty surgeon from 2016 to 2022 were retrospectively reviewed. Beginning January 2020, all patients received 7 days of 300 mg oral cefdinir twice daily immediately postoperatively. Rates of PJI at 3 months were compared between patients who received or did not receive EOA. RESULTS Rates of PJI at 3 months in patients undergoing primary and aseptic revision TJA were significantly lower in those receiving EOA prophylaxis compared to those who did not (0.41 versus 1.13%, respectively; P = .02). After primary TJA, lower PJI rates were observed with EOA prophylaxis utilization (0.23 versus 0.74%, P = .04; odds ratio [OR] 3.85). Following aseptic revision TJA, PJI rates trended toward a significant decrease with the EOA compared to without (1.88 versus 4.83%, respectively; P = .16; OR 2.71). CONCLUSIONS All patients undergoing primary or aseptic revision TJA who received EOA prophylaxis were 3.85 and 2.71 times less likely, respectively, to develop PJI at 3 months compared to those without EOA. Future studies are needed to determine if these results are maintained at postoperative time periods beyond 3 months following primary TJA. LEVEL OF EVIDENCE III, Retrospective review.
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Affiliation(s)
- Kyle E Bundschuh
- Department of Orthopaedic Surgery, Investigation performed at Emory University, Atlanta, Georgia
| | - Brian T Muffly
- Department of Orthopaedic Surgery, Investigation performed at Emory University, Atlanta, Georgia
| | - Ayomide M Ayeni
- Department of Orthopaedic Surgery, Investigation performed at Emory University, Atlanta, Georgia
| | - Kevin Y Heo
- Department of Orthopaedic Surgery, Investigation performed at Emory University, Atlanta, Georgia
| | - Sameer R Khawaja
- Department of Orthopaedic Surgery, Investigation performed at Emory University, Atlanta, Georgia
| | - Adam J Tocio
- Department of Orthopaedic Surgery, Investigation performed at Emory University, Atlanta, Georgia
| | - Anthony L Karzon
- Department of Orthopaedic Surgery, Investigation performed at Emory University, Atlanta, Georgia
| | - Ajay Premkumar
- Department of Orthopaedic Surgery, Investigation performed at Emory University, Atlanta, Georgia
| | - George N Guild
- Department of Orthopaedic Surgery, Investigation performed at Emory University, Atlanta, Georgia
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23
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Wernecke GC, Jin XZ, Lin JL, Harris IA. The Impact of Surgical Approach on 90-Day Prosthetic Joint Infection After Total Hip Replacement - A Population-Based, Propensity Score-Matched Cohort Study. J Arthroplasty 2024; 39:151-156. [PMID: 37380141 DOI: 10.1016/j.arth.2023.06.033] [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: 09/11/2022] [Revised: 06/11/2023] [Accepted: 06/19/2023] [Indexed: 06/30/2023] Open
Abstract
BACKGROUND Prosthetic joint infection (PJI) is a devastating complication of total hip arthroplasty (THA). This study aimed to determine if the anterior approach (AP) influenced the incidence of early PJI in THA compared to posterior approach (PP). METHODS Record linkage was performed between state-wide hospitalization data and a national joint replacement registry to identify unilateral THA performed via the AP or PP. Complete data on 12,605 AP and 25,569 PP THAs were obtained. Propensity score matching (PSM) was undertaken to match covariates between the approaches. Outcomes were the 90-day PJI hospital readmission rate(using narrow and broad definitions) and 90-day PJI revision rate (defined as component removal or exchange). RESULTS The raw PJI readmission rate for AP was lower than PP (0.8% versus 1.1%, respectively). In the PSM analysis, there was no statistically significant difference in PJI readmission rate between approaches using narrow or broad definition of PJI readmission. In terms of revision for infection, both methods showed AP had a significantly lower rate than PP, with an adjusted odds ratio (OR) of 0.47 (95% confidence interval (CI) 0.30, 0.75) for the 1:1 nearest neighbor method and 0.50 (95% CI 0.32, 0.77) for the subclassification method. CONCLUSION After addressing known confounders, there was no significant difference in the 90-day hospital readmission rate for hip PJI between approaches. There was a significantly reduced 90-day PJI revision rate for AP. The difference in revision may reflect differences in the surgical management of PJI between hip approaches rather than a difference in the underlying rate of infection.
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Affiliation(s)
| | - Xing Zhong Jin
- Centre for Big Data Research in Health, University of New South Wales, Kensington, New South Wales, Australia; Sydney Musculoskeletal Health, Kolling Institute, The University of Sydney, Sydney, New South Wales, Australia
| | - Jiun-Lih Lin
- Sydney Knee Specialists, Kogarah, New South Wales, Australia
| | - Ian A Harris
- School of Clinical Medicine, UNSW Medicine and Health, UNSW Sydney, Liverpool, New South Wales, Australia
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24
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McConnell ZA, Patel KM, Mears SC, Stronach BM, Barnes CL, Stambough JB. Systemic Inflammatory Response Syndrome and Prosthetic Joint Infection. J Arthroplasty 2024; 39:236-241. [PMID: 37531981 DOI: 10.1016/j.arth.2023.07.018] [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: 02/28/2023] [Revised: 07/11/2023] [Accepted: 07/25/2023] [Indexed: 08/04/2023] Open
Abstract
BACKGROUND The development of systemic inflammatory response syndrome (SIRS) criteria leads to increased mortality. Little is known about development of SIRS in patients who have prosthetic joint infection (PJI). We aimed to determine the incidence, risk factors, clinical outcomes, and causative organisms in patients who develop SIRS with PJI. METHODS We retrospectively identified 655 patients (321 men, 334 women; 382 total hip, 273 total knee) who have hip or knee PJI at 1 institution between July 1, 2015 and December 31, 2020. We formed 2 groups: patients who have SIRS alert (PJI + SIRS) and patients who do not have SIRS alert (PJI). We analyzed clinical outcomes, comorbidities, and operating room culture results. RESULTS Of 655 patients, 63 developed SIRS with PJI (9.6%). Intensive care unit (ICU) admission rates (27.0 versus. 6.9%, P < .001) and length of stay (7.7 versus. 5.6 days, P = .003) were greater in PJI + SIRS. At 2 years, reoperation (36.5 versus. 22.3%, P = .01) and mortality rates (17.5 versus. 8.8%, P = .03) were greater in PJI + SIRS. Risk factors included deficiency anemia (P = .001), blood loss anemia (P = .013), uncomplicated diabetes (P = .006), diabetes with complication (P = .001), electrolyte disorder (P < .00001), neurological disorder (P = .0001), paralysis (P = .026), renal failure (P = .005), and peptic ulcer disease (P = .004). Staphylococcus aureus more commonly speciated on tissue cultures in PJI + SIRS (P = .002). CONCLUSION The incidence of SIRS is 10% among patients who have PJI. Development of PJI + SIRS is associated with increased lengths of stay, ICU admissions, and 2-year reoperation and mortality rates. Identifying certain comorbidities can stratify patients' risk of developing PJI + SIRS.
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Affiliation(s)
- Zachary A McConnell
- Departments of Orthopaedic Surgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Karan M Patel
- Departments of Orthopaedic Surgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Simon C Mears
- Departments of Orthopaedic Surgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Benjamin M Stronach
- Departments of Orthopaedic Surgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - C Lowry Barnes
- Departments of Orthopaedic Surgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Jeffrey B Stambough
- Departments of Orthopaedic Surgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas
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25
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Richter A, Altemeier A, Hold M, Lenhof S, Stauss R, Ettinger M, Omar M. Drain fluid cultures can rule in but cannot rule out infection persistence after surgical treatment of periprosthetic joint infections. J Orthop Sci 2024; 29:177-182. [PMID: 36462996 DOI: 10.1016/j.jos.2022.11.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2022] [Revised: 09/28/2022] [Accepted: 11/16/2022] [Indexed: 12/03/2022]
Abstract
BACKGROUND Periprosthetic joint infection (PJI) is one of the most common reason for implant failure in arthroplasty. Surgical therapy is essential but there is no standardized guideline to determine infection eradication in multiple-step revision surgery. To date, clinical and laboratory inflammation markers and preoperative arthrocentesis are controversial to evaluate the infection status before reimplantation and therefore are often combined. Drain fluid cultures enable a microbiological analysis without need for further invasive procedure after revision surgery. This retrospective study evaluates the diagnostic performance of drain fluid cultures in diagnosing infection persistence according to the MSIS definition of PJI. METHODS Drain samples have been taken after every revision surgery for microbiological testing. Afterwards, the results have been assigned to the infection status according to the diagnostic criteria of the MSIS definition of PJI. RESULTS 1084 revision surgeries in 183 patients have been included, resulting in a total sample size of 1552 drain fluid cultures. Overall sensitivity was 36.0%, specificity was 90.7% and ROC-AUC was 0.63. CONCLUSION Due to a high specificity and a low sensitivity drain fluid cultures can rule in but cannot rule out infection persistence in PJI.
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Affiliation(s)
- Alena Richter
- Orthopaedic Department - DIAKOVERE Annastift, Hannover Medical School, Anna-von-Borries-Str. 1-7, 30625 Hannover, Germany.
| | - Anna Altemeier
- Orthopaedic Department - DIAKOVERE Annastift, Hannover Medical School, Anna-von-Borries-Str. 1-7, 30625 Hannover, Germany.
| | - Mara Hold
- Orthopaedic Department - DIAKOVERE Annastift, Hannover Medical School, Anna-von-Borries-Str. 1-7, 30625 Hannover, Germany.
| | - Stefan Lenhof
- Trauma Department - Hannover Medical School, Carl-Neuberg-Str 130625 Hannover, Germany.
| | - Ricarda Stauss
- Trauma Department - Hannover Medical School, Carl-Neuberg-Str 130625 Hannover, Germany.
| | - Max Ettinger
- Orthopaedic Department - DIAKOVERE Annastift, Hannover Medical School, Anna-von-Borries-Str. 1-7, 30625 Hannover, Germany.
| | - Mohamed Omar
- Trauma Department - Hannover Medical School, Carl-Neuberg-Str 130625 Hannover, Germany.
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26
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Shichman I, Sobba W, Beaton G, Polisetty T, Nguyen HB, Dipane MV, Hayes E, Aggarwal VK, Sassoon AA, Chen AF, Garceau SP, Schwarzkopf R. The Effect of Prosthetic Joint Infection on Work Status and Quality of Life: A Multicenter, International Study. J Arthroplasty 2023; 38:2685-2690.e1. [PMID: 37353111 DOI: 10.1016/j.arth.2023.06.015] [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: 12/08/2022] [Revised: 06/06/2023] [Accepted: 06/07/2023] [Indexed: 06/25/2023] Open
Abstract
BACKGROUND Periprosthetic joint infection (PJI) and subsequent revision surgeries may affect patients' social and physical health, ability to complete daily activities, and disability status. This study sought to determine how PJI affects patients' quality of life through patient-reported outcome measures with minimum 1-year follow-up. METHODS Patients who suffered PJI following primary total joint arthroplasty (TJA) from 2012 to 2021 were retrospectively reviewed. Patients met Musculoskeletal Infection Society criteria for acute or chronic PJI, underwent revision TJA surgery, and had at least 1 year of follow-up. Patients were surveyed regarding how PJI affected their work and disability status, as well as their mental and physical health. Outcome measures were compared between acute and chronic PJIs. In total, 318 patients (48.4% total knee arthroplasty and 51.6% total hip arthroplasty) met inclusion criteria. RESULTS Following surgical treatment for knee and hip PJI, a substantial proportion of patients reported that they were unable to negotiate stairs (20.5%), had worse physical health (39.6%), and suffered worse mental health (25.2%). A high proportion of patients reported worse quality of life (38.5%) and social satisfaction (35.3%) following PJI. Worse reported patient-reported outcome measures including patients' ability to complete daily physical activities were found among patients undergoing treatment for chronic PJI, and also, 23% of patients regretted their initial decision to pursue primary TJA. CONCLUSIONS A PJI negatively affects patients' ability to carry out everyday activities. This patient population is prone to report challenges overcoming disability and returning to work. Patients should be adequately educated regarding the risk of PJI to decrease later potential regrets. LEVEL OF EVIDENCE Case series (IV).
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Affiliation(s)
- Ittai Shichman
- Adult Reconstructive Division, NYU Langone, New York, New York; Division of Orthopedic Surgery, Tel-Aviv Sourasky Medical Center, Sackler School of Medicine, Tel-Aviv, Israel
| | - Walter Sobba
- Adult Reconstructive Division, NYU Langone, New York, New York
| | - Geidily Beaton
- Adult Reconstructive Division, NYU Langone, New York, New York
| | - Teja Polisetty
- Department of Orthopedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Hillary Brenda Nguyen
- Department of Orthopedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Matthew V Dipane
- Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Emmitt Hayes
- Division of Orthopaedic Surgery, The Ottawa Hospital, Ottawa, Ontario, Canada
| | | | - Adam A Sassoon
- Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Antonia F Chen
- Department of Orthopedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Simon P Garceau
- Division of Orthopaedic Surgery, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Ran Schwarzkopf
- Adult Reconstructive Division, NYU Langone, New York, New York
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27
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Burns AWR, Chao T, Tsai N, Lynch JT, Smith PN. The use of intra-articular vancomycin is safe in primary hip and knee arthroplasty. J Orthop 2023; 46:161-163. [PMID: 37997601 PMCID: PMC10663633 DOI: 10.1016/j.jor.2023.10.017] [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: 10/20/2023] [Accepted: 10/22/2023] [Indexed: 11/25/2023] Open
Abstract
Background The use of a single dose of intra-articular antibiotic (IAA) has been reported in reducing the rate of prosthetic joint injection after total hip and knee arthroplasty. We examine the safety of IAA in primary hip and knee replacement surgery and the blood levels and joint fluid levels of vancomycin utilising this technique. Methods From August to October 2021, 68 patients undergoing primary total joint arthroplasty (THA & TKA) were given 1g vancomycin intra-articularly (IA)after closure of the fascia. All patients received 2g cefazolin intravenously (IV) 30 min prior to the procedure as is our standard prophylaxis, and 21 of the patients (IA + IV) were also administered an additional 1 gm vancomycin IV. Post-operative blood vancomycin, creatinine land eGFR level monitoring was performed d1 and d3. To determine the post-operative intra-articular vancomycin levels, surgical drain fluid was sampled at day 1 and 2, in 10 patients. Results All patients had serum vancomycin levels measured on day 1 and 3. In the group where vancomycin was injected after fascial closure, the average blood vancomycin level day 1 was 5.2 μg/ml (range 2.0-10.9) and day 3 was <1.4 μg/ml. The average pre-op creatinine levels were 69.4 μmol/L (56.1-82.6) compared to 70.2 μmol/L (57.0-83.4) on day 1 and 66.1 μmol/L (52.6-79.6) on day 3, (p = 0.663). The average pre-op eGFR levels (ml/min/1.73 m2) were 82.2 (76.0-88.3) compared to 81.7 (75.6-87.8) on day 1 and 83.0 (76.8-89.2) on day 3 (p = 0.736). Samples of joint fluid aspirated from surgical drains on day 1 and day 2 showed average vancomycin levels of 224 μg/ml and 51 μg/ml respectively, significantly higher than the MIC for Staph aureus. Conclusions The use of intra-articular vancomycin is safe in primary TJA, with no renal damage and delivers levels within the joint which are highly therapeutic for at least 48 h post injection.
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Affiliation(s)
- Alexander W R Burns
- Trauma and Orthopaedic Research Unit, The Canberra Hospital and Australian National University, Canberra, ACT, Australia
| | - Tat Chao
- Trauma and Orthopaedic Research Unit, The Canberra Hospital and Australian National University, Canberra, ACT, Australia
| | - Nicholas Tsai
- Trauma and Orthopaedic Research Unit, The Canberra Hospital and Australian National University, Canberra, ACT, Australia
| | - Joseph T Lynch
- Trauma and Orthopaedic Research Unit, The Canberra Hospital and Australian National University, Canberra, ACT, Australia
| | - Paul N Smith
- Trauma and Orthopaedic Research Unit, The Canberra Hospital and Australian National University, Canberra, ACT, Australia
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28
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Ng MK, Kobryn A, Emara AK, Krebs VE, Mont MA, Piuzzi NS. Decreasing trend of inpatient mortality rates of aseptic versus septic revision total hip arthroplasty: an analysis of 681,034 cases. Hip Int 2023; 33:1063-1071. [PMID: 36480921 DOI: 10.1177/11207000221140346] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND While most revision total hip arthroplasties (rTHAs) are for aseptic loosening/instability, infection accounts for approximately 16%. The purpose of this study was to: (1) quantify mortality rates of aseptic versus septic rTHA; (2) determine if mortality rates have changed over the past 20 years; and (3) identify associated preoperative risk factors, focusing on the utility/validity of the Elixhauser comorbidity index (ECI). METHODS ICD-9/ICD-10 codes were used to identify patients undergoing rTHA in the National Inpatient Sample database between 1998 and 2017. A total of 681,034 cases (576,143 aseptic THA and 104,891 septic THA) were identified. For each patient, demographic variables including age, sex, race, insurance type, ECI, and inhospital mortality were gathered. A logistic regression model was constructed to assess risk of inhospital mortality. RESULTS From 1998 to 2017, inpatient mortality rates of aseptic and septic rTHA decreased from 0.83 to 0.45%, and from 2.58 to 1.24%, respectively. Septic rTHA was independently associated with higher odds of mortality relative to aseptic (odds ratio (OR): 2.305, 95% confidence interval (CI): (2.014, 2.638), p < 0.0001). Increased ECI was associated with higher odds of mortality at both medium (OR: 5.147, 95% CI: (4.433,5.977), p < 0.0001) and high index scores (OR: 13.714, 95% CI: (11.519,16.326), p < 0.0001). CONCLUSIONS Mortality rates for both aseptic and septic rTHA have been declining over the past 20 years, potentially due to patient selection guidelines and advances in medical management. Our study confirms that the ECI is independently associated with increased inpatient mortality.
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Affiliation(s)
- Mitchell K Ng
- Department of Orthopaedic Surgery, Maimonides Medical Center, Brooklyn, New York, USA
| | - Andriy Kobryn
- Department of Orthopaedic Surgery, SUNY Downstate Medical Center, Brooklyn, New York, USA
| | - Ahmed K Emara
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Viktor E Krebs
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Michael A Mont
- Sinai Hospital of Baltimore, Rubin Institute for Advanced Orthopedics, Baltimore, MD, USA
| | - Nicolas S Piuzzi
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, OH, USA
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Viswanathan VK, Aggarwal VA, Subramanian S, Mounasamy V, Sambandam S. What enhances the in-hospital mortality following total hip arthroplasty? A national inpatient sample-based study. Arch Orthop Trauma Surg 2023; 143:6423-6430. [PMID: 36976373 DOI: 10.1007/s00402-023-04850-w] [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: 12/16/2022] [Accepted: 03/18/2023] [Indexed: 03/29/2023]
Abstract
PURPOSE With prolonged life expectancy and advancements in prosthetic designs, the proportion of patients belonging to diverse age groups undergoing total hip arthroplasty (THA) has progressively increased. In this context, the details regarding risk factors associated with mortality after THA, and its prevalence need to be clearly understood. This study sought to identify the possible co-morbidities associated with post-THA mortality. METHODS Based on Nationwide Inpatient Sample (NIS) database, patients undergoing THA from 2016 to 2019 (using ICD-10CMP) were identified. The included cohort was stratified into two groups: "early mortality" and "no mortality" groups. The data regarding patients' demographics, co-morbidities, and associated complications were compared between the groups. RESULTS Overall, 337,249 patients underwent THA, among whom, 332 (0.1%) died during their hospital admission ("early mortality" group). The remaining patients were included under "no mortality" group (336,917 patients). There was significantly higher mortality in the patients, who underwent emergent THA (as compared with elective THA: odd's ratio 0.075; p < 0.001). Based on multivariate analysis, presence of liver cirrhosis, chronic kidney disease (CKD) and previous history of organ transplant increased the odds of mortality {odds ratio [Exp (B)]} after THA by 4.66- (p < 0.001), 2.37-fold (p < 0.001) and 1.91-fold (p = 0.04), respectively. Among post-THA complications, acute renal failure (ARF), pulmonary embolism (PE), pneumonia, myocardial infarction (MI), and prosthetic dislocation increased the odds of post-THA mortality by 20.64-fold (p < 0.001), 19.35-fold (p < 0.001), 8.21-fold (p < 0.001), 2.71-fold (p = 0.05) and 2.54-fold (p < 0.001), respectively. CONCLUSION THA is a safe surgery with low mortality rate during early post-operative period. Cirrhosis, CKD, and previous history of organ transplant were the most common co-morbidities associated with post-THA mortality. Among post-operative complications, ARF, PE, pneumonia, MI, and prosthetic dislocation substantially enhanced the odds of post-THA mortality.
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Affiliation(s)
| | | | - Surabhi Subramanian
- Pediatric Radiology, Alberta Children's Hospital, University of Calgary, Calgary, AB, Canada
| | - Varatharaj Mounasamy
- Department of Orthopedics, University of Texas Southwestern, Dallas VAMC, Dallas, TX, USA
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Koenemann NA, Sauerwald F, Thimel D, Mayr E. A rare case of periprosthetic joint infection of the hip due to Kocuria spp. BMC Geriatr 2023; 23:607. [PMID: 37770826 PMCID: PMC10536817 DOI: 10.1186/s12877-023-04286-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2022] [Accepted: 09/05/2023] [Indexed: 09/30/2023] Open
Abstract
BACKGROUND Kocuria spp. are ubiquitous bacteria that have gained recent attention as potential infectious agents. The most common bacteria in PJI are S. aureus und S. epidermidis. CASE PRESENTATION We present the case of a 72-year-old woman who received total hip arthroplasty after a traumatic medial femoral neck fracture. Postoperatively, due to the clinical presentation of periprosthetic joint infection (PJI) revision surgery was performed twice. The microbiological tissue samples were positive for Kocuria spp. Initially, this was considered contamination and the patient was treated with various antibiotic regimens as well as prednisolone due to the differential diagnosis of pyoderma gangraenosum. However, a specialized histopathology lab performed further testing which substantiated the suspicion of a rare case of PJI due to Kocuria spp. CONCLUSIONS To our knowledge, this is the first reported case of a PJI caused by Kocuria spp. Further clinical research is necessary to assess whether Kocuria spp. are an underestimated cause of PJI.
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Affiliation(s)
- Nora Anais Koenemann
- Klinik Für Unfallchirurgie, Orthopädie, Plastische Und Handchirurgie; Universitätsklinikum Augsburg, Stenglinstr. 2, 86156, Augsburg, Germany.
| | - Fabian Sauerwald
- Klinik Für Unfallchirurgie, Orthopädie, Plastische Und Handchirurgie; Universitätsklinikum Augsburg, Stenglinstr. 2, 86156, Augsburg, Germany
| | - Dierk Thimel
- Klinik Für Unfallchirurgie, Orthopädie, Plastische Und Handchirurgie; Universitätsklinikum Augsburg, Stenglinstr. 2, 86156, Augsburg, Germany
| | - Edgar Mayr
- Klinik Für Unfallchirurgie, Orthopädie, Plastische Und Handchirurgie; Universitätsklinikum Augsburg, Stenglinstr. 2, 86156, Augsburg, Germany
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Persson A, Sköldenberg O, Mohaddes M, Eisler T, Gordon M. Increased mortality after total hip prosthetic joint infection is mainly caused by the comorbidities rather than the infection itself. Acta Orthop 2023; 94:484-489. [PMID: 37753559 PMCID: PMC10523631 DOI: 10.2340/17453674.2023.18619] [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] [Received: 10/17/2022] [Accepted: 08/07/2023] [Indexed: 09/28/2023] Open
Abstract
BACKGROUND AND PURPOSE Periprosthetic joint infection (PJI) is a feared complication of arthroplasty surgery. There is controversy as to whether PJI also correlates with increased mortality. Our aim was to investigate in a nationwide cohort if PJI is an independent risk factor for dying. PATIENTS AND METHODS We performed a retrospective cohort study based on data from the Swedish Hip Arthroplasty Register (SHAR). All patients with a revision THA performed between 1998 and 2017 were included. The outcome is mortality; exposure is PJI according to SHAR. The control group was study participants who underwent aseptic revision. Confounders were age, sex, diagnosis, and comorbidity according to the Elixhauser index. The outcome was analyzed with a Cox proportional hazards model. RESULTS 4,943 PJI revisions and 12,529 non-infected revisions were included in the analysis. The median follow-up time was 4.1 years. In the PJI group, 1,972 patients died and in the control group, 4,512. The incidence rate ratio was 1.19 (95% confidence interval [CI] 1.13-1.25), the crude hazard ratio (HR) 1.19 (CI 1.13-1.25), and the adjusted HR 1.05 (CI 0.99-1.12) for the exposed versus the unexposed group. The strongest confounder was comorbidity. CONCLUSION The increased mortality risk after revision due to PJI is mainly caused by the comorbidity of the patient, rather than by the infection itself.
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Affiliation(s)
- Anders Persson
- Karolinska Institutet, Department of Clinical Sciences at Danderyd Hospital, Stockholm.
| | - Olof Sköldenberg
- Karolinska Institutet, Department of Clinical Sciences at Danderyd Hospital, Stockholm
| | - Maziar Mohaddes
- Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden, and The Swedish Arthroplasty Register, Gothenburg, Sweden
| | - Thomas Eisler
- Karolinska Institutet, Department of Clinical Sciences at Danderyd Hospital, Stockholm
| | - Max Gordon
- Karolinska Institutet, Department of Clinical Sciences at Danderyd Hospital, Stockholm
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Gajda M, Gajda P, Pac A, Gryglewska B, Wojnarski M, Różańska A, Lipińska-Tobiasz I, Wójkowska-Mach J. Post-discharge occurrence of surgical site infections after hip or knee arthroplasty surgery in Poland, a population-based study. Sci Rep 2023; 13:15940. [PMID: 37743386 PMCID: PMC10518305 DOI: 10.1038/s41598-023-43111-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2022] [Accepted: 09/20/2023] [Indexed: 09/26/2023] Open
Abstract
Arthroplasty is a common procedure improving functioning of patients and their quality of life. Infection is a serious complication that determines subsequent management of the prosthesis and the patient. The aim of the study was to investigate the incidence of post-discharge surgical site infections (SSI) and their risk factors. A retrospective analysis of an anonymized database from the National Health Found for 2017 of 56,068 adult patients undergoing hip replacement surgery (HPRO) and 27,457 patients undergoing knee replacement surgery (KPRO). The cumulative incidence of post-discharge SSI was 0.92% for HPRO and 0.95% for KPRO. The main risk factors for hip SSI were male gender, diseases of hematopoietic, musculoskeletal and nervous system. The risk factor for knee SSI was male gender. All comorbidities significantly increased the risk of SSI. The ICU stay and antibiotics administered at discharge in studied population increased the risk of detection of SSI after HPRO and KPRO by up to four and seven times, respectively. For both procedures rehabilitation after surgery and total endoprosthesis decreased incidence of SSIs. The lower experience of the center was related to higher SSI incidence in HPRO in primary (1.5% vs. 0.9%) and in revision surgeries (3.8% vs. 2.1%), but in KPRO, lower experience only in primary surgeries was significantly associated with SSI. The cumulative incidence of post-discharge SSI in Poland is higher than in other European countries. Special attention should be paid to patients with chronic diseases.
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Affiliation(s)
- Mateusz Gajda
- Department of Microbiology, Faculty of Medicine, Jagiellonian University Medical College, Czysta 18 St., 31-121, Kraków, Poland.
- Doctoral School of Medical and Health Sciences, Jagiellonian University Medical College, Łazarza 16 St., 31-530, Kraków, Poland.
| | - Paulina Gajda
- Chair of Epidemiology and Preventive Medicine, Department of Epidemiology, Jagiellonian University Medical College, Kopernika 7 St., 31-034, Kraków, Poland
| | - Agnieszka Pac
- Chair of Epidemiology and Preventive Medicine, Department of Epidemiology, Jagiellonian University Medical College, Kopernika 7 St., 31-034, Kraków, Poland
| | - Barbara Gryglewska
- Department of Internal Medicine and Gerontology, Jagiellonian University Medical College, Jakubowskiego 2 St., 30-886, Kraków, Poland
| | - Marcin Wojnarski
- Faculty of Medicine, Jagiellonian University Medical College, St. Anna 12 St., 33-332, Kraków, Poland
| | - Anna Różańska
- Department of Microbiology, Faculty of Medicine, Jagiellonian University Medical College, Czysta 18 St., 31-121, Kraków, Poland
| | - Inga Lipińska-Tobiasz
- Department of Orthopedics and Traumatology, Hospital in Proszowice, Kopernika 13 St, 32-100, Proszowice, Poland
| | - Jadwiga Wójkowska-Mach
- Department of Microbiology, Faculty of Medicine, Jagiellonian University Medical College, Czysta 18 St., 31-121, Kraków, Poland
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Yuste I, Luciano FC, Anaya BJ, Sanz-Ruiz P, Ribed-Sánchez A, González-Burgos E, Serrano DR. Engineering 3D-Printed Advanced Healthcare Materials for Periprosthetic Joint Infections. Antibiotics (Basel) 2023; 12:1229. [PMID: 37627649 PMCID: PMC10451995 DOI: 10.3390/antibiotics12081229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Revised: 07/12/2023] [Accepted: 07/18/2023] [Indexed: 08/27/2023] Open
Abstract
The use of additive manufacturing or 3D printing in biomedicine has experienced fast growth in the last few years, becoming a promising tool in pharmaceutical development and manufacturing, especially in parenteral formulations and implantable drug delivery systems (IDDSs). Periprosthetic joint infections (PJIs) are a common complication in arthroplasties, with a prevalence of over 4%. There is still no treatment that fully covers the need for preventing and treating biofilm formation. However, 3D printing plays a major role in the development of novel therapies for PJIs. This review will provide a deep understanding of the different approaches based on 3D-printing techniques for the current management and prophylaxis of PJIs. The two main strategies are focused on IDDSs that are loaded or coated with antimicrobials, commonly in combination with bone regeneration agents and 3D-printed orthopedic implants with modified surfaces and antimicrobial properties. The wide variety of printing methods and materials have allowed for the manufacture of IDDSs that are perfectly adjusted to patients' physiognomy, with different drug release profiles, geometries, and inner and outer architectures, and are fully individualized, targeting specific pathogens. Although these novel treatments are demonstrating promising results, in vivo studies and clinical trials are required for their translation from the bench to the market.
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Affiliation(s)
- Iván Yuste
- Pharmaceutics and Food Technology Department, Faculty of Pharmacy, Universidad Complutense de Madrid (UCM), 28040 Madrid, Spain; (I.Y.); (F.C.L.); (B.J.A.); (D.R.S.)
| | - Francis C. Luciano
- Pharmaceutics and Food Technology Department, Faculty of Pharmacy, Universidad Complutense de Madrid (UCM), 28040 Madrid, Spain; (I.Y.); (F.C.L.); (B.J.A.); (D.R.S.)
| | - Brayan J. Anaya
- Pharmaceutics and Food Technology Department, Faculty of Pharmacy, Universidad Complutense de Madrid (UCM), 28040 Madrid, Spain; (I.Y.); (F.C.L.); (B.J.A.); (D.R.S.)
| | - Pablo Sanz-Ruiz
- Orthopaedic and Trauma Department, Hospital General Universitario Gregorio Marañón, 28029 Madrid, Spain;
- Department of Surgery, Faculty of Medicine, Universidad Complutense de Madrid (UCM), 28040 Madrid, Spain
| | - Almudena Ribed-Sánchez
- Hospital Pharmacy Unit, Hospital General Universitario Gregorio Marañón, 28029 Madrid, Spain;
| | - Elena González-Burgos
- Department of Pharmacology, Pharmacognosy and Botany, Faculty of Pharmacy, Universidad Complutense de Madrid (UCM), 28040 Madrid, Spain
| | - Dolores R. Serrano
- Pharmaceutics and Food Technology Department, Faculty of Pharmacy, Universidad Complutense de Madrid (UCM), 28040 Madrid, Spain; (I.Y.); (F.C.L.); (B.J.A.); (D.R.S.)
- Instituto Universitario de Farmacia Industrial, Faculty of Pharmacy, Universidad Complutense de Madrid (UCM), 28040 Madrid, Spain
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Nace J, Chen Z, Bains SS, Kahan ME, Gilson GA, Mont MA, Delanois RE. 1.5-Stage Versus 2-Stage Exchange Total Hip Arthroplasty for Chronic Periprosthetic Joint Infections: A Comparison of Survivorships, Reinfections, and Patient-Reported Outcomes. J Arthroplasty 2023; 38:S235-S241. [PMID: 36878441 DOI: 10.1016/j.arth.2023.02.072] [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: 10/11/2022] [Revised: 01/18/2023] [Accepted: 02/27/2023] [Indexed: 03/08/2023] Open
Abstract
BACKGROUND Management of periprosthetic joint infection after total hip arthroplasty (THA) has traditionally consisted of a 2-stage approach. However, 1.5-stage exchange has garnered recent interest. We compared 1.5-stage to 2-stage exchange recipients. Specifically, we assessed (1) infection-free survivorship and risk factors for reinfection; (2) 2-year surgical/medical outcomes (eg, reoperations, readmissions); (3) Hip Disability and Osteoarthritis Outcome Scores for Joint Replacement (HOOS-JR); and (4) radiographic outcomes (ie, progressive radiolucent lines, subsidences, and failures). METHODS We reviewed a consecutive series of 1.5-stage or planned 2-stage THAs. A total of 123 hips were included (1.5-stage: n = 54; 2-stage: n = 69) with mean clinical follow-up of 2.5 years (up to 8 years). Bivariate analyses assessed incidences of medical and surgical outcomes. Additionally, HOOS-JR scores and radiographs were evaluated. RESULTS The 1.5-stage exchange had 11% greater infection-free survivorship at final follow-up compared to 2 stages (94% versus 83%, P = .048). Morbid obesity was the only independent risk factor demonstrating increased reinfection among both cohorts. No differences in surgical/medical outcomes were observed between groups (P = .730). HOOS-JR scores improved markedly for both cohorts (1.5-stage difference = 44.3, 2-stage difference = 32.5; P < .001). A total of 82% of 1.5-stage patients did not demonstrate progressive femoral or acetabular radiolucencies, while 94% of 2-stage recipients did not have femoral radiolucencies and 90% did not have acetabular radiolucencies. CONCLUSION The 1.5-stage exchange appeared to be an acceptable treatment alternative for periprosthetic joint infections after THAs with noninferior infection eradication. Therefore, this procedure should be considered by joint surgeons for treatment of periprosthetic hip infections.
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Affiliation(s)
- James Nace
- LifeBridge Health, Sinai Hospital of Baltimore, Rubin Institute for Advanced Orthopedics, Baltimore, Maryland
| | - Zhongming Chen
- LifeBridge Health, Sinai Hospital of Baltimore, Rubin Institute for Advanced Orthopedics, Baltimore, Maryland
| | - Sandeep S Bains
- LifeBridge Health, Sinai Hospital of Baltimore, Rubin Institute for Advanced Orthopedics, Baltimore, Maryland
| | - Michael E Kahan
- LifeBridge Health, Sinai Hospital of Baltimore, Rubin Institute for Advanced Orthopedics, Baltimore, Maryland
| | - Gregory A Gilson
- LifeBridge Health, Sinai Hospital of Baltimore, Rubin Institute for Advanced Orthopedics, Baltimore, Maryland
| | - Michael A Mont
- LifeBridge Health, Sinai Hospital of Baltimore, Rubin Institute for Advanced Orthopedics, Baltimore, Maryland
| | - Ronald E Delanois
- LifeBridge Health, Sinai Hospital of Baltimore, Rubin Institute for Advanced Orthopedics, Baltimore, Maryland
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Karczewski D, Schönnagel L, Hipfl C, Akgün D, Hardt S. Periprosthetic knee infection in octogenarians: a single institution experience at midterm outcome. Arch Orthop Trauma Surg 2023; 143:4317-4322. [PMID: 36750492 PMCID: PMC10293346 DOI: 10.1007/s00402-023-04796-z] [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: 09/28/2022] [Accepted: 01/22/2023] [Indexed: 02/09/2023]
Abstract
PURPOSE Periprosthetic joint infections (PJI) of total knee arthroplasties (TKAs) in the elderly is among the clinically most challenging scenarios given multimorbidity combined with poor bone and soft tissue quality. Despite increasing prevalence, limited is known on PJI among this unique group of patients. As such, this study analyzed PJI characteristics, implant survivorship and non-surgical complications of octogenarians revised PJI for the knee. METHODS We identified 31 patients that were revised for PJIs of the knee between 2010 and 2019 using a single university-based registry. Mean age was 83 years (range 80-87), 48% were females, and mean BMI was 29 kg/m2. Mean age adjusted Charlson Comorbidity Index was 7, and mean ASA score was 3. Major causative pathogens included Coagulase-negative Staphylococci (26%), Staphylococcus aureus (13%), and Streptococci (13%). Two-stage exchange was performed in 30 patients, permanent resection arthroplasty in one joint. Kaplan-Meier survivorship analyses were performed. Mean follow-up was 4 years. RESULTS The 2-year survivorship free of any recurrent PJI was 96%, and there was one PJI relapse noted at 6 months. Moreover, there were three additional revisions for aseptic loosening, and one further revision for fracture. As such, the 2-year survivorship free of any revision was 87%. In addition to the aforementioned revisions, there was one additional plate osteosynthesis for a Vancouver C fracture, resulting in a 79% survivorship free of any reoperation at 2 years. Mean perioperative complication score according to the Clavien-Dindo classification was 2 out of 5. A total of three patients died: one patient 40 days after resection arthroplasty, two others 4 months and 8 months after reimplantation. CONCLUSIONS Octogenarians revised for PJI of the knee are at low risk of recurrent infection and overall revision at 2 years. However, moderate rates of perioperative complications and mortality at short term must acknowledge before deciding upon procedure. LEVEL OF EVIDENCE Therapeutic level IV.
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Affiliation(s)
- Daniel Karczewski
- Department of Orthopaedic Surgery, Musculoskeletal Oncology Service, Massachusetts General Hospital-Harvard Medical School, 55 Fruit Street, Boston, MA, 02114, USA.
- Department of Orthopaedic Surgery and Traumatology, Charité Berlin, University Hospital, Chariteplatz 1, 10117, Berlin, Germany.
| | - Lukas Schönnagel
- Department of Orthopaedic Surgery, Musculoskeletal Oncology Service, Massachusetts General Hospital-Harvard Medical School, 55 Fruit Street, Boston, MA, 02114, USA
| | - Christian Hipfl
- Department of Orthopaedic Surgery, Musculoskeletal Oncology Service, Massachusetts General Hospital-Harvard Medical School, 55 Fruit Street, Boston, MA, 02114, USA
| | - Doruk Akgün
- Department of Orthopaedic Surgery, Musculoskeletal Oncology Service, Massachusetts General Hospital-Harvard Medical School, 55 Fruit Street, Boston, MA, 02114, USA
| | - Sebastian Hardt
- Department of Orthopaedic Surgery, Musculoskeletal Oncology Service, Massachusetts General Hospital-Harvard Medical School, 55 Fruit Street, Boston, MA, 02114, USA
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Kwan SA, Lau V, Fliegel BE, Baker C, Courtney PM, Deirmengian GK. Routine Preoperative Dental Clearance for Total Joint Arthroplasty: Is There a Benefit? Cureus 2023; 15:e41352. [PMID: 37546155 PMCID: PMC10399090 DOI: 10.7759/cureus.41352] [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: 07/03/2023] [Indexed: 08/08/2023] Open
Abstract
Background Periprosthetic joint infections (PJIs) place significant psychological and financial burdens on patients and healthcare systems. One measure to reduce the risk of PJIs is preoperative dental screening, for which there is no current consensus recommendation. This study aims to determine whether there is a difference in the rate of PJI and microorganism profile in patients who did and did not obtain preoperative dental clearance. Methodology A retrospective review was conducted among patients undergoing primary total hip arthroplasty and total knee arthroplasty from 2017 to 2021. A cohort of 8,654 patients who underwent routine dental clearance was matched with a cohort of patients who did not. Surgeons who changed their dental clearance protocol were also identified, and the rates of PJIs were compared before and after. Results No statistically significant difference was seen in the rate of PJIs between patients who did and did not undergo routine preoperative dental clearance. No statistically significant difference was seen in the rate of PJIs before and after for surgeons who changed their dental clearance protocol. The microorganism profile between the groups was also found to be without differences. Conclusions Eliminating dental clearance from routine preoperative clearance does not appear to increase the rates of acute PJIs following elective total joint arthroplasty (TJA) or to change the organism profile of the infections that did occur. It may be reasonable to not require routine preoperative dental clearance or to practice selective dental clearance in patients undergoing elective TJA, especially given the increased financial cost and delay in care experienced by patients.
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Affiliation(s)
- Stephanie A Kwan
- Orthopaedic Surgery, Jefferson Health New Jersey, Stratford, USA
| | - Vincent Lau
- Orthopaedic Surgery, Jefferson Health New Jersey, Stratford, USA
| | - Brian E Fliegel
- Orthopaedic Surgery, Jefferson Health New Jersey, Stratford, USA
| | - Colin Baker
- Orthopaedic Surgery, Rothman Orthopaedic Institute, Philadelphia, USA
| | - Paul M Courtney
- Orthopaedic Surgery, Rothman Orthopaedic Institute, Philadelphia, USA
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Norvell MR, Porter M, Ricco MH, Koonce RC, Hogan CA, Basler E, Wong M, Jeffres MN. Cefazolin vs Second-line Antibiotics for Surgical Site Infection Prevention After Total Joint Arthroplasty Among Patients With a Beta-lactam Allergy. Open Forum Infect Dis 2023; 10:ofad224. [PMID: 37363051 PMCID: PMC10289809 DOI: 10.1093/ofid/ofad224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Accepted: 04/20/2023] [Indexed: 06/28/2023] Open
Abstract
Background Cefazolin is a first-line agent for prevention of surgical site infections (SSIs) after total joint arthroplasty. Patients labeled allergic to beta-lactam antibiotics frequently receive clindamycin or vancomycin perioperatively due to the perceived risk of a hypersensitivity reaction after exposure to cefazolin. Methods This single-system retrospective review included patients labeled allergic to penicillin or cephalosporin antibiotics who underwent a primary total hip and/or knee arthroplasty between January 2020 and July 2021. A detailed chart review was performed to compare the frequency of SSI within 90 days of surgery and interoperative hypersensitivity reactions (HSRs) between patients receiving cefazolin and patients receiving clindamycin and/or vancomycin. Results A total of 1128 hip and/or knee arthroplasties from 1047 patients were included in the analysis (cefazolin n = 809, clindamycin/vancomycin n = 319). More patients in the clindamycin and/or vancomycin group had a history of cephalosporin allergy and allergic reactions with immediate symptoms. There were fewer SSIs in the cefazolin group compared with the clindamycin and/or vancomycin group (0.9% vs 3.8%; P < .001) including fewer prosthetic joint infections (0.1% vs 1.9%). The frequency of interoperative HSRs was not different between groups (cefazolin = 0.2% vs clindamycin/vancomycin = 1.3%; P = .06). Conclusions The use of cefazolin as a perioperative antibiotic for infection prophylaxis in total joint arthroplasty in patients labeled beta-lactam allergic is associated with decreased postoperative SSI without an increase in interoperative HSR.
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Affiliation(s)
- Miranda R Norvell
- Correspondence: Meghan N. Jeffres, PharmD, University of Colorado Anschutz Medical Campus, Skaggs School of Pharmacy and Pharmaceutical Sciences, Mail Stop C 238, 12850 E. Montview Blvd, V20-1212, Aurora, CO 80045 (); or Miranda R. Norvell, PharmD, Barnes-Jewish Hospital, Department of Pharmacy, One Barnes-Jewish Hospital Plaza, Mailstop 90-52-411, St Louis, MO 63110-1026 ()
| | - Melissa Porter
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Madison H Ricco
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Ryan C Koonce
- Department of Orthopedic Surgery, University of Colorado Anschutz Medical Campus, School of Medicine, Aurora, Colorado, USA
| | - Craig A Hogan
- Department of Orthopedic Surgery, University of Colorado Anschutz Medical Campus, School of Medicine, Aurora, Colorado, USA
| | - Eric Basler
- Department of Orthopedic Surgery, University of Colorado Anschutz Medical Campus, School of Medicine, Aurora, Colorado, USA
| | - Megan Wong
- UCHealth University of Colorado Hospital, Aurora, Colorado, USA
| | - Meghan N Jeffres
- Correspondence: Meghan N. Jeffres, PharmD, University of Colorado Anschutz Medical Campus, Skaggs School of Pharmacy and Pharmaceutical Sciences, Mail Stop C 238, 12850 E. Montview Blvd, V20-1212, Aurora, CO 80045 (); or Miranda R. Norvell, PharmD, Barnes-Jewish Hospital, Department of Pharmacy, One Barnes-Jewish Hospital Plaza, Mailstop 90-52-411, St Louis, MO 63110-1026 ()
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Giordani FA, Kiernan B, Giordani M, Darrow M, Thorpe S, Meehan JP. Coccidioidomycosis in Joint Replacement: A Review of the Literature With Case Presentations. Arthroplast Today 2023; 21:101123. [PMID: 37012932 PMCID: PMC10065973 DOI: 10.1016/j.artd.2023.101123] [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: 11/16/2022] [Revised: 02/08/2023] [Accepted: 02/10/2023] [Indexed: 04/05/2023] Open
Abstract
Coccidioidomycosis is a fungal infection endemic to certain regions of the Americas. In some cases, the organism may infect the musculoskeletal system, resulting in a prosthetic joint infection (PJI). Due to its difficulty in diagnosis, treatment of coccidioidomycosis in PJI is often delayed. Furthermore, with limited number of case reports, a standard of care in treatment has yet to be established. We present 2 cases of coccidioidomycosis PJI, the extensive evaluation that led to the diagnosis, and the treatment provided. This report highlights the natural progression of coccidioidomycosis in a prosthetic joint, the diagnostic features including histology, advanced imaging, and final treatment administered.
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Affiliation(s)
| | | | | | | | | | - John P. Meehan
- Corresponding author. Department of Orthopaedic Surgery, 4860 Y Street, Suite 3800, Sacramento, CA 95817, USA. Tel.: +1 916 734 5878.
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Doub JB, De Palma BJ, Nandi S. Bacterial Burden, Not Local Immune Response, Differs Between Acute and Chronic Peri-Prosthetic Joint Infections. Surg Infect (Larchmt) 2023. [PMID: 37262179 DOI: 10.1089/sur.2023.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023] Open
Abstract
Background: Conducting gram stains in peri-prosthetic joint infections (PJI) is known to have poor sensitivity. However, the aims of this study were to use gram stain results of acute and chronic PJI to determine differences with respect to bacterial burden and levels of local innate immunologic response. Patients and Methods: Patients with acute and chronic PJI from January 1, 2016 and December 31, 2020 were identified by use of Current Procedural Terminology codes. Manual review of medical records for infecting organisms and gram stain results for stained bacteria and for local tissue inflammation (amount of polymorphonuclear leukocytes seen on high powered microscopic fields) were recorded. Statistical comparisons between acute (n = 70) and chronic (n = 134) PJI were analyzed with respect to gram stain sensitivity and amount of local tissue inflammation. Results: The ability to identify stained bacteria was statistically significantly higher in the acute cohort (61.4%) than the chronic cohort (9.7%; p < 0.0001). Interestingly, the amount of local inflammation was similar for acute and chronic PJI except in the subgroup analysis with chronic polymicrobial (p = 0.0229) and chronic culture negative (p = 0.0001) PJI. Conclusions: This study shows that both acute and chronic PJI had similar levels of local inflammation seen on gram stains, despite higher bacterial burdens in acute infections. This suggests that innate immune responses, and thus likelihood of infection eradication, is not solely dependent on bacterial burden. These findings should spearhead further research evaluating the different immunologic responses that occur in acute and chronic PJI to improve diagnostics, therapeutics, and infection-free implant survival.
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Affiliation(s)
- James B Doub
- Division of Clinical Care and Research, Institute of Human Virology, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Brian J De Palma
- Department of Orthopedic Surgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Sumon Nandi
- Department of Orthopedic Surgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
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Wakabayashi H, Hasegawa M, Naito Y, Tone S, Sudo A. Outcome of Irrigation and Debridement with Topical Antibiotic Delivery Using Antibiotic-Impregnated Calcium Hydroxyapatite for the Management of Periprosthetic Hip Joint Infection. Antibiotics (Basel) 2023; 12:antibiotics12050938. [PMID: 37237841 DOI: 10.3390/antibiotics12050938] [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: 04/07/2023] [Revised: 05/03/2023] [Accepted: 05/19/2023] [Indexed: 05/28/2023] Open
Abstract
We assessed the clinical results of irrigation and debridement (I&D) with antibiotic-impregnated calcium hydroxyapatite (CHA) as a novel antibiotic delivery system for the treatment of prosthetic-joint-associated infection (PJI) after total hip arthroplasty (THA). Thirteen patients (14 hips) treated with I&D for PJI after THA at our institution between 1997 and 2017 were retrospectively evaluated. The study group included four men (five hips) and nine women, with an average age of 66.3 years. Four patients (five hips) had symptoms of infection within less than 3 weeks; however, nine patients had symptoms of infection over 3 weeks. All patients received I&D with antibiotic-impregnated CHA in the surrounding bone. In two hips (two cups and one stem), cup and/or stem revision were performed with re-implantation because of implant loosening. In ten patients (11 hips), vancomycin hydrochloride was impregnated in the CHA. The average duration of follow-up was 8.1 years. Four patients included in this study died of other causes, with an average follow-up of 6.7 years. Eleven of thirteen patients (12 of 14 hips) were successfully treated, and no signs of infection were observed at the latest follow-up. In two patients (two hips) for whom treatment failed, infection was successfully treated with two-stage re-implantation. Both patients had diabetes mellitus and symptoms of infection over 3 weeks. Eighty-six percent of patients were successfully treated. No complications were observed with this antibiotic-impregnated CHA. I&D treatment with antibiotic-impregnated CHA produced a higher rate of success in patients with PJI after THA.
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Affiliation(s)
- Hiroki Wakabayashi
- Department of Orthopaedic Surgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu 514-8507, Japan
| | - Masahiro Hasegawa
- Department of Orthopaedic Surgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu 514-8507, Japan
| | - Yohei Naito
- Department of Orthopaedic Surgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu 514-8507, Japan
| | - Shine Tone
- Department of Orthopaedic Surgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu 514-8507, Japan
| | - Akihiro Sudo
- Department of Orthopaedic Surgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu 514-8507, Japan
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Migliorini F, Weber CD, Bell A, Betsch M, Maffulli N, Poth V, Hofmann UK, Hildebrand F, Driessen A. Bacterial pathogens and in-hospital mortality in revision surgery for periprosthetic joint infection of the hip and knee: analysis of 346 patients. Eur J Med Res 2023; 28:177. [PMID: 37208700 DOI: 10.1186/s40001-023-01138-y] [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: 03/02/2023] [Accepted: 05/09/2023] [Indexed: 05/21/2023] Open
Abstract
INTRODUCTION The management of periprosthetic joint infections (PJI) of the lower limb is challenging, and evidence-based recommendations are lacking. The present clinical investigation characterized the pathogens diagnosed in patients who underwent revision surgery for PJI of total hip arthroplasty (THA) and total knee arthroplasty (TKA). METHODS The present study follows the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE). The institutional databases of the RWTH University Medical Centre of Aachen, Germany, were accessed. The OPS (operation and procedure codes) 5-823 and 5-821 and the ICD (International Statistical Classification of Diseases and Related Health Problems) codes T84.5, T84.7 or T84.8 were used. All patients with PJI of a previous THA and TKA who underwent revision surgery were retrieved and included for analysis. RESULTS Data from 346 patients were collected (181 THAs and 165 TKAs). 44% (152 of 346 patients) were women. Overall, the mean age at operation was 67.8 years, and the mean BMI was 29.2 kg/m2. The mean hospitalization length was 23.5 days. 38% (132 of 346) of patients presented a recurrent infection. CONCLUSION PJI remain a frequent cause for revisions after total hip and knee arthroplasty. Preoperative synovial fluid aspiration was positive in 37%, intraoperative microbiology was positive in 85%, and bacteraemia was present in 17% of patients. Septic shock was the major cause of in-hospital mortality. The most common cultured pathogens were Staph. epidermidis, Staph. aureus, Enterococcus faecalis, and Methicillin-resistant Staph aureus (MRSA). An improved understanding of PJI pathogens is important to plan treatment strategies and guide the choice of empirical antibiotic regimens in patients presenting with septic THAs and TKAs. LEVEL OF EVIDENCE Level III, retrospective cohort study.
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Affiliation(s)
- Filippo Migliorini
- Department of Orthopaedic, Trauma, and Reconstructive Surgery, RWTH University Hospital, Pauwelsstraße 30, 52074, Aachen, Germany.
- Department of Orthopaedic and Trauma Surgery, Eifelklinik St. Brigida, 52152, Simmerath, Germany.
| | - Christian David Weber
- Department of Orthopaedic, Trauma, and Reconstructive Surgery, RWTH University Hospital, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Andreas Bell
- Department of Orthopaedic and Trauma Surgery, Eifelklinik St. Brigida, 52152, Simmerath, Germany
| | - Marcel Betsch
- Department of Orthopaedic and Trauma Surgery, University Hospital of Erlangen, 91054, Erlangen, Germany
| | - Nicola Maffulli
- Department of Medicine, Surgery and Dentistry, University of Salerno, 84081, Baronissi, Italy.
- School of Pharmacy and Bioengineering, Faculty of Medicine, Keele University, Stoke On Trent, ST4 7QB, UK.
- Centre for Sports and Exercise Medicine, Barts and the London School of Medicine and Dentistry, Mile End Hospital, Queen Mary University of London, 275 Bancroft Road, London, E1 4DG, UK.
| | - Vanessa Poth
- Department of Orthopaedic, Trauma, and Reconstructive Surgery, RWTH University Hospital, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Ulf Krister Hofmann
- Department of Orthopaedic, Trauma, and Reconstructive Surgery, RWTH University Hospital, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Frank Hildebrand
- Department of Orthopaedic, Trauma, and Reconstructive Surgery, RWTH University Hospital, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Arne Driessen
- Department of Orthopaedic, Trauma, and Reconstructive Surgery, RWTH University Hospital, Pauwelsstraße 30, 52074, Aachen, Germany
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Lenguerrand E, Whitehouse MR, Beswick AD, Kunutsor SK, Webb JCJ, Mehendale S, Porter M, Blom AW. Mortality and re-revision following single-stage and two-stage revision surgery for the management of infected primary hip arthroplasty in England and Wales. Bone Joint Res 2023; 12:321-330. [PMID: 37158424 PMCID: PMC10167772 DOI: 10.1302/2046-3758.125.bjr-2022-0131.r1] [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: 05/10/2023] Open
Abstract
We compared the risks of re-revision and mortality between two-stage and single-stage revision surgeries among patients with infected primary hip arthroplasty. Patients with a periprosthetic joint infection (PJI) of their primary arthroplasty revised with single-stage or two-stage procedure in England and Wales between 2003 and 2014 were identified from the National Joint Registry. We used Poisson regression with restricted cubic splines to compute hazard ratios (HRs) at different postoperative periods. The total number of revisions and re-revisions undergone by patients was compared between the two strategies. In total, 535 primary hip arthroplasties were revised with single-stage procedure (1,525 person-years) and 1,605 with two-stage procedure (5,885 person-years). All-cause re-revision was higher following single-stage revision, especially in the first three months (HR at 3 months = 1.98 (95% confidence interval (CI) 1.14 to 3.43), p = 0.009). The risks were comparable thereafter. Re-revision for PJI was higher in the first three postoperative months for single-stage revision and waned with time (HR at 3 months = 1.81 (95% CI 1.22 to 2.68), p = 0.003; HR at 6 months = 1.25 (95% CI 0.71 to 2.21), p = 0.441; HR at 12 months = 0.94 (95% CI 0.54 to 1.63), p = 0.819). Patients initially managed with a single-stage revision received fewer revision operations (mean 1.3 (SD 0.7) vs 2.2 (SD 0.6), p < 0.001). Mortality rates were comparable between these two procedures (29/10,000 person-years vs 33/10,000). The risk of unplanned re-revision was lower following two-stage revision, but only in the early postoperative period. The lower overall number of revision procedures associated with a single-stage revision strategy and the equivalent mortality rates to two-stage revision are reassuring. With appropriate counselling, single-stage revision is a viable option for the treatment of hip PJI.
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Affiliation(s)
- Erik Lenguerrand
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Michael R Whitehouse
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol NHS Foundation Trust and University of Bristol, Bristol, UK
| | - Andrew D Beswick
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Setor K Kunutsor
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol NHS Foundation Trust and University of Bristol, Bristol, UK
| | - Jason C J Webb
- Avon Orthopaedic Centre, Southmead Hospital, North Bristol NHS Trust, Bristol, UK
| | - Sanchit Mehendale
- Department of Trauma and Orthopaedics, Bristol Royal Infirmary, Bristol, UK
| | - Martyn Porter
- Centre for Hip Surgery, Wrightington Hospital, Wrightington, UK
| | - Ashley W Blom
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol NHS Foundation Trust and University of Bristol, Bristol, UK
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Chen TW, Gandotra R, Chang HY, Lee MS, Kuo FC, Lee GB. Automatic Detection of Two Synovial Fluid Periprosthetic Joint Infection Biomarkers on an Integrated Microfluidic System. Anal Chem 2023; 95:7693-7701. [PMID: 37145768 DOI: 10.1021/acs.analchem.3c00767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/06/2023]
Abstract
Post-arthroplasty periprosthetic joint infection (PJI) is a serious ailment that can be difficult to diagnose. Herein, we developed a novel integrated microfluidic system (IMS) capable of detecting two common PJI biomarkers, alpha defensin human neutrophil peptide 1 (HNP-1) and C-reactive protein (CRP), from synovial fluid (SF). A magnetic bead-based one-aptamer-one-antibody assay was carried out automatically within 45 min on a single chip for simultaneous detection of both biomarkers at concentration ranges of 0.01-50 (HNP-1) and 1-100 (CRP) mg/L. It is the first report for utilizing these two biomarkers as targets to establish the new one-aptamer-one-antibody assay to detect PJI on-chip, and the aptamers demonstrated high specificity to their SF targets. As 20 clinical samples were correctly diagnosed with our IMS (verified by a common gold standard kit), it could serve as a promising tool for PJI diagnostics.
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Affiliation(s)
- To-Wen Chen
- Department of Power Mechanical Engineering, National Tsing Hua University, Hsinchu 30013, Taiwan
| | - Rishabh Gandotra
- Institute of NanoEngineering and Microsystems, National Tsing Hua University, Hsinchu 30013, Taiwan
| | - Hwan-You Chang
- Institute of Molecular Medicine, National Tsing Hua University, Hsinchu 30013, Taiwan
| | - Mel S Lee
- Department of Orthopaedic Surgery, Paochien Hospital, Pingtung 90064, Taiwan
| | - Feng-Chih Kuo
- Department of Orthopaedic Surgery, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University, Kaohsiung 83301, Taiwan
- College of Medicine, Chang Gung University, Kaohsiung 83301, Taiwan
- Center for General Education, Cheng Shiu University, Kaohsiung 83347, Taiwan
| | - Gwo-Bin Lee
- Department of Power Mechanical Engineering, National Tsing Hua University, Hsinchu 30013, Taiwan
- Institute of NanoEngineering and Microsystems, National Tsing Hua University, Hsinchu 30013, Taiwan
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Harper KD, Park KJ, Brozovich A, Sullivan TC, Serpelloni S, Taraballi F, Incavo SJ, Clyburn TA. Intraosseous Vancomycin in Total Hip Arthroplasty - Superior Tissue Concentrations and Improved Efficiency. J Arthroplasty 2023:S0883-5403(23)00385-6. [PMID: 37088221 DOI: 10.1016/j.arth.2023.04.028] [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: 03/28/2023] [Revised: 04/13/2023] [Accepted: 04/14/2023] [Indexed: 04/25/2023] Open
Abstract
BACKGROUND Literature shows that intraosseous (IO) infusions are capable of providing increased local concentrations compared to those administered via intravenous (IV) access. Successes while using the technique for antibiotic prophylaxis administration in total knee arthroplasty (TKA) prompted consideration for use in total hip arthroplasty (THA) however; no study exists for the use of IO vancomycin in THA. METHODS This single-blinded randomized control trial was performed from December 2020 to May 2022. Twenty patients were randomized into one of two groups: IV vancomycin (15 mg/kg) given routinely, or IO vancomycin (500mg/100cc of NS) injected into the greater trochanter during incision. Serum vancomycin levels were collected at incision and closure. Soft tissue vancomycin levels were taken from the gluteus maximus (at start and end of case), and acetabular pulvinar tissue. Bone vancomycin levels were taken from the femoral head, acetabular reamings, and intramedullary bone. Adverse local/systemic reactions, 30-day and 90-day complications were also tracked. RESULTS A statistically significant reduction in serum vancomycin levels was seen when comparing IO to IV vancomycin at both the start and end of the procedure. All local tissue samples had higher concentrations of vancomycin in the IO group. Statistically significant increases were present within the acetabular bone reamings, and approached significance in intramedullary femoral bone. CONCLUSION This study demonstrates the utility of IO vancomycin in primary THA with increased local tissue and decreased systemic concentrations. With positive findings in an area without tourniquet use, IO may be considered for antibiotic delivery for alternative procedures.
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Affiliation(s)
- Katharine D Harper
- Department of Orthopedic Surgery, Washington DC VA Medical Center, Washington, DC.
| | - Kwan J Park
- Houston Methodist Orthopedics and Sports Medicine, Houston, TX
| | - Ava Brozovich
- Houston Methodist Orthopedics and Sports Medicine, Houston, TX; Center for Musculoskeletal Regeneration, Houston Methodist Research Institute, Houston, TX
| | | | - Stefano Serpelloni
- Center for Musculoskeletal Regeneration, Houston Methodist Research Institute, Houston, TX
| | - Francesca Taraballi
- Center for Musculoskeletal Regeneration, Houston Methodist Research Institute, Houston, TX
| | | | - Terry A Clyburn
- Houston Methodist Orthopedics and Sports Medicine, Houston, TX
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Steadman W, Chapman PR, Schuetz M, Schmutz B, Trampuz A, Tetsworth K. Local Antibiotic Delivery Options in Prosthetic Joint Infection. Antibiotics (Basel) 2023; 12:antibiotics12040752. [PMID: 37107114 PMCID: PMC10134995 DOI: 10.3390/antibiotics12040752] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Revised: 04/03/2023] [Accepted: 04/07/2023] [Indexed: 04/29/2023] Open
Abstract
Prosthetic Joint Infection (PJI) causes significant morbidity and mortality for patients globally. Delivery of antibiotics to the site of infection has potential to improve the treatment outcomes and enhance biofilm eradication. These antibiotics can be delivered using an intra-articular catheter or combined with a carrier substance to enhance pharmacokinetic properties. Carrier options include non-resorbable polymethylmethacrylate (PMMA) bone cement and resorbable calcium sulphate, hydroxyapatite, bioactive glass, and hydrogels. PMMA allows for creation of structural spacers used in multi-stage revision procedures, however it requires subsequent removal and antibiotic compatibility and the levels delivered are variable. Calcium sulphate is the most researched resorbable carrier in PJI, but is associated with wound leakage and hypercalcaemia, and clinical evidence for its effectiveness remains at the early stage. Hydrogels provide a versatile combability with antibiotics and adjustable elution profiles, but clinical usage is currently limited. Novel anti-biofilm therapies include bacteriophages which have been used successfully in small case series.
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Affiliation(s)
- William Steadman
- Jamieson Trauma Institute, Royal Brisbane and Women's Hospital, Herston, Brisbane 4029, Australia
- Department of Orthopaedics, Royal Brisbane and Women's Hospital, Herston, Brisbane 4029, Australia
- Faculty of Health, Queensland University of Technology, Brisbane 4059, Australia
| | - Paul R Chapman
- Jamieson Trauma Institute, Royal Brisbane and Women's Hospital, Herston, Brisbane 4029, Australia
- Herston Infectious Disease Institute, Royal Brisbane and Women's Hospital, Herston, Brisbane 4029, Australia
- Department of Infectious Diseases, Royal Brisbane and Women's Hospital, Herston, Brisbane 4029, Australia
| | - Michael Schuetz
- Jamieson Trauma Institute, Royal Brisbane and Women's Hospital, Herston, Brisbane 4029, Australia
- Department of Orthopaedics, Royal Brisbane and Women's Hospital, Herston, Brisbane 4029, Australia
- Faculty of Health, Queensland University of Technology, Brisbane 4059, Australia
| | - Beat Schmutz
- Jamieson Trauma Institute, Royal Brisbane and Women's Hospital, Herston, Brisbane 4029, Australia
- School of Mechanical, Medical and Process Engineering, Faculty of Engineering, Queensland University of Technology, Brisbane 4000, Australia
- Centre for Biomedical Technologies, Queensland University of Technology, Brisbane 4059, Australia
- Australian Research Council Training Centre for Multiscale 3D Imaging, Modelling, and Manufacturing, Queensland University of Technology, Brisbane 4059, Australia
| | - Andrej Trampuz
- Center for Musculoskeletal Surgery, Septic Unit Charité-Universitätsmedizin, 10117 Berlin, Germany
| | - Kevin Tetsworth
- Department of Orthopaedics, Royal Brisbane and Women's Hospital, Herston, Brisbane 4029, Australia
- School of Medicine, University of Queensland, Brisbane 4029, Australia
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Gramlich Y, Schnetz M, Ruckes C, Kemmerer M, Kremer M, Hoffmann R, Klug A. The optimal diagnostic cut-off of WBC and PMN counts for joint aspiration in periprosthetic joint infection is 2479/µL and 67%, respectively: ICM criteria thresholds are too high. Arch Orthop Trauma Surg 2023:10.1007/s00402-023-04822-0. [PMID: 36941499 DOI: 10.1007/s00402-023-04822-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2022] [Accepted: 02/26/2023] [Indexed: 03/23/2023]
Abstract
BACKGROUND Various organizations have published definitions for periprosthetic joint infection (PJI) with significant differences in the cut-offs of white blood cell (WBC) count and polymorphonuclear (PMN) leukocyte cells. Herein, we aim to analyze optimal cut-offs in patients which are planned to undergo a prosthesis revision and compare them with the actual published thresholds of the International Consensus Meeting (ICM) and European Bone and Joint Infection Society (EBJIS). METHODS A test kit was compiled in a monocentric prospective study, according to the ICM criteria (2018) and 2021 EBJIS criteria. The kit was implemented using: blood samples (including leukocyte count and C-reactive protein); samples for examining the synovial fluid (WBC count, PMN cell differentiation, microbiological culture for incubation over 14 days, alpha-defensin ELISA laboratory test, and leukocyte-esterase test). The cut-offs for WBC and PMN counts were investigated using ROC analyses and Youden index. The ICM 2018 criteria were applied, using alpha-defensin in all cases. Patients which have to undergo a prosthesis revision were included, a pre-operative joint aspiration had been performed, and the patients had been followed up prospectively. RESULTS 405 patients were examined with the compiled test kit; 100% had a complete dataset with respect to alpha-defensin; 383 patients, according to WBC count; and 256, according to PMN cell differentiation The cut-off of 2478.89 cells/µl in the WBC count (sensitivity: 87.70%; specificity: 88.10%) and the cut-off of 66.99% in PMN differentiation showed the best accuracy (sensitivity: 86.00%; specificity: 88.80%). Other published cut-offs for WBC were tested in this cohort and showed the following accuracy: 3000/µl (EBJIS/ICM; sensitivity: 82.10%; specificity: 91.00%), 2000/µl (sensitivity: 89.60%; specificity: 83.40%), and 1500/µl (sensitivity: 91.50%; specificity: 75.00%). The published cut-offs for PMN had the following accuracy in this cohort: 80% (ICM; sensitivity: 66.3%; specificity: 96.50%), 70% (sensitivity: 82.6%; specificity: 90%), and 65% (EBJIS, sensitivity: 86%; specificity: 88.8%). CONCLUSIONS This study aims to improve current cut-offs for PMN- and WB-Count, even though PJI diagnosis is based on the combination of all defined tests. The optimal diagnostic cut-off of WBC and PMN counts was found to be 2479/µL and 67%, respectively, whereas ICM cut-offs in this cohort seem too high, as they provide high specificity but very low sensitivity. On the other hand, a cut-off for WBC count of 1500/µl alone would be very low, leading to low specificity and very high suspicion of PJI. The current consensus guidelines could be actualized considering these results to significantly improve the diagnostic quality. LEVEL OF EVIDENCE II.
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Affiliation(s)
- Y Gramlich
- Department of Trauma and Orthopedic Surgery, Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, Friedberger Landstr. 430, 60389, Frankfurt am Main, Germany.
| | - M Schnetz
- Department of Trauma and Orthopedic Surgery, Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, Friedberger Landstr. 430, 60389, Frankfurt am Main, Germany
| | - C Ruckes
- Interdisciplinary Center for Clinical Studies, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - M Kemmerer
- Department of Trauma and Orthopedic Surgery, Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, Friedberger Landstr. 430, 60389, Frankfurt am Main, Germany
| | - M Kremer
- Department of Trauma and Orthopedic Surgery, Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, Friedberger Landstr. 430, 60389, Frankfurt am Main, Germany
| | - R Hoffmann
- Department of Trauma and Orthopedic Surgery, Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, Friedberger Landstr. 430, 60389, Frankfurt am Main, Germany
| | - A Klug
- Department of Trauma and Orthopedic Surgery, Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, Friedberger Landstr. 430, 60389, Frankfurt am Main, Germany
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Jandl NM, Kleiss S, Mussawy H, Beil FT, Hubert J, Rolvien T. Absolute synovial polymorphonuclear neutrophil cell count as a biomarker of periprosthetic joint infection. Bone Joint J 2023; 105-B:373-381. [PMID: 36924172 DOI: 10.1302/0301-620x.105b4.bjj-2022-0628.r1] [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: 03/18/2023]
Abstract
The aim of this study was to evaluate the diagnostic accuracy of the absolute synovial polymorphonuclear neutrophil cell (PMN) count for the diagnosis or exclusion of periprosthetic joint infection (PJI) after total hip (THA) or knee arthroplasty (TKA). In this retrospective cohort study, 147 consecutive patients with acute or chronic complaints following THA and TKA were included. Diagnosis of PJI was established based on the 2018 International Consensus Meeting criteria. A total of 39 patients diagnosed with PJI (32 chronic and seven acute) and 108 patients with aseptic complications were surgically revised. Using receiver operating characteristic curves and calculating the area under the curve (AUC), an optimal synovial cut-off value of 2,000 PMN/µl was determined (AUC 0.978 (95% confidence interval (CI) 0.946 to 1)). Using this cut-off, sensitivity and specificity of absolute synovial PMN count for PJI were 97.4% (95% CI 91.2 to 100) and 93.5% (95% CI 88.9 to 98.1), respectively. Positive and negative predictive value were 84.4% (95% CI 72.7 to 93.9) and 99.0% (95% CI 96.7 to 100), respectively. Exclusion of 20 patients with acute complications improved specificity to 97.9% (95% CI 94.6 to 100). Different cut-off values for THA (< 3,600 PMN/µl) and TKA (< 2,000 PMN/µl) were identified. Absolute synovial PMN count correlated strongly with synovial alpha-defensin (AD) (r = 0.759; p < 0.001). With a positive AD result, no additional PJI could be identified in any case. Absolute synovial PMN count is a widely available, rapid, cost-effective, and accurate marker in PJI diagnostics, whereas synovial AD appears to be a surrogate parameter of absolute synovial PMN count. Despite limitations in the early postoperative phase, wear, and rheumatic diseases in confirming PJI, an absolute synovial PMN count below 2,000/µl is highly suitable for ruling out PJI, with specific cut-off values for THA and TKA.
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Affiliation(s)
- Nico M Jandl
- Department of Trauma and Orthopaedic Surgery, Division of Orthopaedics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Sebastian Kleiss
- Department of Trauma and Orthopaedic Surgery, Division of Orthopaedics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Haider Mussawy
- Department of Trauma and Orthopaedic Surgery, Division of Orthopaedics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Frank T Beil
- Department of Trauma and Orthopaedic Surgery, Division of Orthopaedics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jan Hubert
- Department of Trauma and Orthopaedic Surgery, Division of Orthopaedics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Tim Rolvien
- Department of Trauma and Orthopaedic Surgery, Division of Orthopaedics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Caldwell M, Hughes M, Wei F, Ngo C, Pascua R, Pugazhendhi AS, Coathup MJ. Promising applications of D-amino acids in periprosthetic joint infection. Bone Res 2023; 11:14. [PMID: 36894568 PMCID: PMC9998894 DOI: 10.1038/s41413-023-00254-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2022] [Revised: 02/02/2023] [Accepted: 02/10/2023] [Indexed: 03/11/2023] Open
Abstract
Due to the rise in our aging population, a disproportionate demand for total joint arthroplasty (TJA) in the elderly is forecast. Periprosthetic joint infection (PJI) represents one of the most challenging complications that can occur following TJA, and as the number of primary and revision TJAs continues to rise, an increasing PJI burden is projected. Despite advances in operating room sterility, antiseptic protocols, and surgical techniques, approaches to prevent and treat PJI remain difficult, primarily due to the formation of microbial biofilms. This difficulty motivates researchers to continue searching for an effective antimicrobial strategy. The dextrorotatory-isoforms of amino acids (D-AAs) are essential components of peptidoglycan within the bacterial cell wall, providing strength and structural integrity in a diverse range of species. Among many tasks, D-AAs regulate cell morphology, spore germination, and bacterial survival, evasion, subversion, and adhesion in the host immune system. When administered exogenously, accumulating data have demonstrated that D-AAs play a pivotal role against bacterial adhesion to abiotic surfaces and subsequent biofilm formation; furthermore, D-AAs have substantial efficacy in promoting biofilm disassembly. This presents D-AAs as promising and novel targets for future therapeutic approaches. Despite their emerging antibacterial efficacy, their role in disrupting PJI biofilm formation, the disassembly of established TJA biofilm, and the host bone tissue response remains largely unexplored. This review aims to examine the role of D-AAs in the context of TJAs. Data to date suggest that D-AA bioengineering may serve as a promising future strategy in the prevention and treatment of PJI.
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Affiliation(s)
- Matthew Caldwell
- Biionix Cluster & College of Medicine, University of Central Florida, 6900 Lake Nona Blvd, Orlando, FL, 32827, USA
| | - Megan Hughes
- School of Biosciences, Cardiff University, CF10 3AT, Wales, UK
| | - Fei Wei
- Biionix Cluster & College of Medicine, University of Central Florida, 6900 Lake Nona Blvd, Orlando, FL, 32827, USA
| | - Christopher Ngo
- Biionix Cluster & College of Medicine, University of Central Florida, 6900 Lake Nona Blvd, Orlando, FL, 32827, USA
| | - Raven Pascua
- Burnett School of Biomedical Sciences, College of Medicine, University of Central Florida, 6900 Lake Nona Blvd, Orlando, FL, 32827, USA
| | - Abinaya Sindu Pugazhendhi
- Biionix Cluster & College of Medicine, University of Central Florida, 6900 Lake Nona Blvd, Orlando, FL, 32827, USA
| | - Melanie J Coathup
- Biionix Cluster & College of Medicine, University of Central Florida, 6900 Lake Nona Blvd, Orlando, FL, 32827, USA.
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Trends in Revision Hip Arthroplasty for Prosthetic Joint Infection: A Single-Center Study of 423 Hips at a High-Volume Center Between 2008 and 2021. J Arthroplasty 2023; 38:1151-1159. [PMID: 36863575 DOI: 10.1016/j.arth.2023.02.061] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Revised: 02/16/2023] [Accepted: 02/21/2023] [Indexed: 03/04/2023] Open
Abstract
BACKGROUND Prosthetic joint infection (PJI) is one of the most devastating complications after total hip arthroplasty (THA), and comorbidities increase the risk. We examined whether there was a temporal change in the demographics, especially regarding comorbidities, of patients who have PJIs and were treated over a 13-year study period at a high-volume academic joint arthroplasty center. In addition, the surgical methods used and the microbiology of the PJIs were assessed. METHODS Revisions (n = 423, 418 patients) due to PJI of the hip performed at our institution between 2008 and September 2021 were identified. All included PJIs fulfilled the 2013 International Consensus Meeting diagnostic criteria. The surgeries were categorized into one of the following categories: debridement, antibiotics, and implant retention, 1-stage revision, and 2-stage revision. Infections were classified as early, acute hematogenous, and chronic infections. RESULTS There was no change in the median age of the patients, but the proportion of ASA-class 4 patients increased from 10.5% to 20%. The incidence of early infections increased from 0.11 per 100 primary THAs in 2008 to 1.09 in 2021. The incidence of 1-stage revisions increased the most, rising from 0.10 per 100 primary THAs in 2010 to 0.91 per 100 primary THAs in 2021. Furthermore, the proportion of infections caused by Staphylococcus aureus increased from 26.3% in 2008 to 2009 to 40% in 2020 to 2021. CONCLUSION The comorbidity burden of PJI patients increased during the study period. This increase may present a treatment challenge, as comorbidities are known to have a negative effect on PJI treatment outcomes.
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Dong S, Mei F, Li JJ, Xing D. Global Cluster Analysis and Network Visualization in Prosthetic Joint Infection: A Scientometric Mapping. Orthop Surg 2023; 15:1165-1178. [PMID: 36855945 PMCID: PMC10102317 DOI: 10.1111/os.13681] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Revised: 11/22/2022] [Accepted: 12/15/2022] [Indexed: 03/02/2023] Open
Abstract
OBJECTIVE Prosthetic joint infection (PJI) is the main reason of failure of total joint arthroplasty (TJA). This study aimed to investigate the global trends and network visualization in research of PJI. METHODS Publications in PJI search during 1980-2022 were extracted from the Science Citation Index-Expanded of Web of Science Core Collection database (WoSCC). The source data was investigated and analyzed by bibliometric methodology. For network visualization, VOS viewer and R software was used to perform bibliographic coupling, co-citation, co-authorship and co-occurrence analysis and to predict the publication trends in PJI research. RESULTS There were 7288 articles included. The number of publications and relative research interests increased gradually per year globally. The USA made the highest contributions in the world and with the highest H-index and the most citations. Journal of Arthroplasty published the highest number of articles in this area. The Mayo Clinic, Thomas Jefferson University (Rothman Institute), Hospital Special Surgery and the Rush University were the most contributive institutions by network visualization. Included studies were divided into four clusters: bacterial pathogenic mechanism and antibacterial drugs study, TJA complications, risk factors and epidemiology of PJI, diagnosis of PJI, and revision surgical management. More articles in PJI could be published over the next few years. CONCLUSION The number of publications about PJI will be increasing dramatically based on the global trends and network visualization. The USA made the highest contributions in PJI. Diagnosis and revision management may be the next hot spots in this field.
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Affiliation(s)
- Shengjie Dong
- Orthopedic Department, Yantaishan Hospital, Yantai, China
| | - Fengyao Mei
- Arthritis Clinic & Research Center, Peking University People's Hospital, Peking University, Beijing, China.,Arthritis Institute, Peking University, Beijing, China
| | - Jiao Jiao Li
- School of Biomedical Engineering, Faculty of Engineering and IT, University of Technology Sydney, Ultimo, Australia
| | - Dan Xing
- Arthritis Clinic & Research Center, Peking University People's Hospital, Peking University, Beijing, China.,Arthritis Institute, Peking University, Beijing, China
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