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Sabater-Martos M, Boadas L, Trebše R, Grenho A, Sanz-Ruiz P, Marais LC, Vaznaisiene D, Ferrari M, Soriano A. Impact of Positive Cultures During the Second Stage of a Two-Stage Exchange: Systematic Review and Meta-Analysis. J Arthroplasty 2024; 39:839-845.e15. [PMID: 37757980 DOI: 10.1016/j.arth.2023.09.022] [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: 06/27/2023] [Revised: 09/13/2023] [Accepted: 09/16/2023] [Indexed: 09/29/2023] Open
Abstract
BACKGROUND Two-stage exchange is a frequently performed procedure in patients who have a periprosthetic joint infection. Positive cultures when performing the second stage are perceived as a risk factor for reinfection. This study aimed to determine the impact of positive cultures during the second stage on the outcome of patients undergoing a 2-stage septic exchange and the impact of stopping the antibiotic treatment before reimplantation. METHODS We systematically searched four databases. We performed a meta-analysis on the risk of complications after positive cultures during second stage and a subgroup analysis by antibiotic holiday period. We included 24 studies. RESULTS Failure in the positive group was 37.0% and in the negative group was 13.7% with an odds ratio (OR) of 4.05. In the subgroup analysis by antibiotic holidays, failure rate without holidays was 15% and with holidays was 17.3% (P = .21). Failure in each group was higher when cultures were positive (without holidays, 25 versus 12.2%, P = .0003, and with holidays 41.1 versus 12.7%, P < .0001), but the risk of failure when cultures were positive was higher in the holiday group (OR 4.798) than in the nonholiday group (OR 2.225) in comparison to those patients who were culture negative at the second stage. CONCLUSIONS Microbiological eradication at second stage was not obtained in 18% of cases and it was associated with a higher failure rate. In patients with positive cultures, withholding antibiotic treatment was associated with lower failure rate. Further studies to define the antibiotic strategy in 2-stage exchange procedure are necessary.
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Affiliation(s)
- Marta Sabater-Martos
- Orthopedic and Traumatology Department, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Laia Boadas
- Orthopedic and Traumatology Department, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Rihard Trebše
- Faculty of Medicine, Valdoltra Orthopedic Hospital, Akaran Slovenija, University of Ljubljana, Ljubljana, Slovenija
| | - André Grenho
- CHULC - Hospital de Curry Cabral Orthopaedics Department, Lisbon, Portugal
| | - Pablo Sanz-Ruiz
- Orthopedic and Traumatology Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Leonard C Marais
- Department of Orthopaedics, School of Clinical Medicine, University of KwaZulu-Natal, KwaZulu-Natal, South Africa
| | - Danguole Vaznaisiene
- Department of Infectious Diseases, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | | | - Alex Soriano
- Department of Infectious Diseases, Hospital Clínic of Barcelona, Barcelona, Spain; University of Barcelona, CIBERINF, Barcelona, Spain
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Krüger L, Strahl A, Koepke LG, Fink B, Beil FT, Hubert J. The Use of Intraoperative Cell Salvage in Two-Stage Revision of Septic Hip Arthroplasties: A Double-Center Retrospective Study. Antibiotics (Basel) 2023; 12:982. [PMID: 37370301 DOI: 10.3390/antibiotics12060982] [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: 04/16/2023] [Revised: 05/22/2023] [Accepted: 05/26/2023] [Indexed: 06/29/2023] Open
Abstract
(1) Background: intraoperative cell salvage (ICS) devices can provide a valuable contribution to patient blood management. An infection of the surgical site presents a formal contraindication to the use of ICS. To date, there is no recommendation for the use of ICS in the context of reimplantation in two-stage septic exchange arthroplasty. (2) Methods: at two hospitals of maximum endoprosthetic care, a retrospective evaluation of patients who had received ICS blood during reimplantation of hip arthroplasties was performed. Patients' and surgical characteristics, intraoperative cultures, and the occurrence of septic complications in the short- and long-term follow-up were recorded. (3) Results: 144 patients were included. Detection of positive cultures during reimplantation occurred in 13 cases. A total of 127 patients showed no complication, 8 patients showed a non-specific septic complication, 6 patients a local persistence of infection, and 3 patients a possible bloodstream-associated infection. No significant correlation was found between the occurrence of complications and the detection of positive intraoperative cultures. (4) Conclusions: no clustering of septic complications due to the use of ICS during reimplantation was found. In the risk-benefit analysis, we considered the use of ICS during reimplantation to be indicated in terms of patient blood management, while the safety of the procedure during septic first-stage resection arthroplasty or septic one-stage exchange arthroplasty was not investigated. Given the paucity of comparative literature, further studies are needed on ideal patient blood management in the setting of septic revision arthroplasty.
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Affiliation(s)
- Lara Krüger
- Department of Trauma and Orthopaedic Surgery, Division of Orthopaedics, University Medical Centre Hamburg-Eppendorf, 20246 Hamburg, Germany
| | - André Strahl
- Department of Trauma and Orthopaedic Surgery, Division of Orthopaedics, University Medical Centre Hamburg-Eppendorf, 20246 Hamburg, Germany
| | - Leon-Gordian Koepke
- Department of Trauma and Orthopaedic Surgery, Division of Spine Surgery, University Medical Centre Hamburg-Eppendorf, 20246 Hamburg, Germany
| | - Bernd Fink
- Department of Trauma and Orthopaedic Surgery, Division of Orthopaedics, University Medical Centre Hamburg-Eppendorf, 20246 Hamburg, Germany
- Department of Joint Replacement, General and Rheumatic Orthopaedics, Orthopaedic Clinic Markgröningen, 71706 Markgröningen, Germany
| | - Frank Timo Beil
- Department of Trauma and Orthopaedic Surgery, Division of Orthopaedics, University Medical Centre Hamburg-Eppendorf, 20246 Hamburg, Germany
| | - Jan Hubert
- Department of Trauma and Orthopaedic Surgery, Division of Orthopaedics, University Medical Centre Hamburg-Eppendorf, 20246 Hamburg, Germany
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Li F, Qiao Y, Zhang H, Cao G, Zhou S. Comparable clinical outcomes of culture-negative and culture-positive periprosthetic joint infections: a systematic review and meta-analysis. J Orthop Surg Res 2023; 18:210. [PMID: 36927390 PMCID: PMC10018887 DOI: 10.1186/s13018-023-03692-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Accepted: 03/08/2023] [Indexed: 03/18/2023] Open
Abstract
PURPOSE The aim of this study was to compare the clinical outcomes of culture-negative periprosthetic joint infection (CN PJI) with those of culture-positive periprosthetic joint infection (CP PJI). METHODS Data were obtained from Embase, Web of Science and EBSCO for all available studies comparing the clinical outcomes of CN PJI with those of CP PJI. The quality of the studies was scored using the Newcastle-Ottawa scale (NOS). Pooled odds ratios (ORs) and 95% confidence intervals (CIs) were used to assess clinical outcomes. Subgroup analyses were performed to explain heterogeneity among the included studies. Publication bias was estimated using Begg's funnel plot. Sensitivity analysis was performed to test the stability of pooled results. RESULTS Thirty studies with 1630 (38.7%) CN PJI and 2577 (61.3%) CP PJI were included in this meta-analysis. The pooled results of the included studies showed that overall failure rate in CN PJI group (19.0%, 309/1630) was significantly lower than that in CP PJI group (23.4%, 604/2577) (OR 0.63, 95% CI 0.47-0.84, P = 0.002). We performed the subgroup analysis based on the surgical strategies, the pooled results of nine studies for patients undergoing debridement, antibiotics and implant retention (DAIR) revealed that failure rate in CN PJI group (22.2%, 53/239) was significantly lower than that in CP PJI group (29.3%, 227/775) (OR 0.62, 95% CI 0.43-0.90, P = 0.01), the pooled results of four studies for patients undergoing one-stage revision revealed that failure rate between CN PJI group (11.5%, 11/96) and CP PJI group (7.6%, 27/355) had no significant difference (OR 1.57, 95% CI 0.75-3.26, P = 0.23), and the pooled results of 19 studies for patients undergoing two-stage revision revealed that failure rate in CN PJI group (16.1%, 171/1062) was significantly lower than that in CP PJI group (20.4%, 206/1010) (OR 0.52, 95% CI 0.34-0.79, P = 0.002). CONCLUSIONS CN PJI group had similar or better survival rate when compared with CP PJI group for patients who underwent DAIR, one-stage or two-stage revision. Negative culture was not a worse prognostic factor for PJI.
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Affiliation(s)
- Feng Li
- Department of Joint Surgery, The 940th Hospital of Joint Logistic Support Force of Chinese People's Liberation Army, Gansu, Lanzhou, China.,Department of Orthopaedics, The 943rd Hospital of Joint Logistic Support Force of Chinese People's Liberation Army, Gansu, Wuwei, China
| | - Yongjie Qiao
- Department of Joint Surgery, The 940th Hospital of Joint Logistic Support Force of Chinese People's Liberation Army, Gansu, Lanzhou, China
| | - Haoqiang Zhang
- Department of Joint Surgery, The 940th Hospital of Joint Logistic Support Force of Chinese People's Liberation Army, Gansu, Lanzhou, China
| | - Guoding Cao
- Department of Orthopaedics, Lanzhou University Second Hospital, Gansu, Lanzhou, China
| | - Shenghu Zhou
- Department of Joint Surgery, The 940th Hospital of Joint Logistic Support Force of Chinese People's Liberation Army, Gansu, Lanzhou, China.
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What is the Safe Distance Between Hip and Knee Implants to Reduce the Risk of Ipsilateral Metachronous Periprosthetic Joint Infection? Clin Orthop Relat Res 2023:00003086-990000000-01108. [PMID: 36862067 PMCID: PMC10344487 DOI: 10.1097/corr.0000000000002598] [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: 09/17/2022] [Accepted: 01/25/2023] [Indexed: 03/03/2023]
Abstract
BACKGROUND Periprosthetic joint infection (PJI), the most common cause of revision after TKA and THA, is a devastating complication for patients that is difficult to diagnose and treat. An increase in the number of patients with multiple joint arthroplasties in the same extremity will result in an increased risk of ipsilateral PJI. However, there is no definition of risk factors, micro-organism patterns, and safe distance between knee and hip implants for this patient group. QUESTIONS/PURPOSES (1) In patients with hip and knee arthroplasties on the same side who experience a PJI of one implant, are there factors associated with the development of subsequent PJI of the other implant? (2) In this patient group, how often is the same organism responsible for both PJIs? (3) Is a shorter distance from an infected prosthetic joint to an ipsilateral prosthetic joint associated with greater odds of subsequent infection of the second joint? METHODS We designed a retrospective study of a longitudinally maintained institutional database that identified all one-stage and two-stage procedures performed for chronic PJI of the hip and knee at our tertiary referral arthroplasty center between January 2010 and December 2018 (n = 2352). Of these patients, 6.8% (161 of 2352) had an ipsilateral hip or knee implant in situ at the time of receiving surgical treatment for a PJI of the hip or knee. The following criteria led to the exclusion of 39% (63 of 161) of these patients: 4.3% (seven of 161) for incomplete documentation, 30% (48 of 161) for unavailability of full-leg radiographs, and 5% (eight of 161) for synchronous infection. With regard to the latter, per internal protocol, all artificial joints were aspirated before septic surgery, allowing us to differentiate between synchronous and metachronous infection. The remaining 98 patients were included in the final analysis. Twenty patients experienced ipsilateral metachronous PJI during the study period (Group 1) and 78 patients did not experience a same-side PJI (Group 2). We analyzed the microbiological characteristics of bacteria during the first PJI and ipsilateral metachronous PJI. Calibrated, full-length plain radiographs were evaluated. Receiver operating characteristic curves were analyzed to determine the optimal cutoff for the stem-to-stem and empty native bone distance. The mean time between the initial PJI and ipsilateral metachronous PJI was 8 ± 14 months. Patients were followed for a minimum of 24 months for any complications. RESULTS The risk of ipsilateral metachronous PJI in the other joint secondary to a joint implant in which PJI develops can increase up to 20% in the first 2 years after the procedure. There was no difference between the two groups in age, sex, initial joint replacement (knee or hip), and BMI. However, patients in the ipsilateral metachronous PJI group were shorter and had a lower weight (1.6 ± 0.1 m and 76 ± 16 kg). An analysis of the microbiological characteristics of bacteria at the time of the initial PJI showed no differences in the proportions of difficult-to-treat, high virulence, and polymicrobial infections between the two groups (20% [20 of 98] versus 80% [78 of 98]). Our findings showed that the ipsilateral metachronous PJI group had a shorter stem-to-stem distance, shorter empty native bone distance, and a higher risk of cement restrictor failure (p < 0.01) than the 78 patients who did not experience ipsilateral metachronous PJI during the study period. An analysis of the receiver operating characteristic curve showed a cutoff of 7 cm for the empty native bone distance (p < 0.01), with a sensitivity of 72% and a specificity of 75%. CONCLUSION The risk of ipsilateral metachronous PJI in patients with multiple joint arthroplasties is associated with shorter stature and stem-to-stem distance. Appropriate position of the cement restrictor and native bone distance are important in reducing the risk of ipsilateral metachronous PJI in these patients. Future studies might evaluate the risk of ipsilateral metachronous PJI owing to bone adjacency. LEVEL OF EVIDENCE Level III, therapeutic study.
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Khan IA, Boyd BO, Chen AF, Cortés-Penfield N, Myers TG, Brown TS, Suh GA, McGwin G, Ghanem ES, Fillingham YA. Utility of Diagnostic Tests Before Reimplantation in Patients Undergoing 2-Stage Revision Total Joint Arthroplasty: A Systematic Review and Meta-analysis. JBJS Rev 2023; 11:01874474-202303000-00007. [PMID: 36947634 DOI: 10.2106/jbjs.rvw.22.00201] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/24/2023]
Abstract
INTRODUCTION Periprosthetic joint infection (PJI) is a devastating complication after total joint arthroplasty (TJA), with treatment failure occurring in 12% to 28% after 2-stage revision. It is vital to identify diagnostic tools indicative of persistent infection or treatment failure after 2-stage revision for PJI. METHODS The Cochrane Library, PubMed (MEDLINE), and EMBASE were searched for randomized controlled trials and comparative observational studies published before October 3, 2021, which evaluated the utility of serum/plasma biomarkers (erythrocyte sedimentation rate [ESR], C-reactive protein [CRP], interleukin-6 [IL-6], fibrinogen, D-dimer), synovial biomarkers (white blood cell [WBC] count, neutrophil percentage [PMN %], alpha-defensin [AD], leukocyte esterase [LE]), tissue frozen section, tissue culture, synovial fluid culture, or sonicated spacer fluid culture indicative of persistent infection before the second stage of 2-stage revision for PJI or treatment failure after 2-stage revision for PJI. RESULTS A total of 47 studies including 6,605 diagnostic tests among 3,781 2-stage revisions for PJI were analyzed. Among those cases, 723 (19.1%) experienced persistent infection or treatment failure. Synovial LE (sensitivity 0.25 [0.10-0.47], specificity 0.99 [0.93-1.00], positive likelihood ratio 14.0 [1.45-135.58]) and serum IL-6 (sensitivity 0.52 [0.33-0.70], specificity 0.92 [0.85-0.96], positive likelihood ratio 7.90 [0.86-72.61]) had the highest diagnostic accuracy. However, no biomarker was associated with a clinically useful negative likelihood ratio. In subgroup analysis, synovial PMN %, synovial fluid culture, serum ESR, and serum CRP had limited utility for detecting persistent infection before reimplantation (positive likelihood ratios ranging 2.33-3.74; negative likelihood ratios ranging 0.31-0.9) and no utility for predicting failure after the second stage of 2-stage revision. CONCLUSIONS Synovial WBC count, synovial PMN %, synovial fluid culture, serum ESR, and serum CRP have modest sensitivity and specificity for predicting persistent infection during the second stage of 2-stage revision, suggesting some combination of these diagnostic tests might be useful before reimplantation. No biomarker or culture accurately predicted treatment failure after reimplantation. LEVEL OF EVIDENCE Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Irfan A Khan
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Brandon O Boyd
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Antonia F Chen
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | | | - Thomas G Myers
- Department of Orthopaedics and Physical Performance, University of Rochester Medical Center, Rochester, New York
| | - Timothy S Brown
- Department of Orthopaedic Surgery, Houston Methodist Orthopaedics & Sports Medicine, Houston, Texas
| | - Gina A Suh
- Division of Infectious Diseases, Mayo Clinic, Rochester, Minnesota
| | - Gerald McGwin
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Elie S Ghanem
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Yale A Fillingham
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
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Mohamed NS, Castrodad IMD, Etcheson JI, Kelemen MN, Plate FJ, Conway JD, Delanois RE. Treatment of Periprosthetic Joint Infection in Total Knee Arthroplasty with a Temporary Intramedullary Nail: Is a Long or Short Nail Better? J Knee Surg 2023; 36:39-46. [PMID: 33946115 DOI: 10.1055/s-0041-1729552] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
To our knowledge, no studies have compared postoperative outcomes between patients who received a temporary short or long intramedullary (IM) nail in the setting of infected total knee arthroplasty (TKA). Therefore, the aim of this study was to compare short-term outcomes for patients who underwent long or short IM nail insertion for treatment of periprosthetic knee infection. Specifically, we compared: (1) success rates; (2) patient reported/functional outcomes; and (3) complications between patients implanted with a short or a long IM nail following PJI of the knee. A retrospective chart review was performed for patients who underwent two-stage exchange arthroplasty with a temporary long or short IM nail between November 2010 and June 2018 at our institution (n = 67). Continuous and categorical variables were assessed using t-test/Mann-Whitney U test and chi-squared test, respectively. Logistic regression analyses were conducted to assess the effect of IM nail length on success rate while adjusting for age, sex, body mass index, and race. A total of 36 patients underwent temporary treatment with a long IM nail, while 31 patients received a short IM nail. There were no differences in success rate for reimplanted patients treated with long and short IM nails (odds ratio 0.992; p = 0.847). Fewer patients with a long IM nail went on to reimplantation (52.8 vs. 83.9%; p = 0.007). There was no difference in satisfaction (7.86 vs. 7.68; p = 0.515), pain scores (3.39 vs. 4.45 points; p = 0.126), or Knee Society score outcome scores (150.61 vs. 166.26 points; p = 0.117) between long or short IM nail patients. Following reimplantation, there was no difference in the number of patients who became reinfected (15.8 vs. 11.5%; p = 0.679) or went on to amputation (0 vs. 7.7%; p = 0.210). Periprosthetic joint infection (PJI) is a rare but serious postoperative complication following TKA. Our findings suggest that the use of long and short IM nails during two-stage exchange can have equal utility in PJI patients with severe bone defects.
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Affiliation(s)
- Nequesha S Mohamed
- Department of Orthopedic Surgery, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Iciar M Davila Castrodad
- Department of Orthopedic Surgery, Hackensack Meridian School of Medicine, Seton Hall University, Nutley, New Jersey
| | - Jennifer I Etcheson
- Department of Orthopedic Surgery and Rehabilitation Medicine, SUNY Downstate Medical Center, Brooklyn, New York
| | - Margaret N Kelemen
- Center for Joint Preservation and Replacement, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - F Johannes Plate
- Department of Orthopedic Surgery, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Janet D Conway
- Center for Joint Preservation and Replacement, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Ronald E Delanois
- Center for Joint Preservation and Replacement, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland
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Are Static Spacers Superior to Articulated Spacers in the Staged Treatment of Infected Primary Knee Arthroplasty? A Systematic Review and Meta-Analysis. J Clin Med 2022; 11:jcm11164854. [PMID: 36013091 PMCID: PMC9409753 DOI: 10.3390/jcm11164854] [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: 07/26/2022] [Revised: 08/10/2022] [Accepted: 08/16/2022] [Indexed: 11/17/2022] Open
Abstract
In the treatment of knee periprosthetic joint infection with a two-stage protocol, static spacers allow for the local delivery of high doses of antibiotics and help to preserve soft tissue tension. Articulated spacers were introduced to better preserve flexion after the reimplantation. The aim of this systematic review is to provide a comprehensive data collection of the results of these different spacers. An in-depth search on the main clinical databases was performed concerning the studies reporting data on the topic. A total of 87 studies and 4250 spacers were included. No significant differences were found both in pooling data analysis and meta-analysis of comparative studies about infection recurrences, complications, and clinical scores. Mean active knee flexion at last follow-up after total knee reimplantation was found to be significantly higher using articulated spacers (91.6° ± 7° for static spacers vs. 100.3° ± 9.9° for articulated spacers; p < 0.001). Meta-analysis also recognized this strong significant difference (p < 0.001). This review has confirmed that articulated spacers do not appear to be inferior to static spacers regarding all clinical outcomes, while they are superior in terms of active flexion. However, the low quality of the studies and the risk for selection bias with complex patients preferentially treated with static spacers need to be accounted for.
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Mohamed NS, Etcheson JI, Wilkie WA, Remily EA, Kluk MW, Thompson J, Plate JF, Mont MA, Delanois RE. Two-Stage Exchange Using a Short Intramedullary Nail for Treatment of Periprosthetic Knee Infections: A Technique Worth Questioning. J Knee Surg 2021; 34:1322-1328. [PMID: 32330974 DOI: 10.1055/s-0040-1708856] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Periprosthetic joint infections (PJIs) following total knee arthroplasty (TKA) are serious orthopaedic complications that pose marked burdens to both patients and health care systems. At our institution, two-stage exchange with a temporary short antibiotic cement-coated intramedullary nail was utilized for the treatment of repeat PJIs in a series of compromised patients with considerable bone loss. This study reports on (1) success rates, (2) functional and pain outcomes, (3) and complications for patients receiving a temporary short intramedullary nail for the treatment of PJI. Our institutional database was queried for all repeat knee PJI patients between March 1st, 2009 and February 28th, 2015. Patients with type II/III Anderson Orthopaedic Research Institute (AORI) bone defects who underwent two-stage exchange arthroplasty with a short antibiotic-coated intramedullary nail were included for analysis (n = 31). Treatment success was determined using the Delphi-based consensus definition of a successfully treated PJI: infection eradication (healed wound with no recurrence of infection by the same organism), no further surgical intervention for infection after reimplantation, and no PJI-related mortality. A paired t-test was performed to assess for continuous variables. A total of 26 patients went on to reimplantation, while 5 patients retained the intramedullary nail. Overall treatment success was 74.2%. Range of motion significantly decreased postoperatively (102.1 vs. 87.3 degrees; p < 0.001), while Knee Society Scores (function) significantly increased (55.6 vs. 77.7, p < 0.001). A majority of patients were full weight-bearing immediately following surgery (38.7%). Treating poor health status patients with PJI of the knee can be difficult after multiple revisions. With a success rate similar to conventional methods, our results demonstrate that two-stage exchange with a temporary short intramedullary nail may be a desirable treatment option for patients with bony defects wishing to avoid amputation or permanent arthrodesis. However, this method does not outperform other treatment modalities, and may not be suitable for all patients. Patient expectations and health status should be carefully assessed to determine if this procedure is appropriate in this complex patient population.
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Affiliation(s)
- Nequesha S Mohamed
- Center for Joint Preservation and Replacement, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Jennifer I Etcheson
- Department of Orthopaedic Surgery and Rehabilitation Medicine, SUNY Downstate Medical Center, Brooklyn, New York
| | - Wayne A Wilkie
- Center for Joint Preservation and Replacement, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Ethan A Remily
- Center for Joint Preservation and Replacement, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Matthew W Kluk
- Center for Joint Preservation and Replacement, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - John Thompson
- Center for Joint Preservation and Replacement, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Johannes F Plate
- Department of Orthopedic Surgery, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, North Carolina
| | - Michael A Mont
- Department of Orthopedic Surgery, Lenox Hill Hospital, New York City, New York
| | - Ronald E Delanois
- Center for Joint Preservation and Replacement, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland
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Röhner E, Jacob B, Böhle S, Rohe S, Löffler B, Matziolis G, Zippelius T. Sodium hypochlorite is more effective than chlorhexidine for eradication of bacterial biofilm of staphylococci and Pseudomonas aeruginosa. Knee Surg Sports Traumatol Arthrosc 2020; 28:3912-3918. [PMID: 32034427 DOI: 10.1007/s00167-020-05887-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Accepted: 01/24/2020] [Indexed: 11/29/2022]
Abstract
PURPOSE Periprosthetic infection is a common reason for surgical revision. Given the increasing resistance of bacteria to antibiotics (e.g., VRE, 4-MRGN) local antiseptic treatment is gaining in importance. However, no standard guideline-based treatment recommendation is yet available. The aim of this study was to investigate the effectiveness of sodium hypochlorite and chlorhexidine against bacterial biofilms. Furthermore, the toxicity of both antiseptics towards human chondrocytes was examined. METHODS Human chondrocytes were isolated, cultivated and treated with sodium hypochlorite and chlorhexidine. The viability of cultures was assessed by determination of cell count, XTT and MTT ELISAs, and fluorescent staining with propidium iodide. Bacterial strains of Staphylococcus aureus, Staphylococcus epidermidis and Pseudomonas aeruginosa were added to liquid media and incubated overnight. After determination of bacterial concentrations polyethylene (PE) devices were inoculated with bacteria for 48 h until biofilms formed. The devices were then washed, treated with antiseptics for 2 and 5 min and subsequently spread on agar plates. RESULTS Sodium hypochlorite is more effective than chlorhexidine in penetrating biofilms of S. aureus, S. epidermidis and P. aeruginosa. Both antiseptics are chondrotoxic, but sodium hypochlorite damages human chondrocytes less than chlorhexidine in vitro. CONCLUSIONS The findings confirm the effectiveness of sodium hypochlorite and chlorhexidine against bacterial biofilms. Both antiseptics can be recommended for the treatment of periprosthetic infections. The toxic effects of sodium hypochlorite and chlorhexidine towards chondrocytes may mean there is a risk of damage to cartilage tissue. LEVEL OF EVIDENCE Controlled experimental study.
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Affiliation(s)
- E Röhner
- Orthopaedic Department of the Waldkliniken Eisenberg, Orthopaedic Professorship of the University Hospital Jena, Campus Eisenberg, Klosterlausnitzer Straße 81, 07607, Eisenberg, Germany.
| | - B Jacob
- Orthopaedic Department of the Waldkliniken Eisenberg, Orthopaedic Professorship of the University Hospital Jena, Campus Eisenberg, Klosterlausnitzer Straße 81, 07607, Eisenberg, Germany
| | - S Böhle
- Orthopaedic Department of the Waldkliniken Eisenberg, Orthopaedic Professorship of the University Hospital Jena, Campus Eisenberg, Klosterlausnitzer Straße 81, 07607, Eisenberg, Germany
| | - S Rohe
- Orthopaedic Department of the Waldkliniken Eisenberg, Orthopaedic Professorship of the University Hospital Jena, Campus Eisenberg, Klosterlausnitzer Straße 81, 07607, Eisenberg, Germany
| | - B Löffler
- Institute of Medical Microbiology, Jena University Hospital, 07747, Jena, Germany
| | - G Matziolis
- Orthopaedic Department of the Waldkliniken Eisenberg, Orthopaedic Professorship of the University Hospital Jena, Campus Eisenberg, Klosterlausnitzer Straße 81, 07607, Eisenberg, Germany
| | - T Zippelius
- Orthopaedic Department of the Waldkliniken Eisenberg, Orthopaedic Professorship of the University Hospital Jena, Campus Eisenberg, Klosterlausnitzer Straße 81, 07607, Eisenberg, Germany
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Coughlan A, Taylor F. Classifications in Brief: The McPherson Classification of Periprosthetic Infection. Clin Orthop Relat Res 2020; 478:903-908. [PMID: 31977434 PMCID: PMC7282566 DOI: 10.1097/corr.0000000000001133] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Accepted: 12/23/2019] [Indexed: 01/31/2023]
Affiliation(s)
- Adam Coughlan
- A. Coughlan, F. Taylor, The Gold Coast University Hospital, Southport, Queensland, Australia
| | - Fraser Taylor
- A. Coughlan, F. Taylor, The Gold Coast University Hospital, Southport, Queensland, Australia
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11
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Palmer JR, Pannu TS, Villa JM, Manrique J, Riesgo AM, Higuera CA. The treatment of periprosthetic joint infection: safety and efficacy of two stage versus one stage exchange arthroplasty. Expert Rev Med Devices 2020; 17:245-252. [DOI: 10.1080/17434440.2020.1733971] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Joseph R. Palmer
- Levitetz Department of Orthopaedic Surgery, Cleveland Clinic Florida, Weston, FL, USA
| | - Tejbir S. Pannu
- Levitetz Department of Orthopaedic Surgery, Cleveland Clinic Florida, Weston, FL, USA
| | - Jesus M. Villa
- Levitetz Department of Orthopaedic Surgery, Cleveland Clinic Florida, Weston, FL, USA
| | - Jorge Manrique
- Levitetz Department of Orthopaedic Surgery, Cleveland Clinic Florida, Weston, FL, USA
| | - Aldo M. Riesgo
- Levitetz Department of Orthopaedic Surgery, Cleveland Clinic Florida, Weston, FL, USA
| | - Carlos A. Higuera
- Levitetz Department of Orthopaedic Surgery, Cleveland Clinic Florida, Weston, FL, USA
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Xu C, Tan TL, Chen JY. Positive Culture During Reimplantation Increases the Risk of Reinfection in Two-Stage Exchange Arthroplasty Despite Administrating Prolonged Antibiotics: A Retrospective Cohort Study and Meta-Analysis. J Arthroplasty 2019; 34:1025-1031. [PMID: 30773359 DOI: 10.1016/j.arth.2019.01.039] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2018] [Revised: 01/07/2019] [Accepted: 01/17/2019] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND The significance of a positive culture at reimplantation remains an important topic of consideration given the lack of clear metrics for when reimplantation can be performed. The purpose of this study is thus to investigate the (1) association between a positive culture during reimplantation and failure following 2-stage exchange arthroplasty and the (2) influence of prolonged antibiotics on these patients. METHODS We retrospectively reviewed 117 patients undergoing 2-stage exchange hip arthroplasty from 2012 to 2016. Of them, 23 had positive culture during reimplantation and were treated with 2 weeks of intravenous and 4 weeks of oral antibiotics following reimplantation. All patients had a minimum follow-up of 1 year. Logistic regression models were performed to identify association between positive culture and subsequent treatment failure. A meta-analysis was also performed to validate findings. A subgroup analysis was performed to explore whether 6-week antibiotics (oral, intravenous, or both) after reimplantation improved outcomes. RESULTS A total of 11 studies, which included 141 cases with a positive culture at reimplantation and 784 with negative cultures, were included in the meta-analysis. The pooled data showed a higher risk of failure in patients with a positive culture than those with a negative culture (41.1% vs 14.8%, odds ratio 4.58). The subgroup analysis revealed that 6 weeks of antibiotic administration following reimplantation decreased the odds of reinfection from 9.35 to 3.12. The findings in the retrospective cohort were consistent with those of the meta-analysis; the failure rate was significantly higher in patients with a positive culture than those with negative cultures (26.1% vs 6.4%, P < .001). CONCLUSION Six weeks of antibiotics appear to decrease the odds of reinfection after reimplantation. However, despite patients receiving 6 weeks of antibiotics after reimplantation, the risk of reinfection in patients with a positive culture at reimplantation is still more than 3 times higher than those with negative cultures. Further studies are needed to investigate optimal management for such patients.
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Affiliation(s)
- Chi Xu
- Department of Orthopaedic Surgery, General Hospital of People's Liberation Army, Beijing, People's Republic of China
| | - Timothy L Tan
- Department of Orthopaedic Surgery, Rothman Institute at Thomas Jefferson University, Philadelphia, PA
| | - Ji-Ying Chen
- Department of Orthopaedic Surgery, General Hospital of People's Liberation Army, Beijing, People's Republic of China
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13
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Aalirezaie A, Bauer TW, Fayaz H, Griffin W, Higuera CA, Krenn V, Krenn V, Molano M, Moojen DJ, Restrepo C, Shahi A, Shubnyakov I, Sporer S, Tanavalee A, Teloken M, Velázquez Moreno JD. Hip and Knee Section, Diagnosis, Reimplantation: Proceedings of International Consensus on Orthopedic Infections. J Arthroplasty 2019; 34:S369-S379. [PMID: 30343965 DOI: 10.1016/j.arth.2018.09.021] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
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Srivastava K, Bozic KJ, Silverton C, Nelson AJ, Makhni EC, Davis JJ. Reconsidering Strategies for Managing Chronic Periprosthetic Joint Infection in Total Knee Arthroplasty: Using Decision Analytics to Find the Optimal Strategy Between One-Stage and Two-Stage Total Knee Revision. J Bone Joint Surg Am 2019; 101:14-24. [PMID: 30601412 DOI: 10.2106/jbjs.17.00874] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Periprosthetic joint infection (PJI) following total knee arthroplasty is a growing concern, as the demand for total knee arthroplasty (TKA) expands annually. Although 2-stage revision is considered the gold standard in management, there is substantial morbidity and mortality associated with this strategy. One-stage revision is associated with lower mortality rates and better quality of life, and there has been increased interest in utilizing the 1-stage strategy. However, surgeons are faced with a difficult decision regarding which strategy to use to treat these infections, considering uncertainty with respect to eradication of infection, quality of life, and societal costs with each strategy. The purpose of the current study was to use decision analysis to determine the optimal decision for the management of PJI following TKA. METHODS An expected-value decision tree was constructed to estimate the quality-adjusted life-years (QALYs) and costs associated with 1-stage and 2-stage revision. Two decision trees were created: Decision Tree 1 was constructed for all pathogens, and Decision Tree 2 was constructed solely for difficult-to-treat infections, including methicillin-resistant infections. Values for parameters in the decision model, such as mortality rate, reinfection rate, and need for additional surgeries, were derived from the literature. Medical costs were derived from Medicare data. Sensitivity analysis determined which parameters in the decision model had the most influence on the optimal strategy. RESULTS In both decision trees, the 1-stage strategy produced greater health utility while also being more cost-effective. In the Monte Carlo simulation for Decision Trees 1 and 2, 1-stage was the dominant strategy in about 85% and 69% of the trials, respectively. Sensitivity analysis showed that the reinfection and 1-year mortality rates were the most sensitive parameters influencing the optimal decision. CONCLUSIONS Despite 2-stage revision being considered the current gold standard for infection eradication in patients with PJI following TKA, the optimal decision that produced the highest quality of life was 1-stage revision. These results should be considered in shared decision-making with patients who experience PJI following TKA. LEVEL OF EVIDENCE Economic and Decision Analysis Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Karan Srivastava
- Department of Orthopaedic Surgery, Henry Ford Health System, Detroit, Michigan
| | - Kevin J Bozic
- Department of Orthopaedic Surgery, University of Texas at Austin Dell Medical School, Austin, Texas
| | - Craig Silverton
- Department of Orthopaedic Surgery, Henry Ford Health System, Detroit, Michigan
| | - Andrew J Nelson
- Department of Orthopaedic Surgery, Henry Ford Health System, Detroit, Michigan
| | - Eric C Makhni
- Department of Orthopaedic Surgery, Henry Ford Health System, Detroit, Michigan
| | - Jason J Davis
- Department of Orthopaedic Surgery, Henry Ford Health System, Detroit, Michigan
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Bian T, Shao H, Zhou Y, Huang Y, Song Y. Tests for predicting reimplantation success of two-stage revision for periprosthetic joint infection: A systematic review and meta-analysis. Orthop Traumatol Surg Res 2018; 104:1115-1123. [PMID: 30030145 DOI: 10.1016/j.otsr.2018.03.017] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2018] [Revised: 03/25/2018] [Accepted: 03/29/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND Several tests are used before reimplantation to detect persistent infection in patients with periprosthetic joint infection (PJI) undergoing two-stage revision. However, there is no consensus as to the optimal tests for excluding persistent infection or predicting successful reimplantation by stage. We aimed to determine the accuracy of different tests used to detect persistent infection after the first stage, and/or predicting failure following reimplantation in patients with PJI. METHODS We conducted a systematic review and meta-analysis of PubMed, Embase and the Cochrane Library databases. Two reviewers independently conducted quality assessments and data extractions to estimate pooled sensitivity and specificity, diagnostic odds ratio and area under the receiver operating characteristic curves (AUSROC) for each test. RESULTS We included 24 studies published between May 1999 and September 2017. Synovial fluid polymorphonuclear neutrophils (PMN)% had the highest sensitivity of 0.70, followed by serum erythrocyte sedimentation rate (0.57) and spacer sonication fluid culture (0.53). Synovial fluid culture had the highest specificity of 0.97, followed by frozen section (0.93) and the Musculoskeletal Infection Society criteria (0.92). Spacer sonication fluid culture was the most accurate test with an AUSROC of 0.8089, followed by synovial fluid culture (0.7749) and frozen section (0.7819). DISCUSSION Spacer sonication fluid culture had a relatively high diagnostic accuracy. We emphasize that no test can be used alone to exclude persistent infection beyond the first stage and/or predict failed reimplantation beyond the second stage. LEVEL OF EVIDENCE II, systematic review and meta-analysis of level 2 to level 4 studies with inconsistent results.
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Affiliation(s)
- Tao Bian
- Department of Orthopedic Surgery, Beijing Jishuitan Hospital, Fourth Clinical College of Peking University, No. 31 Xinjiekou East Street, 100035 Beijing, Xicheng District, China
| | - Hongyi Shao
- Department of Orthopedic Surgery, Beijing Jishuitan Hospital, Fourth Clinical College of Peking University, No. 31 Xinjiekou East Street, 100035 Beijing, Xicheng District, China
| | - Yixin Zhou
- Department of Orthopedic Surgery, Beijing Jishuitan Hospital, Fourth Clinical College of Peking University, No. 31 Xinjiekou East Street, 100035 Beijing, Xicheng District, China.
| | - Yong Huang
- Department of Orthopedic Surgery, Beijing Jishuitan Hospital, Fourth Clinical College of Peking University, No. 31 Xinjiekou East Street, 100035 Beijing, Xicheng District, China
| | - Yang Song
- Department of Orthopedic Surgery, Beijing Jishuitan Hospital, Fourth Clinical College of Peking University, No. 31 Xinjiekou East Street, 100035 Beijing, Xicheng District, China
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Ramczykowski T, Kruppa C, Schildhauer TA, Dudda M. Total hip arthroplasty following illicit drug abuse. Arch Orthop Trauma Surg 2018; 138:1353-1358. [PMID: 29922852 DOI: 10.1007/s00402-018-2980-3] [Citation(s) in RCA: 6] [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: 10/04/2017] [Indexed: 11/24/2022]
Abstract
BACKGROUND The role of illicit drug abuse in total joint arthroplasty is largely unknown and is likely underestimated. Patients with drug addictions often suffer from septic osteoarthritis or a necrosis of the femoral head. Purpose of the study was to evaluate the operative management and clinical outcome of total hip replacement in patients with a history of intravenous drug abuse. METHODS This retrospective study included 15 patients with a history of intravenous drug abuse who underwent total hip arthroplasty. A total of 6 females and 9 males with an average age of 34.3 years were identified. Ten patients presented an acute bacterial coxitis (Coxitis-group) and five an aseptic osteonecrosis of the femoral head (Osteonecrosis-group). RESULTS Ten patients with a bacterial coxitis underwent a two-staged total hip arthroplasty (THA), with temporary insertion of a drug-eluting spacer. Five patients with a necrosis of the femoral head were primarily treated with THA. All patients developed multiple re-infections after insertion of a drug-eluting spacer or THA. Only two patients finally achieved a THA without infection in the period of 3.9 years follow-up. The other 13 patients underwent a Girdlestone arthroplasty (7 patients) or total joint replacement with a chronic fistula (6 patients). CONCLUSION THA in patients with illicit drug abuse shows a low success rate. Following septic osteoarthritis or osteonecrosis in drug-addicted patients, we recommend a two-stage procedure with temporary insertion of a drug-eluting spacer. THA might follow only under strict premises.
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Affiliation(s)
- Tim Ramczykowski
- Department of General and Trauma Surgery, University Hospital Bergmannsheil, Ruhr-University Bochum, Bürkle-de-la-Camp-Platz 1, 44789, Bochum, Germany.
| | - Christiane Kruppa
- Department of General and Trauma Surgery, University Hospital Bergmannsheil, Ruhr-University Bochum, Bürkle-de-la-Camp-Platz 1, 44789, Bochum, Germany
| | - Thomas Armin Schildhauer
- Department of General and Trauma Surgery, University Hospital Bergmannsheil, Ruhr-University Bochum, Bürkle-de-la-Camp-Platz 1, 44789, Bochum, Germany
| | - Marcel Dudda
- Department of Trauma Surgery, University Hospital Essen, Hufelandstraße 55, 45147, Essen, Germany
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Periprosthetic Joint Infection Does Not Preclude Good Outcomes after a Revision Total Knee Arthroplasty: A 7-Year Follow-Up Study of 144 Retrospective Cases. BIOMED RESEARCH INTERNATIONAL 2018; 2018:2582140. [PMID: 30159324 PMCID: PMC6109570 DOI: 10.1155/2018/2582140] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/07/2017] [Revised: 05/08/2018] [Accepted: 07/11/2018] [Indexed: 11/18/2022]
Abstract
Background and Purpose Debate exists on whether septic revision total knee arthroplasty (TKA) results in inferior clinical outcomes, and limited information is available regarding the factors associated with such outcomes. This study aimed to (1) compare clinical outcomes and characteristics of aseptic versus septic revision TKA and (2) identify the risk factors associated with inferior clinical outcomes. Methods We retrospectively reviewed 144 revision TKAs (90 aseptic and 54 septic revisions) that were followed for a minimum of 3 years (mean = 7 years). Clinical outcome data, namely, Knee Society knee and function scores and the Hospital for Special Surgery knee score, were collected. We reviewed 13 pre- and intraoperative variables. Results Postoperative clinical outcomes were inferior in septic revision surgeries (p<0.05). In regression analyses, however, septic revision was not an independent risk factor for poor clinical outcomes. The independent risk factors for poor outcome were identified where Anderson Orthopedic Research Institute grade 3 femoral and tibial bone defects, more than three surgeries, and treatment for persistent infection were associated with inferior clinical outcomes (all p<0.05). Standard two-stage septic revision without grade 3 bone defects or additional surgeries showed comparable outcomes to aseptic revision. Interpretation Clinical outcomes of septic revision were inferior to those of aseptic revision. However, poor outcomes were mainly associated with large bone defects and an increased number of surgeries. The outcomes of aseptic and septic revision surgery were similar when patients with larger bone defects and more than three surgeries were excluded.
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Aali Rezaie A, Goswami K, Shohat N, Tokarski AT, White AE, Parvizi J. Time to Reimplantation: Waiting Longer Confers No Added Benefit. J Arthroplasty 2018; 33:1850-1854. [PMID: 29605153 DOI: 10.1016/j.arth.2018.01.073] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2017] [Revised: 01/11/2018] [Accepted: 01/25/2018] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND While the preferred surgical treatment for chronic periprosthetic joint infection (PJI) in North America is a 2-stage exchange arthroplasty, the optimal time between first-stage and reimplantation surgery remains unknown. This study was conceived to examine the association between time to reimplantation and treatment failure. METHODS Using an institutional database, we identified PJI cases treated with 2-stage exchange arthroplasty between 2000 and 2016. Musculoskeletal Infection Society criteria were used to define PJI, and treatment failure was defined using Delphi criteria. The interstage interval between first-stage and reimplantation surgery for each case was collected, alongside demographics, patient-related and organism-specific data. Multivariate logistic regression analyses were used to examine association with treatment failure. RESULTS Our final analysis consisted of 282 patients with an average time to reimplantation of 100.2 days (range, 20-648). Sixty-three patients (22.3%) failed at 1 year based on Delphi criteria. Time to reimplantation was not significantly associated with failure in both univariate (P = .598) and multivariate (P = .397) models. However, patients reimplanted at >26 weeks were twice as likely to fail in comparison to those reimplanted within <26 weeks (43.8% vs 21.1%), and this finding reached marginal significance (P = .057). Patients who failed had significantly more comorbidities (P = .008). Charlson comorbidity index was the only variable significantly associated with treatment failure in regression analysis (odds ratio, 1.40; 95% confidence interval, 1.06-1.86; P = .019). CONCLUSION The length of the interstage interval was not a statistically significant predictor of failure in patients undergoing 2-stage exchange arthroplasty for PJI.
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Affiliation(s)
- Arash Aali Rezaie
- The Rothman Institute at Thomas Jefferson University, Philadelphia, PA
| | - Karan Goswami
- The Rothman Institute at Thomas Jefferson University, Philadelphia, PA
| | - Noam Shohat
- The Rothman Institute at Thomas Jefferson University, Philadelphia, PA
| | | | - Alexander E White
- Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA
| | - Javad Parvizi
- The Rothman Institute at Thomas Jefferson University, Philadelphia, PA
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Cancienne JM, Granadillo VA, Patel KJ, Werner BC, Browne JA. Risk Factors for Repeat Debridement, Spacer Retention, Amputation, Arthrodesis, and Mortality After Removal of an Infected Total Knee Arthroplasty With Spacer Placement. J Arthroplasty 2018; 33:515-520. [PMID: 28958659 DOI: 10.1016/j.arth.2017.08.037] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2017] [Revised: 07/29/2017] [Accepted: 08/26/2017] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Chronic periprosthetic joint infection (PJI) after total knee arthroplasty (TKA) is most commonly addressed with a 2-stage exchange procedure. The purpose of this study is to examine the natural history of patients who have undergone prosthesis removal and spacer placement and evaluate risk factors for outcomes other than reimplantation. METHODS Patients who underwent removal of an infected TKA and placement of an antibiotic spacer for PJI were identified in a Medicare database. Patients with a study outcome within 1 year were then identified: (1) in hospital mortality, (2) knee arthrodesis, (3) amputation, (4) repeat debridement procedure without reimplantation, and (5) reimplantation. Independent risk factors for these outcomes were evaluated with a multivariate logistic regression analysis. RESULTS A total of 18,533 patients were included. Within 1 year postoperatively, 691 patients (3.7%) died in a hospital setting, 852 patients (4.5%) underwent a knee arthrodesis, 574 patients (3.1%) underwent an amputation, 2683 patients (14.5%) underwent a repeat debridement procedure without being reimplanted, 2323 patients (12.5%) retained their spacer, and 11,420 patients (61.6%) underwent spacer removal and reimplantation within 1 year. Numerous independent patient-related risk factors for these outcomes were identified. CONCLUSION A large number of patients (38.4%) do not undergo reimplantation within 1 year of prosthesis removal and spacer placement. Outcomes after prosthesis removal and antibiotic spacer placement are variable, and there are several independent risk factors for such outcomes that may be used to develop and improve existing treatment strategies for patients presenting with chronic PJI after TKA.
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Affiliation(s)
- Jourdan M Cancienne
- Department of Orthopaedic Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Victor A Granadillo
- Department of Orthopaedic Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Kishan J Patel
- Department of Orthopaedic Surgery, Larkin Community Hospital, South Miami, Florida
| | - Brian C Werner
- Department of Orthopaedic Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - James A Browne
- Department of Orthopaedic Surgery, University of Virginia Health System, Charlottesville, Virginia
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Late Reinfection May Recur More Than 5 Years After Reimplantation of THA and TKA: Analysis of Pathogen Factors. Clin Orthop Relat Res 2018; 476. [PMID: 29529667 PMCID: PMC6259703 DOI: 10.1007/s11999.0000000000000050] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Two-stage reimplantation has consistently yielded high rates of success for patients with chronic prosthetic joint infection, although results more than 5 years after reimplantation are not commonly reported. Numerous factors may contribute to the risk of reinfection, although these factors-as well as the at-risk period after reimplantation-are not well characterized. QUESTIONS/PURPOSES (1) What is the risk of reinfection after reimplantation for prosthetic joint infection at a minimum of 5 years? (2) Is the bacteriology of the index infection associated with late reinfection? (3) Is the presence of bacteria at the time of reimplantation associated with late reinfection? METHODS Between 1995 and 2010, we performed 97 two-stage revisions in 93 patients for prosthetic joint infection of the hip or knee, and all are included in this retrospective study. During that time, the indications for this procedure generally were (1) infections occurring more than 3 months after the index arthroplasty; and (2) more acute infections associated with prosthetic loosening or resistant organisms. One patient (1%) was lost to followup; all others have a minimum of 5 years of followup (mean, 11 years; range, 5-20 years) and all living patients have been seen within the last 2 years. Patients were considered free from infection if they did not have pain at rest or constitutional symptoms such as fever, chills, or malaise. The patients' bacteriology and resistance patterns of these organisms were observed with respect to recurrence of infection. Odds ratios and Fisher's exact test were performed to analyze the data. The incidence of reinfection was determined using cumulative incidence methods that considered death as a competing event. RESULTS Reinfection occurred in 12 of the 97 joints resulting in implant revision. The estimated 10-year cumulative incidence of infection was 14% (95% confidence interval [CI], 7%-23%) and incidence of infection from the same organism was 5% (95% CI, 1%-11%). Five occurred early or within 2 years and three were resistant pathogens (methicillin-resistant Staphylococcus aureus, methicillin-resistant Staphylococcus epidermidis, or vancomycin-resistant Enterococcus). Seven late hematogenous infections occurred and all were > 4 years after reimplantation and involved nonresistant organisms. Three of the five (60%) early infections were caused by resistant bacteria, whereas all seven late infections were caused by different organisms or a combination of different organisms than were isolated in the original infection. The early reinfections were more often caused by resistant organisms, whereas late infections involved different organisms than were isolated in the original infection and none involved resistant organisms. With the numbers available, we found no difference between patients in whom bacteria were detected at the time of reimplantation and those in whom cultures were negative in terms of the risk of reinfection 5 years after reimplantation (18.6% [18 of 97] versus 81.4% [79 of 97], odds ratio 1.56 [95% CI, 0.38-6.44]; p = 0.54); however, with only 93 patients, we may have been underpowered to make this analysis. CONCLUSIONS In our study, resistant organisms were more often associated with early reinfection, whereas late failures were more commonly associated with new pathogens. We believe the most important finding in our study is that substantial risk of late infection remains even among patients who seemed free from infection 2 years after reimplantation for prosthetic joint infections of the hip or knee. This highlights the importance of educating our patients about the ongoing risk of prosthetic joint infection. LEVEL OF EVIDENCE Level III, therapeutic study.
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Rollo G, Pichierri P, Marsilio A, Filipponi M, Bisaccia M, Meccariello L. The challenge of nonunion after osteosynthesis of the clavicle: is it a biomechanical or infection problem? ACTA ACUST UNITED AC 2017; 14:372-378. [PMID: 29354171 DOI: 10.11138/ccmbm/2017.14.3.372] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Introduction The nonunion rate has been reported between 0.1% and 15%. There are also several predisposing factors for the onset of complications: general factors connected with the patient and specific factors related to the fracture site. The purpose of our study is to review the etiology of nonunion of the clavicle in its atrophic form and investigate the outcomes of the revision treatment in a single step. Materials and methods Retrospective study on 71 patients suffering from nonunions due to the following treatments: conservative in 13 patients; plate fixation in 12; closed reduction and fixation with K-wire in 24; open reduction and fixation with K-wire. All patients were operated on in beach chair position and classic approach to the clavicle by incising the previous surgical scar. The clinical and radiographic criteria for evaluating the outcomes were: the Short Form (12) Health Survey (SF-12), the Constant Shoulder Score (CSS) and the Disability Disabilities of the Arm, Shoulder and Score (DASH) and radiographic Union Score (RUS) for bone healing. The evaluation endpoint was set at 12 months. Results Blood and culture tests showed 22 infected nonunions and 49 atrophic or oligoatrophic. In only 10 cases, before surgery, the inflammatory markers were positive. The isolated microorganisms were resistant to common antibiotics. In 70 out of 71 cases, plates and screws on the upper side and fibula allogenic splints at the bottom, associated with cancellous bone grafts taken from the patients' iliac crests, were implanted. In one case, however, it was decided to implant the plate on the front edge of the clavicle and the fibula allogeneic splint on the posterior margin, also associated with a cancellous bone graft taken from the patient's iliac crest. The radiographic bone healing was observed in 107.8 (range 82-160) days for the aseptic nonunions, while in 118.4 (range 82-203) days for the septic ones. The non-healing case was a serious failure that led to asubtotal excision of the clavicle. Conclusions The importance of classification and study of nonunions are essential to achieve positive outcomes. The guiding principle of our work is that aseptic nonunions heal in the operating room, while infected nonunions can be challenged and defeated on the operating table. Restoring the correct length of the clavicle interconnection between the sternum and the shoulder cingulum is indispensable to avoid functional deficits of the upper limb. The fibula splint and the tricorticale bone graft have both mechanical and strong biological values to quickly heal the nonunion. The return to pre-injury quality of life has to be our main goal.
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Affiliation(s)
- Giuseppe Rollo
- UOC Orthopedics and Traumatology, "Vito Fazzi" Hospital, Lecce, Italy
| | - Paolo Pichierri
- UOC Orthopedics and Traumatology, "Vito Fazzi" Hospital, Lecce, Italy
| | - Antonio Marsilio
- UOC Orthopedics and Traumatology, "Vito Fazzi" Hospital, Lecce, Italy
| | - Marco Filipponi
- UOC Orthopedics and Traumatology, "Vito Fazzi" Hospital, Lecce, Italy
| | - Michele Bisaccia
- Division of Orthopedics and Trauma Surgery, University of Perugia, "S. Maria della Misericordia" Hospital, Perugia, Italy
| | - Luigi Meccariello
- UOC Orthopedics and Traumatology, "Vito Fazzi" Hospital, Lecce, Italy
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Lindberg-Larsen M, Pitter FT, Voldstedlund M, Schrøder HM, Bagger J. Microbiological diagnosis in revision of infected knee arthroplasties in Denmark. Infect Dis (Lond) 2017; 49:824-830. [PMID: 28691647 DOI: 10.1080/23744235.2017.1350878] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Abstract
BACKGROUND Revision of infected knee arthroplasties is associated with high failure rates (30-40%). An understanding of the microbiology is important to optimize treatment and outcome. We describe microbiological diagnostic practice and diagnosis in revision of infected knee arthroplasties. METHODS One hundred and two partial revisions (open debridement and exchange of tibial insert) and 213 two-stage procedures performed due to infection in 275 patients from 1 July 2011 to 30 June 2013 were included and analysed by linkage to data from a nationwide registry on microbiological test results. RESULTS 78 (24.8%) revisions were culture negative, 192 (60.9%) showed monomicrobial growth and 43 (14.3%) polymicrobial growth. Staphylococcus aureus was the most frequent isolate in mono-culture in 70 (22.2%) revisions and in polymicrobial culture in 15 revisions with a total frequency of 27.0%. Only one case (1.4%) of methicillin-resistance was registered. Coagulase-negative staphylococci (CoNS) were frequent, sole pathogen in 65 revisions and in polymicrobial cultures in 28 revisions with a total frequency of 29.5%. A pre-operative knee aspiration was performed in 50% and preoperative blood cultures were performed in 22% of cases. In 73% of the preoperative knee-aspirations bacteriological findings were fully or partially in accordance with intraoperative cultures. In 54% of the later re-revisions due to infection (treatment-failures) the cultured species differed from or was not detected at index revision surgery. CONCLUSIONS The 25% culture negative cases in combination with only 50% preoperative knee aspirations and prevailing high failure rates confirm the need for improvement of diagnostic practice and treatment of infected knee arthroplasties.
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Affiliation(s)
- Martin Lindberg-Larsen
- a Department of Orthopaedic Surgery , Odense University Hospital , Odense C , Denmark.,b The Lundbeck Centre for Fast-Track Hip and Knee Arthroplasty , Copenhagen University Hospital Rigshospitalet , Copenhagen Ø , Denmark
| | - Frederik T Pitter
- b The Lundbeck Centre for Fast-Track Hip and Knee Arthroplasty , Copenhagen University Hospital Rigshospitalet , Copenhagen Ø , Denmark.,c Section of Surgical Pathophysiology , Copenhagen University Hospital Rigshospitalet , Copenhagen Ø , Denmark
| | - Marianne Voldstedlund
- d Department of Infectious Disease Epidemiology , Statens Serum Institut , Copenhagen S , Denmark
| | - Henrik M Schrøder
- b The Lundbeck Centre for Fast-Track Hip and Knee Arthroplasty , Copenhagen University Hospital Rigshospitalet , Copenhagen Ø , Denmark.,e Department of Orthopaedic Surgery , Naestved Hospital , Næstved , Denmark
| | - Jens Bagger
- b The Lundbeck Centre for Fast-Track Hip and Knee Arthroplasty , Copenhagen University Hospital Rigshospitalet , Copenhagen Ø , Denmark.,f Department of Orthopaedic Surgery , Copenhagen University Hospital Bispebjerg , Copenhagen NV , Denmark
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Triantafyllopoulos GK, Memtsoudis SG, Zhang W, Ma Y, Sculco TP, Poultsides LA. Periprosthetic Infection Recurrence After 2-Stage Exchange Arthroplasty: Failure or Fate? J Arthroplasty 2017; 32:526-531. [PMID: 27646832 DOI: 10.1016/j.arth.2016.08.002] [Citation(s) in RCA: 66] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2016] [Revised: 06/22/2016] [Accepted: 08/01/2016] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Two-stage exchange arthroplasty remains the preferred method for treating a chronic periprosthetic joint infection (PJI) in North America. However, infection recurrence may occur. Previously, recurrent infections have been classified as persistent (same isolated pathogen) or new (different pathogen identified). We sought to determine (1) recurrence rates among patients with chronic hip and knee PJI, treated with 2-stage exchange arthroplasty; (2) risk factors for infection recurrence; and (3) risk factors for developing persistent vs new infection. METHODS We retrospectively reviewed clinical characteristics of patients with chronic hip and knee PJI, treated with 2-stage revision between January 1998 and March 2014. Minimum follow-up was 24 months. Two multivariate logistic regression models were constructed to determine independent predictors for infection recurrence and persistence. RESULTS In total, 548 patients were identified (283 men, 265 women). Forty-eight had a recurrent infection (8.76%). Men had 54.8% lower odds of PJI recurrence than women (odds ratio [OR] = 0.452; 95% confidence interval [CI], 0.235-0.869). Patients with heart disease had 109% higher odds of infection recurrence than patients without heart disease (OR = 2.09; 95% CI, 1.097-3.081). The risk of infection recurrence was 119% higher in patients with psychiatric disorders than in patients without psychiatric disorders (OR = 2.19; 95% CI, 1.011-4.761). Patients with recurrent knee PJI had 84.6% lower odds of persistent infection (OR = 0.154; 95% CI, 0.034-0.696) compared to hip PJI. Patients with heart disease had 5-fold increased odds for persistent PJI (OR = 5.068; 95% CI, 1.38-22.56). CONCLUSION Female gender, heart disease, and psychiatric disorders increase the risk of hip and knee PJI recurrence. Patients with PJI of the hip and with heart disease are at higher risk of infection persistence.
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Affiliation(s)
- Georgios K Triantafyllopoulos
- Division of Adult Reconstruction and Joint Replacement, Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Medical College of Cornell University, New York, New York
| | - Stavros G Memtsoudis
- Department of Anesthesiology, Hospital for Special Surgery, Weill Medical College of Cornell University, New York, New York
| | - Wei Zhang
- Epidemiology and Biostatistics Core, Hospital for Special Surgery, Weill Medical College of Cornell University, New York, New York
| | - Yan Ma
- Epidemiology and Biostatistics Core, Hospital for Special Surgery, Weill Medical College of Cornell University, New York, New York
| | - Thomas P Sculco
- Division of Adult Reconstruction and Joint Replacement, Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Medical College of Cornell University, New York, New York
| | - Lazaros A Poultsides
- Division of Adult Reconstruction and Joint Replacement, Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Medical College of Cornell University, New York, New York
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Drexler M, Dwyer T, Kuzyk PRT, Kosashvilli Y, Abolghasemian M, Regev GJ, Kadar A, Rutenberg TF, Backstein D. The results of two-stage revision TKA using Ceftazidime-Vancomycin-impregnated cement articulating spacers in Tsukayama Type II periprosthetic joint infections. Knee Surg Sports Traumatol Arthrosc 2016; 24:3122-3130. [PMID: 26272061 DOI: 10.1007/s00167-015-3753-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2014] [Accepted: 08/07/2015] [Indexed: 11/24/2022]
Abstract
PURPOSE This study examined the success and factors associated with failure, of using cement spacers impregnated with high-dose Ceftazidime and Vancomycin when performing two-stage revision for infected total knee arthroplasty (TKA). METHODS A retrospective analysis was performed using a prospectively collected database of 82 patients (median age 68 years, range 39-87) with a confirmed deep TKA infection treated with a two-stage revision. All cement spacers were impregnated with high-dose Ceftazidime and Vancomycin. The rate of success was recorded-an association between failure of treatment, and patient factors, previous surgical treatment, and microbial characteristics was sought. RESULTS The mean time to infection from index arthroplasty was 45 months (range 3-240). The initial two-stage revision was successful in 70/82 patients (85.4 %), who remained free of infection at average follow-up of 36.2 months (range 24-85). A second two-stage revision for infection was required in 12/82 patients (14.6 %), which was successful in 4/12 (33 %). A third two-stage revision was performed in three patients, all of whom had a polymicrobial infection of which only one patient had successful eradication of infection. Recurrent infection was correlated with irrigation and debridement with implant retention prior to initial two-stage revision (p < 0.01), polymicrobial infections (p = 0.035), and infections presenting <6 months after index surgery (p = 0.031). No correlation was seen with age, BMI, type of organism, diabetes mellitus, or Charlson Comorbidity Index. CONCLUSION The findings of this study suggest that the combination of Ceftazidime and Vancomycin in cement spacers is as efficacious as other published single or combined antibiotic mixtures, which is clinically relevant to clinicians treating this difficult problem in the setting of patients with compromised renal function.
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Affiliation(s)
- Michael Drexler
- Mount Sinai Hospital, 600 University Avenue, Toronto, ON, M5G 1X5, Canada.
| | - Tim Dwyer
- Mount Sinai Hospital, 600 University Avenue, Toronto, ON, M5G 1X5, Canada
| | - Paul R T Kuzyk
- Mount Sinai Hospital, 600 University Avenue, Toronto, ON, M5G 1X5, Canada
| | - Yona Kosashvilli
- Mount Sinai Hospital, 600 University Avenue, Toronto, ON, M5G 1X5, Canada
| | | | - Gilad J Regev
- Tel-Aviv Sourasky Medical Center, Tel Aviv University, Waitzman 6 St, 6423906, Tel Aviv, Israel
| | - Assaf Kadar
- Tel-Aviv Sourasky Medical Center, Tel Aviv University, Waitzman 6 St, 6423906, Tel Aviv, Israel
| | - Tal Frenkel Rutenberg
- Tel-Aviv Sourasky Medical Center, Tel Aviv University, Waitzman 6 St, 6423906, Tel Aviv, Israel
| | - David Backstein
- Mount Sinai Hospital, 600 University Avenue, Toronto, ON, M5G 1X5, Canada
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Streitbuerger A, Hardes J, Gosheger G, Dieckmann R, Hoell S. Knee salvage in revision arthroplasty after massive bone loss of the femur condyles (≥Engh III) with a single-modular-hinged knee revision implant. Arch Orthop Trauma Surg 2016; 136:1077-83. [PMID: 27370883 DOI: 10.1007/s00402-016-2491-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2015] [Indexed: 01/29/2023]
Abstract
PURPOSE Massive bone loss of the femur condyles in revision arthroplasty often requires modular-hinged revision implants to restore a stable joint situation. In the present series, the outcome after knee revision surgery using a single modular-hinged revision implant in patients with severe bone defects (>Engh III) is investigated. METHODS Sixty patients with severe bone defects (≥Engh III) after failed primary and revision knee arthroplasty were included. Medium follow-up was 47 (range 10-84) months after knee revision surgery. Medium patient age was 70 (range 33-87) years at the time of surgery. An average of 2.3 prior knee operations per patient was performed. 70 % of the patients required the knee revision implant after two-stage revision because of a deep implant infection. RESULTS Estimated 5 year extremity survival was 95 and 65 % implant survival. Reasons for implant revision in decreasing order were reinfection (30 %), aseptic loosening (13 %), and periprosthetic fracture (9.8 %). The average active range of motion in the knee joint was 88° (range 40°-115°) for flexion. An extension deficit of a mean of -6° was (range -50-5° hyper-extension) observed. Patient age influenced the functional results significantly in terms of reduced walking distances and decreased modified WOMAC score. CONCLUSION In consideration of this complex study, population acceptable functional results can be achieved using a modular knee revision endoprosthesis. In younger patients (<60 years), satisfying results in terms of walking ability and overall satisfactory can be expected. The outcome in older multimorbid patients is worse. Yet, operation in these patients can be feasible to restore enough mobility for daily household activities.
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Affiliation(s)
- Arne Streitbuerger
- Department of Orthopedics, University Hospital of Münster, Albert-Schweitzer-Campus 1, 48149, Münster, NRW, Germany.
| | - Jendrik Hardes
- Department of Orthopedics, University Hospital of Münster, Albert-Schweitzer-Campus 1, 48149, Münster, NRW, Germany
| | - Georg Gosheger
- Department of Orthopedics, University Hospital of Münster, Albert-Schweitzer-Campus 1, 48149, Münster, NRW, Germany
| | - Ralf Dieckmann
- Department of Orthopedics, University Hospital of Münster, Albert-Schweitzer-Campus 1, 48149, Münster, NRW, Germany
| | - Steffen Hoell
- Department of Orthopedics, Paracelsus-Klink Osnabrück, Osnabrück, Germany
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26
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Citak M, Citak M, Kendoff D. [Dynamic versus static cement spacer in periprosthetic knee infection: A meta-analysis]. DER ORTHOPADE 2016; 44:599-606. [PMID: 25694366 DOI: 10.1007/s00132-015-3091-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND The standard of care for treatment of periprosthetic joint infection (PJI) after total knee arthroplasty (TKA) is two-stage revision arthroplasty. The cement spacer in the interim period can be classified as either a static/non-articulating spacers (e.g., traditionally simple cement blocks) or a mobile/articulating spacer. OBJECTIVES The goal of the present meta-analysis is to analyze the outcomes with regard to infection control between dynamic and static knee spacers in the treatment of infected TKA with a minimum 3-year follow-up. MATERIALS AND METHODS We systematically reviewed the literature for potentially relevant articles addressing two-stage revision of an infected TKA using the MEDLINE computerized literature databases. Only 25 articles studies with a minimum follow-up examination of 36 months met the inclusion criteria and were analyzed with regard to infection control after reimplantation between static (318 cases) and dynamic group (700 cases). RESULTS At latest follow-up, the eradication rate in the dynamic group was 89.7% (range 63-100%; SD 9.1) and in the static group 84.8% (range 67-92.4%; SD 7.8; p = 0.32). We are unable to comment on the Hospital for Special Surgery (HSS) Score and complication rates between static and dynamic spacers because the majority of the studies did not report on this. CONCLUSION The data show that there are no differences regarding infection control between static and dynamic spacers in the treatment of infected TKA.
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Affiliation(s)
- Mustafa Citak
- Orthopädische Chirurgie, Helios ENDO-Klinik Hamburg, Holstenstraße 2, 22767, Hamburg, Deutschland,
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27
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Abstract
Revision total knee arthroplasty (TKA) is the treatment of choice in patients with periprosthetic joint infection. It may be performed in either a single stage or two stages. In the latter option, between stages, an antibiotic-loaded spacer may be used to maintain a certain amount of joint stability and mobility after the infected implant is removed, adding an intra-articular concentration of antibiotics. There are two types of antibiotic-loaded cement spacers: static and dynamic. Static spacers basically create a temporary arthrodesis with antibiotic-loaded cement and usually are handmade within the surgical field. Dynamic spacers can be created intraoperatively by using different tools or may be prepackaged by the manufacturer; they allow range of motion between stages. In this article, the authors review the indications, surgical techniques, and results for static and dynamic spacers in two-stage revision TKA.
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Cha MS, Cho SH, Kim DH, Yoon HK, Cho HS, Lee DY, Lee SH, Hwang SC. Two-Stage Total Knee Arthroplasty for Prosthetic Joint Infection. Knee Surg Relat Res 2015; 27:82-9. [PMID: 26060606 PMCID: PMC4458487 DOI: 10.5792/ksrr.2015.27.2.82] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2014] [Revised: 04/13/2015] [Accepted: 05/04/2015] [Indexed: 12/26/2022] Open
Abstract
PURPOSE This retrospective review was conducted to identify prognostic factors for two-stage reimplantation for infected total knee arthroplasty (TKA) and the rate of reinfection following revision TKA. MATERIALS AND METHODS Out of 88 patients diagnosed with post-TKA infection between 1998 and 2011, 76 underwent two-stage reimplantation and were reviewed in this study. The 76 patients were divided into two groups-those who experienced reinfection and those who did not. Comorbidities, culture results, and inflammation indices were analyzed and compared between the two groups. RESULTS Of the 76 patients who underwent a two-stage reimplantation, 18 (23.7%) experienced reinfection. Patients with more than three comorbidities had significantly higher reinfection rates than those with less than three comorbidities (47.1% vs. 4.8%, p=0.032). The reinfection rate between the culture positive prosthetic joint infection group and the culture negative prosthetic joint infection group was not significantly different (p=0.056). Inflammation indices (erythrocyte sedimentation rate [ESR] and C-reactive protein [CRP]) showed a statistically significant difference between patients with reinfection and those without reinfection at 4 weeks after the first-stage surgery. CONCLUSIONS Reimplantation must be carefully performed when the risk of reinfection is high, particularly in patients with more than three systemic or local comorbidities and higher inflammation indices (ESR and CRP) prior to revision TKA.
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Affiliation(s)
- Min Seok Cha
- Department of Orthopaedic Surgery, Saeum Hospital, Seoul, Korea
| | - Se Hyun Cho
- Department of Orthopaedic Surgery, SKY Hospital, Seoul, Korea
| | - Dong Hee Kim
- Department of Orthopaedic Surgery, Institute of Health Sciences, Gyeongsang National University Hospital, Jinju, Korea
| | - Hong Kwon Yoon
- Department of Orthopaedic Surgery, Institute of Health Sciences, Gyeongsang National University Hospital, Jinju, Korea
| | - Ho Seung Cho
- Department of Orthopaedic Surgery, Institute of Health Sciences, Gyeongsang National University Hospital, Jinju, Korea
| | - Dong Yeong Lee
- Department of Orthopaedic Surgery, Institute of Health Sciences, Gyeongsang National University Hospital, Jinju, Korea
| | - Sang Hyuk Lee
- Department of Orthopaedic Surgery, Institute of Health Sciences, Gyeongsang National University Hospital, Jinju, Korea
| | - Sun Chul Hwang
- Department of Orthopaedic Surgery, Institute of Health Sciences, Gyeongsang National University Hospital, Jinju, Korea
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Claassen L, Plaass C, Daniilidis K, Calliess T, von Lewinski G. Two-stage revision total knee arthroplasty in cases of periprosthetic joint infection: an analysis of 50 cases. Open Orthop J 2015; 9:49-56. [PMID: 25949746 PMCID: PMC4415200 DOI: 10.2174/1874325001509010049] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2014] [Revised: 01/27/2015] [Accepted: 02/03/2015] [Indexed: 01/04/2023] Open
Abstract
OBJECTIVES A periprosthetic joint infection (PJI) is a significant complication after total knee arthroplasty (TKA). Still there is no agreement on a perfect diagnosis and treatment algorithm. The aim of this study was to evaluate the success and revision rates after two-stage revision total knee arthroplasty (TKA) and factors that affect the success rate. MATERIAL AND METHODS 50 consecutive two-stage revision TKAs were performed between January 2011 and December 2012. We retrospectively reviewed study patient's charts including demographics, prior surgeries, comorbidities, incidence of persistent infection and revisions. At the final follow-up examination the patient's satisfaction, pain level and disorders were evaluated. A successful clinical outcome was defined as a functioning prosthesis without wound healing disorders, no sinuses tracts or other clinical evidence of a persistent infection. Results : Re-implantation of prosthesis was performed in 47 cases; three patients received a septic arthrodesis. Twelve patients had a persistent infection despite two-stage re-implantation resulting in a success rate of 76.0%. In eight of these twelve patients an infecting germ was isolated during second-stage procedure. Three patients received another two-stage revision arthroplasty and one patient an above knee amputation. A revision was performed in 23 of 50 patients (46.0%). Factors that diminish the success rate were further operations after primary TKA (p = 0.048), prior revision arthroplasties after TKA (p = 0.045), nicotine abuse (p = 0.048), Charlson comorbidity index above a score of 2 (p = 0.031) and a mixed flora during first-stage procedure (p < 0.001). Age, sex, immune status, chronic anticoagulant use, rheumatoid arthritis, body mass index and the presence of multidrug resistant germs showed no significant effect on success rate (p > 0.05). Conclusion : We found that patients who required surgery after the primary TKA, had a higher Charlson comorbidity index or were found to have mixed flora during explantation. The treatment of PJI remains difficult, both for the patient and for the treating surgeons.
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Affiliation(s)
- Leif Claassen
- Orthopedic Department of the Hannover Medical School, Hannover, Germany
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30
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Two-Stage Revision TKA Is Associated with High Complication and Failure Rates. Adv Orthop 2014; 2014:659047. [PMID: 25610660 PMCID: PMC4290645 DOI: 10.1155/2014/659047] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2014] [Revised: 11/26/2014] [Accepted: 11/29/2014] [Indexed: 12/29/2022] Open
Abstract
Despite two-stage revision remaining the gold standard in treating periprosthetic infection of total knee arthroplasty (TKA), there remains uncertainty regarding the actual success rate and the risk factors for failure. We retrospectively reviewed 58 knees with mean follow-up of 38 months who underwent two-stage revision TKAs from 1998 to 2012 by a single surgeon. Failure was defined as persistent infection or reoperation after two-stage revision TKA surgery. Failure occurred in 36%. The overall mortality was 22%. The mean time to reinfection was 26 months. Polymicrobial infection was associated with a higher risk of failure (RR 3.31, P < 0.001). Knees requiring soft tissue coverage were also at a greater risk of failure (RR 2.67, P = 0.001), as were knees that underwent four or more additional surgeries after the primary TKA and prior to stage-one explantation (RR 2.25, P = 0.020). Thus, opportunities exist for improvement in management of infected TKA.
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Wu CH, Gray CF, Lee GC. Arthrodesis should be strongly considered after failed two-stage reimplantation TKA. Clin Orthop Relat Res 2014; 472:3295-304. [PMID: 24488752 PMCID: PMC4182410 DOI: 10.1007/s11999-014-3482-4] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND A two-stage reimplantation procedure is a well-accepted procedure for management of first-time infected total knee arthroplasty (TKA). However, there is a lack of consensus on the treatment of subsequent reinfections. QUESTIONS/PURPOSES The purpose of this study was to perform a decision analysis to determine the treatment method likely to yield the highest quality of life for a patient after a failed two-stage reimplantation. METHODS We performed a systematic review to estimate the expected success rates of a two-stage reimplantation procedure, chronic suppression, arthrodesis, and amputation for treatment of infected TKA. To determine utility values of the various possible health states that could arise after two-stage revision, we used previously published values and methods to determine the utility and disutility tolls for each treatment option and performed a decision tree analysis using the TreeAgePro 2012 software suite (Williamstown, MA, USA). These values were subsequently varied to perform sensitivity analyses, determining thresholds at which different treatment options prevailed. RESULTS Overall, the composite success rate for two-stage reimplantation was 79.1% (range, 33.3%-100%). The utility (successful outcome) and disutility toll (cost for treatment) for two-stage reimplantation were determined to be 0.473 and 0.20, respectively; the toll for undergoing chronic suppression was set at 0.05; the utility for arthrodesis was 0.740 and for amputation 0.423. We set the utilities for subsequent two-stage revision and other surgical procedures by subtracting the disutility toll from the utility each time another procedure was performed. The two-way sensitivity analysis varied the utility status after an additional two-stage reimplantation (0.47-0.99) and chance of a successful two-stage reimplantation (45%-95%). The model was then extended to a three-way sensitivity analysis twice: once by setting the variable arthrodesis utility at a value of 0.47 and once more by setting utility of two-stage reimplantation at 0.05 over the same range of values on both axes. Knee arthrodesis emerged as the treatment most likely to yield the highest expected utility (quality of life) after initially failing a two-stage revision. For a repeat two-stage revision to be favored, the utility of that second two-stage revision had to substantially exceed the published utility of primary TKA of 0.84 and the probability of achieving infection control had to exceed 90%. CONCLUSIONS Based on best available evidence, knee arthrodesis should be strongly considered as the treatment of choice for patients who have persistent infected TKA after a failed two-stage reimplantation procedure. We recognize that particular circumstances such as severe bone loss can preclude or limit the applicability of fusion as an option and that individual clinical circumstances must always dictate the best treatment, but where arthrodesis is practical, our model supports it as the best approach.
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Affiliation(s)
- Chia H. Wu
- Department of Orthopaedic Surgery, University of Pennsylvania, 1 Cupp Pavilion, 39th and Market Streets, Philadelphia, PA 19104 USA
| | - Chancellor F. Gray
- Department of Orthopaedic Surgery, University of Pennsylvania, 1 Cupp Pavilion, 39th and Market Streets, Philadelphia, PA 19104 USA
| | - Gwo-Chin Lee
- Department of Orthopaedic Surgery, University of Pennsylvania, 1 Cupp Pavilion, 39th and Market Streets, Philadelphia, PA 19104 USA
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Claassen L, Radtke K, Ettinger M, Plaass C, von Lewinski G. Preoperative diagnostic for periprosthetic joint infection prior to total knee revision arthroplasty. Orthop Rev (Pavia) 2014; 6:5437. [PMID: 25317311 PMCID: PMC4195990 DOI: 10.4081/or.2014.5437] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2014] [Accepted: 06/09/2014] [Indexed: 12/29/2022] Open
Abstract
Periprosthetic joint infection (PJI) after total knee arthroplasty remains a challenging problem. The aim of this study was to evaluate the accuracy of diagnostic knee aspiration and serum inflammatory markers in diagnostic of a PJI after total knee arthroplasty. Within 2011 and 2012, 46 patients received a one- or two-stage revision arthroplasty of the knee joint. These patients received a total number of 77 operations. A preoperative aspiration was performed in each case. We analyzed the microbiological and histological examinations of the samples from the aspiration and from the revision operation and additionally estimated serum inflammatory markers. The diagnostic aspiration had a specificity of 0.87, a sensitivity of 0.39, a positive predictive value of 0.67 and a negative predictive value of 0.68. For C-reactive protein the specificity was 0.61 and the sensitivity was 0.48, the serum white blood cell count had a specificity of 0.98 and a sensitivity of 0.23. Our data queries whether diagnostic joint aspiration or serum inflammatory markers are sufficient to verify or exclude a PJI.
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Affiliation(s)
- Leif Claassen
- Orthopedic Department, Hannover Medical School , Germany
| | - Kerstin Radtke
- Orthopedic Department, Hannover Medical School , Germany
| | - Max Ettinger
- Orthopedic Department, Hannover Medical School , Germany
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Citak M, Argenson JN, Masri B, Kendoff D, Springer B, Alt V, Baldini A, Cui Q, Deirmengian GK, Del Sel H, Harrer MF, Israelite CL, Jahoda D, Jutte PC, Levicoff E, Meani E, Motta F, Pena OR, Ranawat AS, Safir O, Squire MW, Taunton MJ, Vogely CH, Wellman SS. Spacers. J Arthroplasty 2014; 29:93-9. [PMID: 24342279 DOI: 10.1016/j.arth.2013.09.042] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
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34
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Citak M, Argenson JN, Masri B, Kendoff D, Springer B, Alt V, Baldini A, Cui Q, Deirmengian GK, del Sel H, Harrer MF, Israelite C, Jahoda D, Jutte PC, Levicoff E, Meani E, Motta F, Pena OR, Ranawat AS, Safir O, Squire MW, Taunton MJ, Vogely C, Wellman SS. Spacers. J Orthop Res 2014; 32 Suppl 1:S120-9. [PMID: 24464885 DOI: 10.1002/jor.22555] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
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Schwarzkopf R, Oh D, Wright E, Estok DM, Katz JN. Treatment Failure Among Infected Periprosthetic Patients at a Highly Specialized Revision TKA Referral Practice. Open Orthop J 2013; 7:264-71. [PMID: 23898353 PMCID: PMC3722532 DOI: 10.2174/1874325001307010264] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2013] [Revised: 04/13/2013] [Accepted: 04/20/2013] [Indexed: 01/31/2023] Open
Abstract
Deep infection is a serious and costly complication of total knee arthroplasty (TKA), which can increase patient morbidity and compromise functional outcome and satisfaction. Two-stage revision with an interval of parental antibiotics has been shown to be the most successful treatment in eradicating deep infection following TKA. We report a large series by a single surgeon with a highly specialized revision TKA referral practice. We identified 84 patients treated by a two-stage revision. We defined "successful two-stage revision" as negative intraoperative cultures and no further infection-related procedure. We defined "eradication of infection" on the basis of negative cultures and clinical diagnosis. After a mean follow up of 25 months, eradication of the infection was documented in 90.5% of the patients; some had undergone further surgical intervention after the index two-stage procedure. Successful two-stage revision (e.g. no I&D, fusion, amputation) was documented only in 63.5% of the patients. We also observed a trend between presence of resistant staphylococcus (MRSA) (p=0.05) as well as pre-revision surgical procedures (p=0.08) and a lower likelihood of successfully two-stage revision. Factors affecting the high failure rate included multiple surgeries prior to the two-stage revision done at our institution, and high prevalence of MRSA present among failed cases. The relatively high rate of failure to achieve a successful two-stage revision observed in our series may be attributed to the highly specialized referral practice. Thus increasing the prevalence of patients with previous failed attempts at infection eradication and delayed care as well as more fragile and immune compromised hosts.
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Affiliation(s)
- Ran Schwarzkopf
- Orthopaedic Department, University of California Irvine Medical Center, Orange, CA, USA
| | - Daniel Oh
- Orthopaedic Department, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Elizabeth Wright
- Orthopedic and Arthritis Center for Outcomes Research, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Daniel M Estok
- Orthopaedic Department, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Jeffery N Katz
- Orthopedic and Arthritis Center for Outcomes Research, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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