|
1
|
Capece G, Di Gialleonardo E, Comisi C, Bocchino G, Cinelli V, Mascio A, Fulchignoni C, Greco T, Maccauro G, Perisano C. Treatment Options of Prosthetic Joint Infections Following Total Ankle Arthroplasty: A Systematic Review. J Clin Med 2025; 14:718. [PMID: 39941388 PMCID: PMC11818539 DOI: 10.3390/jcm14030718] [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: 01/12/2025] [Revised: 01/20/2025] [Accepted: 01/21/2025] [Indexed: 02/16/2025] Open
Abstract
Background: This comprehensive systematic review aims to explore and discuss existing treatment modalities for infections in total ankle arthroplasty (TAA), providing insights that may contribute to the establishment of a "standard of care" for these challenging cases. The study analyses the intricate landscape of infected TAA, addressing gaps in the current literature and emphasizing the need to refine treatment strategies. With the reported incidence of periprosthetic joint infection after TAA surpassing rates observed in total hip and knee replacements, the research navigates through various treatment modalities, underscoring the lack of a universally accepted standard of care. Methods: In this systematic review, following PRISMA guidelines, PubMed, Scopus, and Google Scholar, we identified 15 papers addressing the management strategies for infected TAA (162 infected ankle arthroplasty cases).These databases were chosen for their extensive coverage, strong relevance to the research topic, and ease of access, ensuring a thorough and focused retrieval of pertinent literature on the treatment of infected ankle prostheses. The review involved the identification and evaluation of articles providing insights into complications, treatment outcomes, and risk factors. Extracted data were summarized and reported. A descriptive analysis was performed, and when feasible, a statistical analysis was conducted. Results: Treatment modalities included irrigation and debridement (48.8%), revision total ankle arthroplasty (36.3%), primary arthrodesis (7.9%), spacer arthroplasty (4.5%), and primary amputation (3.9%). Complication rates varied, with 46.5% for irrigation and debridement, 20% for two-stage revision, 7.14% for primary arthrodesis, and 25% for spacer arthroplasty. Conclusions: The rising prevalence of TAA underscores the need for a definitive treatment protocol due to severe complications. This review emphasizes careful patient selection and accurate diagnosis. Irrigation and debridement are effective for acute infections, while two-stage revision is a valid alternative for chronic infections. High-quality randomized controlled trials are important for establishing an evidence-based treatment protocol.
Collapse
Affiliation(s)
- Giacomo Capece
- Orthopaedics and Trauma Surgery Unit, Catholic University of The Sacred Heart, 00168 Rome, Italy; (E.D.G.); (C.C.); (G.B.); (V.C.); (A.M.); (C.F.); (T.G.); (G.M.); (C.P.)
- U.O.C. Orthopedics and Traumatology, Ospedale dei Pellegrini, 80134 Naples, Italy
| | - Emidio Di Gialleonardo
- Orthopaedics and Trauma Surgery Unit, Catholic University of The Sacred Heart, 00168 Rome, Italy; (E.D.G.); (C.C.); (G.B.); (V.C.); (A.M.); (C.F.); (T.G.); (G.M.); (C.P.)
| | - Chiara Comisi
- Orthopaedics and Trauma Surgery Unit, Catholic University of The Sacred Heart, 00168 Rome, Italy; (E.D.G.); (C.C.); (G.B.); (V.C.); (A.M.); (C.F.); (T.G.); (G.M.); (C.P.)
| | - Guido Bocchino
- Orthopaedics and Trauma Surgery Unit, Catholic University of The Sacred Heart, 00168 Rome, Italy; (E.D.G.); (C.C.); (G.B.); (V.C.); (A.M.); (C.F.); (T.G.); (G.M.); (C.P.)
| | - Virginia Cinelli
- Orthopaedics and Trauma Surgery Unit, Catholic University of The Sacred Heart, 00168 Rome, Italy; (E.D.G.); (C.C.); (G.B.); (V.C.); (A.M.); (C.F.); (T.G.); (G.M.); (C.P.)
| | - Antonio Mascio
- Orthopaedics and Trauma Surgery Unit, Catholic University of The Sacred Heart, 00168 Rome, Italy; (E.D.G.); (C.C.); (G.B.); (V.C.); (A.M.); (C.F.); (T.G.); (G.M.); (C.P.)
| | - Camillo Fulchignoni
- Orthopaedics and Trauma Surgery Unit, Catholic University of The Sacred Heart, 00168 Rome, Italy; (E.D.G.); (C.C.); (G.B.); (V.C.); (A.M.); (C.F.); (T.G.); (G.M.); (C.P.)
- Department of Ageing, Neurosciences, Head-Neck and Orthopaedics Sciences, Orthopaedics and Trauma Surgery Unit, Fondazione Policlinico Universitario Agostino Gemelli, IRCCS, 00168 Rome, Italy
| | - Tommaso Greco
- Orthopaedics and Trauma Surgery Unit, Catholic University of The Sacred Heart, 00168 Rome, Italy; (E.D.G.); (C.C.); (G.B.); (V.C.); (A.M.); (C.F.); (T.G.); (G.M.); (C.P.)
- Department of Ageing, Neurosciences, Head-Neck and Orthopaedics Sciences, Orthopaedics and Trauma Surgery Unit, Fondazione Policlinico Universitario Agostino Gemelli, IRCCS, 00168 Rome, Italy
- Department of Life Sciences, Health, and Health Professions, Link Campus University, 00165 Rome, Italy
| | - Giulio Maccauro
- Orthopaedics and Trauma Surgery Unit, Catholic University of The Sacred Heart, 00168 Rome, Italy; (E.D.G.); (C.C.); (G.B.); (V.C.); (A.M.); (C.F.); (T.G.); (G.M.); (C.P.)
- Department of Ageing, Neurosciences, Head-Neck and Orthopaedics Sciences, Orthopaedics and Trauma Surgery Unit, Fondazione Policlinico Universitario Agostino Gemelli, IRCCS, 00168 Rome, Italy
| | - Carlo Perisano
- Orthopaedics and Trauma Surgery Unit, Catholic University of The Sacred Heart, 00168 Rome, Italy; (E.D.G.); (C.C.); (G.B.); (V.C.); (A.M.); (C.F.); (T.G.); (G.M.); (C.P.)
- Department of Ageing, Neurosciences, Head-Neck and Orthopaedics Sciences, Orthopaedics and Trauma Surgery Unit, Fondazione Policlinico Universitario Agostino Gemelli, IRCCS, 00168 Rome, Italy
| |
Collapse
|
|
2
|
Atesok K, Scott DJ, Hurwitz S, Gross CE. Diagnosis and Management of Periprosthetic Joint Infections After Total Ankle Arthroplasty. J Am Acad Orthop Surg 2024; 32:728-737. [PMID: 38759226 DOI: 10.5435/jaaos-d-23-01266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2023] [Accepted: 04/14/2024] [Indexed: 05/19/2024] Open
Abstract
Periprosthetic joint infection (PJI) after total ankle arthroplasty (TAA) is a dreaded complication that may lead to catastrophic outcomes. Risk factors include a history of surgery on the operated ankle, low preoperative function scores, diabetes, extended surgical time, and postoperative wound-healing problems. Clinical presentation varies and may include increasing ankle pain and swelling, high temperature, local erythema, wound drainage, and dehiscence. The initial diagnostic evaluation should include plain radiographs, erythrocyte sedimentation rate, C-reactive protein levels, and leukocyte count. In suspected cases with elevated erythrocyte sedimentation rate and C-reactive protein, aspiration of the ankle joint for synovial fluid analysis, Gram staining, and culture should be performed. Antibiotic therapy should be based on the pathogen identified, and the surgical strategy should be determined based on the time lines of PJI. Early PJI can be treated with irrigation and débridement with polyethylene exchange. The surgical treatment of choice for late PJI is two-stage revision arthroplasty, which includes removal of the implant, insertion of an antibiotic spacer, and reimplantation of a TAA. In certain chronic PJI cases, permanent articulating antibiotic spacers can be left in place or an ankle arthrodesis can be performed. Below-knee amputation is considered as the final option after limb-sparing procedures have failed.
Collapse
Affiliation(s)
- Kivanc Atesok
- From the Department of Orthopaedics and Physical Medicine, Medical University of South Carolina, Charleston, SC (Atesok, Scott, and Gross), Department of Orthopaedic Surgery, University of Virginia, Charlottesville, VA (Hurwitz)
| | | | | | | |
Collapse
|
|
3
|
Helbing J, Farley B, Gu A, Zhao AY, Siram G, Stein B, Chodos MD. Diabetes Mellitus and Total Ankle Arthroplasty Complications. Foot Ankle Int 2024; 45:320-327. [PMID: 38327200 DOI: 10.1177/10711007241226929] [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] [Indexed: 02/09/2024]
Abstract
BACKGROUND Postoperative infection, aseptic loosening, and perioperative medical complications after total ankle arthroplasty (TAA) are all devastating problems. While previous studies have shown diabetes as a risk factor predisposing patients to postoperative complications, not all literature supports this association following TAA. The goal of this study is to determine if diabetes influences midterm outcomes following TAA. METHODS An insurance database was utilized to identify patients undergoing TAA for ankle arthritis with a concurrent diagnosis of diabetes based on Current Procedural Terminology (CPT) and International Classification of Diseases, Ninth Revision (ICD-9) and Tenth Revision (ICD-10), diagnosis and procedure codes from 2010 to 2021. The postoperative outcomes of all-cause revision, periprosthetic joint infection (PJI), septic revision, and aseptic revision were compared between patients with and without diabetes with a minimum 2-year follow-up using Kaplan-Meier and multivariate Cox proportional hazards analyses. Patient demographics, comorbidities, and Charlson Comorbidity Index were analyzed via univariate and multivariate analysis. RESULTS The study population included 8317 patients, 345 (4.1%) of whom had a concurrent diabetes diagnosis, who underwent TAA. After multivariate Cox proportional hazards analysis, the 5-year cumulative incidence of being coded as having PJI was 7.3% in patients with known diabetes compared to 3.9% in patients without known diabetes, with a 95% increased risk (hazard ratio [HR] 1.95, 95% CI 1.15-3.30, P = .01). Patients with diabetes also demonstrated a 5-year cumulative incidence of septic revision of 1.4% compared to 0.4% in those without, with a 363% increased risk (HR 4.63, 95% CI 1.22-17.52, P = .02). However, there was no difference in the 5-year cumulative incidence of all-cause revision TAA with 4.6% in patients with diabetes and 4.3% in those without (HR 1.29, 95% CI 0.69-2.44, P = .42). CONCLUSION In this database, the 5-year risk of PJI and septic revision was higher among patients with diabetes compared to those without, but cumulative incidence of all-cause revision TAA was not different between groups. LEVEL OF EVIDENCE Level III, retrospective cohort database study.
Collapse
Affiliation(s)
- Jordan Helbing
- Department of Orthopaedic Surgery, The George Washington University, Washington, DC, USA
| | - Benjamin Farley
- Department of Orthopaedic Surgery, The George Washington University, Washington, DC, USA
| | - Alex Gu
- Department of Orthopaedic Surgery, The George Washington University, Washington, DC, USA
| | - Amy Y Zhao
- Department of Orthopaedic Surgery, The George Washington University, Washington, DC, USA
| | - Gautam Siram
- Department of Orthopaedic Surgery, The George Washington University, Washington, DC, USA
- Centers for Advanced Orthopedics Summit Orthopedic Surgery, Bethesda, MD, USA
| | - Benjamin Stein
- Centers for Advanced Orthopaedics, LLC, Washington, DC, USA
- Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, MD, USA
| | - Marc D Chodos
- Department of Orthopaedic Surgery, The George Washington University, Washington, DC, USA
| |
Collapse
|
|
4
|
Dickinson JD, Collman DR, Russel LH, Choung DJ. Navigating the Challenges of Total Ankle Replacement: Deformity Correction and Infection Considerations. Clin Podiatr Med Surg 2024; 41:119-139. [PMID: 37951670 DOI: 10.1016/j.cpm.2023.06.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2023]
Abstract
In recent years, total ankle replacement (TAR) has gained widespread acceptance as a surgical treatment for end-stage ankle arthritis. This shift is due to notable improvements in implant design, surgical instrumentation, technique, and surgeon expertise, resulting in high levels of patient satisfaction comparable to ankle fusion. Additionally, indications for TAR have expanded to include advanced deformities that were previously considered unsuitable for the procedure, making ankle arthrodesis the only option. Despite these advancements, TAR still carries a higher complication rate compared to other ankle surgeries. The complex anatomy of the ankle, coupled with limited soft tissue, presents significant challenges in managing complications associated with TAR.
Collapse
Affiliation(s)
- Joseph D Dickinson
- Kaiser San Francisco Bay Area Foot and Ankle Residency Program, Department of Orthopedics/Podiatry, Kaiser Permanente Oakland Medical Center, 3600 Broadway, Oakland, CA 94611, USA
| | - David R Collman
- Kaiser San Francisco Bay Area Foot and Ankle Residency Program, Department of Orthopedics, Podiatry, Injury, Sports Medicine, Kaiser Permanente San Francisco Medical Center, 4506th Avenue, French Campus, 5th Floor, San Francisco, CA 94118, USA
| | - Lindsay H Russel
- Department of Orthopedics, Kaiser Permanente South Sacramento Medical Center, 6600 Bruceville Road, Sacramento, CA 95823, USA
| | - Danny J Choung
- Kaiser North Bay Consortium Foot and Ankle Residency Program, Department of Orthopedics/Podiatry, Kaiser Permanente San Rafael, 99 Montecillo Road, San Rafael, CA 94903, USA.
| |
Collapse
|