1
|
Lin Y, Chen W, Peng S, Chang C, Lee S, Lin S. Impact of unplanned second debridement, antibiotics and implant retention on long-term outcomes in knee exchange arthroplasty: Elevated risk of failure and reinfection. J Exp Orthop 2024; 11:e12024. [PMID: 38694767 PMCID: PMC11058667 DOI: 10.1002/jeo2.12024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2023] [Revised: 02/02/2024] [Accepted: 03/26/2024] [Indexed: 05/04/2024] Open
Abstract
Purpose This study investigates the outcomes of two-stage exchange arthroplasty (EA) for periprosthetic joint infection (PJI) following initial or unplanned repeat debridement antibiotics, and implant retention (DAIR). Methods We retrospectively reviewed cases of knee arthroplasty infection treated with two-stage EA after DAIR, spanning from January 1994 to December 2010. A total of 138 patients were included, comprising 112 with initial DAIR and 26 with an unplanned second DAIR. Data on demographics, comorbidities, infection characteristics and causative organisms were analyzed. The primary outcome was implant failure or reinfection, observed over a minimum follow-up of 10 years. Results The overall success rate for two-stage EA was 87% (119/138 patients). Factors identified for treatment failure included reinfection with the same pathogen for unplanned second DAIR (hazard ratio [HR] = 3.41; 95% confidence interval [CI] = 1.35-4.38; p = 0.004), higher reinfection rates in patients undergoing EA after an unplanned second DAIR, especially with a prior history of PJI within 2 years (HR = 4.23; 95% CI = 2.39-5.31; p = 0.002), pre-first DAIR C-reactive protein (CRP) levels over 100 mg/dL (HR = 2.52; 95% CI = 1.98-3.42; p = 0.003) and recurrence with the same pathogen (HR = 2.35; 95% CI = 1.32-4.24; p = 0.007). Additional factors such as male gender (HR = 3.92; 95% CI = 1.21-5.25; p = 0.007) and osteoporosis (T score < -2.5; HR = 3.27; 95% CI = 1.23-5.28; p = 0.005) were identified as risk factors for implant failure in all EA cases. Conclusions This study identifies key risk factors for worse knee EA outcomes following DAIR, including a pre-first DAIR CRP level over 100 mg/L, same pathogen recurrence, and PJI history within 2 years. It shows implant failure rates remain constant across EA cases, regardless of DAIR sequence, particularly with risk factors like male gender and severe osteoporosis (T score < -2.5). These results underscore the need for careful evaluation before an unplanned second DAIR, given its significant impact on EA success. Level of Evidence Level III.
Collapse
Affiliation(s)
- Yu‐Chih Lin
- Department of Orthopaedic SurgeryChang Gung Memorial Hospital (CGMH)KweishanTaoyuanTaiwan
- Bone and Joint Research CenterChang Gung Memorial Hospital (CGMH)KweishanTaoyuanTaiwan
- College of MedicineChang Gung University (CGU)KweishanTaoyuanTaiwan
| | - Wei‐Cheng Chen
- Department of Orthopaedic SurgeryChang Gung Memorial Hospital (CGMH)KweishanTaoyuanTaiwan
- Bone and Joint Research CenterChang Gung Memorial Hospital (CGMH)KweishanTaoyuanTaiwan
- College of MedicineChang Gung University (CGU)KweishanTaoyuanTaiwan
| | - Shih‐Hui Peng
- Department of Orthopaedic SurgeryChang Gung Memorial Hospital (CGMH)KweishanTaoyuanTaiwan
- Bone and Joint Research CenterChang Gung Memorial Hospital (CGMH)KweishanTaoyuanTaiwan
- College of MedicineChang Gung University (CGU)KweishanTaoyuanTaiwan
| | - Chih‐Hsiang Chang
- Department of Orthopaedic SurgeryChang Gung Memorial Hospital (CGMH)KweishanTaoyuanTaiwan
- Bone and Joint Research CenterChang Gung Memorial Hospital (CGMH)KweishanTaoyuanTaiwan
- College of MedicineChang Gung University (CGU)KweishanTaoyuanTaiwan
| | - Sheng‐Hsun Lee
- Department of Orthopaedic SurgeryChang Gung Memorial Hospital (CGMH)KweishanTaoyuanTaiwan
- Bone and Joint Research CenterChang Gung Memorial Hospital (CGMH)KweishanTaoyuanTaiwan
- College of MedicineChang Gung University (CGU)KweishanTaoyuanTaiwan
| | - Sheng‐Hsuan Lin
- Institute of StatisticsNational Yang Ming Chiao Tung UniversityHsinchuTaiwan
| |
Collapse
|
2
|
Goumenos S, Hardt S, Kontogeorgakos V, Trampuz A, Perka C, Meller S. Success Rate After 2-Stage Spacer-Free Total Hip Arthroplasty Exchange and Risk Factors for Reinfection: A Prospective Cohort Study of 187 Patients. J Arthroplasty 2024:S0883-5403(24)00444-3. [PMID: 38759820 DOI: 10.1016/j.arth.2024.05.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Revised: 05/02/2024] [Accepted: 05/03/2024] [Indexed: 05/19/2024] Open
Abstract
BACKGROUND Two-stage prosthesis exchange is the treatment of choice for chronic periprosthetic joint infection (PJI) of a total hip arthroplasty (THA), especially when the bone and surrounding soft tissues are compromised or difficult-to-treat pathogens are implicated. The aims of our study were as follows: (1) to determine the outcome of 2-stage prosthesis exchange for the treatment of PJI after THA and (2) to determine the risk factors for reinfection leading to subsequent revision surgeries after reimplantation. METHODS We prospectively enrolled 187 consecutive patients who underwent a 2-stage THA exchange with resection arthroplasty for PJI from 2013 to 2019. The mean (± SD) duration of follow-up was 54.2 ± 24.9 months (range, 36 to 96), and the mean interval until reimplantation was 9.8 ± 8.9 weeks (range, 2 to 38). All patients remained in a spacer-free girdlestone situation between the 2 stages of treatment. Patients who remained infection-free after their 2-stage treatment were considered to have achieved treatment success. RESULTS The overall success rate was 85.6%. The cumulative probability of reinfection was 11.5% after one year and 14% after 2 years after reimplantation. High virulence or difficult-to-treat pathogens were significant and independent risk factors for reinfection (HR [hazard ratio] = 3.71, 95% CI [confidence interval]: 1.47 to 9.36, P = .006 and HR = 3.85, 95% CI: 1.73 to 8.57, respectively, P = .001), as was previous 2-stage hip prosthesis exchange (HR = 3.58, 95% CI: 1.33 to 9.62, P = .01). Overall reoperation and revision rates were 26.2 and 16.6%, respectively. Re-infected patients had an 80% higher probability of reoperation than noninfected ones (P < .001, log-rank = 102.6), and they were 55% more likely to undergo revision surgery during their follow-up (P < .001, log-rank = 55.4). CONCLUSIONS Reinfection rates after 2-stage spacer-free THA revision for PJI still remain high but are comparable to those including cement spacers. Patients who have had prior failed 2-stage implant exchanges or are infected by high-grade or difficult-to-treat pathogens are at high risk for treatment failure.
Collapse
Affiliation(s)
- Stavros Goumenos
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Center for Musculoskeletal Surgery (CMSC), Berlin, Germany
| | - Sebastian Hardt
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Center for Musculoskeletal Surgery (CMSC), Berlin, Germany
| | - Vasileios Kontogeorgakos
- 1st Department of Orthopaedics and Trauma Surgery, "Attikon" University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Andrej Trampuz
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Center for Musculoskeletal Surgery (CMSC), Berlin, Germany
| | - Carsten Perka
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Center for Musculoskeletal Surgery (CMSC), Berlin, Germany
| | - Sebastian Meller
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Center for Musculoskeletal Surgery (CMSC), Berlin, Germany
| |
Collapse
|
3
|
Deans CF, Kildow BJ, Garvin KL. Recurrent Periprosthetic Joint Infections: Diagnosis, Management, and Outcomes. Orthop Clin North Am 2024; 55:193-206. [PMID: 38403366 DOI: 10.1016/j.ocl.2023.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/27/2024]
Abstract
Periprosthetic joint infection (PJI) remains one of the most common complications after total joint arthroplasty. It is challenging to manage, associated with significant morbidity and mortality, and is a financial burden on the health care system. Failure of 2-stage management for chronic PJI is not uncommon. Repeat infections are oftentimes polymicrobial, multiple drug-resistant microorganisms, or new organisms. Optimizing the success of index 2-stage revision is the greatest prevention against failure of any subsequent management options and requires a robust team-based approach.
Collapse
Affiliation(s)
- Christopher F Deans
- Department of Orthopaedic Surgery and Rehabilitation, University of Nebraska Medical Center, 985640 Nebraska Medical Center, Omaha, NE 68198, USA.
| | - Beau J Kildow
- Department of Orthopaedic Surgery and Rehabilitation, University of Nebraska Medical Center, 985640 Nebraska Medical Center, Omaha, NE 68198, USA
| | - Kevin L Garvin
- Department of Orthopaedic Surgery and Rehabilitation, University of Nebraska Medical Center, 985640 Nebraska Medical Center, Omaha, NE 68198, USA
| |
Collapse
|
4
|
Ortega-Yago A, Pedraza-Corbi A, Argüelles-Linares F, Baeza-Oliete J. Floating Knee Arthrodesis After Prosthetic Knee Infection: A Report of 48 Cases. J Arthroplasty 2024; 39:494-500. [PMID: 37572716 DOI: 10.1016/j.arth.2023.08.011] [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: 04/02/2023] [Revised: 08/03/2023] [Accepted: 08/04/2023] [Indexed: 08/14/2023] Open
Abstract
BACKGROUND Knee arthrodesis is a means of avoiding above-knee amputation after a prosthetic joint infection (PJI). The objective of this study was to analyze the results of floating knee arthrodesis in patients who had a history of aprosthetic knee infection. The analysis consisted of determining reinfection rates, functional results, and the survival of arthrodesis. METHODS There were 48 patients who underwent a cemented floating knee arthrodesis in cases of PJI retrospectively included in the study, having been operated on between 2012 and 2020. In addition to being evaluated clinically, analytically, and radiographically, the patients were assessed functionally by means of a newly-created scale. RESULTS At a mean follow-up of 4 years (1 year to 9 years), 7 patients suffered reinfection (14.6%). The recurrence of infection was not observed to be significantly affected by sex (P = .16), age(P = .09), or the type of surgery previously undergone (P = .18), nor was the McPherson Host Grade (P = .4) observed to have a significant effect. Patients who had a McPherson Limb Grade 3 were more likely to suffer reinfection than those with a McPherson Limb Grade 2 (P = .034). There were 26 patients (54%)fully evaluated and scored on the Knee Arthrodesis Functional Scale(BAOR). For 11 patients (42%), the results were evaluated as excellent, for 11 (42%) acceptable, for 3 (12%) low, and for 1(4%) poor. CONCLUSION The arthrodesis nail is an effective and safe procedure for patients who have a recurrent PJI, providing an effective alternative when the criteria for a new revision total knee arthroplasty are not met.
Collapse
Affiliation(s)
- Amparo Ortega-Yago
- Septic and Reconstructive Surgery Unit, Orthopaedic and Traumatology Section, Hospital Universitari i Politècnic la Fe, Valencia, Spain
| | - Aranza Pedraza-Corbi
- Septic and Reconstructive Surgery Unit, Orthopaedic and Traumatology Section, Hospital Universitari i Politècnic la Fe, Valencia, Spain
| | - Francisco Argüelles-Linares
- Septic and Reconstructive Surgery Unit, Orthopaedic and Traumatology Section, Hospital Universitari i Politècnic la Fe, Valencia, Spain
| | - Jose Baeza-Oliete
- Septic and Reconstructive Surgery Unit, Orthopaedic and Traumatology Section, Hospital Universitari i Politècnic la Fe, Valencia, Spain
| |
Collapse
|
5
|
Baertl S, Rupp M, Kerschbaum M, Morgenstern M, Baumann F, Pfeifer C, Worlicek M, Popp D, Amanatullah DF, Alt V. The PJI-TNM classification for periprosthetic joint infections. Bone Joint Res 2024; 13:19-27. [PMID: 38176440 PMCID: PMC10766470 DOI: 10.1302/2046-3758.131.bjr-2023-0012.r2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2024] Open
Abstract
Aims This study aimed to evaluate the clinical application of the PJI-TNM classification for periprosthetic joint infection (PJI) by determining intraobserver and interobserver reliability. To facilitate its use in clinical practice, an educational app was subsequently developed and evaluated. Methods A total of ten orthopaedic surgeons classified 20 cases of PJI based on the PJI-TNM classification. Subsequently, the classification was re-evaluated using the PJI-TNM app. Classification accuracy was calculated separately for each subcategory (reinfection, tissue and implant condition, non-human cells, and morbidity of the patient). Fleiss' kappa and Cohen's kappa were calculated for interobserver and intraobserver reliability, respectively. Results Overall, interobserver and intraobserver agreements were substantial across the 20 classified cases. Analyses for the variable 'reinfection' revealed an almost perfect interobserver and intraobserver agreement with a classification accuracy of 94.8%. The category 'tissue and implant conditions' showed moderate interobserver and substantial intraobserver reliability, while the classification accuracy was 70.8%. For 'non-human cells,' accuracy was 81.0% and interobserver agreement was moderate with an almost perfect intraobserver reliability. The classification accuracy of the variable 'morbidity of the patient' reached 73.5% with a moderate interobserver agreement, whereas the intraobserver agreement was substantial. The application of the app yielded comparable results across all subgroups. Conclusion The PJI-TNM classification system captures the heterogeneity of PJI and can be applied with substantial inter- and intraobserver reliability. The PJI-TNM educational app aims to facilitate application in clinical practice. A major limitation was the correct assessment of the implant situation. To eliminate this, a re-evaluation according to intraoperative findings is strongly recommended.
Collapse
Affiliation(s)
- Susanne Baertl
- Department of Trauma Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Markus Rupp
- Department of Trauma Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Maximilian Kerschbaum
- Department of Trauma Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Mario Morgenstern
- Center for Musculoskeletal Infections, Department of Orthopaedic and Trauma Surgery, University Hospital of Basel, Basel, Switzerland
| | - Florian Baumann
- Department of Trauma Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Christian Pfeifer
- Department of Trauma Surgery, University Medical Center Regensburg, Regensburg, Germany
- Department Trauma, Orthopaedics and Hand Surgery, Innklinikum Altötting, Altötting, Germany
| | - Michael Worlicek
- Department of Trauma Surgery, University Medical Center Regensburg, Regensburg, Germany
- Department Knee Surgery, Schulthess Clinic, Zurich, Switzerland
| | - Daniel Popp
- Department of Trauma Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Derek F. Amanatullah
- Department of Orthopaedic Surgery, Stanford University, Stanford, California, USA
| | - Volker Alt
- Department of Trauma Surgery, University Medical Center Regensburg, Regensburg, Germany
| |
Collapse
|
6
|
Razii N, Kennedy JW, Shields DW, Hrycaiczuk A, Morgan-Jones R, Meek RMD, Jamal B. Proceedings of the United Kingdom Periprosthetic Joint Infection Meeting 2022: Combined and Arthroplasty Sessions. J Arthroplasty 2024; 39:218-223. [PMID: 37393964 DOI: 10.1016/j.arth.2023.06.039] [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: 03/03/2023] [Revised: 06/15/2023] [Accepted: 06/24/2023] [Indexed: 07/04/2023] Open
Abstract
Considerable variation in practice exists in the prevention, diagnosis, and treatment of periprosthetic joint infection (PJI), which is a devastating complication for patients and surgeons. The consensus principle has been increasingly embraced by the orthopaedic community to help guide practice, especially where high-level evidence remains unavailable. The third United Kingdom Periprosthetic Joint Infection (UK PJI) Meeting was held in Glasgow on April 1, 2022, with more than 180 delegates in attendance, representing orthopaedics, microbiology, infectious diseases, plastic surgery, anesthetics, and allied health professions, including pharmacy and arthroplasty nurses. The meeting comprised a combined session for all delegates, and separate breakout sessions for arthroplasty and fracture-related infection. Consensus questions for each session were prepared in advance by the UK PJI working group, based upon topics that were proposed at previous UK PJI Meetings, and delegates participated in an anonymized electronic voting process. We present the findings of the combined and arthroplasty sessions of the meeting in this article, and each consensus topic is discussed in relation to the contemporary literature.
Collapse
Affiliation(s)
- Nima Razii
- Department of Trauma and Orthopaedics, Queen Elizabeth University Hospital, Glasgow, United Kingdom
| | - John W Kennedy
- Department of Trauma and Orthopaedics, Queen Elizabeth University Hospital, Glasgow, United Kingdom
| | - David W Shields
- Department of Trauma and Orthopaedics, Queen Elizabeth University Hospital, Glasgow, United Kingdom
| | - Alex Hrycaiczuk
- Department of Trauma and Orthopaedics, Queen Elizabeth University Hospital, Glasgow, United Kingdom
| | - Rhidian Morgan-Jones
- Cardiff and Vale Orthopaedic Centre, University Hospital Llandough, Cardiff, United Kingdom
| | - R M Dominic Meek
- Department of Trauma and Orthopaedics, Queen Elizabeth University Hospital, Glasgow, United Kingdom
| | - Bilal Jamal
- Department of Trauma and Orthopaedics, Queen Elizabeth University Hospital, Glasgow, United Kingdom
| |
Collapse
|
7
|
Italia K, Launay M, Gilliland L, Nielsen J, Pareyon R, Hollman F, Salhi A, Maharaj J, Jomaa M, Cutbush K, Gupta A. Single-Stage Revision Reverse Shoulder Arthroplasty: Preoperative Planning, Surgical Technique, and Mixed Reality Execution. J Clin Med 2022; 11:jcm11247422. [PMID: 36556038 PMCID: PMC9788296 DOI: 10.3390/jcm11247422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 12/07/2022] [Accepted: 12/11/2022] [Indexed: 12/23/2022] Open
Abstract
Revision shoulder arthroplasty is increasing with the number of primary shoulder replacements rising globally. Complex primary and revisions of shoulder arthroplasties pose specific challenges for the surgeon, which must be addressed preoperatively and intraoperatively. This article aimed to present strategies for the management of revision of shoulder arthroplasties through a single-stage approach. Preoperatively, patient factors, such as age, comorbidities, and bone quality, should be considered. The use of planning software can aid in accurately evaluating implants in situ and predict bony anatomy that will remain after explantation during the revision surgery. The planning from such software can then be executed with the help of mixed reality technology to allow accurate implant placement. Single-stage revision is performed in two steps (debridement as first step, implantation and reconstruction as the second step), guided by the following principles: adequate debridement while preserving key soft tissue attachments (i.e., rotator cuff, pectoralis major, latissimus dorsi, deltoid), restoration of glenoid joint line using bone grafting, restoration of humeral length, reconstruction and/or reattachment of soft tissues, and strict compliance with the postoperative antibiotic regimen. Preliminary results of single-stage revision shoulder arthroplasty show improvement in patient outcomes (mean 1 year), successful treatment of infection for those diagnosed with periprosthetic joint infection, and improved cost-benefit parameters for the healthcare system.
Collapse
Affiliation(s)
- Kristine Italia
- Queensland Unit for Advanced Shoulder Research (QUASR), Queensland University of Technology, Brisbane, QLD 4000, Australia
- Correspondence: (K.I.); or (A.G.); Tel.: +61-7-3208-5552 (A.G.)
| | - Marine Launay
- Queensland Unit for Advanced Shoulder Research (QUASR), Queensland University of Technology, Brisbane, QLD 4000, Australia
- Akunah, Brisbane, QLD 4120, Australia
| | - Luke Gilliland
- Queensland Unit for Advanced Shoulder Research (QUASR), Queensland University of Technology, Brisbane, QLD 4000, Australia
- Akunah, Brisbane, QLD 4120, Australia
| | - James Nielsen
- Queensland Unit for Advanced Shoulder Research (QUASR), Queensland University of Technology, Brisbane, QLD 4000, Australia
- Akunah, Brisbane, QLD 4120, Australia
| | - Roberto Pareyon
- Queensland Unit for Advanced Shoulder Research (QUASR), Queensland University of Technology, Brisbane, QLD 4000, Australia
- Greenslopes Private Hospital, Brisbane, QLD 4120, Australia
- Brisbane Private Hospital, Brisbane, QLD 4000, Australia
| | - Freek Hollman
- Queensland Unit for Advanced Shoulder Research (QUASR), Queensland University of Technology, Brisbane, QLD 4000, Australia
- Greenslopes Private Hospital, Brisbane, QLD 4120, Australia
- Brisbane Private Hospital, Brisbane, QLD 4000, Australia
| | - Asma Salhi
- Queensland Unit for Advanced Shoulder Research (QUASR), Queensland University of Technology, Brisbane, QLD 4000, Australia
- Akunah, Brisbane, QLD 4120, Australia
| | - Jashint Maharaj
- Queensland Unit for Advanced Shoulder Research (QUASR), Queensland University of Technology, Brisbane, QLD 4000, Australia
| | - Mohammad Jomaa
- Queensland Unit for Advanced Shoulder Research (QUASR), Queensland University of Technology, Brisbane, QLD 4000, Australia
- Greenslopes Private Hospital, Brisbane, QLD 4120, Australia
- Brisbane Private Hospital, Brisbane, QLD 4000, Australia
| | - Kenneth Cutbush
- Queensland Unit for Advanced Shoulder Research (QUASR), Queensland University of Technology, Brisbane, QLD 4000, Australia
- Brisbane Private Hospital, Brisbane, QLD 4000, Australia
| | - Ashish Gupta
- Queensland Unit for Advanced Shoulder Research (QUASR), Queensland University of Technology, Brisbane, QLD 4000, Australia
- Akunah, Brisbane, QLD 4120, Australia
- Greenslopes Private Hospital, Brisbane, QLD 4120, Australia
- Correspondence: (K.I.); or (A.G.); Tel.: +61-7-3208-5552 (A.G.)
| |
Collapse
|
8
|
Soundarrajan D, Rajkumar N, Dhanasekararaja P, Rithika S, Rajasekaran S. A Comparison of Outcomes of Culture positive and Culture negative Acute Knee Prosthetic Joint Infection following Debridement, Antibiotics and Implant Retention (DAIR). EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2022:10.1007/s00590-022-03445-2. [PMID: 36436089 DOI: 10.1007/s00590-022-03445-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/27/2022] [Accepted: 11/20/2022] [Indexed: 06/16/2023]
Abstract
PURPOSE We aim to compare the outcome of culture-positive (CP PJI) and culture-negative (CN PJI) acute knee prosthetic joint infection (PJI) following debridement, antibiotics and implant retention (DAIR) with polyethylene insert exchange. We also aim to analyze the factors associated with the successful outcome of DAIR and the influence of failed DAIR on the outcome of subsequent two-stage revision arthroplasty. METHODS We performed a retrospective review of 36 consecutive patients who underwent DAIR for acute PJI between January 2013 and January 2018. The patient's demographic data, McPherson grade, surgical details, laboratory and microbiology data were retrieved from the medical records. All the patients have been followed up for a minimum of 3 years or until re-operation, revision or death and any complications, incidence of DAIR failure, revision and mortality were noted. RESULTS The mean follow-up was 4.9 ± 2.4 years. Among the 36 patients, 16 had CP PJI and 20 had CN PJI. Among the 16 patients with CP PJI, 8 patients had success with DAIR and 8 patients had a recurrence of infection (50%) at a mean of 21 months (range, 2 weeks to 55 months). Among the 20 patients with CN PJI, 14 patients had success with DAIR and 6 patients had a recurrence of infection [30% (6/20)] at a mean of 69 months (range, 13-221 months) (p < .05). The Kaplan-Meir survival analysis showed survivorship did not vary significantly between both groups (p > .05). Univariate regression analysis showed symptom duration of more than one month found to be significantly associated with the DAIR failure. There was no difference in failure rate after DAIR between age, Charlson comorbidity index, early postoperative versus acute hematogenous group and type of organism grown. Ten out of 14 DAIR failures were successfully managed with two-stage revision surgery with no recurrence of infection till the final follow-up. In the remaining 4 patients, one underwent re-debridement, two underwent arthrodesis and one was left with an antibiotic cement spacer. CONCLUSION DAIR with polyethylene exchange will give comparable results irrespective of the culture positivity. Symptom duration of more than 30 days for DAIR is significantly associated with DAIR failure. DAIR failures can be successfully managed with two-stage revision.
Collapse
Affiliation(s)
| | - Natesan Rajkumar
- Department of Orthopaedics, Ganga Hospital, 313, Mettupalayam Road, Coimbatore, 641 043, India
| | | | - Singh Rithika
- Department of Orthopaedics, Ganga Hospital, 313, Mettupalayam Road, Coimbatore, 641 043, India
| | | |
Collapse
|
9
|
Perez BA, Koressel JE, Lopez VS, Barchick S, Pirruccio K, Lee GC. Does a 2-Stage Debridement Result in Higher Rates of Implant Retention Compared With Single Debridement Alone? J Arthroplasty 2022; 37:S669-S673. [PMID: 35189287 DOI: 10.1016/j.arth.2022.02.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 02/07/2022] [Accepted: 02/10/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND/METHODS We retrospectively reviewed 89 patients with acute prosthetic joint infection treated with debridement, antibiotics, and implant retention (DAIR) or 2-DAIR. Patients had <3 weeks of symptoms and met Musculoskeletal Infection Society criteria for infection. Sixty-three patients were treated with DAIR, whereas 26 patients were managed using a 2-DAIR protocol where patients underwent initial debridement, antibiotic bead placement, and subsequent return to the operating room at an average of 16.3 days for repeat debridement and modular component exchange. Patients received a 6-week course of intravenous antibiotics and 3 months of oral antibiotics for suppression. Demographics, comorbidities, implant retention rates, and complications were compared between the groups. The McPherson host type and infection type classification system were used to categorize patients in both the DAIR and 2-DAIR groups. Regression analysis was performed to control postoperative vs acute hematogenous infection, procedure, and comorbidities. The McPherson host types and infection types were not different between DAIR and 2-DAIR patients, P = .728 and P = .061, respectively. RESULTS There was no difference in the overall implant retention rate between DAIR and 2-DAIR (63.49% vs 69.23%, P = .605). The average days to reinfection was significantly longer for the 2-DAIR cohort compared with DAIR (271.3 vs 165.3, P = .024) in patients who failed treatment. However, when controlling for infection, microorganism, index procedure, and comorbidities, there was no difference in days to reinfection (P = .679). There were no differences in complications, 90-day readmission, or revision rates between the groups. CONCLUSIONS A staged debridement for acute prosthetic joint infection did not improve the rates of infection control. Randomized trials are needed to define indications and potential benefits of 2-DAIR.
Collapse
Affiliation(s)
- Brian A Perez
- Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Joseph E Koressel
- Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Viviana Serra Lopez
- Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Stephen Barchick
- Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Kevin Pirruccio
- Department of Orthopaedic Surgery and Rehabilitation, Yale School of Medicine, New Haven, Connecticut
| | - Gwo-Chin Lee
- Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| |
Collapse
|
10
|
The Fate of Periprosthetic Joint Infection With Corynebacterium striatum: A Rare but Catastrophic Causative Organism. J Arthroplasty 2022; 37:142-149. [PMID: 34624507 DOI: 10.1016/j.arth.2021.09.023] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Revised: 09/24/2021] [Accepted: 09/28/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND The virulence and antibiotic resistance profile of an infecting organism have been shown to impact the outcomes of periprosthetic joint infection (PJI). However, there are no existing data on the outcomes of PJI caused by Corynebacterium striatum, a rare organism. Thus, our objective is to ascertain: (1) the treatment success of PJI caused by this rare organism and (2) patient characteristics in the setting of C striatum PJI. METHODS A retrospective review was conducted on 741 consecutive PJIs managed at 2 hospital facilities by 8 surgeons (February 4, 2015 to October 30, 2019). The inclusion criteria represented the presence of minimum 1 positive culture of C. striatum. After excluding 1 patient with no follow-up, 15 patients were finally analyzed (9 hips/6 knees). Out of 15 patients, 9 underwent explantation with spacer insertion, 5 underwent irrigation and debridement with polyexchange (I&D), and 1 underwent Girdlestone. Out of 9 explanted patients, only 6 cleared infection and were reimplanted. The clinical staging system for PJI was determined using McPherson classification. The mean follow-ups for I&D and explantation were 35 and 23.5 months, respectively. Success of reimplantation was determined using Delphi criteria. RESULTS Out of 5 I&D patients, 40% had to be reoperated because of persistent infection. Out of 6 explanted patients who were reimplanted, 67% failed. According to McPherson, 40% of I&D and 22.2% of explanted patients were significantly compromised hosts. CONCLUSION C. striatum PJI has a high-treatment failure rate in patient undergoing I&D or 2-stage revision surgery. Surgeons should be aware of the difficulty controlling this PJI and advise patients accordingly.
Collapse
|