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Neufeld ME, Sheridan GA, MacDonell T, Howard LC, Masri BA, Keown P, Sherwood K, Donald SG. The John Charnley Award: The Impact of Human Leukocyte Antigen (HLA) Genotype on Bacterial Infection Rates and Successful Eradication in Total Hip Arthroplasty. J Arthroplasty 2024:S0883-5403(24)00548-5. [PMID: 38830432 DOI: 10.1016/j.arth.2024.05.076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Revised: 05/25/2024] [Accepted: 05/27/2024] [Indexed: 06/05/2024] Open
Abstract
BACKGROUND Genetics plays an important role in several medical domains, however, the influence of human leukocyte antigen (HLA) genotype on the development of periprosthetic joint infection (PJI) in total hip arthroplasty (THA) remains unknown. The primary aim of this study was to determine if HLA genotype is associated with the development of bacterial PJI in THA. Secondarily, we evaluated the association between HLA genotype and PJI treatment success. METHODS A retrospective, matched, case-control study was performed using prospectively collected data from a single institution. A total of 49 patients who underwent primary THA were included, with a mean follow-up of 8.5 years (range, 4.2 to 12.9). The 23 cases (PJI) and 26 controls (no PJI) were matched for age, sex, follow-up, body mass index (BMI), primary diagnosis, and comorbidities (P > 0.05). High-resolution genetic analysis targeting 11 separate HLA loci was performed in all patients using serum samples. The HLA gene frequencies and carriage rates were determined and compared between cohorts. A subgroup analysis of PJI treatment success (18) and failure (5) was performed. Statistical significance was set at P = 0.10 for genetic analysis and at 0.05 for all other analyses. RESULTS There were four HLA alleles that were significantly associated with the development of PJI. The 3 at-risk alleles included HLA-C*06:02 (OR [odds ratio] 5.25, 95% CI [confidence interval] 0.96 to 28.6, P = 0.064), HLA-DQA1*04:01 (P = 0.096), and HLA-DQB1*04:02 (P = 0.096). The single protective allele was HLA-C*03:04 (OR 0.12, 95% CI 0.01 to 1.10, P = 0.052). There were no specific HLA alleles that were associated with treatment success or failure. CONCLUSION This study suggests that there are at-risk and protective HLA alleles associated with the development of PJI in THA. To our knowledge, this is the first study to demonstrate an association between patient HLA genotype and the development of PJI. A larger study of the subject matter is necessary and warranted.
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Affiliation(s)
- Michael E Neufeld
- Department of Orthopaedics, University of British Columbia, Vancouver, British Columbia, Canada, V5Z 1M9.
| | - Gerard A Sheridan
- Department of Orthopaedics, University of British Columbia, Vancouver, British Columbia, Canada, V5Z 1M9
| | - Tanya MacDonell
- Department of Orthopaedics, University of British Columbia, Vancouver, British Columbia, Canada, V5Z 1M9
| | - Lisa C Howard
- Department of Orthopaedics, University of British Columbia, Vancouver, British Columbia, Canada, V5Z 1M9
| | - Bassam A Masri
- Department of Orthopaedics, University of British Columbia, Vancouver, British Columbia, Canada, V5Z 1M9
| | - Paul Keown
- Department of Pathology & Laboratory Medicine, University of British Columbia, Vancouver, British Columbia, Canada, V5Z 1M9
| | - Karen Sherwood
- Department of Pathology & Laboratory Medicine, University of British Columbia, Vancouver, British Columbia, Canada, V5Z 1M9
| | - S Garbuz Donald
- Department of Orthopaedics, University of British Columbia, Vancouver, British Columbia, Canada, V5Z 1M9
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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.
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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
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Straub J, Staats K, Vertesich K, Kowalscheck L, Windhager R, Böhler C. Two-stage revision for periprosthetic joint infection after hip and knee arthroplasty. Bone Joint J 2024; 106-B:372-379. [PMID: 38555938 DOI: 10.1302/0301-620x.1064.bjj-2023-0638.r2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/02/2024]
Abstract
Aims Histology is widely used for diagnosis of persistent infection during reimplantation in two-stage revision hip and knee arthroplasty, although data on its utility remain scarce. Therefore, this study aims to assess the predictive value of permanent sections at reimplantation in relation to reinfection risk, and to compare results of permanent and frozen sections. Methods We retrospectively collected data from 226 patients (90 hips, 136 knees) with periprosthetic joint infection who underwent two-stage revision between August 2011 and September 2021, with a minimum follow-up of one year. Histology was assessed via the SLIM classification. First, we analyzed whether patients with positive permanent sections at reimplantation had higher reinfection rates than patients with negative histology. Further, we compared permanent and frozen section results, and assessed the influence of anatomical regions (knee versus hip), low- versus high-grade infections, as well as first revision versus multiple prior revisions on the histological result at reimplantation. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), chi-squared tests, and Kaplan-Meier estimates were calculated. Results Overall, the reinfection rate was 18%. A total of 14 out of 82 patients (17%) with positive permanent sections at reimplantation experienced reinfection, compared to 26 of 144 patients (18%) with negative results (p = 0.996). Neither permanent sections nor fresh frozen sections were significantly associated with reinfection, with a sensitivity of 0.35, specificity of 0.63, PPV of 0.17, NPV of 0.81, and accuracy of 58%. Histology was not significantly associated with reinfection or survival time for any of the analyzed sub-groups. Permanent and frozen section results were in agreement for 91% of cases. Conclusion Permanent and fresh frozen sections at reimplantation in two-stage revision do not serve as a reliable predictor for reinfection.
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Affiliation(s)
- Jennifer Straub
- Department of Orthopaedics and Trauma Surgery, Medical University of Vienna, Vienna, Austria
| | - Kevin Staats
- Department of Orthopaedics and Trauma Surgery, Medical University of Vienna, Vienna, Austria
| | - Klemens Vertesich
- Department of Orthopaedics and Trauma Surgery, Medical University of Vienna, Vienna, Austria
| | - Lars Kowalscheck
- Department of Pathology, Medical University of Vienna, Vienna, Austria
| | - Reinhard Windhager
- Department of Orthopaedics and Trauma Surgery, Medical University of Vienna, Vienna, Austria
| | - Christoph Böhler
- Department of Orthopaedics and Trauma Surgery, Medical University of Vienna, Vienna, Austria
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McPherson EJ, Crawford BM, Kenny SG, Dipane MV, Salarkia S, Stavrakis AI, Chowdhry M. Point-of-Care Coating of Revision Femoral Stems With Antibiotic-Loaded Calcium Sulfate: Reduction in Infection After 2nd Stage Reimplantation but Not With Aseptic Revisions. Arthroplast Today 2024; 25:101302. [PMID: 38304243 PMCID: PMC10830497 DOI: 10.1016/j.artd.2023.101302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Revised: 08/24/2023] [Accepted: 11/04/2023] [Indexed: 02/03/2024] Open
Abstract
Background Infection rates in revision total hip arthroplasty are lower when antibiotic loaded cemented stems are utilized. Inspired by this technique, a point-of-care coating of antibiotic-loaded calcium sulfate (CaSO4) was applied to cementless revision stems in aseptic revision and 2nd stage reimplantation total hip arthroplasty. Methods One hundred eleven consecutive femoral stems were coated. Just prior to insertion, 10 cc of CaSO4 was mixed with 1 g vancomycin and 240 mg tobramycin with the paste applied to the stem. The results were compared to a matched cohort (N = 104) performed across the previous 5 years. The surgical methods were comparable, but for the stem coating. The study group was followed for a minimum of 3 years. Results In the study cohort of 111 patients, there were 69 aseptic revisions with one periprosthetic joint infection (PJI) (1.4%) and 42 second-stage reimplantations with 2 PJIs (4.8%). In the control cohort of 104 patients, there were 74 aseptic revisions with one PJI (1.4%) and 30 second-stage reimplantations with 7 PJIs (23.3%). There was no significant reduction in PJI rate in the aseptic revision subgroup (1.4% study vs 1.4% control group), P = 1.000. Antibiotic stem coating reduced PJI rate in the 2nd stage reimplantation subgroup (23.3% control vs 4.8% study group), P = .028. In both groups, there were no cases of aseptic stem loosening. Conclusions Point-of-care antibiotic coating of cementless revision femoral stems reduces PJI infection rate in 2nd stage reimplantations only. We theorize that microbes persist in the endosteal cortices after resection and may contribute to infection recurrence.
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Affiliation(s)
- Edward J. McPherson
- Department of Orthopedic Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Brooke M. Crawford
- Department of Orthopedic Surgery, The University of Miami Miller School of Medicine, Miami, FL, USA
| | - Steven G. Kenny
- Department of Orthopedic Surgery, The Permanente Medical Group, San Rafael, CA, USA
| | - Matthew V. Dipane
- Department of Orthopedic Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Shahrzad Salarkia
- Department of Orthopedic Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Alexandra I. Stavrakis
- Department of Orthopedic Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Madhav Chowdhry
- Department of Orthopedic Surgery, Jawaharlal Nehru Medical College, AMU, Aligarh, Uttar Pradesh, India
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Manzotti A, Colizzi M, Brioschi D, Cerveri P, Larghi MM, Grassi M. Preoperative infection risk assessment in hip arthroplasty a matched-pair study of the reliability of 3 validated risk scales. Acta Orthop Belg 2023; 89:613-618. [PMID: 38205750 DOI: 10.52628/89.4.10486] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2024]
Abstract
Peri-prosthetic infection (PJI) represents one of the most devastating complications of total hip arthroplasty (THA). The aim of this study is to assess the reliability of different PJI risk assessment scales between two matched pairs of THA groups. This study included 37 patients with PJI following THA performed between 2012 and 2020 (Group A). Each patient in this group was matched, based on sex, age, and follow-up duration, with a control patient who underwent the same surgical procedure without any septic complications (Group B) during the same period. Each patient's assessment included the American Society of Anesthesiologists (ASA) score and a retrospective evaluation using three different preoperative, specific PJI risk assessment scales: the International Consensus Meeting (ICM) Preoperative Risk Calculator for PJI, the Mayo PJI Risk Score, and the KLIC-score. The two groups were statistically compared using descriptive analyses, both for binomial data and numerical variables. Statistically significant higher values were observed in the preoperative ASA score and surgical time in Group A. Statistically different higher scores were determined only with the ICM risk calculator score in Group A. No significant differences were found using the KLIC score and Mayo score between the two groups. We emphasize the reliability of the ASA score as a nonspecific preoperative assessment scale for PJI. The ICM risk calculator was confirmed as a reliable, specific preoperative assessment scale for PJI, suggesting its routine adoption in THA clinical practice.
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Walker LC, Clement ND, Yapp LZ, Deehan DJ. Change in organism between first- and second-stage revision for periprosthetic joint infection of knee arthroplasty independently associated with increased risk of failure. Bone Jt Open 2023; 4:720-727. [PMID: 37730212 PMCID: PMC10511290 DOI: 10.1302/2633-1462.49.bjo-2023-0067.r1] [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: 09/22/2023] Open
Abstract
Aims Achievement of accurate microbiological diagnosis prior to revision is key to reducing the high rates of persistent infection after revision knee surgery. The effect of change in the microorganism between the first- and second-stage revision of total knee arthroplasty for periprosthetic joint infection (PJI) on the success of management is not clear. Methods A two-centre retrospective cohort study was conducted to review the outcome of patients who have undergone two-stage revision for treatment of knee arthroplasty PJI, focusing specifically on isolated micro-organisms at both the first- and second-stage procedure. Patient demographics, medical, and orthopaedic history data, including postoperative outcomes and subsequent treatment, were obtained from the electronic records and medical notes. Results The study cohort consisted of 84 patients, of whom 59.5% (n = 50) had successful eradication of their infection at a mean follow-up of 4.7 years. For the 34 patients who had recurrence of infection, 58.8% (n = 20) had a change in isolated organism, compared to 18% (n = 9) in the infection eradication group (p < 0.001). When adjusting for confound, there was no association when the growth on the second stage was the same as the first (odd ratio (OR) 2.50, 95% confidence interval (CI) 0.49 to 12.50; p = 0.269); however, when a different organism was identified at the second stage, this was independently associated with failure of treatment (OR 8.40, 95% CI 2.91 to 24.39; p < 0.001). There were no other significant differences between the two cohorts with regard to patient demographics or type of organisms isolated. Conclusion Change in the identified microorganism between first- and second-stage revision for PJI was associated with failure of management. Identification of this change in the microorganism prior to commencement of the second stage may help target antibiotic management and could improve the success of surgery in these patients.
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Affiliation(s)
- Lucy C. Walker
- Wessex Deanery, Health Education England, Winchester, UK
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Hipfl C, Leopold V, Becker L, Pumberger M, Perka C, Hardt S. Two-stage revision for periprosthetic joint infection in cemented total hip arthroplasty: an increased risk for failure? Arch Orthop Trauma Surg 2023; 143:4481-4490. [PMID: 36323976 PMCID: PMC10293416 DOI: 10.1007/s00402-022-04671-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2022] [Accepted: 10/22/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND The impact of the prior fixation mode on the treatment outcome of chronic periprosthetic joint infection (PJI) of the hip is unclear. Removal of cemented total hip arthroplasty (THA) is particularly challenging and residual cement might be associated with reinfection. This study seeks to compare the results of two-stage revision for PJI in cemented and cementless THA. METHODS We reviewed 143 consecutive patients undergoing two-stage revision THA for PJI between 2013 and 2018. Thirty-six patients with a fully cemented (n = 6), hybrid femur (n = 26) or hybrid acetabulum (n = 4) THA (cemented group) were matched 1:2 with a cohort of 72 patients who underwent removal of a cementless THA (cementless group). Groups were matched by sex, age, number of prior surgeries and history of infection treatment. Outcomes included microbiological results, interim re-debridement, reinfection, all-cause revision, and modified Harris hip scores (mHHS). Minimum follow-up was 2 years. RESULTS Compared with PJI in cementless THA, patients undergoing removal of cemented THA had increasingly severe femoral bone loss (p = 0.004). Patients in the cemented group had an increased risk for positive cultures during second-stage reimplantation (22% compared to 8%, p = 0.043), higher rates of reinfection (22% compared to 7%, p = 0.021) and all-cause revision (31% compared to 14%, p = 0.039) compared to patients undergoing two-stage revision of cementless THA. Periprosthetic femoral fractures were more frequent in the group of patients with prior cementation (p = .004). Mean mHHS had been 37.5 in the cemented group and 39.1 in the cementless group, and these scores improved significantly in both groups (p < 0.01). CONCLUSION This study shows that chronic infection in cemented THA might be associated with increased bone loss, higher rates of reinfection and all-cause revision following two-stage revision. This should be useful to clinicians counselling patients with hip PJI and can guide treatment and estimated outcomes.
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Affiliation(s)
- Christian Hipfl
- Centre for Musculoskeletal Surgery, Department of Orthopaedics, Charité Universitaetsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany.
| | - Vincent Leopold
- Centre for Musculoskeletal Surgery, Department of Orthopaedics, Charité Universitaetsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Luis Becker
- Centre for Musculoskeletal Surgery, Department of Orthopaedics, Charité Universitaetsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Matthias Pumberger
- Centre for Musculoskeletal Surgery, Department of Orthopaedics, Charité Universitaetsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Carsten Perka
- Centre for Musculoskeletal Surgery, Department of Orthopaedics, Charité Universitaetsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Sebastian Hardt
- Centre for Musculoskeletal Surgery, Department of Orthopaedics, Charité Universitaetsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany
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Steinicke AC, Schwarze J, Gosheger G, Moellenbeck B, Ackmann T, Theil C. Repeat two-stage exchange arthroplasty for recurrent periprosthetic hip or knee infection: what are the chances for success? Arch Orthop Trauma Surg 2023; 143:1731-1740. [PMID: 34982202 PMCID: PMC10030533 DOI: 10.1007/s00402-021-04330-z] [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: 06/18/2021] [Accepted: 12/18/2021] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Two-stage revision is a frequently chosen approach to treat chronic periprosthetic joint infection (PJI). However, management of recurrent infection after a two-stage exchange remains debated and the outcome of a repeat two-stage procedure is unclear. This study investigates the success rates of repeat two-stage exchange arthroplasty and analyzes possible risk factors for failure. MATERIALS AND METHODS We retrospectively identified 55 patients (23 hips, 32 knees) who were treated with repeat resection arthroplasty and planned delayed reimplantation for recurrent periprosthetic joint infection between 2010 and 2019 after a prior two-stage revision at the same institution. The minimum follow-up was 12 months with a median follow-up time of 34 months (IQR 22-51). The infection-free survival, associated revision surgeries, and potential risk factors for further revision were analyzed using Kaplan-Meier survival curves and comparative non-parametric testing. RESULTS 78% (43/55) underwent reimplantation after a repeat implant removal. Of those who completed the second-stage surgery, 37% (16/43) underwent additional revision for infection and 14% (6/55) underwent amputation. The reinfection-free implant survivorship amounted to 77% (95% CI 64-89%) after 1 year and 38% (95% CI 18-57%) after 5 years. Patients with a higher comorbidity score were less likely to undergo second-stage reimplantation (median 5 vs. 3, p = 0.034). Furthermore, obese patients (p = 0.026, Fisher's exact test) and diabetics (p < 0.001, log-rank test) had a higher risk for further infection. Most commonly cultures yielded polymicrobial growth at the repeat two-stage exchange (27%, 15/55) and at re-reinfection (32%, 9/28). Pathogen persistence was observed in 21% (6/28) of re-reinfected patients. CONCLUSION The success rates after repeat two-stage exchange arthroplasty are low. Patients must be counseled accordingly and different modes of treatment should be considered.
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Affiliation(s)
- A C Steinicke
- Department of Orthopedics and Tumor Orthopedics, Muenster University Hospital, Muenster, Albert-Schweitzer-Campus 1, 48149, Muenster, Germany
| | - J Schwarze
- Department of Orthopedics and Tumor Orthopedics, Muenster University Hospital, Muenster, Albert-Schweitzer-Campus 1, 48149, Muenster, Germany
| | - G Gosheger
- Department of Orthopedics and Tumor Orthopedics, Muenster University Hospital, Muenster, Albert-Schweitzer-Campus 1, 48149, Muenster, Germany
| | - B Moellenbeck
- Department of Orthopedics and Tumor Orthopedics, Muenster University Hospital, Muenster, Albert-Schweitzer-Campus 1, 48149, Muenster, Germany
| | - T Ackmann
- Department of Orthopedics and Tumor Orthopedics, Muenster University Hospital, Muenster, Albert-Schweitzer-Campus 1, 48149, Muenster, Germany
| | - C Theil
- Department of Orthopedics and Tumor Orthopedics, Muenster University Hospital, Muenster, Albert-Schweitzer-Campus 1, 48149, Muenster, Germany.
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Wignadasan W, Ibrahim M, Haddad FS. One- or two-stage reimplantation for infected total knee prosthesis? Orthop Traumatol Surg Res 2023; 109:103453. [PMID: 36302451 DOI: 10.1016/j.otsr.2022.103453] [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: 12/08/2021] [Revised: 02/08/2022] [Accepted: 03/02/2022] [Indexed: 11/07/2022]
Abstract
A prosthetic joint infection (PJI) is possibly the most significant potential complication of total knee arthroplasty (TKA) and is associated with substantial morbidity and socioeconomic burden. It is a devastating complication for both the patient and the surgeon alike. A two-stage revision approach for infected TKA has been the standard for surgical management; however, there is growing interest in single-stage revision surgery due to fewer procedures, reduced inpatient hospital stay and reduced costs to healthcare systems. A one-stage exchange is indicated when there is no sign of systemic sepsis and in cases where a microorganism has been isolated. It involves removal of the old prosthesis, debridement of all infected tissue, a copious washout and re-draping, and finally, re-implantation of a new prosthesis. The two-stage approach involves the use of an antibiotic spacer before the second stage is carried out. The length of time between the stages is discussed. Patients with a PJI should be managed by a multidisciplinary team. We recommend these patients are managed in specialist arthroplasty centres by high volume revision arthroplasty specialists.
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Affiliation(s)
- Warran Wignadasan
- University College London Hospitals, 250, Euston Road, London NW1 2 PG, United Kingdom.
| | - Mazin Ibrahim
- University College London Hospitals, 250, Euston Road, London NW1 2 PG, United Kingdom
| | - Fares S Haddad
- University College London Hospitals, 250, Euston Road, London NW1 2 PG, United Kingdom
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Debridement, antibiotics and implant retention for prosthetic joint infection: comparison of outcomes between total hip arthroplasty and hip resurfacing. INTERNATIONAL ORTHOPAEDICS 2022; 46:2799-2806. [PMID: 35960343 DOI: 10.1007/s00264-022-05522-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Accepted: 07/17/2022] [Indexed: 01/22/2023]
Abstract
INTRODUCTION The management of prosthetic joint infection (PJI) has been widely studied in the context of total hip arthroplasty (THA). However, the outcomes of debridement, antibiotics and implant retention (DAIR) for PJI have never been compared between hip resurfacing arthroplasty (HRA) and THA. This led us to carry out a retrospective case-control study comparing the surgical treatment of post-operative infections between HRA and THA to determine the infection remission rate and the medium-term functional outcomes. METHODS This single-centre case-control study analysed 3056 HRA cases of which 13 patients had a PJI treated by DAIR. These patients were age-matched with 15 infected THA hips treated by DAIR and modular component exchange (controls). Their survival (no recurrence of the infection) was compared and factors that could affect the success of the DAIR were explored: sex, body mass index, age at surgery, presence of haematoma, type of bacteria present and antibiotic therapy. RESULTS At a mean follow-up of five years (2-7), the infection control rate was significantly higher in the HRA group (100% [13/13]) than in the THA group (67% [10/15]) (p = 0.044). More patients in the THA group had undergone early DAIR (< 30 days) (73% [11/15]) than in the HRA group (54% [7/13]). There was no significant difference between the two groups in the ASA score, presence of comorbidities, body mass index and duration of the initial arthroplasty procedure. At the review, the Oxford-12 score of 17/60 (12-28) was better in the HRA group than the score of 25/60 (12-40) in the THA group (p = 0.004). CONCLUSION DAIR, no matter the time frame, is a viable therapeutic option for infection control after HRA.
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Wu Y, Zhou J, Liu R, Zeng Y, Sun K, Li M, Peng L, Xu J, Shen B. What Is the Normal Trajectory of C-Reactive Protein, Erythrocyte Sedimentation Rate, Plasma Fibrinogen and D-Dimer after Two-Stage Exchange for Periprosthetic Joint Infection? Orthop Surg 2022; 14:2987-2994. [PMID: 36193876 PMCID: PMC9627072 DOI: 10.1111/os.13533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Revised: 07/21/2022] [Accepted: 09/07/2022] [Indexed: 11/29/2022] Open
Abstract
Objective C‐reactive protein (CRP), erythrocyte sedimentation rate (ESR), plasma fibrinogen and D‐Dimer are used as diagnostic biomarkers of prosthetic joint infection (PJI) after total joint arthroplasty (TJA). The purpose of the study was to investigate the normal trajectory of CRP, ESR, plasma fibrinogen and D‐Dimer at different time points after two‐stage exchange arthroplasty for PJI. Methods We studied 53 patients undergoing two‐stage exchange for PJI at five time points: preoperatively (T0), duration of hospital stays (T1), 30 days (T2), 30–90 days (T3), and 90–180 days (T4) after surgery. The medical records of all patients were well documented and carefully reviewed. The Shapiro–Wilk test was utilized to compare the normal distribution for continuous variables, and the nonnormally distributed data were used for Friedmann's one‐way repeat measures analysis of variances. Post hoc Dunnett's test was used to compare each pair of data to find differences from baseline. Results Compare with T0 point, the levels of CRP and ESR increased significantly and reached peak values at T1 point (all P < 0.001), with median values of 56.40 mg/L (range, 5.54–161.0 mg/L) and 49.00 mm/h (range, 13.00–113.0 mm/h), respectively. In addition, the levels of plasma fibrinogen and D‐Dimer increased significantly and reached peak values at T1 point (all P < 0.001), with median values of 4.13g/L (range, 2.27–6.80 mg/L) and 4.00 mg/L (range, 0.19–14.01 mg/L), respectively. CRP and ESR rapidly declined at the T2 point with significantly compared with T0 point (P = 0.001 and P < 0.001). The levels of CRP, ESR, plasma fibrinogen and D‐Dimer returned to preoperative levels of 5.23 mg/L (range, 1.01–21.70 mg/L), 19.00 mm/h (range, 6.00–60.00 mm/h), 3.38g/L (range, 1.71–5.10 g/L) and 2.33 mm/h (range, 0.19–6.87 mg/L) at T4 point, and there was no significant difference compared with T0 point (all P > 0.05). Conclusions The study demonstrated the normal trajectory of CRP, ESR, plasma fibrinogen and D‐Dimer at five time points in patients who underwent two‐stage exchange for PJI. Thus, the results have the possibility of providing signs of infection after the patient receives two‐stage exchange arthroplasty for PJI, which can benefit from early treatment.
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Affiliation(s)
- Yuangang Wu
- Department of Orthopaedics Surgery, Orthopaedic Research Institute, West China Hospital, West China Medical School, Sichuan University, Chengdu, China
| | - Jinhan Zhou
- Core Facilities of West China Hospital, Sichuan University, Chengdu, China
| | - Ran Liu
- Engineering Research Center of Medical Information Technology, Ministry of Education, West China Hospital, Sichuan University, Chengdu, China
| | - Yi Zeng
- Department of Orthopaedics Surgery, Orthopaedic Research Institute, West China Hospital, West China Medical School, Sichuan University, Chengdu, China
| | - Kaibo Sun
- Department of Orthopaedics Surgery, Orthopaedic Research Institute, West China Hospital, West China Medical School, Sichuan University, Chengdu, China
| | - Mingyang Li
- Department of Orthopaedics Surgery, Orthopaedic Research Institute, West China Hospital, West China Medical School, Sichuan University, Chengdu, China
| | - Linbo Peng
- Department of Orthopaedics Surgery, Orthopaedic Research Institute, West China Hospital, West China Medical School, Sichuan University, Chengdu, China
| | - Jiawen Xu
- Department of Orthopaedics Surgery, Orthopaedic Research Institute, West China Hospital, West China Medical School, Sichuan University, Chengdu, China
| | - Bin Shen
- Department of Orthopaedics Surgery, Orthopaedic Research Institute, West China Hospital, West China Medical School, Sichuan University, Chengdu, China
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12
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Saade A, Urvoy JM, Luque Paz D, Baldeyrou M, Common H, Ropars M, Tattevin P, Jolivet-Gougeon A, Arvieux C. Microbiology and antibiotics after second-stage revision of periprosthetic joint infections: A two-year follow-up cohort. Infect Dis Now 2022; 52:358-364. [DOI: 10.1016/j.idnow.2022.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Revised: 06/16/2022] [Accepted: 06/20/2022] [Indexed: 11/29/2022]
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13
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Asokan A, Ibrahim MS, Thompson JW, Haddad FS. Debridement, antibiotics, and implant retention in non-oncological femoral megaprosthesis infections: minimum 5 year follow-up. J Exp Orthop 2022; 9:32. [PMID: 35403987 PMCID: PMC9001793 DOI: 10.1186/s40634-022-00469-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Accepted: 03/17/2022] [Indexed: 05/31/2023] Open
Abstract
Purpose Megaprostheses are increasingly utilised outside of the oncological setting, and remain at significant risk of periprosthetic joint infection (PJI). Debridement, antibiotic, and implant retention (DAIR) is an established treatment for PJI, however its use in non-oncological patients with femoral megaprostheses has not been widely reported. There are significant differences in patient physiology, treatment goals, and associated risks between these patient cohorts. Methods We identified 14 patients who underwent DAIR for a PJI of their femoral megaprostheses, between 2000 and 2014, whom had their index procedure secondary to non-oncological indications. Patients were managed as part of a multidisciplinary team, with our standardised surgical technique including exchange of all mobile parts, and subsequent antibiotic therapy for a minimum of 3 months. Patients were followed up for a minimum of 5 years. Results Patients included six proximal femoral replacements, five distal femoral replacements, and three total femoral replacements. No patients were lost to follow-up. There were six males and eight females, with a mean age of 67.2 years, and mean ASA of 2.3. Nine patients (64.3%) successfully cleared their infection following DAIR at a minimum of 5 year follow-up. Five patients (35.7%) required further revision surgery, with four patients cleared of infection. No patients who underwent DAIR alone suffered complications as a result of the procedure. Conclusions The use of DAIR in these complex patients can lead to successful outcomes, but the risk of further revision remains high. The success rate (64.3%) remains on par with other studies evaluating DAIR in megaprostheses and in primary arthroplasty. This study indicates judicious use of DAIR can be an appropriate part of the treatment algorithm. Level of evidence II
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Affiliation(s)
- A Asokan
- Department of Trauma and Orthopaedic Surgery, University College Hospital, 235 Euston Road, Fitzrovia, London, NW1 2BU, UK.
| | - M S Ibrahim
- Department of Trauma and Orthopaedic Surgery, University College Hospital, 235 Euston Road, Fitzrovia, London, NW1 2BU, UK
| | - J W Thompson
- Department of Trauma and Orthopaedic Surgery, University College Hospital, 235 Euston Road, Fitzrovia, London, NW1 2BU, UK
| | - F S Haddad
- Department of Trauma and Orthopaedic Surgery, University College Hospital, 235 Euston Road, Fitzrovia, London, NW1 2BU, UK
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14
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Li Y, Zhang X, Guo X, Wulamu W, Yushan N, Ji B, Cao L. Effective Treatment of Single-Stage Revision Using Intra-Articular Antibiotic Infusion for Polymicrobial Periprosthetic Joint Infection. J Arthroplasty 2022; 37:156-161. [PMID: 34619309 DOI: 10.1016/j.arth.2021.09.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Revised: 09/21/2021] [Accepted: 09/28/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND The treatment of polymicrobial periprosthetic joint infection (PJI) confronted distinct challenges. No reports have assessed the efficacy of local antibiotic delivery combined with 1-stage exchange in polymicrobial PJI. METHODS Between January 2013 and December 2018, we retrospectively analyzed the data of 126 patients, including 19 polymicrobial PJIs and 107 monomicrobial PJIs, who underwent single-stage revision using intra-articular antibiotic infusion. The risk factors, microbiology, infection control rate, and clinical outcomes were compared between the 2 groups. RESULTS Higher body mass index, presence of a sinus tract, and prior revisions were the risk factors for polymicrobial PJI. Isolation of Staphylococcus epidermidis, Streptococcus, Enterococcus, and Gram-negative pathogens was highly associated with polymicrobial PJI. Of the 19 polymicrobial PJIs, only 2 patients occurred infection recurrence, which is similar with the result of 6 of 107 patients in the monomicrobial PJI (P = .225). The Harris Hip Score of the polymicrobial group showed no difference from that of the monomicrobial group (78 vs 80; P = .181). Nevertheless, the polymicrobial group exhibited inferior Hospital for Special Surgery knee score relative to the monomicrobial group (77 vs 79; P = .017). CONCLUSION With rational and targeted use of antibiotics, single-stage revision can effectively control polymicrobial infections, and achieve favorable outcomes similar to that in monomicrobial patients. However, this regimen is still needed to be further confirmed, especially in the infections with different microbial species simultaneously. Additionally, obese patients with a sinus tract and those who had prior revisions had a greater risk of polymicrobial PJI.
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Affiliation(s)
- Yicheng Li
- Department of Orthopaedics, First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang, China
| | - Xiaogang Zhang
- Department of Orthopaedics, First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang, China
| | - Xiaobin Guo
- Department of Orthopaedics, First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang, China
| | - Wuhuzi Wulamu
- Department of Orthopaedics, First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang, China
| | - Nuerailijiang Yushan
- Department of Orthopaedics, First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang, China
| | - Baochao Ji
- Department of Orthopaedics, First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang, China
| | - Li Cao
- Department of Orthopaedics, First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang, China
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15
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Liechti EF, Neufeld ME, Soto F, Linke P, Busch SM, Gehrke T, Citak M. Favourable outcomes of repeat one-stage exchange for periprosthetic joint infection of the hip. Bone Joint J 2022; 104-B:27-33. [PMID: 34969284 DOI: 10.1302/0301-620x.104b1.bjj-2021-0970.r1] [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: 11/05/2022]
Abstract
AIMS One-stage exchange for periprosthetic joint infection (PJI) in total hip arthroplasty (THA) is gaining popularity. The outcome for a repeat one-stage revision THA after a failed one-stage exchange for infection remains unknown. The aim of this study was to report the infection-free and all-cause revision-free survival of repeat one-stage exchange, and to investigate the association between the Musculoskeletal Infection Society (MSIS) staging system and further infection-related failure. METHODS We retrospectively reviewed all repeat one-stage revision THAs performed after failed one-stage exchange THA for infection between January 2008 and December 2016. The final cohort included 32 patients. The mean follow-up after repeat one-stage exchange was 5.3 years (1.2 to 13.0). The patients with a further infection-related failure and/or all-cause revision were reported, and Kaplan-Meier survival for these endpoints determined. Patients were categorized according to the MSIS system, and its association with further infection was analyzed. RESULTS A total of eight repeat septic revisions (25%) developed a further infection-related failure, and the five-year infection-free survival was 81% (95% confidence interval (CI) 57 to 92). Nine (28%) underwent a further all-cause revision and the five-year all-cause revision-free survival was 74% (95% CI 52 to 88). Neither the MSIS classification of the host status (p = 0.423) nor the limb status (p = 0.366) was significantly associated with further infection-related failure. CONCLUSION Repeat one-stage exchange for PJI in THA is associated with a favourable five-year infection-free and all-cause revision-free survival. Notably, the rate of infection control is encouraging when compared with the reported rates after repeat two-stage exchange. The results can be used to counsel patients and help clinicians make informed decisions about treatment. With the available number of patients, further infection-related failure was not associated with the MSIS host or limb status. Cite this article: Bone Joint J 2022;104-B(1):27-33.
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Affiliation(s)
- Emanuel F Liechti
- Department of Orthopaedic Surgery, HELIOS ENDO-Klinik Hamburg, Hamburg, Hamburg, Germany.,Department of Orthopaedic Surgery and Traumatology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Michael E Neufeld
- Department of Orthopaedic Surgery, HELIOS ENDO-Klinik Hamburg, Hamburg, Hamburg, Germany.,Department of Orthopaedic Surgery, Lower Limb (Adult Hip & Knee) Reconstruction, The University of British Columbia, Vancouver, Canada
| | - Fernando Soto
- Department of Orthopaedic Surgery, HELIOS ENDO-Klinik Hamburg, Hamburg, Hamburg, Germany.,Department of Orthopaedic Surgery, Hospital Naval de Viña del Mar Almirante Nef, Vina del Mar, Chile
| | - Philip Linke
- Department of Orthopaedic Surgery, HELIOS ENDO-Klinik Hamburg, Hamburg, Hamburg, Germany
| | - Sophia-Marlene Busch
- Department of Orthopaedic Surgery, HELIOS ENDO-Klinik Hamburg, Hamburg, Hamburg, Germany
| | - Thorsten Gehrke
- Department of Orthopaedic Surgery, HELIOS ENDO-Klinik Hamburg, Hamburg, Hamburg, Germany
| | - Mustafa Citak
- Department of Orthopaedic Surgery, HELIOS ENDO-Klinik Hamburg, Hamburg, Hamburg, Germany
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16
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Fang X, Wang Q, Yang X, Zhang F, Huang C, Huang Z, Shen H, Zhang W. What is the appropriate extended duration of antibiotic prophylaxis after two-stage revision for chronic PJI? Bone Joint Res 2021; 10:790-796. [PMID: 34894718 PMCID: PMC8696522 DOI: 10.1302/2046-3758.1012.bjr-2021-0225.r1] [Citation(s) in RCA: 5] [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] [Indexed: 11/06/2022] Open
Abstract
Aims To explore the effect of different durations of antibiotics after stage II reimplantation on the prognosis of two-stage revision for chronic periprosthetic joint infection (PJI). Methods This study involved a retrospective collection of patients who underwent two-stage revision for chronic PJI and continued to use extended antibiotic prophylaxis in two regional medical centres from January 2010 to June 2018. The patients were divided into a short (≤ one month) or a long (> one month) course of treatment based on the duration of antibiotics following stage II reimplantation. The difference in the infection control rate between the two groups was compared, and prognostic factors for recurrence were analyzed. Results A total of 105 patients with chronic PJI were enrolled: 64 patients in the short course group and 41 patients in the long course group. For 99 of the patients, the infection was under control during a follow-up period of at least 24 months after two-stage revision. For the short course group, the mean duration of antibiotic prophylaxis after stage II reimplantation was 20.17 days (SD 5.30) and the infection control rate was 95.3%; for the long course group these were 45.02 days (SD 15.03) and 92.7%, respectively. There was no significant difference in infection control rates between the two groups (p = 0.676). Cox regression analysis found that methicillin-resistant staphylococcus infection (p = 0.015) was an independent prognostic factor for recurrence. Conclusion After stage II reimplantation surgery of two-stage revision for chronic PJI, extended antibiotic prophylaxis for less than one month can achieve good infection control rate. Cite this article: Bone Joint Res 2021;10(12):790–796.
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Affiliation(s)
- Xinyu Fang
- Department of Orthopaedic Surgery, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Qiaojie Wang
- Department of Orthopaedic Surgery, Shanghai Sixth People's Hospital, Shanghai, China
| | - Xurong Yang
- Department of Orthopaedic Surgery, Jiangle County General Hospital, Sanming, China
| | - Feiyang Zhang
- Department of Orthopaedic Surgery, Shanghai Sixth People's Hospital, Shanghai, China
| | - Changyu Huang
- Department of Orthopaedic Surgery, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Zida Huang
- Department of Orthopaedic Surgery, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Hao Shen
- Department of Orthopaedic Surgery, Shanghai Sixth People's Hospital, Shanghai, China
| | - Wenming Zhang
- Department of Orthopaedic Surgery, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
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17
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Li K, Cuadra M, Scarola G, Odum S, Otero J, Griffin W, Springer BD. Complications in the treatment of periprosthetic joint infection of the hip: when do they occur? J Bone Jt Infect 2021; 6:295-303. [PMID: 34377629 PMCID: PMC8339596 DOI: 10.5194/jbji-6-295-2021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Accepted: 05/23/2021] [Indexed: 11/29/2022] Open
Abstract
Prosthetic joint infection (PJI) is a devastating complication after total
hip arthroplasty (THA). The common treatment in the USA is a two-stage
exchange which can be associated with significant morbidity and mortality.
The purpose of this study was to analyze complications in the treatment
course of patients undergoing two-stage exchange for PJI THA and determine
when they occur.
Methods:
We analyzed all patients that underwent two-stage exchange arthroplasty for
treatment of PJI after THA from January 2005 to January 2018 at a single
institution. Complications were categorized as medical or surgical and divided
into interstage and post-reimplantation. Minimum follow-up was 1 year.
Success was based on the MusculoSkeletal Infection Society (MSIS)
definition.
Results:
205 hips (203 patients) underwent first stage of planned two-stage exchange.
The median age was 68 (interquartile range (IQR) 18). There were 97 males and 106 females.
Overall, 73/205 (38 %) patients had at least one complication during
treatment: 13.5 % (25/185) of patients experienced a medical complication
and 28.1 % (52/185) a surgical complication; 2.4 % died within 1 year
of surgery, and 4.9 % (15/203) had mortality at a median of 2.5 years (IQR 4.9); 27 % of patients had complications during the interstage period, most commonly being recurrence of infection requiring additional surgery
(63 %); and 14 % of patients experienced a complication following
reimplantation, most commonly persistence or recurrence of infection
(59 %). While 92 % of patients that initiated treatment were ultimately
reimplanted, only 69 % were infection free at 1 year and required no
additional treatment.
Conclusions:
While two-stage exchanges for PJI in THA have been reported as successful,
there are few reports of the complications during the process. In our
series, significant numbers of patients experienced complications, often
during the interstage period, highlighting the morbidity of this method of
treatment.
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Affiliation(s)
- Katherine Li
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, 1025 Morehead Medical Dr., Suite 300, Charlotte, NC 28203, USA
| | - Mario Cuadra
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, 1320 Scott Ave., Charlotte, NC 28204, USA
| | - Gregory Scarola
- OrthoCarolina Research Institute, Inc., 2001 Vail Ave., Suite 300, Charlotte, NC 28207, USA
| | - Susan Odum
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, 1025 Morehead Medical Dr., Suite 300, Charlotte, NC 28203, USA.,OrthoCarolina Research Institute, Inc., 2001 Vail Ave., Suite 300, Charlotte, NC 28207, USA
| | - Jesse Otero
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, 1025 Morehead Medical Dr., Suite 300, Charlotte, NC 28203, USA.,OrthoCarolina Hip and Knee Center, 2001 Vail Ave. Suite 200A, Charlotte, NC 28207, USA
| | - William Griffin
- OrthoCarolina Hip and Knee Center, 2001 Vail Ave. Suite 200A, Charlotte, NC 28207, USA
| | - Bryan D Springer
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, 1025 Morehead Medical Dr., Suite 300, Charlotte, NC 28203, USA.,OrthoCarolina Hip and Knee Center, 2001 Vail Ave. Suite 200A, Charlotte, NC 28207, USA
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18
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Hipfl C, Carganico T, Leopold V, Perka C, Müller M, Hardt S. Two-Stage Revision Total Hip Arthroplasty Without Spacer Placement: A Viable Option to Manage Infection in Patients With Severe Bone Loss or Abductor Deficiency. J Arthroplasty 2021; 36:2575-2585. [PMID: 33750632 DOI: 10.1016/j.arth.2021.02.040] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Revised: 02/06/2021] [Accepted: 02/15/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND High rates of spacer-related complications in two-stage exchange total hip arthroplasty (THA) have been reported. Patients with advanced bone defects and abductor deficiency may benefit from a nonspacer two-stage revision. This study reports on the clinical course of a contemporary two-stage exchange for periprosthetic hip infection without spacer insertion. METHODS We reviewed 141 infected THAs with extensive bone loss or abductor damage who underwent two-stage exchange without spacer placement. The mean duration from resection arthroplasty to reimplantation was 9 weeks (2-29). Clinical outcomes included interim revision, reinfection, and aseptic revision rates. Restoration of leg-length and offset was assessed radiographically. Modified Harris hip scores were calculated. Mean follow-up was 5 years (3-7). Treatment success was defined using the modified Delphi consensus criteria. RESULTS Thirty-four patients (24%) had treatment failure, including 13 reinfections, 16 interim redebridements for persistent infection, 2 antibiotic suppressive therapies, and 3 prosthetic joint infection-related deaths. Aseptic rerevision after reimplantation was necessary in 14 patients (10%). Dislocation accounted for most aseptic complications, with 20 dislocations occurring in 15 patients (11%). Leg-length and offset were restored to preoperative measures. Mean modified Harris hip scores significantly improved from 35 points to 67 points. CONCLUSION A nonspacer two-stage exchange is a viable option for managing chronically infected THA with severe bone loss or abductor deficiency, showing comparable rates of interim revision and recurrence of infection. Cementless reimplantation demonstrates good midterm survivorship with comparable functional outcomes and leg-length restoration. However, dislocation continues to be a major concern.
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Affiliation(s)
- Christian Hipfl
- Department of Orthopaedics, Charité Universitaetsmedizin Berlin, Centre for Musculoskeletal Surgery, Berlin, Germany
| | - Teresa Carganico
- Department of Orthopaedics, Charité Universitaetsmedizin Berlin, Centre for Musculoskeletal Surgery, Berlin, Germany
| | - Vincent Leopold
- Department of Orthopaedics, Charité Universitaetsmedizin Berlin, Centre for Musculoskeletal Surgery, Berlin, Germany
| | - Carsten Perka
- Department of Orthopaedics, Charité Universitaetsmedizin Berlin, Centre for Musculoskeletal Surgery, Berlin, Germany
| | - Michael Müller
- Department of Orthopaedics, Charité Universitaetsmedizin Berlin, Centre for Musculoskeletal Surgery, Berlin, Germany
| | - Sebastian Hardt
- Department of Orthopaedics, Charité Universitaetsmedizin Berlin, Centre for Musculoskeletal Surgery, Berlin, Germany
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19
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Haddad FS. Celebrating three years of Hip Society and Knee Society supplements. Bone Joint J 2021; 103-B:1174-1175. [PMID: 34192929 DOI: 10.1302/0301-620x.103b7.bjj-2021-0765] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Fares S Haddad
- University College London Hospitals, The Princess Grace Hospital, and The NIHR Biomedical Research Centre at UCLH, London, UK.,The Bone & Joint Journal, London, UK
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20
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Haddad FS. High-quality research and technology to the forefront. Bone Joint J 2021; 103-B:1005-1006. [PMID: 34058881 DOI: 10.1302/0301-620x.103b6.bjj-2021-0647] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Fares S Haddad
- University College London Hospitals NHS Foundation Trust, London, UK.,The Bone & Joint Journal, London, UK
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21
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A retrospective comparison of thromboelastography and conventional coagulation parameters for periprosthetic joint infection diagnosis and reimplantation timing. Clin Chim Acta 2021; 519:118-125. [PMID: 33895127 DOI: 10.1016/j.cca.2021.04.014] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Revised: 03/24/2021] [Accepted: 04/16/2021] [Indexed: 01/25/2023]
Abstract
PURPOSE The diagnostic significance of coagulation parameters in periprosthetic joint infection (PJI) is currently attracting increasing attention. We assessed the diagnostic accuracy of thromboelastography (TEG) for PJI and compared the values of various coagulation indicators for PJI diagnosis and reimplantation timing. METHODS We enrolled 250 patients undergoing revision for aseptic failure (Group A), revision for PJI (Group B), or reimplantation (Group C) during 2013-2020. C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), representative coagulation-related indicators (reaction time [R], clotting time [K], angle and maximum amplitude [MA]) of TEG and routine coagulation indicators, including fibrinogen, D-dimer, fibrin degradation product (FDP), platelets count (PC), mean platelet volume (MPV), distribution width (PDW) and plateletcrit (PCT) as well as PC/MPV ratio(PVR)were measured preoperatively. Receiver operating characteristic (ROC) curves were used to evaluate the utility of all tested indicators for assessing infection. RESULTS All the indicators showed significant differences between groups A and B (P < 0.05) and, except for D-dimer, FDP, MPV and R, between groups B and C (P < 0.05). Similar differences were also observed in biomarkers before first-stage revision and second-stage reimplantation. ROC curves showed that fibrinogen, K, angle and MA outperformed the other coagulation indicators, with areas under the curve of 0.864 to 0.893 and threshold values of 3.55 g/L, 1.2 min, 72.4 deg and 69.1 mm, respectively. The multiple tests of TEG indices (K, angle and MA) and traditional inflammatory markers (CRP and ESR) or conventional coagulation indicators (fibrinogen, PC and PVR) had good sensitivity and specificity for PJI diagnosis, and the diagnostic values of TEG and platelet-associated indicators (PC and PVR) varied in the different subgroups. CONCLUSION TEG was closely related to PJI and could serve as a valuable technique for identifying residual infection before reimplantation. Fibrinogen showed high diagnostic accuracy for PJI and effectively guided the timing of reimplantation.
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22
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Perry DC, Porter DW, Haddad FS. Kingella kingae: rewriting the textbooks. Bone Joint J 2021; 103-B:421-422. [PMID: 33641412 DOI: 10.1302/0301-620x.103b3.bjj-2021-0076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Daniel C Perry
- University of Oxford, Oxford, UK.,Alder Hey Children's Hospital, Liverpool, UK
| | | | - Fares S Haddad
- University College London Hospitals, The Princess Grace Hospital, and The NIHR Biomedical Research Centre at UCLH, London, UK
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23
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Nurmohamed FRHA, van Dijk B, Veltman ES, Hoekstra M, Rentenaar RJ, Weinans HH, Vogely HC, van der Wal BCH. One-year infection control rates of a DAIR (debridement, antibiotics and implant retention) procedure after primary and prosthetic-joint-infection-related revision arthroplasty - a retrospective cohort study. J Bone Jt Infect 2021; 6:91-97. [PMID: 34084696 PMCID: PMC8129908 DOI: 10.5194/jbji-6-91-2021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Accepted: 01/10/2021] [Indexed: 12/28/2022] Open
Abstract
Introduction: Debridement, antibiotics and implant retention (DAIR) procedures are effective treatments for acute postoperative or acute hematogenous periprosthetic joint infections. However, literature reporting on the effectiveness of DAIR procedures performed after a one- or two-stage revision because of a prosthetic joint infection (PJI) (PJI-related revision arthroplasty) is scarce. The aim of this study is to retrospectively evaluate the infection control after 1 year of a DAIR procedure in the case of an early postoperative infection either after primary arthroplasty or after PJI-related revision arthroplasty. Materials and methods: All patients treated with a DAIR procedure within 3 months after onset of PJI between 2009 and 2017 were retrospectively included. Data were collected on patient and infection characteristics. All infections were confirmed by applying the Musculoskeletal Infection Society (MSIS) 2014 criteria. The primary outcome was successful control of infection at 1 year after a DAIR procedure, which was defined as the absence of clinical signs, such as pain, swelling, and erythema; radiological signs, such as protheses loosening; or laboratory signs, such as C-reactive protein (CRP) ( < 10 ) with no use of antibiotic therapy. Results: Sixty-seven patients were treated with a DAIR procedure (41 hips and 26 knees). Successful infection control rates of a DAIR procedure after primary arthroplasty ( n = 51 ) and after prior PJI-related revision arthroplasty ( n = 16 ) were 69 % and 56 %, respectively ( p = 0.38 ). The successful infection control rates of a DAIR procedure after an early acute infection ( n = 35 ) and after a hematogenous infection ( n = 16 ) following primary arthroplasty were both 69 % ( p = 1.00 ). Conclusion: In this limited study population, no statistically significant difference is found in infection control after 1 year between DAIR procedures after primary arthroplasty and PJI-related revision arthroplasty.
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Affiliation(s)
| | - Bruce van Dijk
- Department of Orthopedics, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Ewout S Veltman
- Department of Orthopedics, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Marrit Hoekstra
- Department of Orthopedics, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Rob J Rentenaar
- Department of Microbiology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Harrie H Weinans
- Department of Orthopedics, University Medical Center Utrecht, Utrecht, the Netherlands.,Department of BioMechanical Engineering, Delft University of Technology, Delft, the Netherlands
| | - H Charles Vogely
- Department of Orthopedics, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Bart C H van der Wal
- Department of Orthopedics, University Medical Center Utrecht, Utrecht, the Netherlands
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Slullitel PA, Oñativia JI, Cima I, Zanotti G, Comba F, Piccaluga F, Buttaro MA. Patients with no recurrence of infection five years after two-stage revision hip arthroplasty may be classified as periprosthetic infection 'in remission'. Bone Joint J 2021; 103-B:79-86. [PMID: 33380194 DOI: 10.1302/0301-620x.103b1.bjj-2020-0955.r1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
AIMS We aimed to report the mid- to long-term rates of septic and aseptic failure after two-stage revision surgery for periprosthetic joint infection (PJI) following total hip arthroplasty (THA). METHODS We retrospectively reviewed 96 cases which met the Musculoskeletal Infection Society criteria for PJI. The mean follow-up was 90 months (SD 32). Septic failure was assessed using a Delphi-based consensus definition. Any further surgery undertaken for aseptic mechanical causes was considered as aseptic failure. The cumulative incidence with competing risk analysis was used to predict the risk of septic failure. A regression model was used to evaluate factors associated with septic failure. The cumulative incidence of aseptic failure was also analyzed. RESULTS There were 23 septic failures at final follow-up, with a cumulative incidence of 14% (95% confidence interval (CI) 8% to 22%) at one year, 18% (95% CI 11% to 27%) at two years, 22% (95% CI 14% to 31%) at five years, and 23% (95% CI 15% to 33%) at ten years. Having at least one positive culture (hazard ratio (HR) 2.38 (interquartile range (IQR) 1.19 to 4.74); p = 0.013), or a positive intraoperative frozen section (HR 2.55 (IQR 1.06 to 6.15); p = 0.037) was significantly associated with septic failure after reimplantation. With dislocation being the most common cause of aseptic revision (5.2%), the cumulative incidence of aseptic failure was 1% (95% CI 0% to 5%) at one year, 6% (95% CI 1% to 8%) at five years, and 8% (95%CI 3% to 17%) at ten years. CONCLUSION If there is no recurrent infection in the five years following reimplantation, the chances of further infection thereafter are remote. While the results of a frozen section may be a reliable guide to the timing of reimplantation, intraoperative culture has, currently, only prognostic value. Surgeons should be aware that instability remains a potential indication for further revision surgery. Cite this article: Bone Joint J 2021;103-B(1):79-86.
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Affiliation(s)
- Pablo A Slullitel
- 'Sir John Charnley' Hip Surgery Unit, Institute of Orthopaedics 'Carlos E. Ottolenghi', Italian Hospital of Buenos Aires, Buenos Aires, Argentina
| | - José I Oñativia
- 'Sir John Charnley' Hip Surgery Unit, Institute of Orthopaedics 'Carlos E. Ottolenghi', Italian Hospital of Buenos Aires, Buenos Aires, Argentina
| | - Ignacio Cima
- 'Sir John Charnley' Hip Surgery Unit, Institute of Orthopaedics 'Carlos E. Ottolenghi', Italian Hospital of Buenos Aires, Buenos Aires, Argentina
| | - Gerardo Zanotti
- 'Sir John Charnley' Hip Surgery Unit, Institute of Orthopaedics 'Carlos E. Ottolenghi', Italian Hospital of Buenos Aires, Buenos Aires, Argentina
| | - Fernando Comba
- 'Sir John Charnley' Hip Surgery Unit, Institute of Orthopaedics 'Carlos E. Ottolenghi', Italian Hospital of Buenos Aires, Buenos Aires, Argentina
| | - Francisco Piccaluga
- 'Sir John Charnley' Hip Surgery Unit, Institute of Orthopaedics 'Carlos E. Ottolenghi', Italian Hospital of Buenos Aires, Buenos Aires, Argentina
| | - Martin A Buttaro
- 'Sir John Charnley' Hip Surgery Unit, Institute of Orthopaedics 'Carlos E. Ottolenghi', Italian Hospital of Buenos Aires, Buenos Aires, Argentina
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Theil C, Schmidt-Braekling T, Gosheger G, Schwarze J, Dieckmann R, Schneider KN, Möllenbeck B. Clinical use of linezolid in periprosthetic joint infections - a systematic review. J Bone Jt Infect 2020; 6:7-16. [PMID: 32983842 PMCID: PMC7517662 DOI: 10.5194/jbji-6-7-2020] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Accepted: 06/20/2020] [Indexed: 01/09/2023] Open
Abstract
Introduction: The most common causative organism in periprosthetic joint
infections (PJIs) is Gram-positive bacteria that are increasingly drug
resistant. In these cases the use of linezolid may be warranted. However,
there are conflicting reports regarding its role in antibiotic treatment of
PJIs. The aim of this review is to gather and analyze clinical results and
treatment details on linezolid in patients with PJIs.
Methods: In August 2019, a comprehensive literature search using MEDLINE
(Pubmed and Ovid) and Cochrane Library was performed. A total of 504 records
were screened, and a total of 16 studies including 372 patients treated with
linezolid for a PJI were included in this review based on the PRISMA
criteria and after quality analysis using the MINOR score and Newcastle–Ottawa
scale, as well as assessing level of evidence. Pooling analysis as well as
descriptive analysis was performed.
Results: Based on the results from the studies included, infection control
was achieved in 80 % (range 30 %–100 %) of patients after a mean follow-up
period of 25 (range 2–66) months. The mean duration of treatment was 58 d
intravenous and orally at a median dose of 600 mg bis in die (b.i.d.)
(range 400–900 b.i.d.). A combination therapy with rifampicin was used in
53 % of patients. MRSA (methicillin-resistant Staphylococcus aureus) infections were present in
29 % and resistant CoNS (coagulase-negative Staphylococcus) in 46 %. Adverse effects
occurred in 33 % of cases, mostly anemia, thrombocytopenia and
gastrointestinal complaints leading to treatment discontinuation in 9 %.
However, great heterogeneity was found with respect to surgical treatment,
diagnosis of infection and indication for linezolid.
Discussion: Linezolid is an appropriate option for treatment of resistant
Gram-positive organisms in PJIs. Most commonly 600 mg b.i.d. is used, and a
combination with rifampicin appears feasible although one must consider
individual increases in doses in these cases. However, adverse effects are
common and there are limited data for long-term use and optimal antibiotic
combinations or individual doses.
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Affiliation(s)
- Christoph Theil
- Department of Orthopedics and Tumor Orthopedics, Muenster University Hospital, Albert-Schweitzer-Campus 1, 48149, Münster, Germany
| | - Tom Schmidt-Braekling
- Department of Orthopedics and Tumor Orthopedics, Muenster University Hospital, Albert-Schweitzer-Campus 1, 48149, Münster, Germany
| | - Georg Gosheger
- Department of Orthopedics and Tumor Orthopedics, Muenster University Hospital, Albert-Schweitzer-Campus 1, 48149, Münster, Germany
| | - Jan Schwarze
- Department of Orthopedics and Tumor Orthopedics, Muenster University Hospital, Albert-Schweitzer-Campus 1, 48149, Münster, Germany
| | - Ralf Dieckmann
- Department of Orthopedics and Tumor Orthopedics, Muenster University Hospital, Albert-Schweitzer-Campus 1, 48149, Münster, Germany
| | - Kristian Nikolaus Schneider
- Department of Orthopedics and Tumor Orthopedics, Muenster University Hospital, Albert-Schweitzer-Campus 1, 48149, Münster, Germany
| | - Burkhard Möllenbeck
- Department of Orthopedics and Tumor Orthopedics, Muenster University Hospital, Albert-Schweitzer-Campus 1, 48149, Münster, Germany
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Abstract
AIMS Two-stage exchange arthroplasty is the most common definitive treatment for prosthetic joint infection (PJI) in the USA. Complications that occur during treatment are often not considered. The purpose of this study was to analyze complications in patients undergoing two-stage exchange for infected total knee arthroplasty (TKA) and determine when they occur. METHODS We analyzed all patients that underwent two-stage exchange arthroplasty for treatment of PJI of the knee from January 2010 to December 2018 at a single institution. We categorized complications as medical versus surgical. The intervals for complications were divided into: interstage; early post-reimplantation (three months); and late post-reimplantation (three months to minimum one year). Minimum follow-up was one year. In total, 134 patients underwent a first stage of a two-stage exchange. There were 69 males and 65 females with an mean age at first stage surgery of 67 years (37 to 89). Success was based on the new Musculoskeletal Infection Society (MSIS) definition of success reporting. RESULTS Overall, 70 (52%) patients experienced a complication during the planned two-stage treatment, 36 patients (27%) experienced a medical complication and 47 (41%) patients experienced a surgical complication. There was an 18% mortality rate (24/134) at a mean of 3.7 years (0.09 to 8.3). During the inter-stage period, 28% (37/134) of patients experienced a total of 50 complications at a median of 47 days (interquartile range (IQR) 18 to 139). Of these 50 complications, 22 were medical and 28 required surgery. During this inter-stage period, four patients died (3%) and an additional five patients (4%) failed to progress to the second stage. While 93% of patients (125/134) were reimplanted, only 56% (77/134) of the patients were successfully treated without antibiotic suppression (36%, 28/77) or with antibiotic suppression (19%, 15/77) at one year. CONCLUSION Reported rates of success of two stage exchanges for PJI have not traditionally considered complications in the definition of success. In our series, significant numbers of patients experienced complications, more often after reimplantation, highlighting the morbidity of this method of treatment. Cite this article: Bone Joint J 2020;102-B(6 Supple A):145-150.
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Affiliation(s)
- Molly A Hartzler
- OrthCarolina Hip and Knee Center, Charlotte, North Carolina, USA
| | - Katherine Li
- Atrium Musculoskeletal Institute, Charlotte, North Carolina, USA
| | - Michael B Geary
- Atrium Musculoskeletal Institute, Charlotte, North Carolina, USA
| | - Susan Marie Odum
- OrthoCarolina Research Institute, Charlotte, North Carolina, USA
| | - Bryan D Springer
- OrthCarolina Hip and Knee Center, Charlotte, North Carolina, USA
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Haddad FS. COVID-19 and beyond. Bone Joint J 2020; 102-B:653-654. [PMID: 32475238 DOI: 10.1302/0301-620x.102b6.bjj-2020-0759] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Fares S Haddad
- The Bone & Joint Journal, Professor of Orthopaedic Surgery, University College London Hospitals, The Princess Grace Hospital, and The NIHR Biomedical Research Centre at UCLH, London, UK
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28
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Chang Y, Hsiao YM, Hu CC, Chang CH, Li CY, Ueng SWN, Chen MF. Synovial Fluid Interleukin-16 Contributes to Osteoclast Activation and Bone Loss through the JNK/NFATc1 Signaling Cascade in Patients with Periprosthetic Joint Infection. Int J Mol Sci 2020; 21:ijms21082904. [PMID: 32326301 PMCID: PMC7215706 DOI: 10.3390/ijms21082904] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Revised: 04/10/2020] [Accepted: 04/17/2020] [Indexed: 12/15/2022] Open
Abstract
Because of lipopolysaccharide (LPS)-mediated effects on osteoclast differentiation and bone loss, periprosthetic joint infection (PJI) caused by Gram-negative bacteria increases the risk of aseptic loosening after reimplantation. Synovial fluid interleukin-16 (IL-16) expression was higher in patients with PJI than in patients without joint infection. Thus, we explored the effects of IL-16 on bone. We investigated whether IL-16 modulates osteoclast or osteoblast differentiation in vitro. An LPS-induced bone loss mice model was used to explore the possible advantages of IL-16 inhibition for the prevention of bone loss. IL-16 directly activated p38 and c-Jun N-terminal kinase (JNK)/mitogen-activated protein kinase (MAPK) signaling and increased osteoclast activation markers, including tartrate-resistant acid phosphatase (TRAP), cathepsin K, and nuclear factor of activated T cells 1 (NFATc1). IL-16 directly caused monocytes to differentiate into TRAP-positive osteoclast-like cells through NFATc1 activation dependent on JNK/MAPK signaling. Moreover, IL-16 did not alter alkaline phosphatase activity or calcium deposition during osteoblastic differentiation. Finally, IL-16 inhibition prevented LPS-induced trabecular bone loss and osteoclast activation in vivo. IL-16 directly increased osteoclast activation through the JNK/NFATc1 pathway. IL-16 inhibition could represent a new strategy for treating infection-associated bone loss.
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Affiliation(s)
- Yuhan Chang
- Bone and Joint Research Center, Chang Gung Memorial Hospital, Taoyuan 33305, Taiwan; (Y.C.); (C.-C.H.); (C.-H.C.); (C.-Y.L.); (S.W.N.U.)
- Department of Orthopedic Surgery, Chang Gung Memorial Hospital, Taoyuan 33305, Taiwan
| | - Yi-min Hsiao
- Bone and Joint Research Center, Chang Gung Memorial Hospital, Taoyuan 33305, Taiwan; (Y.C.); (C.-C.H.); (C.-H.C.); (C.-Y.L.); (S.W.N.U.)
- Department of Orthopedic Surgery, Chang Gung Memorial Hospital, Taoyuan 33305, Taiwan
| | - Chih-Chien Hu
- Bone and Joint Research Center, Chang Gung Memorial Hospital, Taoyuan 33305, Taiwan; (Y.C.); (C.-C.H.); (C.-H.C.); (C.-Y.L.); (S.W.N.U.)
- Department of Orthopedic Surgery, Chang Gung Memorial Hospital, Taoyuan 33305, Taiwan
| | - Chih-Hsiang Chang
- Bone and Joint Research Center, Chang Gung Memorial Hospital, Taoyuan 33305, Taiwan; (Y.C.); (C.-C.H.); (C.-H.C.); (C.-Y.L.); (S.W.N.U.)
- Department of Orthopedic Surgery, Chang Gung Memorial Hospital, Taoyuan 33305, Taiwan
- College of Medicine, Chang Gung University, Taoyuan 33302, Taiwan
- Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan 33302, Taiwan
| | - Cai-Yan Li
- Bone and Joint Research Center, Chang Gung Memorial Hospital, Taoyuan 33305, Taiwan; (Y.C.); (C.-C.H.); (C.-H.C.); (C.-Y.L.); (S.W.N.U.)
| | - Steve W. N. Ueng
- Bone and Joint Research Center, Chang Gung Memorial Hospital, Taoyuan 33305, Taiwan; (Y.C.); (C.-C.H.); (C.-H.C.); (C.-Y.L.); (S.W.N.U.)
- Department of Orthopedic Surgery, Chang Gung Memorial Hospital, Taoyuan 33305, Taiwan
- College of Medicine, Chang Gung University, Taoyuan 33302, Taiwan
| | - Mei-Feng Chen
- Bone and Joint Research Center, Chang Gung Memorial Hospital, Taoyuan 33305, Taiwan; (Y.C.); (C.-C.H.); (C.-H.C.); (C.-Y.L.); (S.W.N.U.)
- Correspondence:
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29
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Ji B, Li G, Zhang X, Wang Y, Mu W, Cao L. Effective treatment of single-stage revision using intra-articular antibiotic infusion for culture-negative prosthetic joint infection. Bone Joint J 2020; 102-B:336-344. [PMID: 32114816 DOI: 10.1302/0301-620x.102b3.bjj-2019-0820.r1] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
AIMS In the absence of an identified organism, single-stage revision is contraindicated in prosthetic joint infection (PJI). However, no studies have examined the use of intra-articular antibiotics in combination with single-stage revision in these cases. In this study, we present the results of single-stage revision using intra-articular antibiotic infusion for treating culture-negative (CN) PJI. METHODS A retrospective analysis between 2009 and 2016 included 51 patients with CN PJI who underwent single-stage revision using intra-articular antibiotic infusion; these were compared with 192 culture-positive (CP) patients. CN patients were treated according to a protocol including intravenous vancomycin and a direct intra-articular infusion of imipenem and vancomycin alternately used in the morning and afternoon. In the CP patients, pathogen-sensitive intravenous (IV) antibiotics were administered for a mean of 16 days (12 to 21), and for resistant cases, additional intra-articular antibiotics were used. The infection healing rate, Harris Hip Score (HHS), and Hospital for Special Surgery (HSS) knee score were compared between CN and CP groups. RESULTS Of 51 CN patients, 46 (90.2%) required no additional medical treatment for recurrent infection at a mean of 53.2 months (24 to 72) of follow-up. Impaired kidney function occurred in two patients, and one patient had a local skin rash. No significant difference in the infection control rate was observed between CN and CP PJIs (90.2% (46/51) versus 94.3% (181/192); p = 0.297). The HHS of the CN group showed no substantial difference from that of CP cases (79 versus 81; p = 0.359). However, the CN group showed a mean HSS inferior to that of the CP group (76 versus 80; p = 0.027). CONCLUSION Single-stage revision with direct intra-articular antibiotic infusion can be effective in treating CN PJI, and can achieve an infection control rate similar to that in CP patients. However, in view of systemic toxicity, local adverse reactions, and higher costs, additional strong evidence is needed to verify these treatment regimens. Cite this article: Bone Joint J 2020;102-B(3):336-344.
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Affiliation(s)
- Baochao Ji
- Department of Orthopaedics, First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | - Guoqing Li
- Department of Orthopaedics, First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | - Xiaogang Zhang
- Department of Orthopaedics, First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | - Yang Wang
- Department of Orthopaedics, First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | - Wenbo Mu
- Department of Orthopaedics, First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | - Li Cao
- Department of Orthopaedics, First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
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30
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Affiliation(s)
- Syed S Ahmed
- Maidstone and Tunbridge Wells NHS Trust, London, UK
| | - Fares S Haddad
- The Bone & Joint Journal, Professor of Orthopaedic Surgery, University College London Hospitals, The Princess Grace Hospital, and The NIHR Biomedical Research Centre at UCLH, London, UK
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31
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Ahmed SS, Begum F, Kayani B, Haddad FS. Risk factors, diagnosis and management of prosthetic joint infection after total hip arthroplasty. Expert Rev Med Devices 2019; 16:1063-1070. [PMID: 31752561 DOI: 10.1080/17434440.2019.1696673] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Introduction: Although a relatively rare complication, the incidence and prevalence of prosthetic joint infection (PJI) is certainly rising. This is mainly due to the number of arthroplasties performed each year and our ability to capture more cases. There is currently no consensus in the optimal diagnosis and management of the infected total hip arthroplasty. Various management techniques have been described in literature.Areas covered: We discuss and summarize the literature in diagnosing prosthetic joint infection (PJI) including next-generation sequencing. An in-depth critical analysis of the biomarkers and the novel tests available in the market is reviewed including the evolving nature of the diagnostic criteria for PJI. The key issues in managing infected THA are identified.Expert commentary: The senior authors' expert opinion on diagnostic criteria is discussed. We also stress the importance of tissue/fluid analysis of microbiology and histology being key to diagnosis of PJI. The indications of one-stage versus two-stage revision arthroplasty is examined, including techniques for successful one-stage revision.
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Affiliation(s)
- Syed S Ahmed
- Trauma & Orthopaedics, University College Hospital, London, UK.,Trauma & Orthopaedics, Princess Grace Hospital, London, UK
| | - Fahima Begum
- Trauma & Orthopaedics, University College Hospital, London, UK.,Trauma & Orthopaedics, Princess Grace Hospital, London, UK
| | - Babar Kayani
- Trauma & Orthopaedics, University College Hospital, London, UK.,Trauma & Orthopaedics, Princess Grace Hospital, London, UK
| | - Fares S Haddad
- Trauma & Orthopaedics, University College Hospital, London, UK.,Trauma & Orthopaedics, Princess Grace Hospital, London, UK
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32
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Qu PF, Xu C, Fu J, Li R, Chai W, Chen JY. Does serum interleukin-6 guide the diagnosis of persistent infection in two-stage hip revision for periprosthetic joint infection? J Orthop Surg Res 2019; 14:354. [PMID: 31711522 PMCID: PMC6849312 DOI: 10.1186/s13018-019-1448-7] [Citation(s) in RCA: 7] [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: 08/14/2019] [Accepted: 10/31/2019] [Indexed: 12/15/2022] Open
Abstract
Purpose The diagnosis of persistent infection at reimplantation of two-stage revision arthroplasty for periprosthetic joint infection (PJI) remains challenging. Several studies have shown the benefit of serum interleukin-6 (IL-6) in diagnosing periprosthetic joint infection (PJI). Recent data indicated serum IL-6 could be promising in differentiating persistent infection. The purpose of this study was to validate the efficacy of serum IL-6 in diagnosing persistent infection at reimplantation. Methods A retrospective review of 86 PJI patients with a two-stage exchanged hip arthroplasty from 2013 to 2017 was conducted. Persistent infection was defined using the modified Musculoskeletal Infection Society (MSIS) criteria combined with follow-up results. Serum IL-6 at reimplantation were collected and compared among patients with or without persistent infection. Receiver operating characteristic (ROC) curves were generated to evaluate the diagnostic performance and optimal cut-off value of serum IL-6 at reimplantation. Results Sixteen cases were diagnosed as persistent infection at reimplantation. There was no significant difference in serum IL-6 levels between cases with persistent infection and controls (7.89 pg/ml vs. 5.56 pg/ml; P = 0.179). The area under the ROC curve (AUC) for serum IL-6 in diagnosing persistent infection at reimplantation was 0.59 (95% confidential interval [CI] 0.40–0.77). With the calculated threshold set at 8.12 pg/ml, the corresponding sensitivity, specificity, positive predictive value, and negative predictive values were 38%, 88%, 38%, and 87%, respectively. Conclusion Serum IL-6 is inadequate in diagnosing persistent infection at reimplantation for two-stage revision arthroplasty. With the serum IL-6 threshold set at 8.12 pg/ml, the specificity to rule out persistent infection is high, but the sensitivity to predict persistent infection is not satisfactory.
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Affiliation(s)
- Peng-Fei Qu
- Department of Orthopedics, First Medical Center, General Hospital of People's Liberation Army, No.28 Fuxing Road, Haidian District, Beijing, 100853, China
| | - Chi Xu
- Department of Orthopedics, First Medical Center, General Hospital of People's Liberation Army, No.28 Fuxing Road, Haidian District, Beijing, 100853, China
| | - Jun Fu
- Department of Orthopedics, First Medical Center, General Hospital of People's Liberation Army, No.28 Fuxing Road, Haidian District, Beijing, 100853, China.
| | - Rui Li
- Department of Orthopedics, First Medical Center, General Hospital of People's Liberation Army, No.28 Fuxing Road, Haidian District, Beijing, 100853, China
| | - Wei Chai
- Department of Orthopedics, First Medical Center, General Hospital of People's Liberation Army, No.28 Fuxing Road, Haidian District, Beijing, 100853, China
| | - Ji-Ying Chen
- Department of Orthopedics, First Medical Center, General Hospital of People's Liberation Army, No.28 Fuxing Road, Haidian District, Beijing, 100853, China.
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33
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Periprosthetic Joint Infection Caused by Gram-Positive Versus Gram-Negative Bacteria: Lipopolysaccharide, but not Lipoteichoic Acid, Exerts Adverse Osteoclast-Mediated Effects on the Bone. J Clin Med 2019; 8:jcm8091289. [PMID: 31450783 PMCID: PMC6780630 DOI: 10.3390/jcm8091289] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Revised: 08/15/2019] [Accepted: 08/20/2019] [Indexed: 01/03/2023] Open
Abstract
Periprosthetic joint infection (PJI)-the most common cause of knee arthroplasty failure-may result from Gram-positive (GP) or Gram-negative (GN) bacterial infections. The question as to whether PJI due to GP or GN bacteria can lead to different rates of aseptic loosening after reimplantation remains open. We have investigated this issue through a retrospective review of clinical records obtained from 320 patients with bacterial PJI. The results revealed that, compared with GP infections, GN infections were associated with an increased risk of aseptic loosening. In animal studies, mice underwent intrafemoral injection of lipopolysaccharide (LPS) from GN bacteria or lipoteichoic acid (LTA) from GP bacteria. We demonstrate that LPS-but not LTA-reduced both the number of trabeculae and the bone mineral density in mice. In addition, LPS-treated mice exhibited a reduced body weight, higher serum osteocalcin levels, and an increased number of osteoclasts. LPS accelerated monocyte differentiation into osteoclast-like cells, whereas LTA did not. Finally, ibudilast-a toll-like receptor (TLR)-4 antagonist-was found to inhibit LPS-induced bone loss and osteoclast activation in mice. Taken together, our data indicate that PJI caused by GN bacteria portends a higher risk of aseptic loosening after reimplantation, mainly because of LPS-mediated effects on osteoclast differentiation.
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34
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Bostrom MPG, Haddad FS. The Hip Society Supplement 2019. Bone Joint J 2019; 101-B:1. [PMID: 31146566 DOI: 10.1302/0301-620x.101b6.bjj-2019-0549] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- M P G Bostrom
- Hospital for Special Surgery, New York City, New York, USA
| | - Fares S Haddad
- The Princess Grace Hospital, and The NIHR Biomedical Research Centre at UCLH
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