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Lora-Tamayo J, Mancheño-Losa M, Meléndez-Carmona MÁ, Hernández-Jiménez P, Benito N, Murillo O. Appropriate Duration of Antimicrobial Treatment for Prosthetic Joint Infections: A Narrative Review. Antibiotics (Basel) 2024; 13:293. [PMID: 38666969 PMCID: PMC11047716 DOI: 10.3390/antibiotics13040293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Revised: 03/16/2024] [Accepted: 03/19/2024] [Indexed: 04/29/2024] Open
Abstract
Prosthetic joint infections are considered difficult to treat they needing aggressive surgery and long antimicrobial treatments. However, the exact duration of these therapies has been established empirically. In the last years, several studies have explored the possibility of reducing the length of treatment in this setting, with conflicting results. In this narrative review, we critically appraise the published evidence, considering the different surgical approaches (implant retention [DAIR] and one-step and two-step exchange procedures) separately. In patients managed with DAIR, usually treated for at least 12 weeks, a large, randomized trial failed to show that 6 weeks were non-inferior. However, another randomized clinical trial supports the use of 8 weeks, as long as the surgical conditions are favorable and antibiotics with good antibiofilm activity can be administered. In patients managed with a two-step exchange procedure, usually treated during 6 weeks, a randomized clinical trial showed the efficacy of a 4-week course of antimicrobials. Also, the use of local antibiotics may allow the use of even shorter treatments. Finally, in the case of one-step exchange procedures, there is a trend towards reducing the length of therapy, and the largest randomized clinical trial supports the use of 6 weeks of therapy.
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Affiliation(s)
- Jaime Lora-Tamayo
- Department of Internal Medicine, Hospital Universitario 12 de Octubre, Instituto de Investigación Biomédica imas12 Hospital 12 de Octubre, Facultad de Medicina, Universidad Complutense de Madrid, 28041 Madrid, Spain; (M.M.-L.); (P.H.-J.)
- Spanish Group for the Study of Bone and Joint Infections, Spanish Society of Clinical Microbiology and Infectious Diseases (GEIO-SEIMC), 28003 Madrid, Spain; (N.B.); (O.M.)
- CIBERINFEC—CIBER Enfermedades Infecciosas, Instituto de Salud Carlos III, 28029 Madrid, Spain
| | - Mikel Mancheño-Losa
- Department of Internal Medicine, Hospital Universitario 12 de Octubre, Instituto de Investigación Biomédica imas12 Hospital 12 de Octubre, Facultad de Medicina, Universidad Complutense de Madrid, 28041 Madrid, Spain; (M.M.-L.); (P.H.-J.)
- Spanish Group for the Study of Bone and Joint Infections, Spanish Society of Clinical Microbiology and Infectious Diseases (GEIO-SEIMC), 28003 Madrid, Spain; (N.B.); (O.M.)
| | - María Ángeles Meléndez-Carmona
- Department of Microbiology, Hospital Universitario 12 de Octubre, Instituto de Investigación Biomédica imas12 Hospital 12 de Octubre, 28041 Madrid, Spain;
| | - Pilar Hernández-Jiménez
- Department of Internal Medicine, Hospital Universitario 12 de Octubre, Instituto de Investigación Biomédica imas12 Hospital 12 de Octubre, Facultad de Medicina, Universidad Complutense de Madrid, 28041 Madrid, Spain; (M.M.-L.); (P.H.-J.)
| | - Natividad Benito
- Spanish Group for the Study of Bone and Joint Infections, Spanish Society of Clinical Microbiology and Infectious Diseases (GEIO-SEIMC), 28003 Madrid, Spain; (N.B.); (O.M.)
- CIBERINFEC—CIBER Enfermedades Infecciosas, Instituto de Salud Carlos III, 28029 Madrid, Spain
- Infectious Diseases Unit, Hospital de la Santa Creu i Sant Pau, Institut d’Investigació Biomèdica Sant Pau (IIB SANT PAU), Universitat Autònoma de Barcelona, 08193 Barcelona, Spain
- UQ Centre for Clinical Research (UQCCR), The University of Queensland, Brisbane 4072, Australia
| | - Oscar Murillo
- Spanish Group for the Study of Bone and Joint Infections, Spanish Society of Clinical Microbiology and Infectious Diseases (GEIO-SEIMC), 28003 Madrid, Spain; (N.B.); (O.M.)
- CIBERINFEC—CIBER Enfermedades Infecciosas, Instituto de Salud Carlos III, 28029 Madrid, Spain
- Department of Infectious Diseases, Hospital Universitario Bellvitge, IDIBELL (Instituto de Investigación Biomédica de Bellvitge), 08908 L’Hospitalet de Llobregat, Spain
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2
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Hollyer I, Ivanov D, Kappagoda S, Lowenberg DW, Goodman SB, Amanatullah DF. Selecting a high-dose antibiotic-laden cement knee spacer. J Orthop Res 2023; 41:1383-1396. [PMID: 37127938 DOI: 10.1002/jor.25570] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Accepted: 04/17/2023] [Indexed: 05/03/2023]
Abstract
Prosthetic joint infection [PJI] after total knee arthroplasty (TKA) remains a common and challenging problem for joint replacement surgeons and patients. Once the diagnosis of PJI has been made, patient goals and characteristics as well as the infection timeline dictate treatment. Most commonly, this involves a two-stage procedure with the removal of all implants, debridement, and placement of a static or dynamic antibiotic spacer. Static spacers are commonly indicated for older, less healthy patients that would benefit from soft tissue rest after initial debridement. Mobile spacers are typically used in younger, healthier patients to improve quality of life and reduce soft-tissue contractures during antibiotic spacer treatment. Spacers are highly customizable with regard to antibiotic choice, cement variety, and spacer design, each with reported advantages, drawbacks, and indications that will be covered in this article. While no spacer is superior to any other, the modern arthroplasty surgeon must be familiar with the available modalities to optimize treatment for each patient. Here we propose a treatment algorithm to assist surgeons in deciding on treatment for PJI after TKA.
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Affiliation(s)
- Ian Hollyer
- Department of Orthopaedic Surgery, Stanford University, Redwood City, California, USA
| | - David Ivanov
- Department of Orthopaedic Surgery, Stanford University, Redwood City, California, USA
| | - Shanthi Kappagoda
- Division of Infectious Diseases and Geographic Medicine, Stanford Univeristy, Stanford, California, USA
| | - David W Lowenberg
- Department of Orthopaedic Surgery, Stanford University, Redwood City, California, USA
| | - Stuart B Goodman
- Department of Orthopaedic Surgery, Stanford University, Redwood City, California, USA
| | - Derek F Amanatullah
- Department of Orthopaedic Surgery, Stanford University, Redwood City, California, USA
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3
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Khamkongkaeo A, Jiamprasertboon A, Jinakul N, Srabua P, Tantavisut S, Wongrakpanich A. Antibiotic-loaded hydroxyapatite scaffolds fabricated from Nile tilapia bones for orthopaedics. Int J Pharm X 2023; 5:100169. [PMID: 36861068 PMCID: PMC9969256 DOI: 10.1016/j.ijpx.2023.100169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Revised: 02/01/2023] [Accepted: 02/05/2023] [Indexed: 02/11/2023] Open
Abstract
This work aimed to develop new antibiotic-coated/ antibiotic-loaded hydroxyapatite (HAp) scaffolds for orthopaedic trauma, specifically to treat the infection after fixation of skeletal fracture. The HAp scaffolds were fabricated from the Nile tilapia (Oreochromis niloticus) bones and fully characterized. The HAp scaffolds were coated with 12 formulations of poly (lactic-co-glycolic acid) (PLGA) or poly (lactic acid) (PLA), blended with vancomycin. The vancomycin release, surface morphology, antibacterial properties, and the cytocompatibility of the scaffolds were conducted. The HAp powder contains elements identical to those found in human bones. This HAp powder is suitable as a starting material to build scaffolds. After the scaffold fabrication, The ratio of HAp to β-TCP changed, and the phase transformation of β-TCP to α-TCP was observed. All antibiotic-coated/ antibiotic-loaded HAp scaffolds can release vancomycin into the phosphate-buffered saline (PBS) solution. PLGA-coated scaffolds obtained faster drug release profiles than PLA-coated scaffolds. The low polymer concentration in the coating solutions (20%w/v) gave a faster drug release profile than the high polymer concentration (40%w/v). All groups showed a trace of surface erosion after being submerged in PBS for 14 days. Most of the extracts can inhibit Staphylococcus aureus (S. aureus) and methicillin-resistant S. aureus (MRSA). The extracts not only caused no cytotoxicity to Saos-2 bone cells but also can increase cell growth. This study demonstrates that it is possible to use these antibiotic-coated/ antibiotic-loaded scaffolds in the clinic as an antibiotic bead replacement.
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Key Words
- Antibiotic
- Antibiotic-coated
- Antibiotic-loaded
- CLSI, The Clinical and Laboratory Standards Institute
- DI, Deionized water
- DMSO, Dimethyl sulfoxide
- F10[PLGA40-Hvanc], Formulation 10, HAp saffolds containing high concentration of vancomycin, coated with PLGA 40%w/v
- F11[PLA20-Hvanc], Formulation 11, HAp saffolds containing high concentration of vancomycin, coated with PLA 20%w/v
- F12[PLA40-Hvanc], Formulation 12, HAp saffolds containing high concentration of vancomycin, coated with PLA 40%w/v
- F1[V-PLGA20-Lvanc], Formulation 1, HAp saffolds containing low concentration of vancomycin, coated with PLGA 20%w/v blended with vancomycin
- F2[V-PLGA40-Lvanc], Formulation 2, HAp saffolds containing low concentration of vancomycin, coated with PLGA 40%w/v blended with vancomycin
- F3[V-PLA20-Lvanc], Formulation 3, HAp saffolds containing low concentration of vancomycin, coated with PLA 20%w/v blended with vancomycin
- F4[V-PLA40-Lvanc], Formulation 4, HAp saffolds containing low concentration of vancomycin, coated with PLA 40%w/v blended with vancomycin
- F5[PLGA20-Lvanc], Formulation 5, HAp saffolds containing low concentration of vancomycin, coated with PLGA 20%w/v
- F6[PLGA40-Lvanc], Formulation 6, HAp saffolds containing low concentration of vancomycin, coated with PLGA 40%w/v
- F7[PLA20-Lvanc], Formulation 7, HAp saffolds containing low concentration of vancomycin, coated with PLA 20%w/v
- F8[PLA40-Lvanc], Formulation 8, HAp saffolds containing low concentration of vancomycin, coated with PLA 40%w/v
- F9[PLGA20-Hvanc], Formulation 9, HAp saffolds containing high concentration of vancomycin, coated with PLGA 20%w/v
- FDA, Food and Drug Administration
- FTIR, Fourier transforms infrared spectroscopy
- HAp, Hydroxyapatite
- Hydroxyapatite
- IFSF, The infection after fixation of skeletal fracture
- Nile tilapia
- P.U., Polyurethane
- PBS, Phosphate-buffered saline
- PLA, Poly(lactic acid)
- PLGA, Poly(lactic-co-glycolic acid)
- PVA, Polyvinyl alcohol
- SEM, Scanning electron microscopy
- Scaffold
- Vancomycin
- XRD, X-ray diffraction
- XRF, X-ray fluorescence spectroscopy
- α-TCP, α-tricalcium phosphate
- β-TCP, β-tricalcium phosphate
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Affiliation(s)
- Atchara Khamkongkaeo
- Department of Metallurgical Engineering, Faculty of Engineering, Chulalongkorn University, Bangkok, Thailand
| | - Arreerat Jiamprasertboon
- School of Chemistry, Institute of Science, Suranaree University of Technology, Nakhon Ratchasima, Thailand,Institute of Research and Development, Suranaree University of Technology, Nakhon Ratchasima, Thailand
| | - Nanthawan Jinakul
- Department of Microbiology, Faculty of Pharmacy, Mahidol University, Bangkok, Thailand
| | - Phatraya Srabua
- Scientific and Technological Research Equipment Center (STREC), Chulalongkorn University, Bangkok, Thailand
| | - Saran Tantavisut
- Department of Orthopaedics, Chulalongkorn University, Bangkok, Thailand,Hip Fracture Research Unit, Department of Orthopaedics, Chulalongkorn University, Bangkok, Thailand
| | - Amaraporn Wongrakpanich
- Department of Pharmacy, Faculty of Pharmacy, Mahidol University, Bangkok, Thailand,Corresponding author.
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4
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Teschke M, Christensen A, Far F, Reich RH, Naujokat H. Digitally designed, personalized bone cement spacer for staged TMJ and mandibular reconstruction - Introduction of a new technique. J Craniomaxillofac Surg 2021; 49:935-942. [PMID: 34238634 DOI: 10.1016/j.jcms.2021.05.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Revised: 04/30/2021] [Accepted: 05/13/2021] [Indexed: 10/21/2022] Open
Abstract
The aim of this paper is to introduce an innovative workflow for staged reconstruction of the mandible, including the temporomandibular joint (TMJ), using a temporary, patient-specific spacer. In cases of partial mandibular resection including disarticulation, sometimes needed to treat inflammatory bone disease, the spacer is intended to retain symmetry of the hard tissues, to preserve the soft tissues, and to act as a bactericidal agent. When complete healing of the affected surrounding tissues has occurred, final reconstruction using a patient-matched total TMJ endoprosthesis, in combination with an autogenous free bone flap, can be performed as a second-stage procedure. The crucial steps of the workflow are virtual surgical planning, manufacturing of a two-part silicone mold, and chairside manufacturing of the spacer using an established bone cement with gentamycin. The method was first introduced in two patients suffering from therapy-resistant chronic osteomyelitis. The presented protocol of staged surgery allows a much safer and predictable reconstruction compared with immediate reconstruction. The workflow also minimizes the potential risk of endoprosthesis infection - one of the major risks of implant failure.
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Affiliation(s)
- Marcus Teschke
- Department of Pediatric Craniofacial Plastic Surgery, Childrens Hospital, Wilhelmstift, Hamburg, Germany.
| | - Andy Christensen
- Department of Radiology, University of Ottawa, Ottawa, Ontario, Canada
| | - Frederick Far
- Department of Oral and Maxillofacial Surgery, University Hospital of Bonn, Bonn, Germany
| | - Rudolf H Reich
- Department of Oral and Maxillofacial Surgery, University Hospital of Bonn, Bonn, Germany
| | - Hendrik Naujokat
- Department of Oral and Maxillofacial Surgery, University Hospital of Schleswig-Holstein, Campus Kiel, Kiel, Germany
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5
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Dudareva M, Kümin M, Vach W, Kaier K, Ferguson J, McNally M, Scarborough M. Short or Long Antibiotic Regimes in Orthopaedics (SOLARIO): a randomised controlled open-label non-inferiority trial of duration of systemic antibiotics in adults with orthopaedic infection treated operatively with local antibiotic therapy. Trials 2019; 20:693. [PMID: 31815653 PMCID: PMC6902346 DOI: 10.1186/s13063-019-3832-3] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Accepted: 10/22/2019] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Orthopaedic infections, such as osteomyelitis, diabetic foot infection and prosthetic joint infection, are most commonly treated by a combination of surgical debridement and a prolonged course of systemic antibiotics, usually for at least 4-6 weeks. Use of local antibiotics, implanted directly into the site of infection at the time of surgery, may improve antibiotic delivery and allow us to shorten the duration of systemic antibiotic therapy, thereby limiting the frequency of side effects, cost and selection pressure for antimicrobial resistance. METHODS SOLARIO is a multicentre open-label randomised controlled non-inferiority trial comparing short and long systemic antibiotic therapy alongside local antibiotic therapy. Adult patients with orthopaedic infection, who have given informed consent, will be eligible to participate in the study provided that no micro-organisms identified from deep tissue samples are resistant to locally implanted antibiotics. Participants will be randomised in a 1:1 ratio to receive either a short course (≤ 7 days) or currently recommended long course (≥ 4 weeks) of systemic antibiotics. The primary outcome will be treatment failure by 12 months after surgery, as ascertained by an independent Endpoint Committee blinded to treatment allocation. An absolute non-inferiority margin of 10% will be used for both per-protocol and intention-to-treat populations. Secondary outcomes will include probable and definite treatment failure, serious adverse events, treatment side effects, quality of life scores and cost analysis. DISCUSSION This study aims to assess a treatment strategy that may enable the reduction of systemic antibiotic use for patients with orthopaedic infection. If this strategy is non-inferior, this will be to the advantage of patients and contribute to antimicrobial stewardship. TRIAL REGISTRATION Clinicaltrials.gov, NCT03806166. Registered on 11 November 2019.
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Affiliation(s)
- Maria Dudareva
- Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals, Oxford, UK.
| | - Michelle Kümin
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Werner Vach
- Department of Orthopaedics and Traumatology, Universitätsspital Basel, Basel, Switzerland
| | - Klaus Kaier
- Institute of Medical Biometry and Medical Informatics, Universitätsklinikums Freiburg, Freiburg, Germany
| | - Jamie Ferguson
- Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals, Oxford, UK
| | - Martin McNally
- Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals, Oxford, UK
| | - Matthew Scarborough
- Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals, Oxford, UK
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6
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Dall GF, Tsang STJ, Gwynne PJ, MacKenzie SP, Simpson AHRW, Breusch SJ, Gallagher MP. Unexpected synergistic and antagonistic antibiotic activity against Staphylococcus biofilms. J Antimicrob Chemother 2019; 73:1830-1840. [PMID: 29554250 DOI: 10.1093/jac/dky087] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2017] [Accepted: 02/15/2018] [Indexed: 11/13/2022] Open
Abstract
Objectives To evaluate putative anti-staphylococcal biofilm antibiotic combinations used in the management of periprosthetic joint infections (PJIs). Methods Using the dissolvable bead biofilm assay, the minimum biofilm eradication concentration (MBEC) was determined for the most commonly used antimicrobial agents and combination regimens against staphylococcal PJIs. The established fractional inhibitory concentration (FIC) index was modified to create the fractional biofilm eradication concentration (FBEC) index to evaluate synergism or antagonism between antibiotics. Results Only gentamicin (MBEC 64 mg/L) and daptomycin (MBEC 64 mg/L) were observed to be effective antistaphylococcal agents at clinically achievable concentrations. Supplementation of gentamicin with daptomycin, vancomycin or ciprofloxacin resulted in a similar or lower MBEC than gentamicin alone (FBEC index 0.25-2). Conversely, when rifampicin, clindamycin or linezolid was added to gentamicin, there was an increase in the MBEC of gentamicin relative to its use as a monotherapy (FBEC index 8-32). Conclusions This study found that gentamicin and daptomycin were the only effective single-agent antibiotics against established Staphylococcus biofilms. Interestingly the addition of a bacteriostatic antibiotic was found to antagonize the ability of gentamicin to eradicate Staphylococcus biofilms.
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Affiliation(s)
- G F Dall
- Department of Orthopaedic Surgery, Borders General Hospital, Huntlyburn, Melrose TD6 9BS, UK.,School of Biological Sciences, University of Edinburgh, Darwin Building, King's Buildings, Mayfield Road, Edinburgh EH9 3JR, UK.,Department of Orthopaedic Surgery, University of Edinburgh, Chancellor's Building, 49 Little France Crescent, Old Dalkeith Road, Edinburgh EH16 4SB, UK
| | - S-T J Tsang
- School of Biological Sciences, University of Edinburgh, Darwin Building, King's Buildings, Mayfield Road, Edinburgh EH9 3JR, UK.,Department of Orthopaedic Surgery, University of Edinburgh, Chancellor's Building, 49 Little France Crescent, Old Dalkeith Road, Edinburgh EH16 4SB, UK.,Department of Orthopaedic Surgery, Royal Infirmary of Edinburgh, 51 Little France Crescent, Old Dalkeith Road, Edinburgh EH16 4SA, UK
| | - P J Gwynne
- School of Biological Sciences, University of Edinburgh, Darwin Building, King's Buildings, Mayfield Road, Edinburgh EH9 3JR, UK
| | - S P MacKenzie
- Department of Orthopaedic Surgery, Royal Infirmary of Edinburgh, 51 Little France Crescent, Old Dalkeith Road, Edinburgh EH16 4SA, UK
| | - A H R W Simpson
- Department of Orthopaedic Surgery, University of Edinburgh, Chancellor's Building, 49 Little France Crescent, Old Dalkeith Road, Edinburgh EH16 4SB, UK
| | - S J Breusch
- Department of Orthopaedic Surgery, Royal Infirmary of Edinburgh, 51 Little France Crescent, Old Dalkeith Road, Edinburgh EH16 4SA, UK
| | - M P Gallagher
- School of Biological Sciences, University of Edinburgh, Darwin Building, King's Buildings, Mayfield Road, Edinburgh EH9 3JR, UK
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7
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Risitano S, Sabatini L, Atzori F, Massè A, Indelli PF. Static antibiotic spacers augmented by calcium sulphate impregnated beads in revision TKA: Surgical technique and review of literature. J Orthop 2018; 15:313-318. [PMID: 29556116 DOI: 10.1016/j.jor.2018.02.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2017] [Revised: 01/16/2018] [Accepted: 02/18/2018] [Indexed: 01/20/2023] Open
Abstract
Periprosthetic joint infection (PJI) is a serious complication in total knee arthroplasty (TKA) and represents one of the most common causes of revision. The challenge for surgeons treating an infected TKA is to quickly obtain an infection-free joint in order to re-implant, when possible, a new TKA. Recent literature confirms the role of local antibiotic-loaded beads as a strong bactericidal, allowing higher antibiotic elution when compared with antibiotic loaded spacers only. Unfortunately, classical Polymethylmethacrylate (PMMA) beads might allow bacteria adhesion, secondary development of antibiotic resistance and eventually surgical removal once antibiotics have eluted. This article describes a novel surgical technique using static, custom-made antibiotic loaded spacers augmented by calcium sulphate antibiotic-impregnated beads to improve the success rate of revision TKA in a setting of PJI. The use of calcium sulphate beads has several potential benefits, including a longer sustained local antibiotic release when compared with classical PMMA beads and, being resorbable, not requiring accessory surgical interventions.
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Affiliation(s)
- Salvatore Risitano
- Department of Orthopaedic Surgery and Traumatology, University of Turin, "Città della salute e della scienza"-CTO Hospital of Turin, Turin, ITA, Italy.,Department of Orthopaedic Surgery and Bioengineering, Stanford University School of Medicine and the Palo Alto Veterans Affairs Health Care System (PAVAHCS), Palo Alto, CA, USA
| | - Luigi Sabatini
- Department of Orthopaedic Surgery and Traumatology, University of Turin, "Città della salute e della scienza"-CTO Hospital of Turin, Turin, ITA, Italy
| | - Francesco Atzori
- Department of Orthopaedic Surgery, Cottolengo Hospital, Turin, Italy
| | - Alessandro Massè
- Department of Orthopaedic Surgery and Traumatology, University of Turin, "Città della salute e della scienza"-CTO Hospital of Turin, Turin, ITA, Italy
| | - Pier Francesco Indelli
- Department of Orthopaedic Surgery and Bioengineering, Stanford University School of Medicine and the Palo Alto Veterans Affairs Health Care System (PAVAHCS), Palo Alto, CA, USA
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8
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Frew NM, Cannon T, Nichol T, Smith TJ, Stockley I. Comparison of the elution properties of commercially available gentamicin and bone cement containing vancomycin with 'home-made' preparations. Bone Joint J 2017; 99-B:73-77. [PMID: 28053260 DOI: 10.1302/0301-620x.99b1.bjj-2016-0566.r1] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2016] [Accepted: 09/13/2016] [Indexed: 11/05/2022]
Abstract
AIMS Vancomycin is commonly added to acrylic bone cement during revision arthroplasty surgery. Proprietary cement preparations containing vancomycin are available, but are significantly more expensive. We investigated whether the elution of antibiotic from 'home-made' cement containing vancomycin was comparable with more expensive commercially available vancomycin impregnated cement. MATERIALS AND METHODS A total of 18 cement discs containing either proprietary CopalG+V; or 'home-made' CopalR+G with vancomycin added by hand, were made. Each disc contained the same amount of antibiotic (0.5 g gentamycin, 2 g vancomycin) and was immersed in ammonium acetate buffer in a sealed container. Fluid from each container was sampled at eight time points over a two-week period. The concentrations of gentamicin and vancomycin in the fluid were analysed using high performance liquid chromatography mass spectrometry. RESULTS The highest peak concentrations of antibiotic were observed from the 'home-made' cements containing vancomycin, added as in the operating theatre. The overall elution of antibiotic was, fivefold (vancomycin) and twofold (gentamicin) greater from the 'home-made' mix compared with the commercially mixed cement. The use of a vacuum during mixing had no significant effect on antibiotic elution in any of the samples. CONCLUSION These findings suggest that the addition of 2 g vancomycin powder to gentamicin-impregnated bone cement by hand significantly increases the elution of both antibiotics compared with commercially prepared cements containing vancomycin. We found no significant advantages of using expensive commercially produced vancomycin-impregnated cement and recommend the addition of vancomycin powder by hand in the operating theatre. Cite this article: Bone Joint J 2017;99-B:73-7.
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Affiliation(s)
- N M Frew
- Sheffield Teaching Hospitals NHS Foundation Trust, Herries Road, Sheffield, S5 7AU, UK
| | - T Cannon
- Sheffield Teaching Hospitals NHS Foundation Trust, Herries Road, Sheffield, S5 7AU, UK
| | - T Nichol
- Sheffield Hallam University, City Campus, Howard Street, Sheffield, S1 1WB, UK
| | - T J Smith
- Sheffield Hallam University, City Campus, Howard Street, Sheffield, S1 1WB, UK
| | - I Stockley
- Sheffield Teaching Hospitals NHS Foundation Trust, Herries Road, Sheffield, S5 7AU, UK
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9
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Streubel PN, Simone JP, Morrey BF, Sanchez-Sotelo J, Morrey ME. Infection in total elbow arthroplasty with stable components. Bone Joint J 2016; 98-B:976-83. [DOI: 10.1302/0301-620x.98b7.36397] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2015] [Accepted: 03/03/2016] [Indexed: 11/05/2022]
Abstract
Aims We describe the use of a protocol of irrigation and debridement (I& D) with retention of the implant for the treatment of periprosthetic infection of a total elbow arthroplasty (TEA). This may be an attractive alternative to staged re-implantation. Patients and Methods Between 1990 and 2010, 23 consecutive patients were treated in this way. Three were lost to follow-up leaving 20 patients (21 TEAs) in the study. There were six men and 14 women. Their mean age was 58 years (23 to 76). The protocol involved: component unlinking, irrigation and debridement (I& D), and the introduction of antibiotic laden cement beads; organism-specific intravenous antibiotics; repeat I& D and re-linkage of the implant if appropriate; long-term oral antibiotic therapy. Results The mean follow-up was 7.1 years (2 to 16). The infecting micro-organisms were Staphylococcus aureus in nine, coagulase-negative Staphylococcus in 13, Corynebacterium in three and other in six cases. Re-operations included three repeat staged I& Ds, two repeat superficial I& Ds and one fasciocutaneous forearm flap. One patient required removal of the implant due to persistent infection. All except three patients rated their pain as absent or mild. Outcome was rated as good or excellent in 15 patients (mean Mayo Elbow Performance Score 78 points, (5 to 100) with a mean flexion-extension arc of 103° (40° to 150°)). Conclusion A staged protocol can be successful in retaining stable components of an infected TEA. Function of the elbow may compare unfavourably to that after an uncomplicated TEA. Cite this article: Bone Joint J 2016;98-B:976–83.
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Affiliation(s)
- P. N. Streubel
- University of Nebraska Medical Center,
Nebraska, NE, USA and
Nebraska Medical Center Omaha, NE 68198, USA
| | - J. P. Simone
- Hospital Alemán, Av.
Pueyrredón 1640, ZC 1118, Buenos
Aires, Argentina
| | - B. F. Morrey
- Mayo Clinic, 200
1st St. SW, Rochester, MN
55902, USA
| | | | - M. E. Morrey
- Mayo Clinic, 200
1st St. SW, Rochester, MN
55902, USA
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10
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Green JM, Lawson ST, Liacouras PC, Wise EM, Gentile MA, Grant GT. Custom Anatomical 3D Spacer for Temporomandibular Joint Resection and Reconstruction. Craniomaxillofac Trauma Reconstr 2015; 9:82-7. [PMID: 26889353 DOI: 10.1055/s-0035-1546814] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2014] [Accepted: 10/13/2014] [Indexed: 10/23/2022] Open
Abstract
Two cases are presented using a two-stage approach and a custom antibiotic spacer placement. Temporomandibular reconstruction can be very demanding and accomplished with a variety of methods in preparation of a total joint and ramus reconstruction with total joint prostheses (TMJ Concepts, Ventura, CA). Three-dimensional reconstructions from diagnostic computed tomography were used to establish a virtually planned resection which included the entire condyle-ramus complex. From these data, digital designs were used to manufacture molds to facilitate intraoperative fabrication of precise custom anatomic spacers from rapidly setting antibiotic-impregnated polymethyl methacrylate. Molds were manufactured using vat polymerization (stereolithography) with a photopolymer in the first case and powder bed fusion (electron beam melting) with Ti6AL4V for the second. Surgical methodology and the use of molds for intraoperative spacer fabrication for each case are discussed.
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Affiliation(s)
- John Marshall Green
- Department of Oral Maxillofacial Surgery, Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Sarah T Lawson
- Department of Oral Maxillofacial Surgery, Naval Hospital Bremerton, Bremerton, Washington
| | - Peter C Liacouras
- Department of Radiology, 3D Medical Applications Center, Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Edward M Wise
- Department of Oral Maxillofacial Surgery, Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Michael A Gentile
- Department of Oral Maxillofacial Surgery, Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Gerald Thomas Grant
- Department of Radiology, 3D Medical Applications Center, Walter Reed National Military Medical Center, Bethesda, Maryland
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Peach CA, Nicoletti S, Lawrence TM, Stanley D. Two-stage revision for the treatment of the infected total elbow arthroplasty. Bone Joint J 2013; 95-B:1681-6. [PMID: 24293600 DOI: 10.1302/0301-620x.95b12.31336] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
We report our experience of staged revision surgery for the treatment of infected total elbow arthroplasty (TEA). Between 1998 and 2010 a consecutive series of 33 patients (34 TEAs) underwent a first-stage procedure with the intention to proceed to second-stage procedure when the infection had been controlled. A single first-stage procedure with removal of the components and cement was undertaken for 29 TEAs (85%), followed by the insertion of antibiotic-impregnated cement beads, and five (15%) required two or more first-stage procedures. The most common organism isolated was coagulase-negative Staphylococcus in 21 TEAs (62%). A second-stage procedure was performed for 26 TEAs (76%); seven patients (seven TEAs, 21%) had a functional resection arthroplasty with antibiotic beads in situ and had no further surgery, one had a persistent discharge preventing further surgery. There were three recurrent infections (11.5%) in those patients who underwent a second-stage procedure. The infection presented at a mean of eight months (5 to 10) post-operatively. The mean Mayo Elbow Performance Score (MEPS) in those who underwent a second stage revision without recurrent infection was 81.1 (65 to 95). Staged revision surgery is successful in the treatment of patients with an infected TEA and is associated with a low rate of recurrent infection. However, when infection does occur, this study would suggest that it becomes apparent within ten months of the second stage procedure. Cite this article: Bone Joint J 2013;95-B:1681–6.
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Affiliation(s)
- C. A. Peach
- University Hospital of South Manchester, Shoulder
and Elbow Unit, Southmoor Road, Wythenshawe, Manchester
M23 9LT, UK
| | - S. Nicoletti
- Ospedale San Jacopo, U.O.
Ortopedia e Traumatologia, Raccordo di Pistoia, 51100 Pistoia, Italy
| | - T. M. Lawrence
- University Hospital Coventry and Warwickshire, Clifford
Bridge Road, Coventry, West Midlands
CV2 2DX, UK
| | - D. Stanley
- Northern General Hospital, Herries
Road, Sheffield S5 7AU, UK
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12
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Whittaker JP, Warren RE, Jones RS, Gregson PA. Is prolonged systemic antibiotic treatment essential in two-stage revision hip replacement for chronic Gram-positive infection? ACTA ACUST UNITED AC 2009; 91:44-51. [PMID: 19092003 DOI: 10.1302/0301-620x.91b1.20930] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
When using a staged approach to eradicate chronic infection after total hip replacement, systemic delivery of antibiotics after the first stage is often employed for an extended period of typically six weeks together with the use of an in situ antibiotic-eluting polymethylmethacrylate interval spacer. We report our multi-surgeon experience of 43 consecutive patients (44 hips) who received systemic vancomycin for two weeks in combination with a vancomycin- and gentamicin-eluting spacer system in the course of a two-stage revision procedure for deep infection with a median follow-up of 49 months (25 to 83). The antibiotic-eluting articulating spacers fractured in six hips (13.9%) and dislocated in five patients (11.6%). Successful elimination of the infecting organisms occurred in 38 (92.7%) of 41 hips with three patients developing superinfection with a new organism. We conclude that prolonged systemic antibiotic therapy may not be essential in the two-stage treatment of a total hip replacement for Gram-positive infection, provided that a high concentration of antibiotics is delivered locally using an antibiotic-eluting system.
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Affiliation(s)
- J. P. Whittaker
- Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Trust, Oswestry SY10 7AG, UK
| | - R. E. Warren
- Royal Shrewsbury Hospital, Mytton Oak Road, Shrewsbury, Shropshire SY3 8XQ, UK
| | - R. S. Jones
- Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Trust, Oswestry SY10 7AG, UK
| | - P. A. Gregson
- Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Trust, Oswestry SY10 7AG, UK
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13
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Bridgens J, Davies S, Tilley L, Norman P, Stockley I. Orthopaedic bone cement: do we know what we are using? ACTA ACUST UNITED AC 2008; 90:643-7. [PMID: 18450633 DOI: 10.1302/0301-620x.90b5.19803] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Bone cements produced by different manufacturers vary in their mechanical properties and antibiotic elution characteristics. Small changes in the formulation of a bone cement, which may not be apparent to surgeons, can also affect these properties. The supplier of Palacos bone cement with added gentamicin changed in 2005. We carried out a study to examine the mechanical characteristics and antibiotic elution of Schering-Plough Palacos, Heraeus Palacos and Depuy CMW Smartset bone cements. Both Heraeus Palacos and Smartset bone cements performed significantly better than Schering-Plough Palacos in terms of mechanical characteristics, with and without additional vancomycin (p < 0.001). All cements show a deterioration in flexural strength with increasing addition of vancomycin, albeit staying above ISO minimum levels. Both Heraeus Palacos and Smartset elute significantly more gentamicin cumulatively than Schering-Plough Palacos. Smartset elutes significantly more vancomycin cumulatively than Heraeus Palacos. The improved antibiotic elution characteristics of Smartset and Heraeus Palacos are not associated with a deterioration in mechanical properties. Although marketed as the 'original' Palacos, Heraeus Palacos has significantly altered mechanical and antibiotic elution characteristics compared with the most commonly-used previous version.
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Affiliation(s)
- J Bridgens
- Northern General Hospital, Herries Road, Sheffield S5 7AU, UK.
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14
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Stockley I, Mockford BJ, Hoad-Reddick A, Norman P. The use of two-stage exchange arthroplasty with depot antibiotics in the absence of long-term antibiotic therapy in infected total hip replacement. ACTA ACUST UNITED AC 2008; 90:145-8. [DOI: 10.1302/0301-620x.90b2.19855] [Citation(s) in RCA: 102] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
We present a series of 114 patients with microbiologically-proven chronically-infected total hip replacement, treated between 1991 and 2004 by a two-stage exchange procedure with antibiotic-loaded cement, but without the use of a prolonged course of antibiotic therapy. The mean follow-up for all patients was 74 months (2 to 175) with all surviving patients having a minimum follow-up of two years. Infection was successfully eradicated in 100 patients (87.7%), a rate which is similar to that reported by others, but where prolonged adjuvant antibiotic therapy has been used. Using the technique described, a prolonged course of systemic antibiotics does not appear to be essential and the high cost of the administration of antibiotics can be avoided.
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Affiliation(s)
- I. Stockley
- Sheffield Teaching Hospitals Trust, Herries Road, Sheffield, S5 7AU, UK
| | - B. J. Mockford
- Sheffield Teaching Hospitals Trust, Herries Road, Sheffield, S5 7AU, UK
| | - A. Hoad-Reddick
- Wrightington Hospital, Hall Lane, Appley Bridge, Wigan WN6 9EP, UK
| | - P. Norman
- Sheffield Teaching Hospitals Trust, Herries Road, Sheffield, S5 7AU, UK
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Qiang Z, Jun PZ, Jie XJ, Hang L, Bing LJ, Cai LF. Use of antibiotic cement rod to treat intramedullary infection after nailing: preliminary study in 19 patients. Arch Orthop Trauma Surg 2007; 127:945-51. [PMID: 17387498 DOI: 10.1007/s00402-007-0315-x] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2006] [Indexed: 10/23/2022]
Abstract
The treatment of intramedullary infections after nailing usually includes removal of the nail, debridement, and, in some cases, insertion of antibiotic-impregnated cement beads. We use this self-made antibiotic cement rod to treat intramedullary infections. Compared with the beads, it provides some limited mechanical support and can be preserved in the canal for a long time. We reviewed 19 infected patients who underwent removal of the nails, excision of sinus tracks, debridement of the canal and insertion of the rods. No recurrent infection occurred in 18 cases and 11 cases achieved bone healing, 6 cases achieved partial union. One patient had nonunion and one patient underwent amputation because of severe primary trauma and long-term infection. The rod was removed between 35 and 123 days after implantation. We conclude that the antibiotic cement rods could be a relatively effective, simple and inexpensive method of treating intramedullary infections after nailing.
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Affiliation(s)
- Zheng Qiang
- Department of Orthopaedics, Second Affiliated Hospital, Medical College, Zhejiang University, Hangzhou, PR China.
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16
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Hanssen AD, Spangehl MJ. Practical applications of antibiotic-loaded bone cement for treatment of infected joint replacements. Clin Orthop Relat Res 2004:79-85. [PMID: 15552141 DOI: 10.1097/01.blo.0000143806.72379.7d] [Citation(s) in RCA: 169] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
The use of antibiotic-loaded bone cement is an accepted treatment method for infected joint arthroplasties. It is helpful to separate the use of antibiotic-loaded bone cement as a method of prophylaxis as compared with the treatment of an established infection. A low dose of antibiotic-loaded bone cement (< or = 1 g of antibiotic per batch of cement) should be used for prophylaxis, and high-dose antibiotic-loaded bone cement (> 1 g antibiotic per batch of cement) is indicated for treatment. The only commercially available antibiotic-loaded bone cement products are low dose, with the use of tobramycin or gentamicin as an antibiotic selection. High-dose antibiotic-loaded bone cement requires hand mixing by the surgeon to facilitate the use of high dosages and choices of multiple antibiotics. Treatment of infected hip and knee arthroplasties with high-dose antibiotic-loaded bone cement is aided by the use of spacers of various shapes and sizes. These spacers, whether they are static or articulating (mobile), are meant to provide local delivery of antibiotics, stabilization of soft tissues, facilitation of an easier reimplantation, and improved clinical outcomes.
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Affiliation(s)
- Arlen D Hanssen
- Department of Orthopaedics, Mayo Clinic and Mayo Foundation, Rochester, MN 55906, USA.
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Abstract
Forty-three patients having 49 treatment protocols for periprosthetic total joint infections were staged prospectively, using an osteomyelitis classification system designed to stratify treatment selection according to patient risk factors. Implant salvage was possible in 66% of the infections treated within 30 days of the surgical procedure or within 14 days of symptom onset after a late, septic event. After debridement and implant removal, 88% of the patients with long-standing, refractory infections now have infection-free, functional reconstructions; 64% of these patients have a new, total joint replacement at the original site of treatment. All of the treatment failures, deaths, and amputations occurred in the high-risk patient cohorts prospectively identified within the staging system. Infection duration and the condition of the host are the two most important variables in predicting outcomes in patients with periprosthetic infections.
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