Infected total ankle arthroplasty following routine dental procedure

Treatment Options of Prosthetic Joint Infections Following Total Ankle Arthroplasty: A Systematic Review

Background: This comprehensive systematic review aims to explore and discuss existing treatment modalities for infections in total ankle arthroplasty (TAA), providing insights that may contribute to the establishment of a "standard of care" for these challenging cases. The study analyses the intricate landscape of infected TAA, addressing gaps in the current literature and emphasizing the need to refine treatment strategies. With the reported incidence of periprosthetic joint infection after TAA surpassing rates observed in total hip and knee replacements, the research navigates through various treatment modalities, underscoring the lack of a universally accepted standard of care. Methods: In this systematic review, following PRISMA guidelines, PubMed, Scopus, and Google Scholar, we identified 15 papers addressing the management strategies for infected TAA (162 infected ankle arthroplasty cases).These databases were chosen for their extensive coverage, strong relevance to the research topic, and ease of access, ensuring a thorough and focused retrieval of pertinent literature on the treatment of infected ankle prostheses. The review involved the identification and evaluation of articles providing insights into complications, treatment outcomes, and risk factors. Extracted data were summarized and reported. A descriptive analysis was performed, and when feasible, a statistical analysis was conducted. Results: Treatment modalities included irrigation and debridement (48.8%), revision total ankle arthroplasty (36.3%), primary arthrodesis (7.9%), spacer arthroplasty (4.5%), and primary amputation (3.9%). Complication rates varied, with 46.5% for irrigation and debridement, 20% for two-stage revision, 7.14% for primary arthrodesis, and 25% for spacer arthroplasty. Conclusions: The rising prevalence of TAA underscores the need for a definitive treatment protocol due to severe complications. This review emphasizes careful patient selection and accurate diagnosis. Irrigation and debridement are effective for acute infections, while two-stage revision is a valid alternative for chronic infections. High-quality randomized controlled trials are important for establishing an evidence-based treatment protocol.

Diagnosis and Management of Infected Total Ankle Replacements

As the number of primary total ankle replacements increases for treatment of end-stage ankle arthritis, failures are also expected to rise. Periprosthetic joint infection is among the causes of failures and has been reported to be as high as 5%. Diagnosis is usually made by a combination of clinical examination findings, imaging, laboratory, and microbiological workup. Management is generally separated into limb salvage or amputation. Limb salvage can be challenging and may involve a single versus staged approach. Options include revision arthroplasty or arthrodesis procedures (ankle versus tibiotalocalcaneal), and a multidisciplinary approach is sought to eradicate infection before definitive management.

Total Ankle Replacement Infections: A Systematic Review of the Literature

Periprosthetic infection (PJI) after TAR is a serious complication, often requiring further surgery, including revision arthroplasty, conversion to ankle arthrodesis, or even amputation. This systematic review aims to summarize the current evidence on the management of TAR PJI and provide a comprehensive overview of this topic, especially from an epidemiologic point of view. Three different databases (PubMed, Scopus, and Web of Science) were searched for relevant articles, and further references were obtained by cross-referencing. Seventy-one studies met the inclusion criteria, reporting on cases of TAR PJI. A total of 298 PJIs were retrieved. The mean incidence of PJI was 3.8% (range 0.2-26.1%). Furthermore, 53 (17.8%) were acute PJIs, whereas most of them (156, 52.3%) were late PJIs. Most of the studies were heterogeneous regarding the treatment protocols used, with a two-stage approach performed in most of the cases (107, 35.9%). While the prevalence of ankle PJI remains low, it is potentially one of the most devastating complications of TAR. This review highlights the lack of strong literature regarding TAR infections, thus highlighting a need for multicentric studies with homogeneous data regarding the treatment of ankle PJI to better understand outcomes.

Streptococcus mitis Chorioamnionitis after Dental Scaling and Oral Sex

Background

Oral sex is postulated to be a risk factor for the introduction of bacteria into the amniotic cavity. Common oropharyngeal bacteria have been implicated in reports of second trimester chorioamnionitis via ascending vaginal transmission following oral sex. Dental scaling can also introduce these pathogens into the blood stream, allowing hematogenous spread of oral pathogens to the fetoplacental unit in pregnant patients.

Case

We report a case of Streptococcus mitis chorioamnionitis at 21 weeks and 5 days' gestation in a patient whose only risk factors were recent dental scaling and recent oral sex with a partner known to have periodontal disease.

Conclusion

Bacterial chorioamnionitis should be considered in the differential diagnosis of preterm labour. Oral sex and dental procedures may be risk factors for chorioamnionitis.

What Metrics Can Be Used to Determine the Optimal Timing of Reimplantation in Patients Who Have Undergone Resection Arthroplasty as Part of a Two-Stage Exchange for Infected Total Ankle Arthroplasty (TAA)?

RECOMMENDATION

There is no conclusive data regarding what metrics can be used in order to determine the optimal timing of reimplantation for an infected TAA. We recommend that reimplantation is performed when there are clinical signs of resolution of infection (well-healed wound, lack of erythema, etc), and the serologic markers have substantially declined (>40%) from baseline (measured at the time of diagnosis of infection).

LEVEL OF EVIDENCE

Consensus.

DELEGATE VOTE

Agree: 100%, Disagree: 0%, Abstain: 0% (Unanimous, Strongest Consensus).

What Is the Treatment "Algorithm" for an Infected Total Ankle Arthroplasty (TAA)?

RECOMMENDATION

The treatment of an infected total ankle arthroplasty (TAA) is largely dictated by the acuity of the infection. The following treatment algorithm modified for TAA is recommended.¹⁹.

LEVEL OF EVIDENCE

Limited.

DELEGATE VOTE

Agree: 100%, Disagree: 0%, Abstain: 0% (Unanimous, Strongest Consensus).

What Are the Predictors of Treatment Failure in Patients Who Have Undergone Two-Stage Exchange for Infected Total Ankle Arthroplasty (TAA)?

RECOMMENDATION

Predictors for treatment failure in patients undergoing 2-stage exchange for infected total ankle arthroplasty (TAA) include compromised soft tissues (eg, sinus tract and exposed hardware), significant bone involvement/osteomyelitis, and insufficient timing of antibiotic course before reimplantation.

LEVEL OF EVIDENCE

Moderate.

DELEGATE VOTE

Agree: 100%, Disagree: 0%, Abstain: 0% (Unanimous, Strongest Consensus).

What Is the Definition of Acute and Chronic Periprosthetic Joint Infection (PJI) of Total Ankle Arthroplasty (TAA)?

RECOMMENDATION

There is a paucity of data for defining acute or chronic periprosthetic joint infection (PJI) following total ankle arthroplasty (TAA) in the literature. Any discussion of PJI after ankle replacement is entirely reliant on the literature surrounding knee and hip arthroplasty.

LEVEL OF EVIDENCE

Consensus.

DELEGATE VOTE

Agree: 100%, Disagree: 0%, Abstain: 0% (Unanimous, Strongest Consensus).

Diagnostic Criteria and Treatment of Acute and Chronic Periprosthetic Joint Infection of Total Ankle Arthroplasty

Background:

Prosthetic joint infection (PJI) after total ankle arthroplasty (TAA) is a serious complication that results in significant consequences to the patient and threatens the survival of the ankle replacement. PJI in TAA may require debridement, placement of antibiotic spacer, revision arthroplasty, conversion to arthrodesis, or potentially below the knee amputation. While the practice of TAA has gained popularity in recent years, there is some minimal data regarding wound complications in acute or chronic PJI of TAA. However, of the limited studies that describe complications of PJI of TAA, even fewer studies describe the criteria used in diagnosing PJI. This review will cover the current available literature regarding total ankle arthroplasty infection and will propose a model for treatment options for acute and chronic PJI in TAA.

Methods:

A review of the current literature was conducted to identify clinical investigations in which prosthetic joint infections occurred in total ankle arthroplasty with associated clinical findings, radiographic imaging, and functional outcomes. The electronic databases for all peer-reviewed published works available through January 31, 2018, of the Cochrane Library, PubMed MEDLINE, and Google Scholar were explored using the following search terms and Boolean operators: “total ankle replacement” OR “total ankle arthroplasty” AND “periprosthetic joint infection” AND “diagnosis” OR “diagnostic criteria.” An article was considered eligible for inclusion if it concerned diagnostic criteria of acute or chronic periprosthetic joint infection of total ankle arthroplasty regardless of the number of patients treated, type of TAA utilized, conclusion, or level of evidence of study.

Results:

No studies were found in the review of the literature describing criteria for diagnosing PJI specific to TAA.

Conclusions:

Literature describing the diagnosis and treatment of PJI in TAA is entirely reliant on the literature surrounding knee and hip arthroplasty. Because of the limited volume of total ankle arthroplasty in comparison to knee and hip arthroplasty, no studies to our knowledge exist describing diagnostic criteria specific to total ankle arthroplasty with associated reliability. Large multicenter trials may be required to obtain the volume necessary to accurately describe diagnostic criteria of PJI specific to TAA.

Level of Evidence:

Level III, systematic review.

Is Antibiotic Prophylaxis Necessary Before Dental Procedures in Patients Post Total Ankle Arthroplasty?

BACKGROUND:

The need for dental antibiotic prophylaxis after orthopedic surgery remains unclear. Current recommendations are based on patients with total hip and total knee arthroplasties. We investigated available evidence regarding the need for dental antibiotic prophylaxis in patients post foot and ankle surgery, specifically total ankle arthroplasty. Additionally, we examined the microbiology behind the risk of transient bacteremia from dental procedures and whether this leads to an increased risk for postoperative infection in foot and ankle surgery.

METHODS:

We performed a MEDLINE literature review of English articles between 1980 and 2018 on patients with prosthetic joints undergoing dental work, and studies evaluating hematogenous prosthetic joint infection (PJI) and dental antibiotic prophylaxis. We additionally included articles on PJI post total ankle arthroplasty, as well as committee guidelines.

RESULTS:

There is no literature at present that evaluates transient bacteremia with dental procedures in patients following foot and ankle surgery. The data on this topic are isolated to PJI rates in the context of hip and total knee arthroplasty. This is of particular interest as rates of total ankle arthroplasty PJI have been reported to be 2- to 4-fold higher than in hip and total knee arthroplasty.

CONCLUSION:

The concern for postoperative infection due to transient bacteremia without dental antibiotic prophylaxis can be extrapolated to patients undergoing foot and ankle surgeries. Some data suggest that oral cavity bacteria can seed a prosthetic joint, though no clear relationship has been demonstrated. Similar risk factors have been identified between hip and knee PJI and total ankle arthroplasty. In light of the absence of scrutiny of and guidelines on this topic in foot and ankle surgery, it may be advisable to apply similar principles to decision-making in patients after foot and ankle surgery.

LEVEL OF EVIDENCE:

Level III, systematic review.

How To Diagnose and Treat Infection in Total Ankle Arthroplasty

Periprosthetic infection after total ankle arthroplasty (TAA) is a serious complication, often requiring revision surgery, including revision arthroplasty, conversion to ankle arthrodesis, or even amputation. Risk factors for periprosthetic ankle infection include prior surgery at the site of infection, low functional preoperative score, diabetes, and wound healing problems. The clinical presentation of patients with periprosthetic ankle joint infection can be variable and dependent on infection manifestation: acute versus chronic. The initial evaluation in patients with suspected periprosthetic joint infections should include blood tests: C-reactive protein and erythrocyte sedimentation rate. Joint aspiration and synovial fluid analysis can help confirm suspected periprosthetic ankle infection.

Cement arthroplasty for ankle joint destruction

BACKGROUND

The aim of this study was to investigate the outcomes of cement arthroplasty used as a primary salvage procedure to treat ankle joint destruction.

METHODS

This study included sixteen patients who underwent primary cement arthroplasty from May 2004 to March 2012 because of an ankle disorder, including intractable infection, nonunion, or a large bone defect or tumor. The mean age of the patients was fifty-seven years (range, twenty-three to seventy-four years), and the mean follow-up period was thirty-nine months (range, fourteen to 100 months). The cement spacer position, cement breakage, osteolysis around the inserted cement, and alignment of the joint were evaluated radiographically. American Orthopaedic Foot & Ankle Society (AOFAS) scores and visual analogue scale (VAS) pain scores were recorded preoperatively and at the time of final follow-up. Functional questionnaires were used to assess the duration for which the patient could walk continuously, use of walking aids, sports activity, consumption of pain medication, and the patient's subjective assessment of the percentage of overall improvement compared with before the cement arthroplasty.

RESULTS

The cement spacer was retained without breakage for a mean of thirty-nine months (range, fourteen to 100 months). Osteolysis around the cement was observed in one patient at seventy-eight months, and subluxation developed in one patient. The mean AOFAS and VAS pain scores improved from 39 (range, 11 to 71) preoperatively to 70 (range, 47 to 88) postoperatively (p = 0.001) and from 8 (range, 4 to 9) to 3 (range, 1 to 7) (p = 0.001), respectively. At the final follow-up evaluation, nine of the sixteen patients did not require walking aids, ten used no pain medication, and nine were able to walk continuously for more than an hour. One patient complained of persistent pain and was considered to have had a failure of the procedure.

CONCLUSIONS

Primary cement arthroplasty might be a treatment option for advanced ankle destruction in elderly and less active patients.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Antibiotic prophylaxis to reduce the risk of joint implant contamination during dental surgery seems unnecessary

INTRODUCTION

Joint implant infection rates range between 0.5% and 3%. Contamination may be hematogenous, originating in oro-dental infection and, as in endocarditis, antibiotic prophylaxis has been recommended to cover oro-dental surgery in immunodepressed patients with joint implants less than 2 years old, despite the lack of any formal proof of efficacy. In this context, the cost and side effects of such prophylaxis raise the question of its real utility.

MATERIALS AND METHODS

A search of Pubmed was performed using the following keywords: prosthetic joint infection, dental procedure, antibiotic prophylaxis, hematogenous infection, dental infection, bacteremia, and endocarditis. Six hundred and fifty articles were retrieved, 68 of which were analyzed in terms of orthopedic prosthetic infection and/or endocarditis and oro-dental prophylaxis, as relevant to the following questions: frequency and intensity of bacteremia of oro-dental origin, frequency of prosthetic joint infection secondary to dental surgery, and objective efficacy of antibiotic prophylaxis in dental surgery in patients with joint implants.

RESULTS

Bacteremia of oro-dental origin is more frequently associated with everyday activities such as mastication than with tooth extraction. Isolated cases of prosthetic contamination from dental infection have been reported, but epidemiological studies in joint implant bearers found that absence of antibiotic prophylaxis during oro-dental surgery did not increase the rate of prosthetic infection. The analysis was not able to answer the question of the efficacy of dental antibiotic prophylaxis in immunodepressed patients; however, oro-dental hygiene and regular dental treatment reduce the risk of prosthetic infection by 30%.

DISCUSSION AND CONCLUSION

The present update is in agreement with the conclusions of ANSM expert group, which advised against antibiotic prophylaxis in oro-dental surgery in implant bearers, regardless of implant duration or comorbidity: the associated costs and risks are disproportional to efficacy. LEVEL OF EVIDENCE AND TYPE OF STUDY: Level V; expert opinion.

What is the true incidence of dental pathology in the total joint arthroplasty population?

One million total joint arthroplasties (TJAs) are performed annually in the United States. The incidence of oral disease has not been documented in this population. To understand the scope of disease, a descriptive longitudinal population-based study sought to define the true incidence of dental pathology in the TJA population. One hundred consecutive TJA patients from a dedicated arthroplasty practice were sent for dental clearance, including oral examination, cleaning, radiographs, and treatment of active decay. The incidence of pathology was documented. Of 10 patients, 23 (23%) were treated before being cleared for arthroplasty. Sixty-six procedures were performed--2.9 problems per patient. No patient developed TJA infection. Routine preoperative dental clearance revealed 23% incidence of pathology, and no patient developed TJA infection.

Haemophilic arthropathy of the ankle treated by total ankle replacement: a case series

The standard treatment for end-stage osteoarthritis of the ankle joint in haemophilic patients has been fusion of the ankle joint. Total ankle replacement is still controversial as a treatment option. The objective of this prospective study was to evaluate the mid-term outcome in patients treated with total ankle replacement using an unconstrained three-component ankle implant. Ten haemophilic ankles in eight patients (mean age: 43.2 years, range 26.7-57.5) treated with total ankle replacement were followed up for a minimum of 2.7 years (mean: 5.6, range 2.7-7.6). The outcome was measured with clinical and radiological evaluations. There were no intra- or peri-operative complications. The AOFAS-hindfoot-score increased from 38 (range 8-57) preoperatively to 81 (range 69-95) postoperatively. All patients were satisfied with the results. Four patients became pain free; in the whole patient cohort pain level decreased from 7.1 (range 4-9) preoperatively to 0.8 (range 0-3) postoperatively. All categories of SF-36 score showed significant improvements in quality of life. In one patient, open ankle arthrolysis was performed because of painful arthrofibrosis. For patients with haemophilic osteoarthritis of the ankle joint, total ankle replacement is a valuable alternative treatment to ankle fusion.