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Lin Y, Chen W, Peng S, Chang C, Lee S, Lin S. Impact of unplanned second debridement, antibiotics and implant retention on long-term outcomes in knee exchange arthroplasty: Elevated risk of failure and reinfection. J Exp Orthop 2024; 11:e12024. [PMID: 38694767 PMCID: PMC11058667 DOI: 10.1002/jeo2.12024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2023] [Revised: 02/02/2024] [Accepted: 03/26/2024] [Indexed: 05/04/2024] Open
Abstract
Purpose This study investigates the outcomes of two-stage exchange arthroplasty (EA) for periprosthetic joint infection (PJI) following initial or unplanned repeat debridement antibiotics, and implant retention (DAIR). Methods We retrospectively reviewed cases of knee arthroplasty infection treated with two-stage EA after DAIR, spanning from January 1994 to December 2010. A total of 138 patients were included, comprising 112 with initial DAIR and 26 with an unplanned second DAIR. Data on demographics, comorbidities, infection characteristics and causative organisms were analyzed. The primary outcome was implant failure or reinfection, observed over a minimum follow-up of 10 years. Results The overall success rate for two-stage EA was 87% (119/138 patients). Factors identified for treatment failure included reinfection with the same pathogen for unplanned second DAIR (hazard ratio [HR] = 3.41; 95% confidence interval [CI] = 1.35-4.38; p = 0.004), higher reinfection rates in patients undergoing EA after an unplanned second DAIR, especially with a prior history of PJI within 2 years (HR = 4.23; 95% CI = 2.39-5.31; p = 0.002), pre-first DAIR C-reactive protein (CRP) levels over 100 mg/dL (HR = 2.52; 95% CI = 1.98-3.42; p = 0.003) and recurrence with the same pathogen (HR = 2.35; 95% CI = 1.32-4.24; p = 0.007). Additional factors such as male gender (HR = 3.92; 95% CI = 1.21-5.25; p = 0.007) and osteoporosis (T score < -2.5; HR = 3.27; 95% CI = 1.23-5.28; p = 0.005) were identified as risk factors for implant failure in all EA cases. Conclusions This study identifies key risk factors for worse knee EA outcomes following DAIR, including a pre-first DAIR CRP level over 100 mg/L, same pathogen recurrence, and PJI history within 2 years. It shows implant failure rates remain constant across EA cases, regardless of DAIR sequence, particularly with risk factors like male gender and severe osteoporosis (T score < -2.5). These results underscore the need for careful evaluation before an unplanned second DAIR, given its significant impact on EA success. Level of Evidence Level III.
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Affiliation(s)
- Yu‐Chih Lin
- Department of Orthopaedic SurgeryChang Gung Memorial Hospital (CGMH)KweishanTaoyuanTaiwan
- Bone and Joint Research CenterChang Gung Memorial Hospital (CGMH)KweishanTaoyuanTaiwan
- College of MedicineChang Gung University (CGU)KweishanTaoyuanTaiwan
| | - Wei‐Cheng Chen
- Department of Orthopaedic SurgeryChang Gung Memorial Hospital (CGMH)KweishanTaoyuanTaiwan
- Bone and Joint Research CenterChang Gung Memorial Hospital (CGMH)KweishanTaoyuanTaiwan
- College of MedicineChang Gung University (CGU)KweishanTaoyuanTaiwan
| | - Shih‐Hui Peng
- Department of Orthopaedic SurgeryChang Gung Memorial Hospital (CGMH)KweishanTaoyuanTaiwan
- Bone and Joint Research CenterChang Gung Memorial Hospital (CGMH)KweishanTaoyuanTaiwan
- College of MedicineChang Gung University (CGU)KweishanTaoyuanTaiwan
| | - Chih‐Hsiang Chang
- Department of Orthopaedic SurgeryChang Gung Memorial Hospital (CGMH)KweishanTaoyuanTaiwan
- Bone and Joint Research CenterChang Gung Memorial Hospital (CGMH)KweishanTaoyuanTaiwan
- College of MedicineChang Gung University (CGU)KweishanTaoyuanTaiwan
| | - Sheng‐Hsun Lee
- Department of Orthopaedic SurgeryChang Gung Memorial Hospital (CGMH)KweishanTaoyuanTaiwan
- Bone and Joint Research CenterChang Gung Memorial Hospital (CGMH)KweishanTaoyuanTaiwan
- College of MedicineChang Gung University (CGU)KweishanTaoyuanTaiwan
| | - Sheng‐Hsuan Lin
- Institute of StatisticsNational Yang Ming Chiao Tung UniversityHsinchuTaiwan
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Bruyninckx S, Metsemakers WJ, Depypere M, Henckaerts L, van den Hout E, Onsea J, Ghijselings S, Vles GF. Local antibiotic delivery via intra-articular catheter infusion for the treatment of periprosthetic joint infection: a systematic review. Arch Orthop Trauma Surg 2024:10.1007/s00402-024-05341-2. [PMID: 38691147 DOI: 10.1007/s00402-024-05341-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2024] [Accepted: 04/14/2024] [Indexed: 05/03/2024]
Abstract
INTRODUCTION There is an increasing interest in the use of intra-articular (IA) antibiotic infusion as a stand-alone or adjuvant therapy to standard revision surgery for periprosthetic joint infection (PJI). The objective of this systematic review is to evaluate the evidence with respect to this up-and-coming treatment modality. METHODS A systematic review of studies published until April 2023 was conducted using PubMed, Embase, MEDLINE and Cochrane databases. Quality assessment was performed with the National Institute of Health quality assessment tool. Inclusion criteria were adult patients (≥ 18 years) with a mean follow-up of ≥ 11 months and a score ≥ 6 on the National Institute of Health quality assessment tool. Primary outcome was eradication of infection. RESULTS 15 articles, encompassing 631 PJIs in 626 patients, were included in the final analysis, all level IV case series. The majority was treated with single-stage revision with adjuvant IA antibiotic infusion (79.1%). The remaining PJIs were treated with stand-alone IA antibiotic infusion (12.2%), DAIR (debridement, antibiotics and implant retention) with adjuvant IA antibiotic infusion (5.7%) or two-stage revision with adjuvant IA antibiotic infusion (3.0%). Mean duration of IA antibiotic infusion was 19 days (range 3-50). An overall failure rate of approximately 11% was found. In total 117 complications occurred, 71 were non-catheter-related and 46 were catheter-related. The most common catheter-related complications were premature loss of the catheter (18/46) and elevated blood urea nitrogen (BUN) and creatinine levels (12/46). CONCLUSIONS Due to the lack of comparative studies the (added) benefit of IA antibiotic infusion in the treatment of PJI remains uncertain. Based on the current evidence, we would advise against using it as a stand-alone treatment. A prospective randomized controlled trial using a well-described infusion protocol is needed to see if the potential benefits justify the increased costs and potential complications of this treatment modality.
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Affiliation(s)
- S Bruyninckx
- Department of Orthopaedic Surgery, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium.
| | - W J Metsemakers
- Department of Trauma Surgery, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium
- Department of Development and Regeneration, KU Leuven, Herestraat 49-Box 805, 3000, Leuven, Belgium
| | - M Depypere
- Department of Laboratory Medicine, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium
- Department of Microbiology, Immunology and Transplantation, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - L Henckaerts
- Department of Microbiology, Immunology and Transplantation, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium
- Department of General Internal Medicine, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium
- Laboratory for Clinical Infectious and Inflammatory Disorders, KU Leuven, Herestraat 49, Leuven, Belgium
| | - E van den Hout
- Department of General Internal Medicine, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium
- Laboratory for Clinical Infectious and Inflammatory Disorders, KU Leuven, Herestraat 49, Leuven, Belgium
| | - J Onsea
- Department of Trauma Surgery, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium
- Department of Development and Regeneration, KU Leuven, Herestraat 49-Box 805, 3000, Leuven, Belgium
| | - S Ghijselings
- Department of Orthopaedic Surgery, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - G F Vles
- Department of Orthopaedic Surgery, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium
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Mirghaderi P, Eshraghi N, Sheikhbahaei E, Razzaghof M, Roustai-Geraylow K, Pouramini A, Eraghi MM, Kafi F, Javad Mortazavi SM. Does Using Highly Porous Tantalum in Revision Total Hip Arthroplasty Reduce the Rate of Periprosthetic Joint Infection? A Systematic Review and Meta-Analysis. Arthroplast Today 2024; 25:101293. [PMID: 38298809 PMCID: PMC10827600 DOI: 10.1016/j.artd.2023.101293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 10/15/2023] [Accepted: 11/05/2023] [Indexed: 02/02/2024] Open
Abstract
Background Studies suggest tantalum (Ta) implants may have inherent antibacterial properties. However, there is no consensus regarding the effectiveness of Ta in preventing periprosthetic joint infection (PJI) after revision total hip arthroplasty (rTHA). Methods We searched 5 main databases for articles reporting the rate of PJI following rTHA using Ta implants from inception to February 2022. The PJI rates of the Ta group were meta-analyzed, compared with the control group, and represented as relative risks (RRs) in forest plots. Results We identified 67 eligible studies (28,414 joints) for assessing the prevalence of PJI following rTHA using Ta implants. Among these studies, only 9 compared the Ta implant group with a control group. The overall PJI rate following rTHA using Ta implants was 2.9% (95% confidence interval [CI]: 2.2%-3.8%), while it was 5.7% (95% CI = 4.1%-7.8%) if only septic revisions were considered. Comparing the Ta and control groups showed a significantly lower PJI rate following all-cause rTHA with an RR = 0.80 (95% CI = 0.65-0.98, P < .05). There was a trend toward lower reinfection rates in the Ta group after rTHA in septic cases, although the difference was not statistically significant (RR = 0.75, 95% CI = 0.44-1.29, P = .30). Conclusions Ta implants are associated with a lower PJI rate following all-cause rTHA but not after septic causes. Despite positive results, the clinical significance of Ta still remains unclear since the PJI rate was only reduced by 20%. Level of Evidence IV.
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Affiliation(s)
- Peyman Mirghaderi
- Surgical Research Society (SRS), Students’ Scientific Research Center, Tehran University of Medical Sciences, Tehran, Iran
- Joint Reconstruction Research Center (JRRC), Tehran University of Medical Sciences, Tehran, Iran
| | - Nasim Eshraghi
- Surgical Research Society (SRS), Students’ Scientific Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Erfan Sheikhbahaei
- Surgical Research Society (SRS), Students’ Scientific Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammadreza Razzaghof
- Joint Reconstruction Research Center (JRRC), Tehran University of Medical Sciences, Tehran, Iran
| | - Kiarash Roustai-Geraylow
- Surgical Research Society (SRS), Students’ Scientific Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Alireza Pouramini
- Surgical Research Society (SRS), Students’ Scientific Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammad Mirahmadi Eraghi
- Surgical Research Society (SRS), Students’ Scientific Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Fatemeh Kafi
- Surgical Research Society (SRS), Students’ Scientific Research Center, Tehran University of Medical Sciences, Tehran, Iran
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Hrubina M, Necas L, Sammoudi D, Cabala J, Lisy P, Holjencik J, Melisik M, Cibula Z. Dynamic hip screw in proximal femoral fractures followed by "single-stage" hip arthroplasty-retrospective analysis. Eur J Orthop Surg Traumatol 2024; 34:1087-1093. [PMID: 37938320 PMCID: PMC10858082 DOI: 10.1007/s00590-023-03695-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Accepted: 08/13/2023] [Indexed: 11/09/2023]
Abstract
The aim of this study is to present the results of single-stage total hip arthroplasty (THA) after Dynamic Hip Screw (DHS) failure, or secondary posttraumatic osteoarthrosis. From 2003 to 2020, 15 THAs were performed in group of 15 patients for the treatment of DHS failure, or for late complications following femoral neck and pertrochanteric fractures. The mean follow-up period after arthroplasty was 46.9 months (range 7-139). The patients were evaluated retrospectively-both clinically and radiographically, focussing on the demography, infection rate and other complications (revision surgery), during the year 2023. 9 males and 6 females were included in the study, with a mean age of 56.5 years (range 29-93) at the time of primary osteosynthesis. Each of them had proximal femoral fracture treated primarily with a DHS and then late one-stage revision surgery, with hardware removal and THA implantation. The median time between DHS osteosynthesis and THA was 41.2 months (range 4-114). Four patients (26.6%) had complications after THA, with the need for revision in two cases (13.3%). Dislocation rate was 6.6% (one case), with the need for repeated-revision of THA. The infection rate was 6.6% (one patient) with the need for revision of THA. Peroperative periprosthetic femoral fracture was observed in 13.3% (two patients) without any other problems. Six patients (40%) died during the follow-up period. Single-stage total hip arthroplasty with concomitant hardware removal bears a high- mortality rate, with a higher incidence of postoperative complications compared to elective THA.
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Affiliation(s)
- Maros Hrubina
- Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Martin, Slovak Republic.
- University Department of Orthopaedic Surgery, University Hospital Martin, Kollarova 2, 036 59, Martin, Slovak Republic.
| | - Libor Necas
- Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Martin, Slovak Republic
- University Department of Orthopaedic Surgery, University Hospital Martin, Kollarova 2, 036 59, Martin, Slovak Republic
| | - Diaa Sammoudi
- University Department of Orthopaedic Surgery, University Hospital Martin, Kollarova 2, 036 59, Martin, Slovak Republic
| | - Juraj Cabala
- University Department of Orthopaedic Surgery, University Hospital Martin, Kollarova 2, 036 59, Martin, Slovak Republic
| | - Peter Lisy
- University Department of Orthopaedic Surgery, University Hospital Martin, Kollarova 2, 036 59, Martin, Slovak Republic
| | - Jozef Holjencik
- University Department of Orthopaedic Surgery, University Hospital Martin, Kollarova 2, 036 59, Martin, Slovak Republic
| | - Marian Melisik
- Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Martin, Slovak Republic
- University Department of Orthopaedic Surgery, University Hospital Martin, Kollarova 2, 036 59, Martin, Slovak Republic
| | - Zoltan Cibula
- Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Martin, Slovak Republic
- University Department of Orthopaedic Surgery, University Hospital Martin, Kollarova 2, 036 59, Martin, Slovak Republic
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Anzillotti G, Guazzoni E, Conte P, Di Matteo V, Kon E, Grappiolo G, Loppini M. Using Three-Dimensional Printing Technology to Solve Complex Primary Total Hip Arthroplasty Cases: Do We Really Need Custom-Made Guides and Templates? A Critical Systematic Review on the Available Evidence. J Clin Med 2024; 13:474. [PMID: 38256607 PMCID: PMC10816635 DOI: 10.3390/jcm13020474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Revised: 01/06/2024] [Accepted: 01/12/2024] [Indexed: 01/24/2024] Open
Abstract
The burden of osteoarthritis (OA) is around 300 million people affected worldwide, with the hip representing a commonly affected joint. Total hip arthroplasty (THA) has been used with notable success as a definitive treatment to improve pain and function in hip OA patients. The recent advent of new technologies, such as 3D printing, has pushed the application of these new concepts toward applications for the well-known THA. Currently, the evidence on the use of 3D printing to aid complex primary THA cases is still scarce. METHODS An extensive literature review was conducted to retrieve all articles centered on the use of 3D printing in the setting of primary THA. RESULTS A total of seven studies were included in the present systematic review. Four studies investigated the use of 3D-printed surgical guides to be used during surgery. The remaining three studies investigated the benefit of the use of 3D-printed templates of the pelvis to simulate the surgery. CONCLUSIONS The use of 3D printing could be a promising aid to solve difficult primary total hip arthroplasty cases. However, the general enthusiasm in the field is not supported by high-quality studies, hence preventing us from currently recommending its application in everyday practice.
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Affiliation(s)
- Giuseppe Anzillotti
- IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089 Milan, Italy; (G.A.); (E.G.); (P.C.); (V.D.M.); (E.K.); (G.G.)
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, 20072 Milan, Italy
| | - Edoardo Guazzoni
- IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089 Milan, Italy; (G.A.); (E.G.); (P.C.); (V.D.M.); (E.K.); (G.G.)
- Fondazione Livio Sciutto Onlus, Campus Savona, Università Degli Studi di Genova, 17100 Savona, Italy
| | - Pietro Conte
- IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089 Milan, Italy; (G.A.); (E.G.); (P.C.); (V.D.M.); (E.K.); (G.G.)
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, 20072 Milan, Italy
| | - Vincenzo Di Matteo
- IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089 Milan, Italy; (G.A.); (E.G.); (P.C.); (V.D.M.); (E.K.); (G.G.)
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, 20072 Milan, Italy
- Faculty of Medicine and Surgery, Catholic University of Sacred Heart, Largo Francesco Vito 1, 00168 Rome, Italy
| | - Elizaveta Kon
- IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089 Milan, Italy; (G.A.); (E.G.); (P.C.); (V.D.M.); (E.K.); (G.G.)
- Department of Traumatology, Orthopaedics and Disaster Surgery, Sechenov University, Moscow 119991, Russia
| | - Guido Grappiolo
- IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089 Milan, Italy; (G.A.); (E.G.); (P.C.); (V.D.M.); (E.K.); (G.G.)
- Fondazione Livio Sciutto Onlus, Campus Savona, Università Degli Studi di Genova, 17100 Savona, Italy
| | - Mattia Loppini
- IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089 Milan, Italy; (G.A.); (E.G.); (P.C.); (V.D.M.); (E.K.); (G.G.)
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, 20072 Milan, Italy
- Fondazione Livio Sciutto Onlus, Campus Savona, Università Degli Studi di Genova, 17100 Savona, Italy
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Lenguerrand E, Whitehouse MR, Beswick AD, Kunutsor SK, Webb JCJ, Mehendale S, Porter M, Blom AW. Mortality and re-revision following single-stage and two-stage revision surgery for the management of infected primary hip arthroplasty in England and Wales. Bone Joint Res 2023; 12:321-330. [PMID: 37158424 PMCID: PMC10167772 DOI: 10.1302/2046-3758.125.bjr-2022-0131.r1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/10/2023] Open
Abstract
We compared the risks of re-revision and mortality between two-stage and single-stage revision surgeries among patients with infected primary hip arthroplasty. Patients with a periprosthetic joint infection (PJI) of their primary arthroplasty revised with single-stage or two-stage procedure in England and Wales between 2003 and 2014 were identified from the National Joint Registry. We used Poisson regression with restricted cubic splines to compute hazard ratios (HRs) at different postoperative periods. The total number of revisions and re-revisions undergone by patients was compared between the two strategies. In total, 535 primary hip arthroplasties were revised with single-stage procedure (1,525 person-years) and 1,605 with two-stage procedure (5,885 person-years). All-cause re-revision was higher following single-stage revision, especially in the first three months (HR at 3 months = 1.98 (95% confidence interval (CI) 1.14 to 3.43), p = 0.009). The risks were comparable thereafter. Re-revision for PJI was higher in the first three postoperative months for single-stage revision and waned with time (HR at 3 months = 1.81 (95% CI 1.22 to 2.68), p = 0.003; HR at 6 months = 1.25 (95% CI 0.71 to 2.21), p = 0.441; HR at 12 months = 0.94 (95% CI 0.54 to 1.63), p = 0.819). Patients initially managed with a single-stage revision received fewer revision operations (mean 1.3 (SD 0.7) vs 2.2 (SD 0.6), p < 0.001). Mortality rates were comparable between these two procedures (29/10,000 person-years vs 33/10,000). The risk of unplanned re-revision was lower following two-stage revision, but only in the early postoperative period. The lower overall number of revision procedures associated with a single-stage revision strategy and the equivalent mortality rates to two-stage revision are reassuring. With appropriate counselling, single-stage revision is a viable option for the treatment of hip PJI.
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Affiliation(s)
- Erik Lenguerrand
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Michael R Whitehouse
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol NHS Foundation Trust and University of Bristol, Bristol, UK
| | - Andrew D Beswick
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Setor K Kunutsor
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol NHS Foundation Trust and University of Bristol, Bristol, UK
| | - Jason C J Webb
- Avon Orthopaedic Centre, Southmead Hospital, North Bristol NHS Trust, Bristol, UK
| | - Sanchit Mehendale
- Department of Trauma and Orthopaedics, Bristol Royal Infirmary, Bristol, UK
| | - Martyn Porter
- Centre for Hip Surgery, Wrightington Hospital, Wrightington, UK
| | - Ashley W Blom
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol NHS Foundation Trust and University of Bristol, Bristol, UK
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Matsuno Y, Takegami Y, Tokutake K, Takami H, Kurokawa H, Iwata M, Terasawa S, Yamauchi KI, Imagama S. Incidence and Risk Factors for Fracture-Related Infection After Peri-Prosthetic Femoral Fractures: A Multicenter Retrospective Study (TRON Group Study). Surg Infect (Larchmt) 2023. [PMID: 37155200 DOI: 10.1089/sur.2022.347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/10/2023] Open
Abstract
Background: Fracture-related infection (FRI) sometimes occurs with peri-prosthetic femoral fracture (PPF) treatment. Fracture-related infection often leads to multiple re-operations, possible non-union, a decreased clinical function, and long-term antibiotic treatment. In this multicenter study, we aimed to clarify the incidence of FRI, the causative organisms of wound infection, and the risk factors associated with post-operative infection for PPF. Patients and Methods: Among 197 patients diagnosed with peri-prosthetic femoral fracture who received surgical treatment in 11 institutions (named the TRON group) from 2010 to 2019, 163 patients were included as subjects. Thirty-four patients were excluded because of insufficient follow-up (less than six months) or data loss. We extracted the following risk factors for FRI: gender, body mass index, smoking history, diabetes mellitus, chronic hepatitis, rheumatoid arthritis, dialysis, history of osteoporosis treatment, injury mechanism (high- or low-energy), Vancouver type, and operative information (waiting period for surgery, operation time, amount of blood loss, and surgical procedure). We conducted a logistic regression analysis to investigate the risk factors for FRI using these extracted items as explanatory variables and the presence or absence of FRI as the response variable. Results: Fracture-related infection occurred after surgery for PPF in 12 of 163 patients (7.3%). The most common causative organism was Staphylococcus aureus (n = 7). The univariable analysis showed differences for dialysis (p = 0.001), Vancouver type (p = 0.036), blood loss during surgery (p = 0.001), and operative time (p = 0.001). The multivariable logistic-regression analysis revealed that the patient background factor of dialysis (odds ratio [OR], 22.9; p = 0.0005), and the operative factor of Vancouver type A fracture (OR, 0.039-1.18; p = 0.018-0.19) were risk factors for FRI. Conclusions: The rate of post-operative wound infection in patients with a PPF was 7.3%. Staphylococcus was the most frequent causative organism. The surgeon should pay attention to infection after surgery for patients with Vancouver type A fractures and those undergoing dialysis.
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Affiliation(s)
- Yuji Matsuno
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Yasuhiko Takegami
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Katsuhiro Tokutake
- Department of Hand Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Hideomi Takami
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Hiroshi Kurokawa
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Manato Iwata
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Satoshi Terasawa
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Ken-Ichi Yamauchi
- Department of Orthopedic Surgery, Toyohashi Municipal Hospital, Toyohashi, Japan
| | - Shiro Imagama
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
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van den Kieboom J, Tirumala V, Xiong L, Klemt C, Kwon YM. Periprosthetic joint infection is the main reason for failure in patients following periprosthetic fracture treated with revision arthroplasty. Arch Orthop Trauma Surg 2022; 142:3565-3574. [PMID: 33991236 DOI: 10.1007/s00402-021-03948-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2020] [Accepted: 05/03/2021] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Periprosthetic fracture after primary total hip and knee arthroplasty (THA; TKA) can be challenging, requiring open reduction internal fixation (ORIF), revision, or both. The aim of this study was to evaluate the outcomes and risk factors associated with re-revision surgery following failed revision arthroplasty for periprosthetic fracture. METHODS A total of 316 consecutive THA patients and 79 consecutive TKA patients underwent a revision for periprosthetic fracture, of which 68 THA patients (21.5%) and 15 TKA patients (18.9%) underwent re-revision surgery. The most common indication for hip and knee re-revision was periprosthetic joint infection (PJI) in 28 THA patients (46.6%) and 11 TKA patients (47.8%). RESULTS The complication rates of THA and TKA revision were 24.3% and 25.3% respectively, and 35.0% and 39.1% respectively for re-revision surgery at an average follow-up of 4.5 years. Periprosthetic joint infection was the most common indication for THA and TKA re-revision (46.7%; 47.8%) and third revision surgery (15.0%; 13.0%). Factors significantly contributing to an increased risk of THA and TKA re-revision included revision with plate fixation and revision with combined ORIF. CONCLUSION The overall complication rate of THA and TKA re-revision surgery following failed revision surgery for periprosthetic fracture was higher than of revision surgery. The most common indication for re-revision and third revision was periprosthetic joint infection. These findings may assist surgeons in the management and preoperative counseling of patients undergoing THA and TKA revision surgery for a periprosthetic fracture to optimize the outcomes for these patients. LEVEL OF EVIDENCE Level III, case-control retrospective analysis.
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Affiliation(s)
- Janna van den Kieboom
- Bioengineering Laboratory, Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA, 02114, USA
| | - Venkatsaiakhil Tirumala
- Bioengineering Laboratory, Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA, 02114, USA
| | - Liang Xiong
- Bioengineering Laboratory, Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA, 02114, USA
| | - Christian Klemt
- Bioengineering Laboratory, Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA, 02114, USA
| | - Young-Min Kwon
- Bioengineering Laboratory, Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA, 02114, USA.
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9
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Blom AW, Beswick AD, Burston A, Carroll FE, Garfield K, Gooberman-Hill R, Harris S, Kunutsor SK, Lane A, Lenguerrand E, MacGowan A, Mallon C, Moore AJ, Noble S, Palmer CK, Rolfson O, Strange S, Whitehouse MR. Infection after total joint replacement of the hip and knee: research programme including the INFORM RCT. Programme Grants Appl Res 2022. [DOI: 10.3310/hdwl9760] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Background
People with severe osteoarthritis, other joint conditions or injury may have joint replacement to reduce pain and disability. In the UK in 2019, over 200,000 hip and knee replacements were performed. About 1 in 100 replacements becomes infected, and most people with infected replacements require further surgery.
Objectives
To investigate why some patients are predisposed to joint infections and how this affects patients and the NHS, and to evaluate treatments.
Design
Systematic reviews, joint registry analyses, qualitative interviews, a randomised controlled trial, health economic analyses and a discrete choice questionnaire.
Setting
Our studies are relevant to the NHS, to the Swedish health system and internationally.
Participants
People with prosthetic joint infection after hip or knee replacement and surgeons.
Interventions
Revision of hip prosthetic joint infection with a single- or two-stage procedure.
Main outcome measures
Long-term patient-reported outcomes and reinfection. Cost-effectiveness of revision strategies over 18 months from two perspectives: health-care provider and Personal Social Services, and societal.
Data sources
National Joint Registry; literature databases; published cohort studies; interviews with 67 patients and 35 surgeons; a patient discrete choice questionnaire; and the INFORM (INFection ORthopaedic Management) randomised trial.
Review methods
Systematic reviews of studies reporting risk factors, diagnosis, treatment outcomes and cost comparisons. Individual patient data meta-analysis.
Results
In registry analyses, about 0.62% and 0.75% of patients with hip and knee replacement, respectively, had joint infection requiring surgery. Rates were four times greater after aseptic revision. The costs of inpatient and day-case admissions in people with hip prosthetic joint infection were about five times higher than those in people with no infection, an additional cost of > £30,000. People described devastating effects of hip and knee prosthetic joint infection and treatment. In the treatment of hip prosthetic joint infection, a two-stage procedure with or without a cement spacer had a greater negative impact on patient well-being than a single- or two-stage procedure with a custom-made articulating spacer. Surgeons described the significant emotional impact of hip and knee prosthetic joint infection and the importance of a supportive multidisciplinary team. In systematic reviews and registry analyses, the risk factors for hip and knee prosthetic joint infection included male sex, diagnoses other than osteoarthritis, high body mass index, poor physical status, diabetes, dementia and liver disease. Evidence linking health-care setting and surgeon experience with prosthetic joint infection was inconsistent. Uncemented fixation, posterior approach and ceramic bearings were associated with lower infection risk after hip replacement. In our systematic review, synovial fluid alpha-defensin and leucocyte esterase showed high diagnostic accuracy for prosthetic joint infection. Systematic reviews and individual patient data meta-analysis showed similar reinfection outcomes in patients with hip or knee prosthetic joint infection treated with single- and two-stage revision. In registry analysis, there was a higher rate of early rerevision after single-stage revision for hip prosthetic joint infection, but, overall, 40% fewer operations are required as part of a single-stage procedure than as part of a two-stage procedure. The treatment of hip or knee prosthetic joint infection with early debridement and implant retention may be effective in > 60% of cases. In the INFORM randomised controlled trial, 140 patients with hip prosthetic joint infection were randomised to single- or two-stage revision. Eighteen months after randomisation, pain, function and stiffness were similar between the randomised groups (p = 0.98), and there were no differences in reinfection rates. Patient outcomes improved earlier in the single-stage than in the two-stage group. Participants randomised to a single-stage procedure had lower costs (mean difference –£10,055, 95% confidence interval –£19,568 to –£542) and higher quality-adjusted life-years (mean difference 0.06, 95% confidence interval –0.07 to 0.18) than those randomised to a two-stage procedure. Single-stage was the more cost-effective option, with an incremental net monetary benefit at a threshold of £20,000 per quality-adjusted life-year of £11,167 (95% confidence interval £638 to £21,696). In a discrete choice questionnaire completed by 57 patients 18 months after surgery to treat hip prosthetic joint infection, the most valued characteristics in decisions about revision were the ability to engage in valued activities and a quick return to normal activity.
Limitations
Some research was specific to people with hip prosthetic joint infection. Study populations in meta-analyses and registry analyses may have been selected for joint replacement and specific treatments. The INFORM trial was not powered to study reinfection and was limited to 18 months’ follow-up. The qualitative study subgroups were small.
Conclusions
We identified risk factors, diagnostic biomarkers, effective treatments and patient preferences for the treatment of hip and knee prosthetic joint infection. The risk factors include male sex, diagnoses other than osteoarthritis, specific comorbidities and surgical factors. Synovial fluid alpha-defensin and leucocyte esterase showed high diagnostic accuracy. Infection is devastating for patients and surgeons, both of whom describe the need for support during treatment. Debridement and implant retention is effective, particularly if performed early. For infected hip replacements, single- and two-stage revision appear equally efficacious, but single-stage has better early results, is cost-effective at 18-month follow-up and is increasingly used. Patients prefer treatments that allow full functional return within 3–9 months.
Future work
For people with infection, develop information, counselling, peer support and care pathways. Develop supportive care and information for patients and health-care professionals to enable the early recognition of infections. Compare alternative and new treatment strategies in hip and knee prosthetic joint infection. Assess diagnostic methods and establish NHS diagnostic criteria.
Study registration
The INFORM randomised controlled trial is registered as ISRCTN10956306. All systematic reviews were registered in PROSPERO (as CRD42017069526, CRD42015023485, CRD42018106503, CRD42018114592, CRD42015023704, CRD42017057513, CRD42015016559, CRD42015017327 and CRD42015016664).
Funding
This project was funded by the National Institute for Health and Care Research (NIHR) Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 10, No. 10. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Ashley W Blom
- National Institute for Health and Care Research Bristol Biomedical Research Centre, University Hospitals Bristol and Weston NHS Foundation Trust and University of Bristol, Bristol, UK
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Andrew D Beswick
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Amanda Burston
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Fran E Carroll
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Kirsty Garfield
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- Bristol Randomised Trials Collaboration, University of Bristol, Bristol, UK
| | - Rachael Gooberman-Hill
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Shaun Harris
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- Bristol Randomised Trials Collaboration, University of Bristol, Bristol, UK
| | - Setor K Kunutsor
- National Institute for Health and Care Research Bristol Biomedical Research Centre, University Hospitals Bristol and Weston NHS Foundation Trust and University of Bristol, Bristol, UK
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Athene Lane
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- Bristol Randomised Trials Collaboration, University of Bristol, Bristol, UK
| | - Erik Lenguerrand
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | | | - Charlotte Mallon
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Andrew J Moore
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Sian Noble
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Cecily K Palmer
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- National Institute for Health and Care Research Applied Research Collaboration West (NIHR ARC West), University Hospitals Bristol NHS Foundation Trust and University of Bristol, Bristol, UK
| | - Ola Rolfson
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Simon Strange
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Michael R Whitehouse
- National Institute for Health and Care Research Bristol Biomedical Research Centre, University Hospitals Bristol and Weston NHS Foundation Trust and University of Bristol, Bristol, UK
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
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10
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Um SH, Min BW, Lee KJ, Kim DW, Bae KC, Cho CH, Son ES. Screw augmented cement spacer for deficient acetabulum in periprosthetic infection following Total Hip Arthroplasty. Orthop Traumatol Surg Res 2022; 108:103041. [PMID: 34389497 DOI: 10.1016/j.otsr.2021.103041] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2020] [Revised: 01/30/2021] [Accepted: 02/15/2021] [Indexed: 02/03/2023]
Abstract
For periprosthetic joint infection (PJI) treatment, revision total hip arthroplasty using an antibiotic loaded cement spacer is one of the important surgical methods. However, revision total hip arthroplasty using antibiotic-loaded cement spacers poses a risk of spacer dislodgement in patients with acetabular deficiency. We hypothesized that screw augmentation would be more stable and result in lower rates of cement spacer dislodgement in acetabular deficient patients. Thus, we suggest a method of screw augmentation with cement spacers to treat periprosthetic infection in patients with a deficient acetabulum. And we aim to report better clinical outcomes after revision total hip arthroplasty for infection control using screw augmented cement spacer insertion technique. Level of evidence: IV.
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Affiliation(s)
- Sang-Hyun Um
- Department of Orthopedic Surgery, Dongsan Medical Center, Keimyung University, School of Medicine, Daegu, Republic of Korea
| | - Byung-Woo Min
- Department of Orthopedic Surgery, Dongsan Medical Center, Keimyung University, School of Medicine, Daegu, Republic of Korea
| | - Kyung-Jae Lee
- Department of Orthopedic Surgery, Dongsan Medical Center, Keimyung University, School of Medicine, Daegu, Republic of Korea.
| | - Dong-Wan Kim
- Department of Orthopedic Surgery, Dongsan Medical Center, Keimyung University, School of Medicine, Daegu, Republic of Korea
| | - Ki-Cheor Bae
- Department of Orthopedic Surgery, Dongsan Medical Center, Keimyung University, School of Medicine, Daegu, Republic of Korea
| | - Chul-Hyun Cho
- Department of Orthopedic Surgery, Dongsan Medical Center, Keimyung University, School of Medicine, Daegu, Republic of Korea
| | - Eun-Suck Son
- Department of Orthopedic Surgery, Dongsan Medical Center, Keimyung University, School of Medicine, Daegu, Republic of Korea
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11
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Coraça-Huber DC, Steixner SJM, Najman S, Stojanovic S, Finze R, Rimashevskiy D, Saginova D, Barbeck M, Schnettler R. Lyophilized Human Bone Allograft as an Antibiotic Carrier: An In Vitro and In Vivo Study. Antibiotics (Basel) 2022; 11:antibiotics11070969. [PMID: 35884224 PMCID: PMC9312243 DOI: 10.3390/antibiotics11070969] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Revised: 07/04/2022] [Accepted: 07/13/2022] [Indexed: 02/04/2023] Open
Abstract
Background: Antibiotics delivered from implanted bone substitute materials (BSM) can potentially be used to prevent acute infections and biofilm formation, providing high concentrations of antibiotics at the surgical site without systemic toxicity. In addition, BSM should allow osteoconductivity supporting bone healing without further surgery. Promising results have been achieved using lyophilized bone allografts mixed with antibiotics. Methods: In this study specially prepared human bone allografts were evaluated as an antibiotic carrier in vitro and in vivo. The efficacy of different antibiotic-impregnated bone allografts was measured by drug release tests in vitro and in vivo and bacterial susceptibility tests using four bacterial species usually responsible for implant-associated infections. Results: The loading procedures of allograft bone substitutes with antibiotics were successful. Some of the antibiotic concentrations exceeded the MIC90 for up to 7 days in vitro and for up to 72 h in vivo. The susceptibility tests showed that S. epidermidis ATCC 12228 was the most susceptible bacterial species in comparison to the other strains tested for all antibiotic substances. Vancomycin and rifampicin showed the best results against standard and patient-isolated strains in vitro. In vivo, new bone formation was comparable in all study groups including the control group without antibiotic loading. Conclusions: Human bone allografts showed the capacity to act as customized loaded antibiotic carriers to prevent acute infections and should be considered in the management of bone infections in combination with systemic antimicrobial therapy.
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Affiliation(s)
- Débora C. Coraça-Huber
- Research Laboratory for Biofilms and Implant Associated Infections (BIOFILM LAB), Experimental Orthopaedics, University Hospital for Orthopaedics and Traumatology, Medical University of Innsbruck, Peter-Mayr-Strasse 4b, Room 204, 6020 Innsbruck, Austria;
- Correspondence: ; Tel.: +43-512-9003-71697; Fax: +43-512-9003-73691
| | - Stephan J. M. Steixner
- Research Laboratory for Biofilms and Implant Associated Infections (BIOFILM LAB), Experimental Orthopaedics, University Hospital for Orthopaedics and Traumatology, Medical University of Innsbruck, Peter-Mayr-Strasse 4b, Room 204, 6020 Innsbruck, Austria;
| | - Stevo Najman
- Department of Cell and Tissue Engineering, Scientific Research Center for Biomedicine, Faculty of Medicine, University of Niš, Blvd. Dr Zorana Djindjica, 18108 Niš, Serbia; (S.N.); (S.S.)
- Department of Biology and Human Genetics, Faculty of Medicine, University of Niš, Blvd. Dr Zorana Djindjica, 18108 Niš, Serbia
| | - Sanja Stojanovic
- Department of Cell and Tissue Engineering, Scientific Research Center for Biomedicine, Faculty of Medicine, University of Niš, Blvd. Dr Zorana Djindjica, 18108 Niš, Serbia; (S.N.); (S.S.)
- Department of Biology and Human Genetics, Faculty of Medicine, University of Niš, Blvd. Dr Zorana Djindjica, 18108 Niš, Serbia
| | - Ronja Finze
- University Medical Centre, Justus Liebig University of Giessen, 35390 Giessen, Germany; (R.F.); (R.S.)
| | - Denis Rimashevskiy
- Department of Traumatology and Orthopedics, Peoples Friendship University of Russia, Miklukho-Maklaya Street 6, 117198 Moscow, Russia;
| | - Dina Saginova
- National Scientific Center of Traumatology and Orthopedics Named after Academician N. D. Batpenov, 15a Abylay khan Ave., Nur-Sultan 01000, Kazakhstan;
| | - Mike Barbeck
- Clinic and Policlinic for Dermatology and Venereology, University Medical Center Rostock, 18057 Rostock, Germany;
- BerlinAnalytix GmbH, 12109 Berlin, Germany
| | - Reinhard Schnettler
- University Medical Centre, Justus Liebig University of Giessen, 35390 Giessen, Germany; (R.F.); (R.S.)
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12
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Edwards NM, Varnum C, Nelissen RGHH, Overgaard S, Pedersen AB. The association between socioeconomic status and the 30- and 90-day risk of infection after total hip arthroplasty : a registry-based cohort study of 103,901 patients with osteoarthritis. Bone Joint J 2022; 104-B:221-226. [PMID: 35094583 DOI: 10.1302/0301-620x.104b2.bjj-2021-1030.r1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
AIMS The aim of this study was to examine whether socioeconomic status (SES) is associated with a higher risk of infections following total hip arthroplasty (THA) at 30 and 90 days. METHODS We obtained individual-based information on SES markers (cohabitation, education, income, and savings) on 103,901 THA patients from Danish health registries between 1 January 1995 and 31 December 2017. The primary outcome measure was any hospital-treated infection (i.e. all infections). The secondary outcomes were further specified to specific hospital-treated infections (pneumonia, urinary tract infection, and periprosthetic joint infection). The primary timepoint was within 90 days. In addition, the outcomes were further evaluated within 30 days. We calculated the cumulative incidence, and used the pseudo-observation method and generalized linear regression to estimate adjusted risk ratios (RRs) with 95% confidence intervals (CIs) for each marker. RESULTS The cumulative incidence of any infection at 90 days was highest in patients who lived alone (1.5% (95% CI 1.3 to 1.6)) versus cohabitant (0.7% (95% CI 0.7 to 0.8)), had the lowest educational achievement (1.1% (95% CI 1.0 to 1.2)) versus highest (0.7% (95% CI 0.5 to 0.8)), had the lowest income (1.6% (95% CI 1.5 to 1.70)) versus highest (0.4% (95% CI 0.3 to 0.5)), or had lowest savings (1.3% (95% CI 1.2 to 1.4)) versus highest (0.7% (95% CI 0.6 to 0.8)). Within 90 days, the RRs for any infection were 1.3 (95% CI 1.2 to 1.4) for patients living alone versus cohabiting, 1.2 (95% CI 1.0 to 1.3) for low education achievement versus high, 1.7 (95% CI 1.4 to 2.1) for low income versus high income, and 1.5 (95% CI 1.4 to 1.8) for low savings versus high savings. The same trends were also seen for any infections within the first 30 days. CONCLUSION Our study provides evidence that socioeconomic inequality adversely influences the risk of infection after THA, thus contributing to healthcare disparities and inequalities. We found that living alone, low educational achievement, low income, or low savings were associated with higher risks of infections within the first 30 and 90 days after THA. Therefore, the development of targeted intervention strategies with the aim of increasing awareness of patients identified as being at greatest risk is needed to mitigate the impact of SES on the risk of infections following THA. Cite this article: Bone Joint J 2022;104-B(2):221-226.
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Affiliation(s)
- Nina M Edwards
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | - Claus Varnum
- Department of Orthopaedic Surgery, Lillebaelt Hospital, Vejle, Denmark.,Department of Regional Health Research, University of Southern Denmark, Odense, Denmark.,Department of Orthopaedic Surgery and Traumatology, Odense Universitetshospital, Odense, Denmark.,Danish Hip Arthroplasty Register, Copenhagen, Denmark
| | - Rob G H H Nelissen
- Department of Orthopaedics, Leids Universitair Medisch Centrum, Leiden, Netherlands
| | - Søren Overgaard
- Danish Hip Arthroplasty Register, Copenhagen, Denmark.,Copenhagen University Hospital, Bispebjerg Department of Orthopaedic Surgery and Traumatology, Frederiksberg Hospital, Copenhagen, Denmark.,Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Alma B Pedersen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark
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13
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Unfried RI, Krause LMF, Cezimbra HM, Pacheco LS, Larangeira JA, Ribeiro TA. A Retrospective Observational Cohort Study of Periprosthetic Hip Infection Treated by one-stage Method Including Cases With Bone Graft Reconstruction. Clin Med�Insights�Arthritis�Musculoskelet Disord 2022; 15:11795441221090344. [PMID: 35547099 PMCID: PMC9081729 DOI: 10.1177/11795441221090344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/16/2021] [Accepted: 03/03/2022] [Indexed: 11/17/2022]
Abstract
Purpose: Prosthetic joint infection (PJI) is a devastating complication that can affect hip arthroplasty. Its treatment is extremely difficult, and issues regarding the optimal treatment remain unanswered. This study intended to show the effectiveness of the one-stage treatment of PJI. Materials and Methods: A retrospective observational cohort study performed from July 2014- August 2018. All patients with suspected PJI were included. Major and minor criteria developed by the International Consensus on Periprosthetic Joint Infection (ICPJI) was used to define infection. Laboratory tests and image exams were performed, and all patients were followed for at least 2 years. Outcomes: Success rate (2018 ICPJI definition to success) in treatment of PJI using one-stage revision method. Clinical and functional outcomes defined by Harris Hip Score (HHS). Results: Thirty-one patients were screened and 18 analyzed. 69.85 ± 9.76 years was the mean age. Mean follow-up time was 63.84 ± 18.55 months. Ten patients had acetabular defects and required bone graft reconstruction. Sixteen patients were classified as Tier 1, 1 as Tier 3D, and as 1 Tier 3E. Almost 90% of patients submitted to one-stage revision with acetabulum graft reconstruction were free of infection. The overall infection survival rate was 78.31±6.34 months. Candida albicans and sinus tract were statistically significant in univariate Cox’s analysis. The predictor of one-stage revision surgery failure that remained final Cox’s regression model was C. albicans (hazard ratio [HR]: 4.47). Conclusion: Treatment through one-stage revision surgery associated with 6 months of antimicrobial is a viable option with acceptable results even when bone graft reconstruction is necessary. C. albicans was a strong predictor of failure in this cohort.
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Affiliation(s)
- Ricardo Issler Unfried
- Department of and Traumatology, University Hospital of Santa Maria (SOT-HUSM), Federal University of Santa Maria (UFSM), Santa Maria, Brazil
- Master’s Course in Health and Life Sciences, Universidade Franciscana (UFN), Santa Maria, Brazil
| | | | - Helen Minussi Cezimbra
- Department of Infectious Diseases, University Hospital of Santa Maria, Federal University of Santa Maria (UFSM), Santa Maria, Brazil
| | - Liliane Souto Pacheco
- Medicine School, Hospital São Francisco de Assis (HSFA), Universidade Franciscana (UFN), Santa Maria, Brazil
- Department of Infectious Diseases, University Hospital of Santa Maria, Federal University of Santa Maria (UFSM), Santa Maria, Brazil
| | - João Alberto Larangeira
- Department of and Traumatology, University Hospital of Santa Maria (SOT-HUSM), Federal University of Santa Maria (UFSM), Santa Maria, Brazil
| | - Tiango Aguiar Ribeiro
- Department of and Traumatology, University Hospital of Santa Maria (SOT-HUSM), Federal University of Santa Maria (UFSM), Santa Maria, Brazil
- Master’s Course in Health and Life Sciences, Universidade Franciscana (UFN), Santa Maria, Brazil
- Medicine School, Hospital São Francisco de Assis (HSFA), Universidade Franciscana (UFN), Santa Maria, Brazil
- Postgraduate Program of Health Science, Federal University of Santa Maria (UFSM), Santa Maria, Brazil
- Department of Surgery in Orthopaedic, Medicine School, Federal University of Santa Maria (UFSM), Santa Maria, Brazil
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14
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Gaillard-Campbell D, Gross TP, Webb L. Antibiotic Delivery via Hickman Catheter for the Treatment of Prosthetic Joint Infection. Orthopedics 2021; 44:e395-e401. [PMID: 34039203 DOI: 10.3928/01477447-20210414-12] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Infection rates for total joint arthroplasty range from 1% to 2%, and infection carries significant risk. The traditional course of treatment is irrigation and debridement, but historically, success rates have been variable. The goals of this study were to evaluate the safety and efficacy of Hickman catheterization in the treatment of prosthetic joint infection and to assess its value as an alternative to irrigation and debridement. The authors retrospectively analyzed 26 Hickman catheterizations in the treatment of acute early, acute late, and chronic late infections of primary and revision hip and knee arthroplasty. Initial arthroplasty procedures were performed between 2006 and 2018, with all cases followed for a minimum of 1 year postoperatively. The authors evaluated surgical data, clinical outcomes, and success rates, and they compared their success rates with reported values for cases treated with irrigation and debridement. The authors' success rate was 100% for acute early hip infection, 100% for chronic knee infection, and 80.0% for chronic hip infection. They reported a 75.0% success rate in the treatment of acute late infection for hip arthroplasty and a rate of 62.5% for knee arthroplasty. Postoperative clinical outcomes were significantly improved for both hips and knees for all infection types. The success rates for the treatment of acute early prosthetic joint infection and chronic late prosthetic knee infection were superior to available reported rates on irrigation and debridement. The authors also reported the highest success rate for the treatment of acute late infection. The current data suggest that Hickman catheterization is a promising safe and effective alternative to irrigation and debridement for the treatment of prosthetic joint infection. [Orthopedics. 2021;44(3):e395-e401.].
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15
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Kumar D, Singh S, Srivastava S, Singh SK, Singh A, Sharma Y. Outcome of total hip arthroplasty in patients with failed open reduction and internal fixation of acetabular fractures. J Clin Orthop Trauma 2021; 20:101480. [PMID: 34262847 PMCID: PMC8253977 DOI: 10.1016/j.jcot.2021.101480] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2021] [Revised: 06/15/2021] [Accepted: 06/15/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The problem of failed acetabulum fracture fixation is increasing due to increased incidence of high-velocity injury and a large number of patients are being operated on in the past few years. Limited evidence is available regarding results of Total hip arthroplasty (THA) in patients with failed acetabulum fracture fixation surgery. We assessed the clinical, radiological and postoperative complications. Besides this, we also evaluated functional outcome and quality of life following THA in failed open reduction and internal fixation of acetabular fractures. METHOD The current retrospective study was performed at the tertiary center from 2015 to 2020. Eighteen patients of failed acetabulum fracture fixation surgery (14 males and 4 females) were included with a mean follow-up period of 2.4 years. Postero-lateral approach was done in all cases. Clinico-radiological outcome, functional outcomes were recorded according to Harris Hip score (HHS) and quality of life was assessed by using the 12-Item Short Form Health Survey (SF-12) score. Postoperative complications were also assessed. RESULTS The age of patients ranged from 20 years to 68 years with a mean age of 44.7 years. 16 of the patients (88.9%) had a united acetabular fracture while 2 of them (11.1%) presented with un-united acetabular fracture. The THA implant was found to be stable in all 18 cases. The Harris Hip score of the study ranged from 82 to 95 with a mean of 89.72 ± 4.24 while the SF-12 score ranged from 40.0 to 49.4 with a mean of 44.29 ± 2.95. Out of 18 cases, 11 (61.1%) returned with excellent outcomes while the rest 7 (38.9%) returned with good outcomes as per Harris Hips score criteria. The correlation and regression analysis shows between HHS and SF-12 was positive and statistically significant (r = 0.592, p = 0.010). CONCLUSION THA in patients with failed acetabulum fracture fixation surgery provides a reliable option with satisfactory outcomes along with a better quality of life.
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Affiliation(s)
- Dharmendra Kumar
- Corresponding author.304,faculty residence jagat narayan road KGMU, 226003, India.
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16
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Abstract
Biofilms are aggregates formed as a protective survival state by microorganisms to adapt to the environment and can be resistant to antimicrobial agents and host immune responses due to chemical or physical diffusion barriers, modified nutrient environments, suppression of the growth rate within biofilms, and the genetic adaptation of cells within biofilms. With the widespread use of medical devices, medical device-associated biofilms continue to pose a serious threat to human health, and these biofilms have become the most important source of nosocomial infections. However, traditional antimicrobial agents cannot completely eliminate medical device-associated biofilms. New strategies for the treatment of these biofilms and targeting biofilm infections are urgently required. Several novel approaches have been developed and identified as effective and promising treatments. In this review, we briefly summarize the challenges associated with the treatment of medical device-associated biofilm infections and highlight the latest promising approaches aimed at preventing or eradicating these biofilms.
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Madariaga S, Vargas-Reverón C, Tornero E, Alías A, Capurro B, Combalia A, Fernández-Valencia JÁ, Muñoz-Mahamud E. Outcomes of hip arthroplasty with concomitant hardware removal: influence of the type of implant retrieved and impact of positive intraoperative cultures. Arch Orthop Trauma Surg 2021; 141:333-339. [PMID: 33241448 DOI: 10.1007/s00402-020-03692-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Accepted: 11/11/2020] [Indexed: 10/22/2022]
Abstract
INTRODUCTION The impact of residual internal fixation devices on subsequent procedures about the hip has not been clearly well defined. The objective of the current study is to evaluate the outcome of hip arthroplasty after hardware retrieval as a one-stage replacement, to analyze possible differences related to the type of removed implant, and to assess the impact of unexpected intraoperative cultures during implant retrieval. MATERIALS AND METHODS We present a retrospective study including all those cases undergoing hip arthroplasty with concomitant hardware removal (cannulated screws, intramedullary nail, or dynamic hip screw) from 2005 to 2018. We evaluated demographics, intraoperative cultures, early infection rate, and other complications. RESULTS A total of 55 cases were included in the study. The median time between the implant surgery and the hip arthroplasty was 113 days. The removed devices included 6 cannulated screws, 34 intramedullary nails, and 15 dynamic hip screws. Up to 74.5% of the failed osteosynthesis belonged to intertrochanteric femoral fractures. Dislocation rate was 9.1% (1.8% requiring revision surgery), 25.5% of the cases needed further new surgeries after the hip arthroplasty, and 49.1% died during the follow-up period. Any-cause revision surgery and mortality rates were significantly increased after intramedullary nail removal. Intraoperative cultures were performed in 46 cases, and in 9 (16.4%), there was bacterial contamination: 6 cases (10.9%) presented one single positive culture and 3 (5.5%) presented ≥ 2 positive cultures for the same microorganism. A total of five cases (9.1%) presented early prosthetic joint infection that required debridement. None of these five cases had presented positive cultures at the implant removal. CONCLUSION According to our results, hip arthroplasty with concomitant hardware removal is related to a high 5-year mortality rate, mainly when intramedullary nail is retrieved. Whereas a high risk of early prosthetic joint infection is associated, it seems not to be related to the elevated presence of unexpected positive cultures.
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Affiliation(s)
- Salvador Madariaga
- Department of Orthopaedics and Trauma Surgery, Hospital Clinic of Barcelona, University of Barcelona, C/Villarroel 170, 08036, Barcelona, Spain
| | - Caribay Vargas-Reverón
- Department of Orthopaedics and Trauma Surgery, Hospital Clinic of Barcelona, University of Barcelona, C/Villarroel 170, 08036, Barcelona, Spain
| | - Eduard Tornero
- Department of Orthopaedics and Trauma Surgery, Hospital Clinic of Barcelona, University of Barcelona, C/Villarroel 170, 08036, Barcelona, Spain.,Bone and Joint Infection Unit, Hospital Clinic of Barcelona, University of Barcelona, C/Villarroel 170, 08036, Barcelona, Spain
| | - Alfonso Alías
- Department of Orthopaedics and Trauma Surgery, Hospital Clinic of Barcelona, University of Barcelona, C/Villarroel 170, 08036, Barcelona, Spain
| | - Bruno Capurro
- Department of Orthopaedics and Trauma Surgery, Hospital Clinic of Barcelona, University of Barcelona, C/Villarroel 170, 08036, Barcelona, Spain
| | - Andreu Combalia
- Department of Orthopaedics and Trauma Surgery, Hospital Clinic of Barcelona, University of Barcelona, C/Villarroel 170, 08036, Barcelona, Spain.,Bone and Joint Infection Unit, Hospital Clinic of Barcelona, University of Barcelona, C/Villarroel 170, 08036, Barcelona, Spain
| | - Jenaro Ángel Fernández-Valencia
- Department of Orthopaedics and Trauma Surgery, Hospital Clinic of Barcelona, University of Barcelona, C/Villarroel 170, 08036, Barcelona, Spain.,Bone and Joint Infection Unit, Hospital Clinic of Barcelona, University of Barcelona, C/Villarroel 170, 08036, Barcelona, Spain
| | - Ernesto Muñoz-Mahamud
- Department of Orthopaedics and Trauma Surgery, Hospital Clinic of Barcelona, University of Barcelona, C/Villarroel 170, 08036, Barcelona, Spain. .,Bone and Joint Infection Unit, Hospital Clinic of Barcelona, University of Barcelona, C/Villarroel 170, 08036, Barcelona, Spain.
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18
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Abstract
AIMS This study aimed to compare the effect of antibiotic-loaded bone cement (ALBC) versus plain bone cement (PBC) on revision rates for periprosthetic joint infection (PJI) and all-cause revisions following primary elective total hip arthroplasty (THA) and total knee arthroplasty (TKA). METHODS MEDLINE, Embase, Web of Science, and Cochrane databases were systematically searched for studies comparing ALBC versus PBC, reporting on revision rates for PJI or all-cause revision following primary elective THA or TKA. A random-effects meta-analysis was performed. The study was registered in the International Prospective Register of Systematic Reviews (PROSPERO ID CRD42018107691). RESULTS Nine studies and one registry report were identified, enabling the inclusion of 371,977 THA and 671,246 TKA. Pooled analysis for THA demonstrated ALBC was protective against revision for PJI compared with PBC (relative risk (RR) 0.66, 95% confidence interval (CI) 0.56 to 0.77; p < 0.001), however, no differences were seen for all-cause revision rate (RR 0.62, 95% CI 0.35 to 1.09; p = 0.100). For TKA, there were no significant differences in revision rates for PJI or all causes between ALBC and PBC (RR 0.92, 95% CI 0.59 to 1.45; p = 0.730, and RR 0.73, 95% CI 0.53 to 1.02; p = 0.060, respectively). CONCLUSION ALBC demonstrated a protective effect against revision for PJI compared with PBC in THA with no difference in all-cause revisions. No differences in revision rates for PJI and all-cause revision between ALBC and PBC for TKA were observed. Cite this article: Bone Joint J 2021;103-B(1):7-15.
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Affiliation(s)
- Muhamed M Farhan-Alanie
- Medical School, University of Warwick, Coventry, UK.,Trauma & Orthopaedics, University Hospital Coventry & Warwickshire, Coventry, UK
| | - Henry G Burnand
- University of Bristol, Learning & Research Centre, Bristol, UK
| | - Michael R Whitehouse
- National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol, Bristol, UK
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19
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Thaler M, Dammerer D, Ban M, Leitner H, Khosravi I, Nogler M. Femoral Revision Total Hip Arthroplasty Performed through the Interval of the Direct Anterior Approach. J Clin Med 2021; 10:337. [PMID: 33477498 DOI: 10.3390/jcm10020337] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 01/13/2021] [Accepted: 01/15/2021] [Indexed: 12/18/2022] Open
Abstract
Background: we report the clinical outcomes for femoral revision total hip replacement (THR) using the Direct Anterior Approach (DAA) interval. Methods: 149 patients (165 hips) with a mean age of 68.9 years (range, 33.2–91.0 years) and a mean follow-up of 4.2 years (1.1–8.9 years) were included. The indication for revision surgery was aseptic stem loosening in 131 (79.4%) hips, periprosthetic fracture in 29 (17.6%) hips, revision for stem malalignment in one (0.6%) hip, and prosthetic failure in four (2.4%) hips. Results: an endofemoral approach was used for 156 hips, and a Wagner transfemoral osteotomy was used for nine hips. An additional cup revision was done in 52 hips (uncemented cup: n = 29; cemented cup: n = 21; acetabular cage: n = 2). The overall complication rate was 14.5% (24 complications). Ten patients (10 hips) were revised (8 cups, 2 liners, 2 stems) with an average time to revision of 6 months (range, 3–23 months). The median preoperative Western Ontario McMasters Osteoarthritis Score (WOMAC) score was 52.5 (Inter Quartile Range (IQR): 33.3), which improved to 27.2 (IQR: 30) postoperatively (p < 0.01). Conclusion: use of the DAA achieved similar results when compared with other surgical approaches in terms of clinical outcomes and complications, including dislocation rate. These results suggest that femoral revision using the DAA interval can be a safe and reliable procedure.
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20
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Abstract
INTRODUCTION We retrospectively analyzed a consecutive group of patients operated for bone tumors of extremity and pelvis who received only perioperative antibiotics (Group A) against a similar group that had additional 1 g topical vancomycin sprinkled in the wound before closure (Group B). The aim was to determine if the addition of topical vancomycin decreases the incidence of deep surgical site infection (SSI). MATERIALS AND METHODS A total of 221 patients operated between January 2011 and December 2011 were analyzed in Group A and 254 patients operated between April 2012 and March 2013 were analyzed in Group B. Any patient who required operative intervention for wound discharge was considered to be infected. All patients had a 1 year follow-up to determine the incidence of SSI. RESULTS The overall rate of SSI was 7% (31 of 475 patients). Seventeen (8%) of Group A patients had SSI as against 14 (6 %) of Group B patients (P = 0.337). A subgroup analysis of endoprosthetic reconstructions, internal fixation implants (plates/intramedullary nails), extracorporeal radiation treated bones and strut allografts showed no difference between the two groups of patients. CONCLUSION Our data suggest that the addition of topical vancomycin before wound closure in patients operated for bone tumors does not decrease the incidence of SSI. Further investigation of this technique using a case-controlled methodology with an increase in the dose of vancomycin may be warranted.
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Affiliation(s)
- Suman Byregowda
- Department of Surgical Oncology, Tata Memorial Centre, Mumbai, Maharashtra, India
| | - Ajay Puri
- Department of Surgical Oncology, Tata Memorial Centre, Mumbai, Maharashtra, India
| | - Ashish Gulia
- Department of Surgical Oncology, Tata Memorial Centre, Mumbai, Maharashtra, India
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21
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Pizzo RA, Patel JN, Viola A, Keller DM, Yoon RS, Liporace FA. Reducing Dislocations of Antibiotic Hip Spacers via Hybrid Cement-screw Constrained Liner Fixation: A Case Series. Hip Pelvis 2020; 32:207-213. [PMID: 33335869 PMCID: PMC7724021 DOI: 10.5371/hp.2020.32.4.207] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 04/23/2020] [Accepted: 04/24/2020] [Indexed: 11/24/2022] Open
Abstract
Purpose Infection following total hip arthroplasty is a challenging and devastating complication. In two-stage revision arthroplasty, antibiotic spacers, although efficacious, can be associated with an unacceptable rate of mechanical complications (e.g., fracture, dislocation). This series describes 15 patients with infected total hip prostheses treated with hybrid cement-screw fixation constrained liner antibiotic spacers to enhance stability and minimize mechanical complications. Materials and Methods All patients with an infected hip prosthesis undergoing two-stage revision arthroplasty at a single academic medical center were identified and screened for inclusion. Clinical and radiographic data including patient demographics and outcome measures were collected and retrospectively analyzed. Results Two patients died of unrelated causes at an average of 6-week postoperatively. Infections in the remaining thirteen patients (100%) were successfully eradicated; all underwent uncomplicated revision arthroplasty at a mean duration of 99.5 days after the placement of the antibiotic spacer. No dislocations, fractures, or other mechanical failures of any spacer were observed in this series. Conclusion The hybrid cement-screw fixation technique for constrained liner antibiotic spacers is a reliable and effective treatment method for eradicating prosthetic joint infections without mechanical complications.
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Affiliation(s)
- Richard A Pizzo
- Department of Orthopaedic Surgery, Jersey City Medical Center, Jersey City, NJ, USA
| | - Jay N Patel
- Department of Orthopaedic Surgery, Jersey City Medical Center, Jersey City, NJ, USA
| | - Anthony Viola
- Department of Orthopaedic Surgery, Jersey City Medical Center, Jersey City, NJ, USA
| | - David M Keller
- Department of Orthopaedic Surgery, Jersey City Medical Center, Jersey City, NJ, USA
| | - Richard S Yoon
- Department of Orthopaedic Surgery, Jersey City Medical Center, Jersey City, NJ, USA
| | - Frank A Liporace
- Department of Orthopaedic Surgery, Jersey City Medical Center, Jersey City, NJ, USA
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22
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Veltman ES, Lenguerrand E, Moojen DJF, Whitehouse MR, Nelissen RGHH, Blom AW, Poolman RW. Similar risk of complete revision for infection with single-dose versus multiple-dose antibiotic prophylaxis in primary arthroplasty of the hip and knee: results of an observational cohort study in the Dutch Arthroplasty Register in 242,179 patients. Acta Orthop 2020; 91:794-800. [PMID: 32698642 PMCID: PMC8023957 DOI: 10.1080/17453674.2020.1794096] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Background and purpose - The optimal type and duration of antibiotic prophylaxis for primary arthroplasty of the hip and knee are subject to debate. We compared the risk of complete revision (obtained by a 1- or 2-stage procedure) for periprosthetic joint infection (PJI) after primary total hip or knee arthroplasty between patients receiving a single dose of prophylactic antibiotics and patients receiving multiple doses of antibiotics for prevention of PJI. Patients and methods - A cohort of 130,712 primary total hip and 111,467 knee arthroplasties performed between 2011 and 2015 in the Netherlands was analyzed. We linked data from the Dutch arthroplasty register to a survey collected across all Dutch institutions on hospital-level antibiotic prophylaxis policy. We used restricted cubic spline Poisson models adjusted for hospital clustering to compare the risk of revision for infection according to type and duration of antibiotic prophylaxis received. Results - For total hip arthroplasties, the rates of revision for infection were 31/10,000 person-years (95% CI 28-35), 39 (25-59), and 23 (15-34) in the groups that received multiple doses of cefazolin, multiple doses of cefuroxime, and a single dose of cefazolin, respectively. The rates for knee arthroplasties were 27/10,000 person-years (95% CI 24-31), 40 (24-62), and 24 (16-36). Similar risk of complete revision for infection among antibiotic prophylaxis regimens was found when adjusting for confounders. Interpretation - In a large observational cohort we found no apparent association between the type or duration of antibiotic prophylaxis and the risk of complete revision for infection. This does question whether there is any advantage to the use of prolonged antibiotic prophylaxis beyond a single dose.
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MESH Headings
- Anti-Bacterial Agents/administration & dosage
- Antibiotic Prophylaxis/methods
- Arthroplasty, Replacement, Hip/adverse effects
- Arthroplasty, Replacement, Hip/methods
- Arthroplasty, Replacement, Knee/adverse effects
- Arthroplasty, Replacement, Knee/methods
- Cefazolin/administration & dosage
- Cefuroxime/administration & dosage
- Dose-Response Relationship, Drug
- Duration of Therapy
- Female
- Humans
- Male
- Middle Aged
- Netherlands/epidemiology
- Outcome and Process Assessment, Health Care
- Prosthesis-Related Infections/diagnosis
- Prosthesis-Related Infections/epidemiology
- Prosthesis-Related Infections/prevention & control
- Prosthesis-Related Infections/surgery
- Reoperation/methods
- Reoperation/statistics & numerical data
- Risk Adjustment/methods
- Risk Adjustment/statistics & numerical data
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Affiliation(s)
- Ewout S Veltman
- Department of Orthopaedic and Trauma Surgery, Joint Research, OLVG, Amsterdam, the Netherlands
- Department of Orthopaedics, Leiden University Medical Center, Leiden, the Netherlands
| | - Erik Lenguerrand
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Dirk Jan F Moojen
- Department of Orthopaedic and Trauma Surgery, Joint Research, OLVG, Amsterdam, the Netherlands
| | - Michael R Whitehouse
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- National Institute for Health Research Bristol Biomedical Research Centre, University Hospital Bristol NHS Foundation Trust and University of Bristol, UK
| | - Rob G H H Nelissen
- Department of Orthopaedics, Leiden University Medical Center, Leiden, the Netherlands
| | - Ashley W Blom
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- National Institute for Health Research Bristol Biomedical Research Centre, University Hospital Bristol NHS Foundation Trust and University of Bristol, UK
| | - Rudolf W Poolman
- Department of Orthopaedic and Trauma Surgery, Joint Research, OLVG, Amsterdam, the Netherlands
- Department of Orthopaedics, Leiden University Medical Center, Leiden, the Netherlands
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23
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Simpson CR, Kelly HM, Murphy CM. Synergistic use of biomaterials and licensed therapeutics to manipulate bone remodelling and promote non-union fracture repair. Adv Drug Deliv Rev 2020; 160:212-233. [PMID: 33122088 DOI: 10.1016/j.addr.2020.10.011] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 10/16/2020] [Accepted: 10/20/2020] [Indexed: 12/16/2022]
Abstract
Disrupted bone metabolism can lead to delayed fracture healing or non-union, often requiring intervention to correct. Although the current clinical gold standard bone graft implants and commercial bone graft substitutes are effective, they possess inherent drawbacks and are limited in their therapeutic capacity for delayed union and non-union repair. Research into advanced biomaterials and therapeutic biomolecules has shown great potential for driving bone regeneration, although few have achieved commercial success or clinical translation. There are a number of therapeutics, which influence bone remodelling, currently licensed for clinical use. Providing an alternative local delivery context for these therapies, can enhance their efficacy and is an emerging trend in bone regenerative therapeutic strategies. This review aims to provide an overview of how biomaterial design has advanced from currently available commercial bone graft substitutes to accommodate previously licensed therapeutics that target local bone restoration and healing in a synergistic manner, and the challenges faced in progressing this research towards clinical reality.
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Affiliation(s)
- Christopher R Simpson
- Tissue Engineering Research Group, Department of Anatomy and Regenerative Medicine, Royal College of Surgeons in Ireland (RCSI), Dublin, Ireland
| | - Helena M Kelly
- Tissue Engineering Research Group, Department of Anatomy and Regenerative Medicine, Royal College of Surgeons in Ireland (RCSI), Dublin, Ireland; School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland (RCSI), Dublin, Ireland
| | - Ciara M Murphy
- Tissue Engineering Research Group, Department of Anatomy and Regenerative Medicine, Royal College of Surgeons in Ireland (RCSI), Dublin, Ireland; Trinity Centre for Biomedical Engineering, Trinity College Dublin (TCD), Dublin, Ireland; Advanced Materials and Bioengineering Research Centre (AMBER), RCSI and TCD, Dublin, Ireland.
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Özden R, Davut S, Doğramacı Y, Kalacı A, Duman İG, Uruç V. Treatment of secondary hip arthritis from shell fragment and gunshot injury in the Syrian civil war. J Orthop Surg Res 2020; 15:464. [PMID: 33032647 PMCID: PMC7545849 DOI: 10.1186/s13018-020-01993-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Accepted: 10/01/2020] [Indexed: 11/25/2022] Open
Abstract
Background In gunshot and shell fragment injuries to the hip joint, orthopedic intervention includes wound assessment and care, osteosynthesis of fractures, and avoiding of infection and osteoarthritis. Individuals injured in the Syrian civil war were frequently transferred to the authors’ institution in neighboring city. Orthopedic trauma exposures were determined in approximately 30% of these patients. The aim of this study was to evaluate the outcomes of the patients with secondary hip arthritis due to prior gunshot and shell fragment (shrapnel) injuries who underwent primary total hip arthroplasty. Methods This retrospective study reviewed 26 patients (24 males, 2 females) who underwent hip arthroplasty due to prior gunshot and shell fragment injuries from November 2013 to January 2019. For all patients, the Harris Hip Score (HHS) was evaluated preoperatively and after surgery. Results Mean age was 31.5 (range, 19–48) years. The mean preoperative HHS was 52.95 points, and the mean postoperative HHS was 79.92 points at the final follow-up after surgery. Patients with shell fragment injuries to the hip joint had higher infection rates, but it is not statistically significant. Conclusions An anatomic reduction of the fracture may not be possible in these cases as a result of significant bone and/or cartilage loss. Total hip arthroplasty can be done after gunshot- and shell fragment-related posttraumatic arthritis. It is an effective treatment choice to reduce pain and improve function, but the surgeon must be very careful because of high rate of infection.
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Affiliation(s)
- Raif Özden
- Department of Orthopaedics and Traumatology, Faculty of Medicine, Mustafa Kemal University, Serinyol, 31001, Antakya, Hatay, Turkey.
| | - Serkan Davut
- Department of Orthopaedics and Traumatology, Faculty of Medicine, Mustafa Kemal University, Serinyol, 31001, Antakya, Hatay, Turkey
| | - Yunus Doğramacı
- Department of Orthopaedics and Traumatology, Faculty of Medicine, Mustafa Kemal University, Serinyol, 31001, Antakya, Hatay, Turkey
| | - Aydıner Kalacı
- Department of Orthopaedics and Traumatology, Faculty of Medicine, Mustafa Kemal University, Serinyol, 31001, Antakya, Hatay, Turkey
| | - İbrahim Gökhan Duman
- Department of Orthopaedics and Traumatology, Faculty of Medicine, Mustafa Kemal University, Serinyol, 31001, Antakya, Hatay, Turkey
| | - Vedat Uruç
- Department of Orthopaedics and Traumatology, Faculty of Medicine, Mustafa Kemal University, Serinyol, 31001, Antakya, Hatay, Turkey
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25
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Bingham JS, Hassebrock JD, Christensen AL, Beauchamp CP, Clarke HD, Spangehl MJ. Screening for Periprosthetic Joint Infections With ESR and CRP: The Ideal Cutoffs. J Arthroplasty 2020; 35:1351-1354. [PMID: 31883823 DOI: 10.1016/j.arth.2019.11.040] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2019] [Revised: 11/25/2019] [Accepted: 11/27/2019] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND The purpose of this study was to (1) determine the sensitivity and specificity of erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) when screening for a periprosthetic joint infection (PJI) using the standard MSIS cutoff of 30 mm/h and 10 mg/L, respectively, and (2) determine the optimal ESR and CRP cutoff to achieve a sensitivity ≥95%. METHODS We retrospectively analyzed 81 PJI patients and 83 noninfected arthroplasty patients. We calculated the sensitivity and specificity (and 95% confidence intervals) for ESR and CRP at thresholds of 30 mm/h and 10 mg/L, respectively. We determined the optimal cutoff for both ESR and CRP to yield a sensitivity greater than or equal to 95%. RESULTS The ESR cutoff that resulted in a sensitivity ≥ to 95% (95% CI: 85.2-97.6%) was 10 mm/h, and the CRP cutoff that resulted in a sensitivity ≥ to 95% (95% CI: 87.1-98.4%) was 5 mg/L. The sensitivity and specificity with a combined ESR and CRP of 10 mm/h and 5 mg/L was 100% (95% CI: 94.1-100%) and 54.7% (95% CI: 46.4-62.3%). CONCLUSION When using ESR and CRP as a screening tool with the accepted cutoffs of 30 mm/h and 10 mg/L, there is an unacceptably low sensitivity and a high number of false negatives. Therefore, further recommendation must be given to lowering these thresholds to avoid the devastating morbidity of a missed PJI. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Joshua S Bingham
- Department of Orthopedic Surgery, Mayo Clinic, Arizona, Phoenix, AZ
| | | | - Austin L Christensen
- Arizona College of Osteopathic Medicine, Midwestern University Glendale, Glendale, AZ
| | | | - Henry D Clarke
- Department of Orthopedic Surgery, Mayo Clinic, Arizona, Phoenix, AZ
| | - Mark J Spangehl
- Department of Orthopedic Surgery, Mayo Clinic, Arizona, Phoenix, AZ
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Kawasmi SH, Ajlouni J, Almanaseer Q, Kaylani L, Hassan A. Epidermolysis Bullosa: A Case of Successful Total Hip Arthroplasty. Cureus 2020; 12:e7508. [PMID: 32373411 PMCID: PMC7195200 DOI: 10.7759/cureus.7508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Epidermolysis bullosa (EB) is a rare dermatological disease in which patients suffer from skin fragility and blisters. One of the major complications is the development of skin infections, which may preclude surgical intervention. We present a case of a 49-year-old female with a past medical history of EB, who presented to the emergency department (ED) with right groin pain of one-hour duration after falling on her right side. The patient underwent a successful open reduction and internal fixation for her right hip without complications. Over the course of three months after the procedure, she experienced worsening of the pain accompanied by skin necrosis and total collapse of the femoral head. Subsequent total hip replacement surgery was performed using a cementless (Zimmer, Warsaw, IN) prosthesis and fixated via cannulated screws. To decrease the risk of infection, IV cefazolin was given as a prophylactic antibiotic preoperatively. Vancomycin IV and imipenem/cilastatin IV were given for four days postoperatively. We made sure that our patient is experiencing the least possible pain by giving sufficient analgesics after the surgery. We used morphine, paracetamol, and gabapentin for pain control. For 25 days after the surgery, the patient did not complain of any pain. Upon follow-up, sutures were removed, and no surgical wound infection, rashes, or lacerations were noted. We encourage orthopedic surgeons dealing with patients suffering from dermatological conditions with fragile skin such as EB and decreased level of activity that requires total hip arthroplasty to proceed with the surgical intervention after considering adequate infection control to improve quality of life.
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Affiliation(s)
| | - Jihad Ajlouni
- Orthopaedics, Jordan University Hospital, Amman, JOR
| | | | | | - Abbas Hassan
- Plastic and Reconstructive Surgery, Northwestern University Feinberg School of Medicine, Chicago, USA
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Kunutsor SK, Barrett MC, Whitehouse MR, Craig RS, Lenguerrand E, Beswick AD, Blom AW. Incidence, temporal trends and potential risk factors for prosthetic joint infection after primary total shoulder and elbow replacement: Systematic review and meta-analysis. J Infect 2020; 80:426-436. [DOI: 10.1016/j.jinf.2020.01.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Revised: 12/16/2019] [Accepted: 01/14/2020] [Indexed: 02/06/2023]
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Carpenter CVE, Wylde V, Moore AJ, Sayers A, Blom AW, Whitehouse MR. Perceived occurrence of an adverse event affects patient-reported outcomes after total hip replacement. BMC Musculoskelet Disord 2020; 21:118. [PMID: 32085754 PMCID: PMC7035750 DOI: 10.1186/s12891-020-3127-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Accepted: 02/10/2020] [Indexed: 11/14/2022] Open
Abstract
Background Dislocation, periprosthetic fracture and infection are serious complications of total hip replacement (THR) and which negatively impact on patients’ outcomes including satisfaction, quality of life, mental health and function. The accuracy with which patients report adverse events (AEs) after surgery varies. The impact of patient self-reporting of AEs on patient-reported outcome measures (PROMs) after THR is yet to be investigated. Our aim was to determine the effect of confirmed and perceived AEs on PROMs after primary THR. Methods A prospective single-centre cohort study of patients undergoing primary THR, with one-year follow-up, was performed. Participants completed forms pre-operatively and 3, 6, 9 and 12 months post-operatively, including Work Productivity and Activity Impairment (WPAI), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), EuroQol-5D-3 L (EQ5D), Self-Administered Patient Satisfaction (SAPS) and AE reporting questionnaires. Results were reported in three groups: No AE, reported but not confirmed AE and confirmed AE. A generalised linear model was used to compare among groups using robust standard errors (SE). Results Forty-one AEs were reported in a cohort of 417 patients (234 females), with 30 AEs reported by 3 months. Eleven (27 reported) infections, two (six reported) periprosthetic fractures and two (eight reported) dislocations were confirmed. Those in the no AE group reported significantly better outcomes that the reported AE group as measured by WOMAC Co-Eff 14.27 (p = 0.01), EQ5D − 0.128 (p = 0.02) and SAPS − 9.926 (p = 0.036) and the combined reported and confirmed AE groups as measured by WOMAC Co-Eff 13.72 (p = 0.002), EQ5D − 0.129 (p = 0.036) and SAPS − 11.512 (p = 0.004). No significant differences were seen in WPAI among groups. Conclusions Patients who report AEs have worse outcomes than those who do not, regardless of whether the AEs can be confirmed by standard medical record review methods. The observed negative trends suggest that patient perception of AEs may influence patient outcome in a similar way to those with confirmed AEs.
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Affiliation(s)
- Charlotte V E Carpenter
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, 1st Floor Learning & Research Building, Southmead Hospital, Bristol, BS10 5NB, UK.
| | - Vikki Wylde
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, 1st Floor Learning & Research Building, Southmead Hospital, Bristol, BS10 5NB, UK.,National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol NHS Foundation Trust and University of Bristol, Bristol, UK
| | - Andrew J Moore
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, 1st Floor Learning & Research Building, Southmead Hospital, Bristol, BS10 5NB, UK
| | - Adrian Sayers
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, 1st Floor Learning & Research Building, Southmead Hospital, Bristol, BS10 5NB, UK
| | - Ashley W Blom
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, 1st Floor Learning & Research Building, Southmead Hospital, Bristol, BS10 5NB, UK.,National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol NHS Foundation Trust and University of Bristol, Bristol, UK
| | - Michael R Whitehouse
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, 1st Floor Learning & Research Building, Southmead Hospital, Bristol, BS10 5NB, UK.,National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol NHS Foundation Trust and University of Bristol, Bristol, UK
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Patel JN, Pizzo RA, Yoon RS, Liporace FA. Addressing Antibiotic Hip Spacer Instability via Hybrid Screw-cement Fixation of a Constrained Liner and Cement-rebar Interface Techniques: A Technical Narrative. J Am Acad Orthop Surg 2020; 28:166-70. [PMID: 31567542 DOI: 10.5435/JAAOS-D-19-00116] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
Prosthetic joint infection is a challenging and devastating complication after total hip arthroplasty. The benchmark for treatment remains two-stage revision arthroplasty, in which an antibiotic-impregnated spacer is used to eradicate the infection. Although several types of spacer constructs have been described, they have historically been associated with high rates of mechanical complications, namely, dislocation, spacer fracture, and periprosthetic femur fracture. Spacer dislocation is the most common, with reported rates as high as 41%. Here, the authors present a surgical technique to improve the mechanical stability of an articulating hip spacer via a hybrid screw-cement fixation technique that allows for joint motion and weight bearing during the treatment period while minimizing the risk of mechanical failure. An additional technique is described to address acetabular bone loss, which has been associated with a higher spacer dislocation rate, through a cement-rebar interface construct.
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Abstract
OBJECTIVES Understanding patients' preferences for treatment is crucial to provision of good care and shared decisions, especially when more than one treatment option exists for a given condition. One such condition is infection of the area around the prosthesis after hip replacement, which affects between 0.4% and 3% of patients. There is more than one treatment option for this major complication, and our study aimed to assess the value that patients place on aspects of revision surgery for periprosthetic hip infection. DESIGN We identified four attributes of revision surgery for periprosthetic hip infection. Using a discrete choice experiment (DCE), we measured the value placed on each attribute by 57 people who had undergone either one-stage or two-stage revision surgery for infection. SETTING The DCE was conducted with participants from nine National Health Service hospitals in the UK. PARTICIPANTS Adults who had undergone revision surgery for periprosthetic hip infection (N=57). RESULTS Overall, the strongest preference was for a surgical option that resulted in no restrictions on engaging in valued activities after a new hip is fitted (β=0.7). Less valued but still important attributes included a shorter time taken from the start of treatment to return to normal activities (6 months; β=0.3), few or no side effects from antibiotics (β=0.2), and having only one operation (β=0.2). CONCLUSIONS The results highlight that people who have had revision surgery for periprosthetic hip infection most value aspects of care that affect their ability to engage in normal everyday activities. These were the most important characteristics in decisions about revision surgery.
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Affiliation(s)
- Fran E Carroll
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Rachael Gooberman-Hill
- Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Simon Strange
- Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Ashley W Blom
- Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Andrew J Moore
- Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
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31
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Gök MA, Kafadar MT, Yeğen SF. Comparison of negative-pressure incision management system in wound dehiscence: A prospective, randomized, observational study. J Med Life 2019; 12:276-283. [PMID: 31666831 PMCID: PMC6814883 DOI: 10.25122/jml-2019-0033] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Wound dehiscence is a significant problem faced by surgeons after major abdominal surgery. In this study, it was aimed to select the best incision management system to keep the incision edges together and prevent wound opening, and infection by protecting the incision. In this study, 60 patients who underwent abdominal surgery were evaluated regarding their risk of wound dehiscence. In our clinic, high-risk cases of abdominal surgery are performed, the risk factors being ischemia along the incision line, dirty and contaminated wound, obesity, tension on the suture line, traumatization of the wound site, age at onset (> 65), body mass index (BMI) > 30, diabetes mellitus, chronic obstructive pulmonary disease (COPD), immunosuppressive drug users. A prospective study protocol was planned after ASA (American Society of Anesthesiologists) physical status class assignment. Patients were divided into three groups: patients who underwent a postoperative negative-pressure therapy dressing, patients who underwent subcutaneous aspiration drainage, and patients who received standard dressing. The aim of this study was to evaluate the decompensation, surgical site infection, seroma, hospital stay and costs and to evaluate the results in the postoperative period. Sixty patients were randomized (n = 20, for each group). Thirty-one (51%) of the patients were male, and the mean age was 64.3 ± 8.9 (46-85). The mean BMI was 30.45 ± 7.2. There was no statistically significant difference (p≥0.05) between groups in terms of sex, age, and BMI. The ASA score and surgical interventions were similar between the groups. Wound dehiscence rate was 25% (n = 8), 20% (n = 6) and 3% (n = 1) for the Standard Dressing (SD), Aspiration Drainage (AD) and Negative-Pressure (NP) groups, respectively (p <0.017). Duration of hospitalization was 16.45 ± 6.6, 14.3 ± 7.4 and 8.95 ± 2.8 days (p <0.001) for SD, AD and NP groups, respectively. No statistically significant difference was found between the groups regarding other variables (p≥0.05 for all variables). Negative-pressure wound treatment is an easy, fast and practical technique which reduces lateral tension and swelling. It provides perfusion support and helps to protect the surgical field against external sources of infection.
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Affiliation(s)
- Mehmet Ali Gök
- Clinic of General Surgery, Health Sciences University, Derince Training and Research Hospital, Kocaeli, Turkey
| | - Mehmet Tolga Kafadar
- Clinic of General Surgery, Health Sciences University, Mehmet Akif İnan Training and Research Hospital, Şanlıurfa, Turkey
| | - Serkan Fatih Yeğen
- Clinic of General Surgery, Ali Osman Sönmez Oncology Hospital, Bursa, Turkey
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Fowler TJ, Sayers A, Whitehouse MR. Two-stage revision surgery for periprosthetic joint infection following total hip arthroplasty. Ann Transl Med 2019; 7:S261. [PMID: 32015980 DOI: 10.21037/atm.2019.12.126] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Timothy J Fowler
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, Southmead Hospital, Bristol, UK
| | - Adrian Sayers
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, Southmead Hospital, Bristol, UK
| | - Michael R Whitehouse
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, Southmead Hospital, Bristol, UK.,National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol NHS Foundation Trust, University of Bristol, Bristol, UK
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Guan H, Xu C, Fu J, Ni M, Li X, Chai W, Hao L, Zhou Y, Chen J. Diagnostic criteria of periprosthetic joint infection: a prospective study protocol to validate the feasibility of the 2018 new definition for Chinese patients. BMC Musculoskelet Disord 2019; 20:552. [PMID: 31747958 PMCID: PMC6868824 DOI: 10.1186/s12891-019-2941-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Accepted: 11/12/2019] [Indexed: 12/29/2022] Open
Abstract
Background Periprosthetic joint infection (PJI) is a challenging complication following total joint arthroplasty (TJA), and the diagnostic criteria remains controversial. The 2018 new definition proposed in May 2018 consists of new diagnostic criteria for PJI. We conducted a retrospective study and demonstrated that the new definition could improve the diagnostic efficiency in Chinese patients. However, missing data led to bias in the previous retrospective study. Therefore, this prospective study is designed to further validate the feasibility of 2018 new definition (and its modified version) for Chinese patients. Methods/design This is a single-centre, prospective diagnostic study with 1 year of follow-up. The patients enrolled in the trial will be divided into a PJI group and an Aseptic group based on the eligibility criteria. We will recruit at least 70 patients for each group from October 2019 to October 2020. Blood samples, synovial fluid samples and intraoperative variables of all the included patients will be collected to assess various indicators. We will integrate the results of the various tests and examine the diagnostic efficiency (sensitivity and specificity) of five diagnostic criteria. Discussion We design the prospective study in the hope of reducing the bias caused by missing data. Therefore, the prospective study will further support the conclusion of our preceding retrospective study. The results of this study will be submitted to a peer-reviewed journal for publication. Conclusion Through this prospective study, we will validate the feasibility of the 2018 new PJI definition (and its modified version) for Chinese patients and determine the optimal method of PJI diagnosis. Trial registration Chinese Clinical Trial Registry, ChiCTR1900025395. Registered on 25 August 2019.
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Affiliation(s)
- Haitao Guan
- Department of Orthopaedics, Chinese People's Liberation Army General Hospital (301 Hospital), 28 Fuxing Rd, 100853, Beijing, People's Republic of China.,Medical School of Nankai University, Tianjin, China
| | - Chi Xu
- Department of Orthopaedics, Chinese People's Liberation Army General Hospital (301 Hospital), 28 Fuxing Rd, 100853, Beijing, People's Republic of China
| | - Jun Fu
- Department of Orthopaedics, Chinese People's Liberation Army General Hospital (301 Hospital), 28 Fuxing Rd, 100853, Beijing, People's Republic of China
| | - Ming Ni
- Department of Orthopaedics, Chinese People's Liberation Army General Hospital (301 Hospital), 28 Fuxing Rd, 100853, Beijing, People's Republic of China
| | - Xiang Li
- Department of Orthopaedics, Chinese People's Liberation Army General Hospital (301 Hospital), 28 Fuxing Rd, 100853, Beijing, People's Republic of China
| | - Wei Chai
- Department of Orthopaedics, Chinese People's Liberation Army General Hospital (301 Hospital), 28 Fuxing Rd, 100853, Beijing, People's Republic of China
| | - Libo Hao
- Department of Orthopaedics, Chinese People's Liberation Army General Hospital (301 Hospital), 28 Fuxing Rd, 100853, Beijing, People's Republic of China
| | - Yonggang Zhou
- Department of Orthopaedics, Chinese People's Liberation Army General Hospital (301 Hospital), 28 Fuxing Rd, 100853, Beijing, People's Republic of China
| | - Jiying Chen
- Department of Orthopaedics, Chinese People's Liberation Army General Hospital (301 Hospital), 28 Fuxing Rd, 100853, Beijing, People's Republic of China.
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Jacobs AME, Valkering LJJ, Bénard M, Meis JF, Goosen JHM. Evaluation One Year after DAIR Treatment in 91 Suspected Early Prosthetic Joint Infections in Primary Knee and Hip Arthroplasty. J Bone Jt Infect 2019; 4:238-244. [PMID: 31700773 PMCID: PMC6831808 DOI: 10.7150/jbji.37757] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Accepted: 09/24/2019] [Indexed: 01/08/2023] Open
Abstract
INTRODUCTION Early recognition and appropriate initial treatment with debridement, antibiotics and implant retention (DAIR) if a suspicion of an early prosthetic joint infection (PJI) is present can eradicate infection on first attempt and prevent implant failure. We evaluated the outcome after 1 year of patients treated with DAIR after primary total knee arthroplasty (TKA) or total hip arthroplasty (THA). Furthermore, we determined preoperative, microbiology, and treatment factors related to failure after DAIR. METHODS A retrospective cohort study was assembled with 91 patients undergoing DAIR with a high suspicion of an early PJI. Records were reviewed for demographics, preoperative laboratory results, microbiological data, given treatment and postoperative follow-up. The primary outcome was infection-free implant survival at 1 year. Repeated DAIR was not considered as treatment failure. RESULTS The rate of infection-free implant survival following DAIR in a suspected early PJI was 85% (95% confidence intervals (CI) 78-91). Cultures remained negative in 20 patients, with no occurrence of infection during follow-up. A higher failure rate was seen in early PJI caused by Enterococcus faecalis (p=0.04). Multivariate analysis showed a statistically significant association between treatment failure and high C-reactive protein level (CRP >100) (odds ratio 10.0, 95% CI [1.5-70]) and multiple DAIR procedures (≥2) (odds ratio 5.0, 95%CI [1.1-23]). CONCLUSION If an early PJI is suspected DAIR is the appointed treatment with up to 2 debridement procedures. Since culture-negative DAIRs were not related to any complications during follow-up, overtreatment of suspected PJI seems to do no significant harm with respect to implant failure.
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Affiliation(s)
- Anouk M E Jacobs
- Department of Orthopaedic Surgery, Prosthetic Joint Infection Unit, Sint Maartenskliniek, Nijmegen, the Netherlands.,Sint Maartenskliniek Research, Sint Maartenskliniek, Nijmegen, the Netherlands
| | - Lucia J J Valkering
- Department of Orthopaedic Surgery, Prosthetic Joint Infection Unit, Sint Maartenskliniek, Nijmegen, the Netherlands
| | - Menno Bénard
- Sint Maartenskliniek Research, Sint Maartenskliniek, Nijmegen, the Netherlands
| | - Jacques F Meis
- Department of Medical Microbiology and Infectious Diseases, Canisius-Wilhelmina Ziekenhuis, Nijmegen, the Netherlands.,Department of Medical Microbiology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Jon H M Goosen
- Department of Orthopaedic Surgery, Prosthetic Joint Infection Unit, Sint Maartenskliniek, Nijmegen, the Netherlands
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Rajesh K, Rangaswamy MK, Zhang C, Haldar S, Kumarasamy M, Agarwal A, Roy P, Lahiri D. Surface Modified Metallic Orthopedic Implant for Sustained Drug Release and Osteocompatibility. ACS Appl Bio Mater 2019; 2:4181-4192. [DOI: 10.1021/acsabm.9b00443] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Affiliation(s)
- Kanike Rajesh
- Biomaterials and Multiscale Mechanics Lab, Department of Metallurgical and Materials Engineering, Indian Institute of Technology Roorkee, Roorkee 247667, India
| | - Manoj Kumar Rangaswamy
- Biomaterials and Multiscale Mechanics Lab, Department of Metallurgical and Materials Engineering, Indian Institute of Technology Roorkee, Roorkee 247667, India
| | - Cheng Zhang
- Plasma Forming Laboratory, Department of Mechanical and Materials Engineering, Florida International University, Miami, Florida 33174, United States
| | - Swati Haldar
- Centre for Nanotechnology, Indian Institute of Technology Roorkee, Roorkee 247667, India
| | - Murali Kumarasamy
- Centre for Nanotechnology, Indian Institute of Technology Roorkee, Roorkee 247667, India
| | - Arvind Agarwal
- Plasma Forming Laboratory, Department of Mechanical and Materials Engineering, Florida International University, Miami, Florida 33174, United States
| | - Partha Roy
- Department of Biotechnology, Indian Institute of Technology Roorkee, Roorkee 247667, India
| | - Debrupa Lahiri
- Biomaterials and Multiscale Mechanics Lab, Department of Metallurgical and Materials Engineering, Indian Institute of Technology Roorkee, Roorkee 247667, India
- Centre for Nanotechnology, Indian Institute of Technology Roorkee, Roorkee 247667, India
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Svensson K, Rolfson O, Kärrholm J, Mohaddes M. Similar Risk of Re-Revision in Patients after One- or Two-Stage Surgical Revision of Infected Total Hip Arthroplasty: An Analysis of Revisions in the Swedish Hip Arthroplasty Register 1979⁻2015. J Clin Med 2019; 8:jcm8040485. [PMID: 30974876 PMCID: PMC6518190 DOI: 10.3390/jcm8040485] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Revised: 03/29/2019] [Accepted: 04/04/2019] [Indexed: 12/23/2022] Open
Abstract
Late chronic infection is a devastating complication after total hip arthroplasty (THA) and is often treated with surgery. The one-stage surgical procedure is believed to be the more advantageous from a patient and cost perspective, but there is no consensus on whether the one- or two-stage procedure is the better option. We analysed the risk for re-revision in infected primary THAs repaired with either the one- or two-stage method. Data was obtained from the Swedish Hip Arthroplasty Register and the study groups were patients who had undergone a one-stage (n = 404) or two-stage (n = 1250) revision due to infection. Risk of re-revision was analysed using Kaplan–Meier analysis with log-rank test and Cox regression analysis. The cumulative survival rate was similar in the two groups at 15 years after surgery (p = 0.1). Adjusting for covariates, the risk for re-revision due to all causes did not differ between patients who were operated on with the one- or two-stage procedure (Hazard Ratio (HR) = 0.9, 95% Confidence Interval (C.I.) = 0.7–1.2, p = 0.5). The risk for re-revision due to infection (HR = 0.7, 95% C.I. = 0.4–1.1, p = 0.2) and aseptic loosening (HR = 1.2, 95% C.I. = 0.8–1.8, p = 0.5) was similar. This study could not determine whether the one-stage method was inferior in cases when the performing surgeons chose to use the one-stage method.
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Affiliation(s)
- Karin Svensson
- Department of Orthopaedics, Sahlgrenska University Hospital, 431 80 Mölndal, Sweden.
- Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, 431 80 Mölndal, Sweden
- The Swedish Hip Arthroplasty Register, 413 45, Gothenburg, Sweden
| | - Ola Rolfson
- Department of Orthopaedics, Sahlgrenska University Hospital, 431 80 Mölndal, Sweden.
- Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, 431 80 Mölndal, Sweden
- The Swedish Hip Arthroplasty Register, 413 45, Gothenburg, Sweden
| | - Johan Kärrholm
- Department of Orthopaedics, Sahlgrenska University Hospital, 431 80 Mölndal, Sweden.
- Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, 431 80 Mölndal, Sweden
- The Swedish Hip Arthroplasty Register, 413 45, Gothenburg, Sweden
| | - Maziar Mohaddes
- Department of Orthopaedics, Sahlgrenska University Hospital, 431 80 Mölndal, Sweden.
- Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, 431 80 Mölndal, Sweden
- The Swedish Hip Arthroplasty Register, 413 45, Gothenburg, Sweden
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Sebastian S, Malhotra R, Dhawan B. Prosthetic Joint Infection: A Major Threat to Successful Total Joint Arthroplasty. Indian J Med Microbiol 2018; 36:475-487. [DOI: 10.4103/ijmm.ijmm_19_11] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Kunutsor SK, Beswick AD, Whitehouse MR, Wylde V, Blom AW. Debridement, antibiotics and implant retention for periprosthetic joint infections: A systematic review and meta-analysis of treatment outcomes. J Infect 2018; 77:479-488. [PMID: 30205122 DOI: 10.1016/j.jinf.2018.08.017] [Citation(s) in RCA: 79] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2017] [Revised: 05/10/2018] [Accepted: 08/14/2018] [Indexed: 01/19/2023]
Abstract
OBJECTIVES We aimed to assess infection control rates after DAIR in patients with periprosthetic joint infection (PJI) following joint arthroplasty and evaluate factors associated with infection control using a systematic review and meta-analysis. METHODS We searched MEDLINE, EMBASE, Web of Science, Cochrane databases and reference lists of relevant studies up to May 2017. Longitudinal studies conducted in patients with PJI treated exclusively by DAIR were eligible. Infection control rates were meta-analysed using random-effect models after arcsine transformation. RESULTS We included 93 articles based on 99 unique observational studies with data on 4897 PJIs treated by DAIR. The infection control rate for DAIR ranged from 11.1% to 100% with an overall pooled estimate of 61.4% (95% CI, 57.3-65.4) and a 95% prediction interval of 25.5% to 91.8%. Infection control rates remained generally similar for several relevant characteristics, except for evidence of variation by age, geographical location, type of infection and joint affected, duration of parenteral antibiotic therapy after the DAIR procedure, and period (year) of DAIR procedure. CONCLUSIONS The DAIR approach remains an option for the treatment of PJI as it is associated with acceptable infection control rates, particularly in acute postoperative infections and infections of the hip and shoulder joints.
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Affiliation(s)
- Setor K Kunutsor
- National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol NHS Foundation Trust and University of Bristol, Learning & Research Building (Level 1), Southmead Hospital, Bristol BS10 5NB, UK; Translational Health Sciences, Bristol Medical School, Musculoskeletal Research Unit, University of Bristol, Learning & Research Building (Level 1), Southmead Hospital, Bristol BS10 5NB, UK.
| | - Andrew D Beswick
- Translational Health Sciences, Bristol Medical School, Musculoskeletal Research Unit, University of Bristol, Learning & Research Building (Level 1), Southmead Hospital, Bristol BS10 5NB, UK
| | - Michael R Whitehouse
- National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol NHS Foundation Trust and University of Bristol, Learning & Research Building (Level 1), Southmead Hospital, Bristol BS10 5NB, UK; Translational Health Sciences, Bristol Medical School, Musculoskeletal Research Unit, University of Bristol, Learning & Research Building (Level 1), Southmead Hospital, Bristol BS10 5NB, UK
| | - Vikki Wylde
- National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol NHS Foundation Trust and University of Bristol, Learning & Research Building (Level 1), Southmead Hospital, Bristol BS10 5NB, UK; Translational Health Sciences, Bristol Medical School, Musculoskeletal Research Unit, University of Bristol, Learning & Research Building (Level 1), Southmead Hospital, Bristol BS10 5NB, UK
| | - Ashley W Blom
- National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol NHS Foundation Trust and University of Bristol, Learning & Research Building (Level 1), Southmead Hospital, Bristol BS10 5NB, UK; Translational Health Sciences, Bristol Medical School, Musculoskeletal Research Unit, University of Bristol, Learning & Research Building (Level 1), Southmead Hospital, Bristol BS10 5NB, UK
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Mooney JA, Pridgen EM, Manasherob R, Suh G, Blackwell HE, Barron AE, Bollyky PL, Goodman SB, Amanatullah DF. Periprosthetic bacterial biofilm and quorum sensing. J Orthop Res 2018; 36:2331-2339. [PMID: 29663554 DOI: 10.1002/jor.24019] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2017] [Accepted: 04/04/2018] [Indexed: 02/04/2023]
Abstract
Periprosthetic joint infection (PJI) is a common complication after total joint arthroplasty leading to severe morbidity and mortality. With an aging population and increasing prevalence of total joint replacement procedures, the burden of PJI will be felt not only by individual patients, but in increased healthcare costs. Current treatment of PJI is inadequate resulting in incredibly high failure rates. This is believed to be largely mediated by the presence of bacterial biofilms. These polymicrobial bacterial colonies form within secreted extracellular matrices, adhering to the implant surface and local tissue. The biofilm architecture is believed to play a complex and critical role in a variety of bacterial processes including nutrient supplementation, metabolism, waste management, and antibiotic and immune resistance. The establishment of these biofilms relies heavily on the quorum sensing communication systems utilized by bacteria. Early stage research into disrupting bacterial communication by targeting quorum sensing show promise for future clinical applications. However, prevention of the biofilm formation via early forced induction of the biofilm forming process remains yet unexplored. © 2018 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 36:2331-2339, 2018.
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Affiliation(s)
- Jake A Mooney
- Stanford University, School of Medicine, Stanford, California
| | - Eric M Pridgen
- Department of Orthopaedic Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Robert Manasherob
- Department of Orthopaedic Surgery, Stanford Hospitals and Clinics, Broadway Street, Redwood City, Stanford 94063, California
| | - Gina Suh
- Department of Medicine, Stanford School of Medicine, Stanford, California
| | - Helen E Blackwell
- Department of Chemistry, University of Wisconsin-Madison, Madison, Wisconsin
| | - Annelise E Barron
- Department of Bioengineering, School of Medicine, Stanford University, Stanford, California
| | - Paul L Bollyky
- Division of Infectious Diseases, Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Stuart B Goodman
- Department of Orthopaedic Surgery, Stanford Hospitals and Clinics, Broadway Street, Redwood City, Stanford 94063, California
| | - Derek F Amanatullah
- Department of Orthopaedic Surgery, Stanford Hospitals and Clinics, Broadway Street, Redwood City, Stanford 94063, California
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Heim CE, Vidlak D, Odvody J, Hartman CW, Garvin KL, Kielian T. Human prosthetic joint infections are associated with myeloid-derived suppressor cells (MDSCs): Implications for infection persistence. J Orthop Res 2018; 36:1605-1613. [PMID: 29139571 PMCID: PMC5953848 DOI: 10.1002/jor.23806] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2017] [Accepted: 11/11/2017] [Indexed: 02/04/2023]
Abstract
UNLABELLED Prosthetic joint infection (PJI) is a devastating complication of joint arthroplasty surgery typified by biofilm formation. Currently, mechanisms whereby biofilms persist and evade immune-mediated clearance in immune competent patients remain largely ill-defined. Therefore, the current study characterized leukocyte infiltrates and inflammatory mediator expression in tissues from patients with PJI compared to aseptic loosening. CD33+ HLA-DR- CD66b+ CD14-/low granulocytic myeloid-derived suppressor cells (G-MDSCs) were the predominant leukocyte population at sites of human PJI compared to aseptic tissues. MDSCs inhibit T cell proliferation, which coincided with reduced T cells in PJIs compared to aseptic tissues. IL-10, IL-6, and CXCL1 were significantly elevated in PJI tissues and have been implicated in MDSC inhibitory activity, expansion, and recruitment, respectively, which may account for their preferential increase in PJIs. This bias towards G-MDSC accumulation during human PJI could account for the chronicity of these infections by preventing the pro-inflammatory, antimicrobial actions of immune effector cells. CLINICAL SIGNIFICANCE Animal models of PJI have revealed a critical role for MDSCs and IL-10 in promoting infection persistence; however, whether this population is prevalent during human PJI and across distinct bacterial pathogens remains unknown. This study has identified that granulocytic-MDSC infiltrates are unique to human PJIs caused by distinct bacteria, which are not associated with aseptic loosening of prosthetic joints. Better defining the immune status of human PJIs could lead to novel immune-mediated approaches to facilitate PJI clearance in combination with conventional antibiotics. © 2017 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 36:1605-1613, 2018.
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Affiliation(s)
- Cortney E. Heim
- Department of Pathology and Microbiology, University of Nebraska Medical Center, Omaha, NE 68198
| | - Debbie Vidlak
- Department of Pathology and Microbiology, University of Nebraska Medical Center, Omaha, NE 68198
| | - Jessica Odvody
- Department of Pathology and Microbiology, University of Nebraska Medical Center, Omaha, NE 68198
| | - Curtis W. Hartman
- Department of Orthopaedic Surgery and Rehabilitation, University of Nebraska Medical Center, Omaha, NE 68198
| | - Kevin L. Garvin
- Department of Orthopaedic Surgery and Rehabilitation, University of Nebraska Medical Center, Omaha, NE 68198
| | - Tammy Kielian
- Department of Pathology and Microbiology, University of Nebraska Medical Center, Omaha, NE 68198,Corresponding Author: Tammy Kielian, Ph.D., University of Nebraska Medical Center, Department of Pathology and Microbiology, 985900 Nebraska Medical Center, Omaha, NE 68198-5900, Phone: (402) 559-8002, FAX: (402) 559-5900,
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Harold RE, Butler BA, Lamplot J, Luu HH, Lawton CD, Manning D. Multifaceted aseptic protocol decreases surgical site infections following hip arthroplasty. Hip Int 2018; 28:182-8. [PMID: 28967053 DOI: 10.5301/hipint.5000551] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
INTRODUCTION We investigate the effectiveness of a comprehensive aseptic protocol in reducing surgical site infection (SSI) after hip arthroplasty in a single medical centre with a high prevalence of methicillin-resistant Staphylococcus aureus (MRSA). METHODS A prospectively collected database of all patients undergoing hip arthroplasty in a single centre between 2005 and 2011 was reviewed for SSI using Centers for Disease Control (CDC) criteria and AAOS guidelines. All patients were administered an aseptic protocol consisting of: preoperative 2% mupirocin nasal ointment and 0.4% chlorhexidine surgical-site wipes; modified instrument care; perioperative prophylactic vancomycin and cefazolin; and surgical-site skin preparation with chlorhexidine, alcohol and iodophor. We compare our protocol hip arthroplasty SSI rate to our institutional historical control and to contemporary literature. RESULTS Among 774 patients, 69% were ASA>2, 45% had BMI≥30 and 10.3% had rheumatoid arthritis. We found an overall 0.39% infection rate; significantly lower than our institutional historical control (0.39% vs. 2.60%, p<0.001, OR 0.15, NNT 200) and significantly lower than 6 published reports (p<0.001-0.022, OR 0.16-0.22). Compared to these cohorts, significantly more of our patients were ASA>2, had BMI≥30 or had rheumatoid arthritis. Patients with 3 or more identifiable risk factors were at an increased risk of SSI compared to those with 2 or fewer risk factors. CONCLUSIONS Our aseptic protocol decreases SSI in a high-risk population undergoing hip arthroplasty in a medical centre and community with a high prevalence of MRSA.
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Graves N, Wloch C, Wilson J, Barnett A, Sutton A, Cooper N, Merollini K, McCreanor V, Cheng Q, Burn E, Lamagni T, Charlett A. A cost-effectiveness modelling study of strategies to reduce risk of infection following primary hip replacement based on a systematic review. Health Technol Assess 2018; 20:1-144. [PMID: 27468732 DOI: 10.3310/hta20540] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND A deep infection of the surgical site is reported in 0.7% of all cases of total hip arthroplasty (THA). This often leads to revision surgery that is invasive, painful and costly. A range of strategies is employed in NHS hospitals to reduce risk, yet no economic analysis has been undertaken to compare the value for money of competing prevention strategies. OBJECTIVES To compare the costs and health benefits of strategies that reduce the risk of deep infection following THA in NHS hospitals. To make recommendations to decision-makers about the cost-effectiveness of the alternatives. DESIGN The study comprised a systematic review and cost-effectiveness decision analysis. SETTING 77,321 patients who had a primary hip arthroplasty in NHS hospitals in 2012. INTERVENTIONS Nine different treatment strategies including antibiotic prophylaxis, antibiotic-impregnated cement and ventilation systems used in the operating theatre. MAIN OUTCOME MEASURES Change in the number of deep infections, change in the total costs and change in the total health benefits in quality-adjusted life-years (QALYs). DATA SOURCES Literature searches using MEDLINE, EMBASE, Cumulative Index to Nursing and Allied Health Literature and the Cochrane Central Register of Controlled Trials were undertaken to cover the period 1966-2012 to identify infection prevention strategies. Relevant journals, conference proceedings and bibliographies of retrieved papers were hand-searched. Orthopaedic surgeons and infection prevention experts were also consulted. REVIEW METHODS English-language papers only. The selection of evidence was by two independent reviewers. Studies were included if they were interventions that reported THA-related deep surgical site infection (SSI) as an outcome. Mixed-treatment comparisons were made to produce estimates of the relative effects of competing infection control strategies. RESULTS Twelve studies, six randomised controlled trials and six observational studies, involving 123,788 total hip replacements (THRs) and nine infection control strategies, were identified. The quality of the evidence was judged against four categories developed by the National Institute for Health and Care Excellence Methods for Development of NICE Public Health Guidance ( http://publications.nice.org.uk/methods-for-the-development-of-nice-public-health-guidance-third-edition-pmg4 ), accessed March 2012. All evidence was found to fit the two highest categories of 1 and 2. Nine competing infection control interventions [treatments (Ts) 1-9] were used in a cohort simulation model of 77,321 patients who had a primary THR in 2012. Predictions were made for cases of deep infection and total costs, and QALY outcomes. Compared with a baseline of T1 (no systemic antibiotics, plain cement and conventional ventilation) all other treatment strategies reduced risk. T6 was the most effective (systemic antibiotics, antibiotic-impregnated cement and conventional ventilation) and prevented a further 1481 cases of deep infection, and led to the largest annual cost savings and the greatest gains to QALYs. The additional uses of laminar airflow and body exhaust suits indicate higher costs and worse health outcomes. CONCLUSIONS T6 is an optimal strategy for reducing the risk of SSI following THA. The other strategies that are commonly used among NHS hospitals lead to higher cost and worse QALY outcomes. Policy-makers, therefore, have an opportunity to save resources and improve health outcomes. The effects of laminar air flow and body exhaust suits might be further studied if policy-makers are to consider disinvesting in these technologies. LIMITATIONS A wide range of evidence sources was synthesised and there is large uncertainty in the conclusions. FUNDING The National Institute for Health Research Health Technology Assessment programme and the Queensland Health Quality Improvement and Enhancement Programme (grant number 2008001769).
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Affiliation(s)
- Nicholas Graves
- School of Public Health and Social Work, Queensland University of Technology, Brisbane, QLD, Australia
| | | | - Jennie Wilson
- College of Nursing, Midwifery and Healthcare, University of West London, London, UK
| | - Adrian Barnett
- School of Public Health and Social Work, Queensland University of Technology, Brisbane, QLD, Australia
| | - Alex Sutton
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Nicola Cooper
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Katharina Merollini
- School of Public Health and Social Work, Queensland University of Technology, Brisbane, QLD, Australia
| | - Victoria McCreanor
- School of Public Health and Social Work, Queensland University of Technology, Brisbane, QLD, Australia
| | - Qinglu Cheng
- School of Public Health and Social Work, Queensland University of Technology, Brisbane, QLD, Australia
| | - Edward Burn
- School of Public Health and Social Work, Queensland University of Technology, Brisbane, QLD, Australia
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Trela-Larsen L, Sayers A, Blom AW, Webb JCJ, Whitehouse MR. The association between cement type and the subsequent risk of revision surgery in primary total hip replacement. Acta Orthop 2018; 89:40-46. [PMID: 29072088 PMCID: PMC5810831 DOI: 10.1080/17453674.2017.1393224] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Background and purpose - To further improve the success of joint replacement surgery, attention needs to be paid to variations associated with improved or worsened outcomes. We investigated the association between the type of bone cement used and the risk of revision surgery after primary total hip replacement. Methods - We conducted a prospective study of data from the National Joint Registry for England and Wales between April 1, 2003 and December 31, 2013. 199,205 primary total hip replacements performed for osteoarthritis where bone cement was used were included. A multilevel over-dispersed piecewise Poisson model was used to estimate differences in the rate of revision by bone cement type adjusted for implant type, head size, age, sex, ASA grade, and surgical approach. Results - The rate of revision was higher in DePuy CMW3 medium viscosity with gentamicin (IRR 2.0, 95% CI 1.5-2.7) and DePuy SmartSet high viscosity plain (IRR 2.7, 95% CI 1.1-5.5), and lower in DePuy CMW1 high viscosity plain (IRR 0.44, 95% CI 0.19-0.89) bone cements compared with Heraeus Palacos high viscosity with gentamicin. Revision rates were similar between plain and antibiotic-loaded bone cement. Interpretation - The majority of bone cements performed similarly well, excluding DePuy SmartSet high viscosity and CMW3 high viscosity with gentamicin, which both had higher revision rates. We found no clear differences by viscosity or antibiotic content.
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Affiliation(s)
- Lea Trela-Larsen
- Musculoskeletal Research Unit, School of Clinical Sciences, University of Bristol, Southmead Hospital, Bristol, UK
| | - Adrian Sayers
- Musculoskeletal Research Unit, School of Clinical Sciences, University of Bristol, Southmead Hospital, Bristol, UK,School of Social and Community, Based Medicine, University of Bristol, Bristol, UK,Correspondence:
| | - Ashley William Blom
- Musculoskeletal Research Unit, School of Clinical Sciences, University of Bristol, Southmead Hospital, Bristol, UK,Avon Orthopaedic Centre, Southmead Hospital, Bristol, UK
| | - Jason Crispin John Webb
- Musculoskeletal Research Unit, School of Clinical Sciences, University of Bristol, Southmead Hospital, Bristol, UK,Avon Orthopaedic Centre, Southmead Hospital, Bristol, UK
| | - Michael Richard Whitehouse
- Musculoskeletal Research Unit, School of Clinical Sciences, University of Bristol, Southmead Hospital, Bristol, UK,Avon Orthopaedic Centre, Southmead Hospital, Bristol, UK
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Briggs T, Blunn G, Hislop S, Ramalhete R, Bagley C, McKenna D, Coathup M. Antimicrobial photodynamic therapy-a promising treatment for prosthetic joint infections. Lasers Med Sci 2017; 33:523-532. [PMID: 29247432 PMCID: PMC5862934 DOI: 10.1007/s10103-017-2394-4] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2017] [Accepted: 11/20/2017] [Indexed: 12/13/2022]
Abstract
Periprosthetic joint infection (PJI) is associated with high patient morbidity and a large financial cost. This study investigated Photodynamic Therapy (PDT) as a means of eradicating bacteria that cause PJI, using a laser with a 665-nm wavelength and methylene blue (MB) as the photosensitizer. The effectiveness of MB concentration on the growth inhibition of methicillin-sensitive Staphylococcus aureus (MSSA), methicillin-resistant Staphylococcus aureus (MRSA), Staphylococcus epidermidis, Pseudomonas aeruginosa and Acinetobacter baumannii was investigated. The effect of laser dose was also investigated and the optimized PDT method was used to investigate its bactericidal effect on species within planktonic culture and following the formation of a biofilm on polished titanium and hydroxyapatite coated titanium discs. Results showed that Staphylococci were eradicated at the lowest concentration of 0.1 mM methylene blue (MB). With P. aeruginosa and A. baumannii, increasing the MB concentration improved the bactericidal effect. When the laser dose was increased, results showed that the higher the power of the laser the more bacteria were eradicated with a laser power ≥ 35 J/cm2 and an irradiance of 35 mW/cm2, eradicating all S. epidermidis. The optimized PDT method had a significant bactericidal effect against planktonic MRSA and S. epidermidis compared to MB alone, laser alone, or control (no treatment). When biofilms were formed, PDT treatment had a significantly higher bactericidal effect than MB alone and laser alone for all species of bacteria investigated on the polished disc surfaces. P. aeruginosa grown in a biofilm was shown to be less sensitive to PDT when compared to Staphylococci, and a HA-coated surface reduced the effectiveness of PDT. This study demonstrated that PDT is effective for killing bacteria that cause PJI.
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Affiliation(s)
- Timothy Briggs
- Royal National Orthopaedic Hospital, HA7 4LP, Brockley Hill, HA7 4LP, Stanmore, UK
| | - Gordon Blunn
- Institute of Orthopaedics and Musculo-Skeletal Science, Division of Surgery & Interventional Science, University College London, Royal National Orthopaedic Hospital, Brockley Hill, Stanmore, Middlesex, HA7 4LP, UK
| | - Simon Hislop
- Royal National Orthopaedic Hospital, HA7 4LP, Brockley Hill, HA7 4LP, Stanmore, UK
| | - Rita Ramalhete
- Institute of Orthopaedics and Musculo-Skeletal Science, Division of Surgery & Interventional Science, University College London, Royal National Orthopaedic Hospital, Brockley Hill, Stanmore, Middlesex, HA7 4LP, UK.
| | - Caroline Bagley
- Institute of Orthopaedics and Musculo-Skeletal Science, Division of Surgery & Interventional Science, University College London, Royal National Orthopaedic Hospital, Brockley Hill, Stanmore, Middlesex, HA7 4LP, UK
| | - David McKenna
- Royal National Orthopaedic Hospital, HA7 4LP, Brockley Hill, HA7 4LP, Stanmore, UK
| | - Melanie Coathup
- Institute of Orthopaedics and Musculo-Skeletal Science, Division of Surgery & Interventional Science, University College London, Royal National Orthopaedic Hospital, Brockley Hill, Stanmore, Middlesex, HA7 4LP, UK
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Akinola B, Quansah B, Gouliouris T, Carrothers AD. A retained stitch in time saves 9 - but does it increase the risk of deep prosthetic infection? Hip Int 2017; 27:564-6. [PMID: 28574122 DOI: 10.5301/hipint.5000501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/24/2017] [Indexed: 02/04/2023]
Abstract
INTRODUCTION During the posterior approach to the hip, the short external rotators are detached and secured with stay sutures. At the time of definitive closure, some surgeons incorporate the initial sutures into their repair while others discard for fresh sutures, presumably as an infection prevention measure. We have conducted a pilot study to investigate whether the incorporation of the primary stay sutures may constitute an infection risk to the patient undergoing a total hip replacement through the posterior approach. MATERIALS AND METHODS The pilot study was conducted between August 2014 and June 2015. A pair of suture specimens were sent from 25 patients to microbiology, 1 set of primary stay sutures and 1 set of control sutures. All operations were carried out by the senior author through a posterior approach. RESULTS All specimens were analysed for bacterial and fungal growth, using extended cultures. 1 set of primary sutures had a positive growth, likely from skin contamination; 1 set of control sutures also had a positive growth, likely from environmental contamination. CONCLUSIONS Our pilot study suggests that the practice of incorporating the primary stay sutures for definitive soft tissue repair of the short external rotators, rather than exchanging them for new sutures, can be deemed safe.
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Iwakiri K, Kobayashi A, Seki M, Ando Y, Tsujio T, Hoshino M, Nakamura H. Waterless Hand Rub Versus Traditional Hand Scrub Methods for Preventing the Surgical Site Infection in Orthopedic Surgery. Spine (Phila Pa 1976) 2017; 42:1675-9. [PMID: 28422796 DOI: 10.1097/BRS.0000000000002200] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
UNLABELLED MINI: Fourteen hundred consecutive patients were investigated for evaluating the utility of waterless hand rub before orthopaedic surgery. The risk in the surgical site infection incidence was the same, but costs of liquids used for hand hygiene were cheaper and the hand hygiene time was shorter for waterless protocol, compared with traditional hand scrub. STUDY DESIGN A retrospective cohort study with prospectively collected data. OBJECTIVE The aim of this study was to compare SSI incidences, the cost of hand hygiene agents, and hand hygiene time between the traditional hand scrub and the waterless hand rub protocols before orthopedic surgery. SUMMARY OF BACKGROUND DATA Surgical site infections (SSI) prolong hospitalization and are a leading nosocomial cause of morbidity and a source of excess cost. Recently, a waterless hand rub protocol comprising alcohol based chlorhexidine gluconate for use before surgery was developed, but no studies have yet examined its utility in orthopedic surgery. METHODS Fourteen hundred consecutive patients who underwent orthopedic surgery (spine, joint replacement, hand, and trauma surgeries) in our hospital since April 1, 2012 were included. A total of 712 cases underwent following traditional hand scrub between April 1, 2012 and April 30, 2013 and 688 cases underwent following waterless hand rub between June 1, 2013 and April 30, 2014. We compared SSI incidences within all and each subcategory between two hand hygiene protocols. All patients were screened for SSI within 1 year after surgery. We compared the cost of hand hygiene agents and hand hygiene time between two groups. RESULTS The SSI incidences were 1.3% (9 of 712) following the traditional protocol (2 deep and 7 superficial infections) and 1.1% (8 of 688) following the waterless protocol (all superficial infections). There were no significant differences between the two groups. The costs of liquids used for one hand hygiene were about $2 for traditional hand scrub and less than $1 for waterless hand rub. The mean hand hygiene time was 264 seconds with the traditional protocol and 160 seconds with the waterless protocol. CONCLUSION Waterless hand rub with an alcohol based chlorhexidine gluconate solution can be a safe, quick, and cost-effective alternative to traditional hand scrub. LEVEL OF EVIDENCE 3.
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Zhu W, Liu F, He J. Synthesis of imidazolium-containing mono-methacrylates as polymerizable antibacterial agents for acrylic bone cements. J Mech Behav Biomed Mater 2017; 74:176-182. [DOI: 10.1016/j.jmbbm.2017.06.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2017] [Revised: 05/30/2017] [Accepted: 06/04/2017] [Indexed: 10/18/2022]
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Grammatopoulos G, Kendrick B, McNally M, Athanasou NA, Atkins B, McLardy-Smith P, Taylor A, Gundle R. Outcome Following Debridement, Antibiotics, and Implant Retention in Hip Periprosthetic Joint Infection-An 18-Year Experience. J Arthroplasty 2017; 32:2248-2255. [PMID: 28385345 DOI: 10.1016/j.arth.2017.02.066] [Citation(s) in RCA: 68] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2016] [Revised: 01/27/2017] [Accepted: 02/18/2017] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Debridement-antibiotics-and-implant-retention (DAIR) may be considered a suitable surgical option in periprosthetic joint infections (PJIs) with soundly fixed prostheses, despite chronicity. This study aims to define the long-term outcome following DAIR in hip PJI. METHODS We reviewed all hip DAIRs performed between 1997 and 2013 (n = 122) to define long-term outcome and identify factors influencing it. Data recorded included patient demographics, medical history, type of DAIR performed (+/- exchange of modular components), and organisms identified. Outcome measures included complications and/or mortality rate, implant survivorship, and functional outcome (Oxford Hip Score). RESULTS Most DAIRs (67%) were of primary arthroplasties and 60% were performed within 6 weeks from the index arthroplasty. Infection eradication was achieved in 68% of the first DAIR procedure. In 32 cases, more than one DAIR was required. Infection eradication was achieved in 85% of the cases (104/122) with the (single or multiple) DAIR approach. The most common complication was PJI-persistence (15%), followed by dislocation (14%). Very good functional outcomes were obtained, especially in primary arthroplasties. All streptococcus infections were resolved with DAIR and had better outcome. Twenty-one hips have been revised (17%) to-date, 16 were for persistence of PJI. The 10-y implant survivorship was 77%. Early PJI and exchanging modular components at DAIR were independent factors for a 4-fold increased infection eradication and improved long-term implant survival. CONCLUSION DAIR is, therefore, a valuable option in the treatment of hip PJI, especially in the early postoperative period (≤6 weeks), with good outcomes. However, DAIR is associated with increased morbidity; further surgery may be necessary and instability may occur. Where possible, exchange of modular implants should be undertaken.
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Affiliation(s)
| | | | - Martin McNally
- Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford, UK
| | | | - Bridget Atkins
- Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford, UK
| | | | - Adrian Taylor
- Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford, UK
| | - Roger Gundle
- Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford, UK
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Lenguerrand E, Whitehouse MR, Beswick AD, Jones SA, Porter ML, Blom AW. Revision for prosthetic joint infection following hip arthroplasty: Evidence from the National Joint Registry. Bone Joint Res 2017. [PMID: 28642256 PMCID: PMC5492333 DOI: 10.1302/2046-3758.66.bjr-2017-0003.r1] [Citation(s) in RCA: 79] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Objectives We used the National Joint Registry for England, Wales, Northern Ireland and the Isle of Man (NJR) to investigate the risk of revision due to prosthetic joint infection (PJI) for patients undergoing primary and revision hip arthroplasty, the changes in risk over time, and the overall burden created by PJI. Methods We analysed revision total hip arthroplasties (THAs) performed due to a diagnosis of PJI and the linked index procedures recorded in the NJR between 2003 and 2014. The cohort analysed consisted of 623 253 index primary hip arthroplasties, 63 222 index revision hip arthroplasties and 7585 revision THAs performed due to a diagnosis of PJI. The prevalence, cumulative incidence functions and the burden of PJI (total procedures) were calculated. Overall linear trends were investigated with log-linear regression. Results We demonstrated a prevalence of revision THA due to prosthetic joint infection of 0.4/100 procedures following primary and 1.6/100 procedures following revision hip arthroplasty. The prevalence of revision due to PJI in the three months following primary hip arthroplasty has risen 2.3-fold (95% confidence interval (CI) 1.3 to 4.1) between 2005 and 2013, and 3.0-fold (95% CI 1.1 to 8.5) following revision hip arthroplasty. Over 1000 procedures are performed annually as a consequence of hip PJI, an increase of 2.6-fold between 2005 and 2013. Conclusions Although the risk of revision due to PJI following hip arthroplasty is low, it is rising and, coupled with the established and further predicted increased incidence of both primary and revision hip arthroplasty, this represents a growing and substantial treatment burden. Cite this article: E. Lenguerrand, M. R. Whitehouse, A. D. Beswick, S. A. Jones, M. L. Porter, A. W. Blom. Revision for prosthetic joint infection following hip arthroplasty: Evidence from the National Joint Registry. Bone Joint Res 2017;6:391–398. DOI: 10.1302/2046-3758.66.BJR-2017-0003.R1.
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Affiliation(s)
- E Lenguerrand
- Musculoskeletal Research Unit, School of Clinical Sciences, University of Bristol, 1st Floor Learning & Research Building, Southmead Hospital, Bristol, BS10 5NB, UK
| | - M R Whitehouse
- Musculoskeletal Research Unit, School of Clinical Sciences, University of Bristol, 1st Floor Learning & Research Building, Southmead Hospital, Bristol, BS10 5NB, UK
| | - A D Beswick
- Musculoskeletal Research Unit, School of Clinical Sciences, University of Bristol, 1st Floor Learning & Research Building, Southmead Hospital, Bristol, BS10 5NB, UK
| | - S A Jones
- Cardiff & Vale University Health Board, University Hospital Llandough, Penlan Road, Llandough, Penarth, Vale of Glamorgan, CF64 2XX, UK
| | - M L Porter
- Centre for Hip Surgery, Wrightington Hospital, Lancashire, WN6 9EP, UK
| | - A W Blom
- Musculoskeletal Research Unit, School of Clinical Sciences, University of Bristol, 1st Floor Learning & Research Building, Southmead Hospital, Bristol, BS10 5NB, UK
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Moore AJ, Blom AW, Whitehouse MR, Gooberman-Hill R. Managing uncertainty - a qualitative study of surgeons' decision-making for one-stage and two-stage revision surgery for prosthetic hip joint infection. BMC Musculoskelet Disord 2017; 18:154. [PMID: 28403859 PMCID: PMC5388991 DOI: 10.1186/s12891-017-1499-z] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2016] [Accepted: 03/22/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Approximately 88,000 primary hip replacements are performed in England and Wales each year. Around 1% go on to develop deep prosthetic joint infection. Between one-stage and two-stage revision arthroplasty best treatment options remain unclear. Our aims were to characterise consultant orthopaedic surgeons' decisions about performing either one-stage or two-stage revision surgery for patients with deep prosthetic infection (PJI) after hip arthroplasty, and to identify whether a randomised trial comparing one-stage with two-stage revision would be feasible. METHODS Semi-structured interviews were conducted with 12 consultant surgeons who perform revision surgery for PJI after hip arthroplasty at 5 high-volume National Health Service (NHS) orthopaedic departments in England and Wales. Surgeons were interviewed before the development of a multicentre randomised controlled trial. Data were analysed using a thematic approach. RESULTS There is no single standardised surgical intervention for the treatment of PJI. Surgeons balance multiple factors when choosing a surgical strategy which include multiple patient-related factors, their own knowledge and expertise, available infrastructure and the infecting organism. Surgeons questioned whether it was appropriate that the two-stage revision remained the best treatment, and some surgeons' willingness to consider more one-stage revisions had increased over recent years and were influenced by growing evidence showing equivalence between surgical techniques, and local observations of successful one-stage revisions. Custom-made articulating spacers was a practice that enabled uncertainty to be managed in the absence of definitive evidence about the superiority of one surgical technique over the other. Surgeons highlighted the need for research evidence to inform practice and thought that a randomised trial to compare treatments was needed. Most surgeons thought that patients who they treated would be eligible for trial participation in instances where there was uncertainty about the best treatment option. CONCLUSIONS Surgeons highlighted the need for evidence to support their choice of revision. Some surgeons' willingness to consider one-stage revision for infection had increased over time, largely influenced by evidence of successful one-stage revisions. Custom-made articulating spacers also enabled surgeons to manage uncertainty about the superiority of surgical techniques. Surgeons thought that a prospective randomised controlled trial comparing one-stage with two-stage joint replacement is needed and that randomisation would be feasible.
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Affiliation(s)
- Andrew J Moore
- School of Clinical Sciences, University of Bristol, Bristol, UK.
| | - Ashley W Blom
- School of Clinical Sciences, University of Bristol, Bristol, UK
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