1
|
Sadhwani S, Kamson A, Frear AJ, Sadaka N, Urish KL. Current Concepts on the Clinical and Economic Impact of Periprosthetic Joint Infections. Orthop Clin North Am 2024; 55:151-159. [PMID: 38403362 DOI: 10.1016/j.ocl.2023.09.001] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/27/2024]
Abstract
Total joint arthroplasty (TJA) is a common procedure performed throughout the entire world in hopes of alleviating debilitating hip or knee pain. The projected number of TJAs performed in the United States alone is projected to exceed 1.9 million by 2030 and 5 million by 2040. With the significant increase in TJA performed, more periprosthetic joint infections (PJIs) are likely to be encountered. PJIs are a devastating complication of TJA. The economic and clinical burden must be understood and respected to minimize occurrence and allow optimal patient outcomes.
Collapse
Affiliation(s)
- Shaan Sadhwani
- Arthritis and Arthroplasty Design Group, Department of Orthopaedic Surgery, School of Medicine, University of Pittsburgh, Pittsburgh, PA 15219, USA; Department of Orthopaedic Surgery, UPMC Central PA, Harrisburg, PA 17109, USA
| | - Anthony Kamson
- Arthritis and Arthroplasty Design Group, Department of Orthopaedic Surgery, School of Medicine, University of Pittsburgh, Pittsburgh, PA 15219, USA; Department of Orthopaedic Surgery, UPMC Central PA, Harrisburg, PA 17109, USA
| | - Andrew J Frear
- Arthritis and Arthroplasty Design Group, Department of Orthopaedic Surgery, School of Medicine, University of Pittsburgh, Pittsburgh, PA 15219, USA
| | - Nadine Sadaka
- Arthritis and Arthroplasty Design Group, Department of Orthopaedic Surgery, School of Medicine, University of Pittsburgh, Pittsburgh, PA 15219, USA
| | - Kenneth L Urish
- Arthritis and Arthroplasty Design Group, Department of Orthopaedic Surgery, School of Medicine, University of Pittsburgh, Pittsburgh, PA 15219, USA; Arthritis and Arthroplasty Design Group, The Bone and Joint Center, Magee Womens Hospital of the University of Pittsburgh Medical Center; Department of Orthopaedic Surgery, Clinical and Translational Science Institute, University of Pittsburgh; Department of Bioengineering, Clinical and Translational Science Institute, University of Pittsburgh.
| |
Collapse
|
2
|
Cochrane NH, Kim BI, Stauffer TP, Hallows RK, Urish KL, Carvajal Alba JA, Seyler TM. Revision Total Knee Arthroplasty With an Imageless, Second-Generation Robotic System. J Arthroplasty 2024:S0883-5403(24)00118-9. [PMID: 38355066 DOI: 10.1016/j.arth.2024.02.018] [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: 09/29/2023] [Revised: 02/01/2024] [Accepted: 02/07/2024] [Indexed: 02/16/2024] Open
Abstract
BACKGROUND Robotic-assisted total knee arthroplasty is increasingly used in revision total knee arthroplasty (rTKA), with imageless systems recently receiving Food and Drug Administration (FDA) approval. However, there remains a paucity of literature on the use of robotic assistance in revision total knee arthroplasty (TKA). This paper describes the imageless surgical technique for robotic revision TKA using a second-generation robotic system and details both intraoperative and 90-day outcomes. METHODS This was a retrospective review of 115 robotic revision TKAs from March 2021 to May 2023 at 3 tertiary academic centers. Patient demographics, perioperative surgical data, and 90-day outcomes were collected. Pain and Patient-Reported Outcomes Measurement Information System scores preoperatively and postoperatively were recorded. All-cause reoperations at the final follow-up were detailed. The mean patient age was 65 years (range, 43 to 88), and 58% were women. The mean follow-up time was 13 months (range, 3 to 51). RESULTS The most common indications for rTKA were instability (n = 37, 32%) and aseptic loosening (n = 42, 37%). There were 83 rTKAs to a posterior-stabilized liner, 22 to a varus-valgus constrained liner, and 5 to a hinged construct. The median polyethylene size was 11 (interquartile range, 10 to 13), and 93% of patients had their joint line restored within 5 millimeters of the native contralateral knee. Within the 90-day postoperative window, there were 8 emergency department visits and 2 readmissions. At the final follow-up, there were 5 reoperations and 2 manipulations under anesthesia. There were 4 patients who required irrigation and debridement after superficial wound dehiscence, and one had an arthrotomy disruption after a fall. CONCLUSIONS This review demonstrates favorable intraoperative and 90-day outcomes and suggests that imageless robotic surgery is a promising modality in rTKA. Further studies comparing the longitudinal outcomes after robotic and conventional rTKA are warranted.
Collapse
Affiliation(s)
- Niall H Cochrane
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina
| | - Billy I Kim
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina
| | - Taylor P Stauffer
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina
| | - Rhett K Hallows
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina
| | - Kenneth L Urish
- Arthritis and Arthroplasty Design Group, The Bone and Joint Center, Magee Womens Hospital of the University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania; Department of Bioengineering, and Clinical and Translational Science Institute, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Jaime A Carvajal Alba
- Department of Orthopaedic Surgery, University of Miami Health System, Miami, Florida
| | - Thorsten M Seyler
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina
| |
Collapse
|
3
|
Como M, Reddy RP, Hankins ML, Kane GE, Ma D, Alexander PG, Urish KL, Karimi A, Lin A. Quantitative Real-Time Polymerase Chain Reaction May Serve as a Useful Adjunct to Conventional Culture in The Detection of Cutibacterium acnes in the Glenohumeral Joint: A Study of 100 Consecutive Patients. Arch Bone Jt Surg 2024; 12:102-107. [PMID: 38420518 PMCID: PMC10898805 DOI: 10.22038/abjs.2023.70190.3295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Accepted: 12/16/2023] [Indexed: 03/02/2024]
Abstract
Objectives Synovial fluid or tissue culture is the current gold standard for diagnosis of infection, but Cutibacterium acnes (C. acnes) is a frequent cause of shoulder PJI and is a notoriously fastidious organism. The purpose of this study was to compare quantitative real-time polymerase chain reaction (qRT-PCR) to standard culture as a more rapid, sensitive means of identifying C. acnes from the glenohumeral joint. We hypothesized that qRT-PCR would be more effective than standard culture at identifying C. acnes and would have greater sensitivity and specificity for detecting infection. Methods This was a prospective observational study with 100 consecutive patients undergoing arthroscopic or open shoulder surgery with known positive and negative controls. Intraoperatively, synovial fluid and tissue was obtained for C. acnes qRT-PCR and results were blinded to the gold standard microbiology cultures. Results Clinical review demonstrated 3 patients (3%) with positive cultures, none of which were positive for C. acnes. Of the samples tested by the C. acnes qRT-PCR standard curve, 12.2% of tissue samples and 4.5% of fluid samples were positive. Culture sensitivity was 60.0%, specificity was 100.0%, PPV was 100.0%, and NPV was 97.9%. C. acnes qRT-PCR standard curve sensitivity, specificity, PPV, and NPV was 60.0%, 90.3%, 25.0%, and 97.7% respectively for tissue specimens and 0%, 95.2%, 0%, and 95.2% respectively, for fluid specimens. For combination of culture and tissue qRT-PCR, the sensitivity, specificity, PPV and NPV was 100%, 90.3%, 35.7%, and 100%, respectively. Conclusion We report that qRT-PCR for C. acnes identified the organism more frequently than conventional culture. While these findings demonstrate the potential utility of qRT-PCR, the likelihood of false positive results of qRT-PCR should be considered. Thus, qRT-PCR may be useful as an adjuvant to current gold standard workup of synovial fluid or tissue culture for the diagnosis of infection.
Collapse
|
4
|
Onallah H, Hazan R, Nir-Paz R, Brownstein MJ, Fackler JR, Horne B, Hopkins R, Basu S, Yerushalmy O, Alkalay-Oren S, Braunstein R, Rimon A, Gelman D, Khalifa L, Adler K, Abdalrhman M, Gelman S, Katvan E, Coppenhagen-Glazer S, Moses A, Oster Y, Dekel M, Ben-Ami R, Khoury A, Kedar DJ, Meijer SE, Ashkenazi I, Bishouty N, Yahav D, Shostak E, Livni G, Paul M, Gross M, Ormianer M, Aslam S, Ritter M, Urish KL, La Hoz RM, Khatami A, Britton PN, Lin RCY, Iredell JR, Petrovic-Fabijan A, Lynch S, Tamma PD, Yamshchikov A, Lesho E, Morales M, Werzen A, Saharia K. Refractory Pseudomonas aeruginosa infections treated with phage PASA16: A compassionate use case series. Med 2023; 4:600-611.e4. [PMID: 37562400 DOI: 10.1016/j.medj.2023.07.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Revised: 06/23/2023] [Accepted: 07/11/2023] [Indexed: 08/12/2023]
Abstract
BACKGROUND A growing number of compassionate phage therapy cases were reported in the last decade, with a limited number of clinical trials conducted and few unsuccessful clinical trials reported. There is only a little evidence on the role of phages in refractory infections. Our objective here was to present the largest compassionate-use single-organism/phage case series in 16 patients with non-resolving Pseudomonas aeruginosa infections. METHODS We summarized clinical phage microbiology susceptibility data, administration protocol, clinical data, and outcomes of all cases treated with PASA16 phage. In all intravenous phage administrations, PASA16 phage was manufactured and provided pro bono by Adaptive Phage Therapeutics. PASA16 was administered intravenously, locally to infection site, or by topical use to 16 patients, with data available for 15 patients, mainly with osteoarticular and foreign-device-associated infections. FINDINGS A few minor side effects were noted, including elevated liver function enzymes and a transient reduction in white blood cell count. Good clinical outcome was documented in 13 out of 15 patients (86.6%). Two clinical failures were reported. The minimum therapy duration was 8 days with a once- to twice-daily regimen. CONCLUSIONS PASA16 with antibiotics was found to be relatively successful in patients for whom traditional treatment approaches have failed previously. Such pre-phase-1 cohorts can outline potential clinical protocols and facilitate the design of future trials. FUNDING The study was funded in part by The Israeli Science Foundation IPMP (ISF_1349/20), Rosetrees Trust (A2232), United States-Israel Binational Science Foundation (2017123), and the Milgrom Family Support Program.
Collapse
Affiliation(s)
- Hadil Onallah
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 9112102, Israel; The Israeli Phage Therapy Center (IPTC) of Hadassah Medical Center and the Hebrew University, Jerusalem 9112102, Israel
| | - Ronen Hazan
- The Israeli Phage Therapy Center (IPTC) of Hadassah Medical Center and the Hebrew University, Jerusalem 9112102, Israel; Institute of Biomedical and Oral Research (IBOR), Faculty of Dental Medicine, The Hebrew University of Jerusalem, Jerusalem 9112102, Israel
| | - Ran Nir-Paz
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 9112102, Israel; The Israeli Phage Therapy Center (IPTC) of Hadassah Medical Center and the Hebrew University, Jerusalem 9112102, Israel; Department of Clinical Microbiology and Infectious Diseases, Hadassah-Hebrew University Medical Center (HHUMC), Jerusalem 9112000, Israel.
| | | | | | - Bri'Anna Horne
- Adaptive Phage Therapeutics, Gaithersburg, MD 20878, USA
| | - Robert Hopkins
- Adaptive Phage Therapeutics, Gaithersburg, MD 20878, USA
| | - Subhendu Basu
- Adaptive Phage Therapeutics, Gaithersburg, MD 20878, USA
| | - Ortal Yerushalmy
- The Israeli Phage Therapy Center (IPTC) of Hadassah Medical Center and the Hebrew University, Jerusalem 9112102, Israel; Institute of Biomedical and Oral Research (IBOR), Faculty of Dental Medicine, The Hebrew University of Jerusalem, Jerusalem 9112102, Israel
| | - Sivan Alkalay-Oren
- The Israeli Phage Therapy Center (IPTC) of Hadassah Medical Center and the Hebrew University, Jerusalem 9112102, Israel; Institute of Biomedical and Oral Research (IBOR), Faculty of Dental Medicine, The Hebrew University of Jerusalem, Jerusalem 9112102, Israel
| | - Ron Braunstein
- The Israeli Phage Therapy Center (IPTC) of Hadassah Medical Center and the Hebrew University, Jerusalem 9112102, Israel; Institute of Biomedical and Oral Research (IBOR), Faculty of Dental Medicine, The Hebrew University of Jerusalem, Jerusalem 9112102, Israel
| | - Amit Rimon
- The Israeli Phage Therapy Center (IPTC) of Hadassah Medical Center and the Hebrew University, Jerusalem 9112102, Israel; Institute of Biomedical and Oral Research (IBOR), Faculty of Dental Medicine, The Hebrew University of Jerusalem, Jerusalem 9112102, Israel
| | - Daniel Gelman
- The Israeli Phage Therapy Center (IPTC) of Hadassah Medical Center and the Hebrew University, Jerusalem 9112102, Israel; Institute of Biomedical and Oral Research (IBOR), Faculty of Dental Medicine, The Hebrew University of Jerusalem, Jerusalem 9112102, Israel; Department of Military Medicine, Faculty of Medicine, The Hebrew University of Jerusalem, Jerusalem 9112102, Israel
| | - Leron Khalifa
- The Israeli Phage Therapy Center (IPTC) of Hadassah Medical Center and the Hebrew University, Jerusalem 9112102, Israel; Institute of Biomedical and Oral Research (IBOR), Faculty of Dental Medicine, The Hebrew University of Jerusalem, Jerusalem 9112102, Israel
| | - Karen Adler
- The Israeli Phage Therapy Center (IPTC) of Hadassah Medical Center and the Hebrew University, Jerusalem 9112102, Israel; Institute of Biomedical and Oral Research (IBOR), Faculty of Dental Medicine, The Hebrew University of Jerusalem, Jerusalem 9112102, Israel
| | - Mohanad Abdalrhman
- The Israeli Phage Therapy Center (IPTC) of Hadassah Medical Center and the Hebrew University, Jerusalem 9112102, Israel; Department of Clinical Microbiology and Infectious Diseases, Hadassah-Hebrew University Medical Center (HHUMC), Jerusalem 9112000, Israel
| | - Shira Gelman
- The Israeli Phage Therapy Center (IPTC) of Hadassah Medical Center and the Hebrew University, Jerusalem 9112102, Israel; Institute of Biomedical and Oral Research (IBOR), Faculty of Dental Medicine, The Hebrew University of Jerusalem, Jerusalem 9112102, Israel; Department of Military Medicine, Faculty of Medicine, The Hebrew University of Jerusalem, Jerusalem 9112102, Israel
| | - Eyal Katvan
- The Martin (Szusz) Department of Land of Israel Studies and Archaeology, Bar Ilan University, Ramat-Gan 52900, Israel; Peres Academic Center, Rehovot 7610202, Israel
| | - Shunit Coppenhagen-Glazer
- The Israeli Phage Therapy Center (IPTC) of Hadassah Medical Center and the Hebrew University, Jerusalem 9112102, Israel; Institute of Biomedical and Oral Research (IBOR), Faculty of Dental Medicine, The Hebrew University of Jerusalem, Jerusalem 9112102, Israel
| | - Allon Moses
- Department of Clinical Microbiology and Infectious Diseases, Hadassah-Hebrew University Medical Center (HHUMC), Jerusalem 9112000, Israel
| | - Yonatan Oster
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 9112102, Israel; Department of Clinical Microbiology and Infectious Diseases, Hadassah-Hebrew University Medical Center (HHUMC), Jerusalem 9112000, Israel
| | - Michal Dekel
- Infectious Diseases Unit, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6423906, Israel
| | - Ronen Ben-Ami
- Infectious Diseases Unit, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6423906, Israel
| | - Amal Khoury
- Infectious Diseases Unit, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6423906, Israel
| | - Daniel J Kedar
- Department of Plastic and Reconstructive Surgery, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6423906, Israel
| | - Suzy E Meijer
- Department of Plastic and Reconstructive Surgery, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6423906, Israel
| | - Itay Ashkenazi
- Division of Orthopedic Surgery, Tel Aviv Sourasky Medical Center, Tel Aviv 6423906, Israel
| | - Nancy Bishouty
- Pharmacy Department, Tel Aviv Sourasky Medical Center, Tel Aviv 6423906, Israel
| | - Dafna Yahav
- Infectious Disease Unit, Rabin Medical Center, Petah Tikva 49100, Israel
| | - Eran Shostak
- Pediatric Cardiac Intensive Care Unit, Schneider Children's Medical Center, Petah Tikva 4920235, Israel
| | - Gilat Livni
- Pediatric Infectious Diseases Unit, Schneider Children's Medical Center, Petah Tikva 4920235, Israel
| | - Mical Paul
- Rambam Health Care Campus and Faculty of Medicine, The Technion - Israel Institute of Technology, Haifa 3109601, Israel
| | - Menachem Gross
- Department of Otolaryngology-Head and Neck Surgery, Hadassah-Hebrew University Medical Center, Jerusalem 9112000, Israel
| | - Matityahou Ormianer
- Department of Otolaryngology-Head and Neck Surgery, Hadassah-Hebrew University Medical Center, Jerusalem 9112000, Israel
| | - Saima Aslam
- Division of Infectious Diseases and Global Public Health, University of California, San Diego, La Jolla, CA 92093, USA; Center for Innovative Phage Applications and Therapeutics, University of California, San Diego, La Jolla, CA 92093, USA
| | - Michele Ritter
- Division of Infectious Diseases and Global Public Health, University of California, San Diego, La Jolla, CA 92093, USA
| | - Kenneth L Urish
- Bone and Joint Center, Magee Hospital, Department of Orthopedic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA 15260, USA
| | - Ricardo M La Hoz
- Division of Infectious Disease and Geographic Medicine, University of Texas Southwestern Medical Center, Dallas, TX 75390, USA
| | - Ameneh Khatami
- Department of Infectious Diseases and Microbiology, The Children's Hospital at Westmead, Westmead, NSW 2145, Australia; Sydney Medical School, The University of Sydney, Sydney, NSW 2006, Australia
| | - Philip N Britton
- Department of Infectious Diseases and Microbiology, The Children's Hospital at Westmead, Westmead, NSW 2145, Australia; Sydney Medical School, The University of Sydney, Sydney, NSW 2006, Australia
| | - Ruby C Y Lin
- Centre for Infectious Diseases and Microbiology, Westmead Institute for Medical Research, Westmead, NSW 2145, Australia
| | - Jonathan R Iredell
- Sydney Medical School, The University of Sydney, Sydney, NSW 2006, Australia; Centre for Infectious Diseases and Microbiology, Westmead Institute for Medical Research, Westmead, NSW 2145, Australia
| | - Aleksandra Petrovic-Fabijan
- Centre for Infectious Diseases and Microbiology, Westmead Institute for Medical Research, Westmead, NSW 2145, Australia
| | - Stephanie Lynch
- Centre for Infectious Diseases and Microbiology, Westmead Institute for Medical Research, Westmead, NSW 2145, Australia
| | - Pranita D Tamma
- Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
| | - Alexandra Yamshchikov
- Infectious Diseases Unit, Rochester Regional Health, Rochester, NY 14617, USA; Infectious Diseases Unit, University of Rochester Medical Center, Rochester, NY 14617, USA
| | - Emil Lesho
- Infectious Diseases Unit, Rochester Regional Health, Rochester, NY 14617, USA
| | - Megan Morales
- Division of Infectious Diseases, Virginia Commonwealth University, Richmond, VA 23284, USA
| | - Alissa Werzen
- Division of Infectious Diseases, Jefferson Medicine, Philadelphia, PA 19107, USA
| | - Kapil Saharia
- University of Maryland School of Medicine, Baltimore, MD 21201, USA
| |
Collapse
|
5
|
Carlos NBT, Drain NP, Byrapogu VK, Lippe D, Romano R, Kuzmishin S, Rajesh D, Angele S, Urish KL. An Analysis of Radiographic Leg Length Discrepancy and Hip Offset in Patients at Risk of Developing Osteoarthritis. Arthroplast Today 2023; 22:101151. [PMID: 37342363 PMCID: PMC10277515 DOI: 10.1016/j.artd.2023.101151] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2022] [Revised: 04/03/2023] [Accepted: 04/23/2023] [Indexed: 06/22/2023] Open
Abstract
Background Leg length and hip offset are important principles in total hip arthroplasty (THA). Patients may endorse leg length differences (LLD) postoperatively that may be anatomical or functional. The objective of this study was to determine the normal radiographic variation in leg length and hip offset in a preosteoarthritic population without a THA. Methods A retrospective study was completed using data from the Osteoarthritis Initiative, a prospective longitudinal study. Patients at risk of developing or with early osteoarthritis without inflammatory arthritis or prior THA were included. Measurements were made from full limb length anterior-posterior (AP) radiographs. Multiple linear regression models were employed to predict side-to-side differences in LLD, Δ femoral offset (FO), Δ abductor muscle length (AML), Δ abductor lever arm, and Δ AP pelvic offset. Results The mean radiographic LLD was 4.6 mm, with 12 mm within 1 standard deviation. No significant differences were detected between LLD and sex, age, body mass index, or height. The median radiographic differences in FO, AML, abductor lever arm, and AP pelvic offset were 3.2 mm, 4.8 mm, 3.6 mm, and 3.3 mm, respectively. Height was predictive of Δ FO, while both height and age were predictive of Δ AML. Conclusions Radiographic leg length variations in a population without symptomatic or radiographic osteoarthritis exist. FO and AML are dependent on patient characteristics. Preoperative radiographic LLD is not predicted by age, gender, body mass index, or height. It should be stressed that anatomic reconstruction is one of the many goals of arthroplasty and can stand in conflict with the priority and primary goals of stability and fixation, which should be prioritized.
Collapse
Affiliation(s)
- Noel Bien T. Carlos
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Arthritis and Arthroplasty Development Laboratory, Department of Orthopaedic Surgery, School of Medicine, Pittsburgh, PA, USA
| | - Nicholas P. Drain
- Arthritis and Arthroplasty Development Laboratory, Department of Orthopaedic Surgery, School of Medicine, Pittsburgh, PA, USA
| | - Venkata Kalyan Byrapogu
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Arthritis and Arthroplasty Development Laboratory, Department of Orthopaedic Surgery, School of Medicine, Pittsburgh, PA, USA
| | - Daniel Lippe
- Arthritis and Arthroplasty Development Laboratory, Department of Orthopaedic Surgery, School of Medicine, Pittsburgh, PA, USA
- Philadelphia College of Osteopathic Medicine, Philadelphia, PA, USA
| | - Rachel Romano
- Arthritis and Arthroplasty Development Laboratory, Department of Orthopaedic Surgery, School of Medicine, Pittsburgh, PA, USA
- University of Pittsburgh, Pittsburgh, PA, USA
| | - Sam Kuzmishin
- Arthritis and Arthroplasty Development Laboratory, Department of Orthopaedic Surgery, School of Medicine, Pittsburgh, PA, USA
- University of Pittsburgh, Pittsburgh, PA, USA
| | - Darini Rajesh
- Arthritis and Arthroplasty Development Laboratory, Department of Orthopaedic Surgery, School of Medicine, Pittsburgh, PA, USA
- University of Pittsburgh, Pittsburgh, PA, USA
| | - Sophia Angele
- Arthritis and Arthroplasty Development Laboratory, Department of Orthopaedic Surgery, School of Medicine, Pittsburgh, PA, USA
- University of Pittsburgh, Pittsburgh, PA, USA
| | - Kenneth L. Urish
- Arthritis and Arthroplasty Development Laboratory, Department of Orthopaedic Surgery, School of Medicine, Pittsburgh, PA, USA
- University of Pittsburgh, Pittsburgh, PA, USA
| |
Collapse
|
6
|
Parker DM, Koch JA, Gish CG, Brothers KM, Li W, Gilbertie J, Rowe SE, Conlon BP, Byrapogu VKC, Urish KL. Hydrogen Peroxide, Povidone-Iodine and Chlorhexidine Fail to Eradicate Staphylococcus aureus Biofilm from Infected Implant Materials. Life (Basel) 2023; 13:1230. [PMID: 37374013 DOI: 10.3390/life13061230] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 05/18/2023] [Accepted: 05/18/2023] [Indexed: 06/29/2023] Open
Abstract
Hydrogen peroxide, povidone-iodine, and chlorhexidine are antiseptics that are commonly added to irrigants to either prevent or treat infection. There are little clinical data available that demonstrate efficacy of adding antiseptics to irrigants in the treatment of periprosthetic joint infection after biofilm establishment. The objective of the study was to assess the bactericidal activity of the antiseptics on S. aureus planktonic and biofilm. For planktonic irrigation, S. aureus was exposed to different concentrations of antiseptics. S. aureus biofilm was developed by submerging a Kirschner wire into normalized bacteria and allowing it to grow for forty-eight hours. The Kirschner wire was then treated with irrigation solutions and plated for CFU analysis. Hydrogen peroxide, povidone-iodine, and chlorhexidine were bactericidal against planktonic bacteria with over a 3 log reduction (p < 0.0001). Unlike cefazolin, the antiseptics were not bactericidal (less than 3 log reduction) against biofilm bacteria but did have a statistical reduction in biofilm as compared to the initial time point (p < 0.0001). As compared to cefazolin treatment alone, the addition of hydrogen peroxide or povidone-iodine to cefazolin treatment only additionally reduced the biofilm burden by less than 1 log. The antiseptics demonstrated bactericidal properties with planktonic S. aureus; however, when used to irrigate S. aureus biofilms, these antiseptics were unable to decrease biofilm mass below a 3 log reduction, suggesting that S. aureus biofilm has a tolerance to antiseptics. This information should be considered when considering antibiotic tolerance in established S. aureus biofilm treatment.
Collapse
Affiliation(s)
- Dana M Parker
- Arthritis and Arthroplasty Design Lab, Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, PA 15261, USA
| | - John A Koch
- Arthritis and Arthroplasty Design Lab, Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, PA 15261, USA
| | - Charles G Gish
- Arthritis and Arthroplasty Design Lab, Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, PA 15261, USA
| | - Kimberly M Brothers
- Arthritis and Arthroplasty Design Lab, Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, PA 15261, USA
| | - William Li
- Arthritis and Arthroplasty Design Lab, Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, PA 15261, USA
| | - Jessica Gilbertie
- Center for One Health Research, Edward Via College of Osteopathic Medicine, Blacksburg, VA 24060, USA
| | - Sarah E Rowe
- Department of Microbiology and Immunology, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| | - Brian P Conlon
- Department of Microbiology and Immunology, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
- Marsico Lung Institute, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| | - Venkata K C Byrapogu
- Arthritis and Arthroplasty Design Lab, Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, PA 15261, USA
| | - Kenneth L Urish
- Arthritis and Arthroplasty Design Lab, Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, PA 15261, USA
- Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA 15261, USA
| |
Collapse
|
7
|
Dickerson DM, Mariano ER, Szokol JW, Harned M, Clark RM, Mueller JT, Shilling AM, Udoji MA, Mukkamala SB, Doan L, Wyatt KEK, Schwalb JM, Elkassabany NM, Eloy JD, Beck SL, Wiechmann L, Chiao F, Halle SG, Krishnan DG, Cramer JD, Ali Sakr Esa W, Muse IO, Baratta J, Rosenquist R, Gulur P, Shah S, Kohan L, Robles J, Schwenk ES, Allen BFS, Yang S, Hadeed JG, Schwartz G, Englesbe MJ, Sprintz M, Urish KL, Walton A, Keith L, Buvanendran A. Multiorganizational consensus to define guiding principles for perioperative pain management in patients with chronic pain, preoperative opioid tolerance, or substance use disorder. Reg Anesth Pain Med 2023:rapm-2023-104435. [PMID: 37185214 DOI: 10.1136/rapm-2023-104435] [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: 02/13/2023] [Accepted: 04/12/2023] [Indexed: 05/17/2023]
Abstract
Significant knowledge gaps exist in the perioperative pain management of patients with a history of chronic pain, substance use disorder, and/or opioid tolerance as highlighted in the US Health and Human Services Pain Management Best Practices Inter-Agency Task Force 2019 report. The report emphasized the challenges of caring for these populations and the need for multidisciplinary care and a comprehensive approach. Such care requires stakeholder alignment across multiple specialties and care settings. With the intention of codifying this alignment into a reliable and efficient processes, a consortium of 15 professional healthcare societies was convened in a year-long modified Delphi consensus process and summit. This process produced seven guiding principles for the perioperative care of patients with chronic pain, substance use disorder, and/or preoperative opioid tolerance. These principles provide a framework and direction for future improvement in the optimization and care of 'complex' patients as they undergo surgical procedures.
Collapse
Affiliation(s)
- David M Dickerson
- Department of Anesthesiology, Critical Care and Pain Medicine, NorthShore University HealthSystem, Evanston, Illinois, USA
- Department of Anesthesia & Critical Care, University of Chicago Pritzker School of Medicine, Chicago, Illinois, USA
| | - Edward R Mariano
- Anesthesiology and Perioperative Care Service, VA Palo Alto Health Care System, Palo Alto, California, USA
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Joseph W Szokol
- Department of Anesthesiology, University of Southern California Keck School of Medicine, Los Angeles, California, USA
| | - Michael Harned
- Department of Anesthesiology, Division of Pain Medicine, University of Kentucky, Lexington, Kentucky, USA
| | - Randall M Clark
- American Society of Anesthesiologists, Park Ridge, Illinois, USA
| | - Jeffrey T Mueller
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic Arizona, Phoenix, Arizona, USA
| | - Ashley M Shilling
- Department of Anesthesiology, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Mercy A Udoji
- Department of Anesthesiology, Emory University School of Medicine, Atlanta, Georgia, USA
- Atlanta VA Health Care System, Decatur, Georgia, USA
| | | | - Lisa Doan
- Department of Anesthesiology, PerioperativeCare and Pain Medicine, New York University School of Medicine, New York, New York, USA
| | - Karla E K Wyatt
- Department of Anesthesiology, Perioperativeand Pain Medicine, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
| | - Jason M Schwalb
- Department of Neurosurgery, Henry Ford Medical Group, Detroit, Michigan, USA
| | - Nabil M Elkassabany
- Department of Anesthesiology, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Jean D Eloy
- Department of Anesthesiology, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Stacy L Beck
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Maternal Fetal Medicine, University of Pittsburgh Medical Center Health System, Pittsburgh, Pennsylvania, USA
| | - Lisa Wiechmann
- Department of Surgery, NewYork-Presbyterian/Columbia University Medical Center, New York, New York, USA
| | - Franklin Chiao
- Department of Anesthesiology, Westchester Medical Center, Valhalla, New York, USA
| | - Steven G Halle
- Department of Anesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Deepak G Krishnan
- Department of Oral & Maxillofacial Surgery, University of Cincinnati Medical Center, Cincinnati, Ohio, USA
- Department of Oral & Maxillofacial Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - John D Cramer
- Department of Otolaryngology - Head and Neck Surgery, Wayne State University, Detroit, Michigan, USA
| | - Wael Ali Sakr Esa
- Department of Pain Management, Cleveland Clinic, Cleveland, Ohio, USA
| | - Iyabo O Muse
- Department of Anesthesiology, Montefiore Medical Center, Bronx, New York, USA
- Department of Anesthesiology, Westchester Medical Center Health Network, Valhalla, New York, USA
| | - Jaime Baratta
- Department of Anesthesiology and Perioperative Medicine, Thomas Jefferson University Sidney Kimmel Medical College, Philadelphia, Pennsylvania, USA
| | | | - Padma Gulur
- Department of Anesthesiology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Shalini Shah
- Department of Anesthesiology and Perioperative Care, University of California Irvine, Orange, California, USA
| | - Lynn Kohan
- Department of Anesthesiology, University of Virginia, Charlottesville, Virginia, USA
| | - Jennifer Robles
- Department of Urology Division of Endourology and Stone Disease, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Surgical Service, Veterans Affairs Tennessee Valley Healthcare System, Nashville, Tennessee, USA
| | - Eric S Schwenk
- Department of Anesthesiology and Perioperative Medicine, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Brian F S Allen
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Stephen Yang
- Department of Surgery, Division of Thoracic Surgery, Johns Hopkins Medical Institutions Campus, Baltimore, Maryland, USA
| | | | - Gary Schwartz
- AABP Integrative Pain Care, Melville, New York, USA
- Maimonides Medical Center, Brooklyn, New York, USA
| | | | - Michael Sprintz
- Sprintz Center for Pain and Recovery, Shenandoah, Texas, USA
| | - Kenneth L Urish
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Ashley Walton
- American Society of Anesthesiologists, Washington, District of Columbia, USA
| | - Lauren Keith
- American Society of Anesthesiologists, Park Ridge, Illinois, USA
| | - Asokumar Buvanendran
- Department of Anesthesiology, Rush University Medical Center, Chicago, Illinois, USA
| |
Collapse
|
8
|
Brothers KM, Parker DM, Taguchi M, Ma D, Mandell JB, Thurlow LL, Byrapogu VC, Urish KL. Dose optimization in surgical prophylaxis: sub-inhibitory dosing of vancomycin increases rates of biofilm formation and the rates of surgical site infection. Sci Rep 2023; 13:4593. [PMID: 36944677 PMCID: PMC10030625 DOI: 10.1038/s41598-023-30951-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2022] [Accepted: 03/03/2023] [Indexed: 03/23/2023] Open
Abstract
Antibiotic stewardship is viewed as having great public health benefit with limited direct benefit to the patient at the time of administration. The objective of our study was to determine if inappropriate administration of antibiotics could create conditions that would increase the rates of surgical infection. We hypothesized that sub-MIC levels of vancomycin would increase Staphylococcus aureus growth, biofilm formation, and rates of infection. S. aureus MRSA and MSSA strains were used for all experiments. Bacteria were grown planktonically and monitored using spectrophotometry. Quantitative agar culture was used to measure planktonic and biofilm bacterial burden. A mouse abscess model was used to confirm phenotypes in vivo. In the planktonic growth assay, increases in bacterial burden at ¼ MIC vancomycin were observed in USA300 JE2 by 72 h. Similar findings were observed with ½ MIC in Newman and SH1000. For biofilm formation, USA300 JE2 at ¼ and ½ MIC vancomycin increased biofilm formation by approximately 1.3- and 2.3-fold respectively at 72 h as compared to untreated controls. Similar findings were observed with Newman and SH1000 with a 2.4-fold increase in biofilm formation at ½ MIC vancomycin. In a mouse abscess model, there was a 1.2-fold increase with sub-MIC vancomycin at 3 days post infection. Our study showed that Sub-optimal vancomycin dosing promoted S. aureus planktonic growth and biofilm formation, phenotypic measures of bacterial virulence. This phenotype induced by sub-MIC levels of vancomycin was also observed to increase rates of infection and pathogenesis in our mouse model. Risks of exposure to sub-MIC concentrations with vancomycin in surgical procedures are greater as there is decreased bioavailability in tissue in comparison to other antibiotics. This highlights the importance of proper antibiotic selection, stewardship, and dosing for both surgical prophylaxis and treatment of infection.
Collapse
Affiliation(s)
- Kimberly M Brothers
- Arthritis and Arthroplasty Design Group, Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Dana M Parker
- Arthritis and Arthroplasty Design Group, Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Masashi Taguchi
- Arthritis and Arthroplasty Design Group, Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, PA, USA
- Department of Orthopaedic Surgery, Ageo Medical Clinic, 3133 Haraichi, Ageo-Shi, Saitama, Japan
| | - Dongzhu Ma
- Arthritis and Arthroplasty Design Group, Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Jonathan B Mandell
- Arthritis and Arthroplasty Design Group, Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Lance L Thurlow
- Department of Microbiology and Immunology, University of North Carolina, Chapel Hill, NC, USA
| | - Venkata C Byrapogu
- Arthritis and Arthroplasty Design Group, Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Kenneth L Urish
- Arthritis and Arthroplasty Design Group, Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, PA, USA.
- Arthritis and Arthroplasty Design Group, and The Bone and Joint Center, Department of Orthopaedic Surgery, Department of Bioengineering, Department of Biomedical Engineering, and Clinical and Translational Science Institute, Magee Womens Hospital of the University of Pittsburgh Medical Center, University of Pittsburgh, Pittsburgh, PA, 15219, USA.
| |
Collapse
|
9
|
Byrapogu VK, Gale T, Hamlin B, Urish KL, Anderst W. Medial Unicompartmental Knee Arthroplasty Restores Native Knee Kinematics During Activities of Daily Living: A Pilot Study. Ann Biomed Eng 2023; 51:308-317. [PMID: 35852649 DOI: 10.1007/s10439-022-03021-z] [Citation(s) in RCA: 1] [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] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 07/12/2022] [Indexed: 01/25/2023]
Abstract
The ability of unicompartmental knee arthroplasty (UKA) to restore native knee kinematics during activities of daily living remains unclear. The objectives of this prospective study were to identify changes in knee kinematics after medial UKA (mUKA) and to determine if mUKA restores native knee kinematics during activities of daily living. We hypothesized that kinematics are different between the mUKA knee and contralateral knee before surgery, that mUKA restores native knee kinematics, and that mUKA does not affect lateral compartment dynamic joint space. Nine participants performed walking, chair rise, stair ascent and stair descent within a biplane radiography system before and after mUKA. Bilateral knee kinematics were determined for each activity using a validated tracking process that matched subject-specific bones and implants to the biplane radiographs. Compared to contralateral knee, the pre-UKA knee was more adducted (p ≤ 0.019), and more laterally translated (p ≤ 0.008) during all four activities. Additionally, compared to contralateral knee, pre-UKA knee was less internally rotated (p ≤ 0.044) during chair rise and stair ascent. Lateral compartment dynamic joint space did not change during any activity from pre to post mUKA. Our results indicate that mUKA generally restores native kinematics during activities of daily living without altering lateral compartment dynamic joint space.
Collapse
Affiliation(s)
- Venkata K Byrapogu
- Department of Orthopaedic Surgery, Orthopaedic Biodynamics Laboratory, University of Pittsburgh, 3820 South Water Street, Pittsburgh, PA, 15206, USA
| | - Tom Gale
- Department of Orthopaedic Surgery, Orthopaedic Biodynamics Laboratory, University of Pittsburgh, 3820 South Water Street, Pittsburgh, PA, 15206, USA
| | - Brian Hamlin
- Department of Orthopaedic Surgery, Orthopaedic Biodynamics Laboratory, University of Pittsburgh, 3820 South Water Street, Pittsburgh, PA, 15206, USA.,The Bone & Joint Center, Magee-Womens Hospital of the University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Kenneth L Urish
- Department of Orthopaedic Surgery, Orthopaedic Biodynamics Laboratory, University of Pittsburgh, 3820 South Water Street, Pittsburgh, PA, 15206, USA.,The Bone & Joint Center, Magee-Womens Hospital of the University of Pittsburgh Medical Center, Pittsburgh, PA, USA.,Department of Orthopaedic Surgery, Arthritis and Arthroplasty Design Group, University of Pittsburgh, Pittsburgh, PA, USA.,Department of Bioengineering, and Clinical and Translational Science Institute, University of Pittsburgh, Pittsburgh, PA, USA
| | - William Anderst
- Department of Orthopaedic Surgery, Orthopaedic Biodynamics Laboratory, University of Pittsburgh, 3820 South Water Street, Pittsburgh, PA, 15206, USA.
| |
Collapse
|
10
|
Daji AV, Workman KK, Yoo CJ, Smith CN, Kumar D, Weber MA, Snyder MJ, Urish KL. Risk Stratification and Pain Outcomes Following Revision Total Hip Arthroplasty for Adverse Local Tissue Reactions. J Arthroplasty 2022; 37:2406-2411. [PMID: 35738363 DOI: 10.1016/j.arth.2022.06.012] [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: 03/22/2022] [Revised: 06/10/2022] [Accepted: 06/14/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Revision total hip arthroplasty (THA) for adverse local tissue reactions (ALTRs) secondary to head-neck taper corrosion is associated with a high complication rate. Diagnosis of ALTR is based on risk stratification using the patient's history and examination, implant risk, serum metal ion levels, and imaging. The purpose of this study was to determine if stratification using similar risk factors is predictive of outcomes following revision THA for metal-on-polyethylene (MoP) ALTR. METHODS We performed a retrospective review on 141 patients revised for ALTR due to head-neck taper corrosion. Pain outcomes following surgery were analyzed using a generalized linear mixed model. Complications were defined as instability/dislocation, infection, fracture, nerve palsy, leg-length discrepancy, or reoperation. RESULTS The overall complication rate was 17.7%. The odds of having pain decreased by 44% after revision surgery (Odds Ratio = 0.56, 95% Confidence Interval: 0.324 to 0.952). There was no significant difference in instability/dislocation based on either increased or decreased head-neck offset (P = .67) or magnetic resonance imaging findings of abductor loss, effusion size, and degree of ALTR (P = .73). Increased serum cobalt (P = .31) and chromium (P = .08) levels did not predict complications; however, a decreased cobalt-chromium ratio was associated with postoperative complications (2.8 versus 3.5; P = .002). CONCLUSION These findings are the first to suggest that patients who have ALTR after MoP THA undergoing revision surgery demonstrated major pain relief. Increasing femoral head offset did not change rates of instability/dislocation. In clinical scenarios where preoperative cobalt-chromium femoral head offsets were greater than available ceramic head offsets, a mandatory decrease in femoral head offset did not increase rates of instability/dislocation.
Collapse
Affiliation(s)
- Akshay V Daji
- Department of Orthopaedic Surgery, HCA Florida JFK/University of Miami Miller School of Medicine, Palm Beach, Florida
| | - Kalain K Workman
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center-Pinnacle, Harrisburg, Pennsylvania
| | - Charlie J Yoo
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center-Pinnacle, Harrisburg, Pennsylvania
| | - Clair N Smith
- Department of Orthopaedic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Deepak Kumar
- Department of Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Margaret A Weber
- Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota
| | - Matthew J Snyder
- Department of Radiology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Kenneth L Urish
- Department of Orthopaedic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; Arthritis and Arthroplasty Design Lab, Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania; Department of Bioengineering, Clinical and Translational Science Institute, University of Pittsburgh, Pittsburgh, Pennsylvania
| |
Collapse
|
11
|
Huang DB, Brothers KM, Mandell JB, Taguchi M, Alexander PG, Parker DM, Shinabarger D, Pillar C, Morrissey I, Hawser S, Ghahramani P, Dobbins D, Pachuda N, Montelaro R, Steckbeck JD, Urish KL. Engineered peptide PLG0206 overcomes limitations of a challenging antimicrobial drug class. PLoS One 2022; 17:e0274815. [PMID: 36112657 PMCID: PMC9481017 DOI: 10.1371/journal.pone.0274815] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Accepted: 09/02/2022] [Indexed: 11/24/2022] Open
Abstract
The absence of novel antibiotics for drug-resistant and biofilm-associated infections is a global public health crisis. Antimicrobial peptides explored to address this need have encountered significant development challenges associated with size, toxicity, safety profile, and pharmacokinetics. We designed PLG0206, an engineered antimicrobial peptide, to address these limitations. PLG0206 has broad-spectrum activity against >1,200 multidrug-resistant (MDR) ESKAPEE clinical isolates, is rapidly bactericidal, and displays potent anti-biofilm activity against diverse MDR pathogens. PLG0206 displays activity in diverse animal infection models following both systemic (urinary tract infection) and local (prosthetic joint infection) administration. These findings support continuing clinical development of PLG0206 and validate use of rational design for peptide therapeutics to overcome limitations associated with difficult-to-drug pharmaceutical targets.
Collapse
Affiliation(s)
- David B. Huang
- Peptilogics, Pittsburgh, Pennsylvania, United States of America
- * E-mail: (DBH); (KLU)
| | - Kimberly M. Brothers
- Department of Orthopedic Surgery, Arthritis and Arthroplasty Design Group, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
| | - Jonathan B. Mandell
- Department of Orthopedic Surgery, Arthritis and Arthroplasty Design Group, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
| | - Masashi Taguchi
- Department of Orthopedic Surgery, Arthritis and Arthroplasty Design Group, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
- Department of Orthopedic Surgery, Tokyo Women’s Medical University, Medical Center East, Tokyo, Japan
| | - Peter G. Alexander
- Department of Orthopedic Surgery, Arthritis and Arthroplasty Design Group, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
| | - Dana M. Parker
- Department of Orthopedic Surgery, Arthritis and Arthroplasty Design Group, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
| | | | - Chris Pillar
- Micromyx, Kalamazoo, Michigan, United States of America
| | | | | | | | - Despina Dobbins
- Peptilogics, Pittsburgh, Pennsylvania, United States of America
| | | | - Ronald Montelaro
- Department of Microbiology and Molecular Genetics, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
| | | | - Kenneth L. Urish
- Department of Orthopedic Surgery, Arthritis and Arthroplasty Design Group, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
- The Bone and Joint Center, Magee Women’s Hospital of the University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, United States of America
- Department of Bioengineering, and Clinical and Translational Science, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
- * E-mail: (DBH); (KLU)
| |
Collapse
|
12
|
Drain NP, Bertolini DM, Anthony AW, Feroze MW, Chao R, Onyekweli T, Longo SE, Hersh BL, Smith CN, Rothenberger SD, Shah NB, Urish KL. High Mortality After Total Knee Arthroplasty Periprosthetic Joint Infection is Related to Preoperative Morbidity and the Disease Process but Not Treatment. J Arthroplasty 2022; 37:1383-1389. [PMID: 35314288 DOI: 10.1016/j.arth.2022.03.046] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [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: 12/26/2021] [Revised: 02/23/2022] [Accepted: 03/12/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Periprosthetic joint infection (PJI) mortality rate is approximately 20%. The etiology for high mortality remains unknown. The objective of this study was to determine whether mortality was associated with preoperative morbidity (frailty), sequalae of treatment, or the PJI disease process itself. METHODS A multicenter observational study was completed comparing 184 patients treated with septic revision total knee arthroplasty (TKA) to a control group of 38 patients treated with aseptic revision TKA. Primary outcomes included time and the cause of death. Secondary outcomes included preoperative comorbidities and Charlson Comorbidity Index (CCMI) measured preoperatively and at various postoperative timepoints. RESULTS The septic revision TKA cohort experienced earlier mortality compared to the aseptic cohort, with a higher mortality rate at 90 days, 1, 2, and 3 years after index revision surgery (P = .01). There was no significant difference for any single cause of death (P > .05 for each). The mean preoperative CCMI was higher (P = .005) in the septic revision TKA cohort. Both septic and aseptic cohorts experienced a significant increase in CCMI from the preoperative to 3 years postoperative (P < .0001 and P = .002) and time of death (P < .0001 both) timepoints. The septic revision TKA cohort had a higher CCMI 3 years postoperatively (P = .001) and at time of death (P = .046), but not one year postoperatively (P = .119). CONCLUSION Compared to mortality from aseptic revision surgery, septic revision TKA is associated with earlier mortality, but there is no single specific etiology. As quantified by changes in CCMI, PJI mortality was associated with both frailty and the PJI disease process, but not treatment.
Collapse
Affiliation(s)
- Nicholas P Drain
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | | | - Austin W Anthony
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Muhammad W Feroze
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Richard Chao
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Tito Onyekweli
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Sadie E Longo
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Beverly L Hersh
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Clair N Smith
- Department of Physical Therapy and Rehabilitation, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Scott D Rothenberger
- Center for Research on Health Care Data Center, Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Neel B Shah
- Division of Infectious Disease, Department of Internal Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Kenneth L Urish
- Arthritis and Arthroplasty Design Group, The Bone and Joint Center, Magee Womens Hospital of the University of Pittsburgh Medical Center; Department of Orthopaedic Surgery, Department of Bioengineering, and Clinical and Translational Science Institute, University of Pittsburgh; Department of Biomedical Engineering, Carnegie Mellon University, Pittsburgh, Pennsylvania
| |
Collapse
|
13
|
Ma D, Brothers KM, Maher PL, Phillips NJ, Simonetti D, Pasculle AW, Richardson AR, Cooper VS, Urish KL. Staphylococcus aureus genotype variation among and within periprosthetic joint infections. J Orthop Res 2022; 40:420-428. [PMID: 33713379 PMCID: PMC8435540 DOI: 10.1002/jor.25031] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [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: 10/27/2020] [Revised: 01/29/2021] [Accepted: 03/10/2021] [Indexed: 02/04/2023]
Abstract
Staphylococcus aureus is a common organism in orthopedic infections, but little is known about the genetic diversity of strains during an infectious process. Using periprosthetic joint infection (PJI) as a model, a prospective study was designed to quantify genetic variation among S. aureus strains both among and within patients. Whole genome sequencing and multilocus sequence typing was performed to genotype these two populations at high resolution. In nasal cultures, 78% of strains were of clonal complexes CC5, CC8, and CC30. In PJI cultures, only 63% could be classified in these common clonal complexes. The PJI cultures had a larger proportion of atypical strains, and these atypical strains were associated with poor host status and compromised immune conditions. Mutations in genes involved in fibronectin binding (ebh, fnbA, clfA, and clfB) systematically distinguished later PJI isolates from the first PJI isolate from each patient. Repeated mutations in S. aureus genes associated with extracellular matrix binding were identified, suggesting adaptive, parallel evolution of S. aureus during the development of PJI.
Collapse
Affiliation(s)
- Dongzhu Ma
- Arthritis and Arthroplasty Design Group; Department of Orthopaedic Surgery; University of Pittsburgh; Pittsburgh, Pennsylvania, USA
| | - Kimberly M. Brothers
- Arthritis and Arthroplasty Design Group; Department of Orthopaedic Surgery; University of Pittsburgh; Pittsburgh, Pennsylvania, USA
| | - Patrick L. Maher
- Arthritis and Arthroplasty Design Group; Department of Orthopaedic Surgery; University of Pittsburgh; Pittsburgh, Pennsylvania, USA
| | - Nathan J. Phillips
- Department of Microbiology and Molecular Genetics, and Center for Evolutionary Biology and Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Deborah Simonetti
- Clinical Microbiology Laboratory; University of Pittsburgh Medical Center; Pittsburgh, Pennsylvania, USA
| | - A. William Pasculle
- Department of Pathology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Anthony R. Richardson
- Department of Microbiology and Molecular Genetics, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Vaughn S. Cooper
- Department of Microbiology and Molecular Genetics, and Center for Evolutionary Biology and Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Kenneth L. Urish
- Arthritis and Arthroplasty Design Group; Department of Orthopaedic Surgery; University of Pittsburgh; Pittsburgh, Pennsylvania, USA,Corresponding author: Kenneth Urish MD PhD; Arthritis and Arthroplasty Design Group, The Bone and Joint Center, Magee Womens Hospital of the University of Pittsburgh Medical Center; Department of Orthopaedic Surgery, Department of Bioengineering, and Clinical and Translational Science Institute, University of Pittsburgh; Department of Biomedical Engineering, Carnegie Mellon University, Pittsburgh, PA, 15219;
| |
Collapse
|
14
|
Snyder MJ, Weber MA, Kromka JJ, Sims MM, Smith CN, Daji AV, Kumar D, Borrero CG, Cordle AC, DiGioia AM, Hamlin BR, Plakseychuk AY, Urish KL. Predictors of Adverse Local Tissue Reaction in a High-Risk Population. Arthroplast Today 2022; 13:125-129. [PMID: 35106348 PMCID: PMC8784296 DOI: 10.1016/j.artd.2021.12.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 11/30/2021] [Accepted: 12/15/2021] [Indexed: 11/08/2022] Open
Abstract
Background Adverse local tissue reaction (ALTR) is a recognized complication of total hip arthroplasty (THA) with metal-on-polyethylene (MoP) bearing surface implants. Specific models of THA implants have been identified as having a higher incidence of ALTR. The purpose of this study is to determine if serum metal levels, patient symptoms, implant factors, and imaging findings can be predictive of ALTR within this high-risk population. Methods We retrospectively reviewed an observational cohort of 474 patients who underwent MoP THA and were at increased risk of having ALTR. Patients were stratified based on the presence or absence of ALTR. Patient symptoms, serum metal ions, implant head offset, and imaging findings were compared. Results Patients with ALTR were more likely to be symptomatic (52.9% vs 9.9%, P < .0001). The presence of ALTR was associated with significantly higher serum cobalt and chromium levels (6.2 ppb vs 3.6 ppb, P < .0001; 2.3 ppb vs 1.2 ppb, P < .0001). Head offsets greater than 4 mm were associated with a higher prevalence of ALTR (53% vs 38%, P = .05). On metal artifact reduction sequence magnetic resonance imaging, patients with ALTR had larger effusions (4.7 cm vs 2.1 cm, P < .001) and a higher incidence of trochanteric bursitis (47% vs 16%, P < .001). Conclusions In high-risk MoP implants, serum cobalt and chromium levels are elevated, even in patients without ALTR. A larger femoral head offset is a risk factor for the development of ALTR. Our study suggests that patients presenting with painful THA and elevated metal ions require risk stratification based on patient symptoms, metal artifact reduction sequence magnetic resonance imaging findings, and implant factors.
Collapse
|
15
|
Staats A, Burback PW, Eltobgy M, Parker DM, Amer AO, Wozniak DJ, Wang SH, Stevenson KB, Urish KL, Stoodley P. Synovial Fluid-Induced Aggregation Occurs across Staphylococcus aureus Clinical Isolates and is Mechanistically Independent of Attached Biofilm Formation. Microbiol Spectr 2021; 9:e0026721. [PMID: 34523997 PMCID: PMC8557890 DOI: 10.1128/spectrum.00267-21] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Accepted: 08/17/2021] [Indexed: 12/29/2022] Open
Abstract
Rapid synovial fluid-induced aggregation of Staphylococcus aureus is currently being investigated as an important factor in the establishment of periprosthetic joint infections (PJIs). Pathogenic advantages of aggregate formation have been well documented in vitro, including recalcitrance to antibiotics and protection from host immune defenses. The objective of the present work was to determine the strain dependency of synovial fluid-induced aggregation by measuring the degree of aggregation of 21 clinical S. aureus isolates cultured from either PJI or bloodstream infections using imaging and flow cytometry. Furthermore, by measuring attached bacterial biomass using a conventional crystal violet assay, we assessed whether there is a correlation between the aggregative phenotype and surface-associated biofilm formation. While all of the isolates were stimulated to aggregate upon exposure to bovine synovial fluid (BSF) and human serum (HS), the extent of aggregation was highly variable between individual strains. Interestingly, the PJI isolates aggregated significantly more upon BSF exposure than those isolated from bloodstream infections. While we were able to stimulate biofilm formation with all of the isolates in growth medium, supplementation with either synovial fluid or human serum inhibited bacterial surface attachment over a 24 h incubation. Surprisingly, there was no correlation between the degree of synovial fluid-induced aggregation and quantity of surface-associated biofilm as measured by a conventional biofilm assay without host fluid supplementation. Taken together, our findings suggest that synovial fluid-induced aggregation appears to be widespread among S. aureus strains and mechanistically independent of biofilm formation. IMPORTANCE Bacterial infections of hip and knee implants are rare but devastating complications of orthopedic surgery. Despite a widespread appreciation of the considerable financial, physical, and emotional burden associated with the development of a prosthetic joint infection, the establishment of bacteria in the synovial joint remains poorly understood. It has been shown that immediately upon exposure to synovial fluid, the viscous fluid in the joint, Staphylococcus aureus rapidly forms aggregates which are resistant to antibiotics and host immune cell clearance. The bacterial virulence associated with aggregate formation is likely a step in the establishment of prosthetic joint infection, and as such, it has the potential to be a potent target of prevention. We hope that this work contributes to the future development of therapeutics targeting synovial fluid-induced aggregation to better prevent and treat these infections.
Collapse
Affiliation(s)
- Amelia Staats
- Department of Microbiology, The Ohio State University, Columbus, Ohio, USA
- Department of Microbial Infection and Immunity, The Ohio State University, Columbus, Ohio, USA
| | - Peter W. Burback
- Department of Microbial Infection and Immunity, The Ohio State University, Columbus, Ohio, USA
| | - Mostafa Eltobgy
- Department of Microbial Infection and Immunity, The Ohio State University, Columbus, Ohio, USA
| | - Dana M. Parker
- Arthritis and Arthroplasty Design Group, Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Amal O. Amer
- Department of Microbial Infection and Immunity, The Ohio State University, Columbus, Ohio, USA
| | - Daniel J. Wozniak
- Department of Microbiology, The Ohio State University, Columbus, Ohio, USA
- Department of Microbial Infection and Immunity, The Ohio State University, Columbus, Ohio, USA
| | - Shu-Hua Wang
- Department of Internal Medicine, Division of Infectious Diseases, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Kurt B. Stevenson
- Department of Internal Medicine, Division of Infectious Diseases, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Kenneth L. Urish
- Arthritis and Arthroplasty Design Group, Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Paul Stoodley
- Department of Microbial Infection and Immunity, The Ohio State University, Columbus, Ohio, USA
- Department of Orthopaedics, The Ohio State University, Columbus, Ohio, USA
- National Centre for Advanced Tribology at Southampton (nCATS), National Biofilm Innovation Centre (NBIC), Department of Mechanical Engineering, University of Southampton, United Kingdom
| |
Collapse
|
16
|
Qi X, Brothers KM, Ma D, Mandell JB, Donegan NP, Cheung AL, Richardson AR, Urish KL. The Staphylococcus aureus toxin-antitoxin system YefM-YoeB is associated with antibiotic tolerance and extracellular dependent biofilm formation. J Bone Jt Infect 2021; 6:241-253. [PMID: 34262845 PMCID: PMC8273624 DOI: 10.5194/jbji-6-241-2021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [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] [Received: 09/23/2020] [Accepted: 05/26/2021] [Indexed: 11/20/2022] Open
Abstract
The high antibiotic tolerance of Staphylococcus aureus biofilms is associated with challenges
for treating periprosthetic joint infection. The toxin–antitoxin system,
YefM–YoeB, is thought to be a regulator for antibiotic tolerance, but its
physiological role is unknown. The objective of this study was to determine
the biofilm and antibiotic susceptibility phenotypes associated with S. aureus yoeB
homologs. We hypothesized the toxin–antitoxin yoeB homologs contribute to
biofilm formation and antibiotic susceptibility. Disruption of yoeB1 and
yoeB2 resulted in decreased biofilm formation in comparison to Newman and JE2
wild-type (WT) S. aureus strains. In comparison to yoeB mutants, both Newman and JE2 WT
strains had higher polysaccharide intercellular adhesin (PIA) production.
Treatment with sodium metaperiodate increased biofilm formation in Newman
WT, indicating biofilm formation may be increased under conditions of
oxidative stress. DNase I treatment decreased biofilm formation in Newman
WT but not in the absence of yoeB1 or yoeB2. Additionally, WT strains had a higher
extracellular DNA (eDNA) content in comparison to yoeB mutants but no
differences in biofilm protein content. Moreover, loss of yoeB1 and yoeB2 decreased
biofilm survival in both Newman and JE2 strains. Finally, in a neutropenic
mouse abscess model, deletion of yoeB1 and yoeB2 resulted in reduced bacterial
burden. In conclusion, our data suggest that yoeB1 and yoeB2 are associated with
S. aureus planktonic growth, extracellular dependent biofilm formation, antibiotic
tolerance, and virulence.
Collapse
Affiliation(s)
- Xinyu Qi
- Arthritis and Arthroplasty Design Group (AAD Lab), Department of Orthopaedic Surgery, College of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Department of Orthopedic Surgery, the First Affiliated Hospital of Traditional Chinese Medicine of Guangzhou University, Guangzhou, Guangdong, China
| | - Kimberly M Brothers
- Arthritis and Arthroplasty Design Group (AAD Lab), Department of Orthopaedic Surgery, College of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Dongzhu Ma
- Arthritis and Arthroplasty Design Group (AAD Lab), Department of Orthopaedic Surgery, College of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Jonathan B Mandell
- Arthritis and Arthroplasty Design Group (AAD Lab), Department of Orthopaedic Surgery, College of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Niles P Donegan
- Department of Microbiology and Immunology, Geisel School of Medicine at Dartmouth, Hanover, NH, New Hampshire, USA
| | - Ambrose L Cheung
- Department of Microbiology and Immunology, Geisel School of Medicine at Dartmouth, Hanover, NH, New Hampshire, USA
| | - Anthony R Richardson
- Department of Microbiology and Molecular Genetics, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Kenneth L Urish
- Arthritis and Arthroplasty Design Group (AAD Lab), Department of Orthopaedic Surgery, College of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| |
Collapse
|
17
|
Weber MA, Snyder MJ, Workman KK, Sims MM, Smith CN, Kumar D, Daji AV, Borrero CG, Cordle AC, DiGioia AM, Hamlin BR, Plakseychuk AY, Urish KL. Comparison of Asymptomatic and Symptomatic Adverse Local Tissue Reaction in Patients With Head-Neck Taper Corrosion. J Arthroplasty 2021; 36:S358-S362. [PMID: 33036841 PMCID: PMC7965776 DOI: 10.1016/j.arth.2020.09.014] [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: 04/28/2020] [Revised: 08/29/2020] [Accepted: 09/11/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Diagnosis of adverse local tissue reaction (ALTR) in metal-on-polyethylene (MoP) total hip arthroplasty (THA) secondary to head-neck taper corrosion is challenging. The purpose of this study is to compare differences between asymptomatic and symptomatic ALTR in an observational cohort, including presentation, metal ion differences, and metal artifact reduction sequence (MARS) magnetic resonance imaging (MRI) findings. METHODS We performed a retrospective review of an observational cohort of 492 MoP THA patients at increased risk of developing ALTR. Ninety-four patients underwent revision arthroplasty for ALTR. Patients were stratified into symptomatic and asymptomatic ALTR groups. Presentation, metal ion levels, and imaging findings were compared. RESULTS For patients with confirmed ALTR, 41% were asymptomatic. There was a statistically significant difference in the serum chromium levels between symptomatic and asymptomatic ALTR patients (2.2 μg/L vs 3.1 μg/L, P = .05). There was no statistically significant difference between the serum cobalt levels or MRI findings in these 2 groups. We observed that extracapsular disease associated with ALTR could be misinterpreted as trochanteric bursitis. CONCLUSION Almost half of the MoP THA ALTR cases identified were asymptomatic. Cobalt levels could not differentiate between symptomatic and asymptomatic pseudotumor formation. Symptomatic and asymptomatic MoP ALTRs have similar MARS MRI characteristics. Our findings suggest that it is essential to risk stratify patients who could potentially have ALTR based on implant type, symptoms, ion levels, and MARS MRI.
Collapse
Affiliation(s)
| | | | - Kalain K Workman
- Department of Orthopedic Surgery, University of Pittsburgh Medical Center-Pinnacle, Harrisburg, PA
| | - Margaret M Sims
- The Bone & Joint Center, Magee Women's Hospital of the University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Clair N Smith
- Department of Orthopedic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Deepak Kumar
- University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Akshay V Daji
- University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Camilo G Borrero
- Department of Radiology, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Andrew C Cordle
- Department of Radiology, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Anthony M DiGioia
- The Bone & Joint Center, Magee Women's Hospital of the University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Brian R Hamlin
- The Bone & Joint Center, Magee Women's Hospital of the University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Anton Y Plakseychuk
- The Bone & Joint Center, Magee Women's Hospital of the University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Kenneth L Urish
- The Bone & Joint Center, Magee Women's Hospital of the University of Pittsburgh Medical Center, Pittsburgh, PA; Arthritis and Arthroplasty Design Lab, Department of Orthopaedic Surgery, University of Pittsburgh; Department of Bioengineering, and Clinical and Translational Science Institute, University of Pittsburgh, Pittsburgh, PA
| |
Collapse
|
18
|
Zlotnicki J, Gabrielli A, Urish KL, Brothers KM. Clinical Evidence of Current Irrigation Practices and the Use of Oral Antibiotics to Prevent and Treat Periprosthetic Joint Infection. Orthop Clin North Am 2021; 52:93-101. [PMID: 33752842 PMCID: PMC7990073 DOI: 10.1016/j.ocl.2020.12.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Affiliation(s)
- Jason Zlotnicki
- Arthritis and Arthroplasty Design Group, Department of
Orthopaedic Surgery, College of Medicine, University of Pittsburgh, Pittsburgh,
Pennsylvania, USA
| | - Alexandra Gabrielli
- Arthritis and Arthroplasty Design Group, Department of
Orthopaedic Surgery, College of Medicine, University of Pittsburgh, Pittsburgh,
Pennsylvania, USA
| | - Kenneth L. Urish
- Arthritis and Arthroplasty Design Group, Department of
Orthopaedic Surgery, College of Medicine, University of Pittsburgh, Pittsburgh,
Pennsylvania, USA
| | - Kimberly M. Brothers
- Arthritis and Arthroplasty Design Group, Department of
Orthopaedic Surgery, College of Medicine, University of Pittsburgh, Pittsburgh,
Pennsylvania, USA,Corresponding Author: Kimberly M.
Brothers, PhD, Arthritis and Arthroplasty Design Group, University of
Pittsburgh Medical School, Department of Orthopaedic Surgery, University of
Pittsburgh; Bridgeside Point II, 450 Technology Dr. Pittsburgh, PA, 15219;
| |
Collapse
|
19
|
Kundu S, Ashinsky BG, Bouhrara M, Dam EB, Demehri S, Shifat-E-Rabbi M, Spencer RG, Urish KL, Rohde GK. Reply to Roemer and Guermazi: Early biochemical changes on MRI can predict risk of symptomatic progression. Proc Natl Acad Sci U S A 2021; 118:e2024679118. [PMID: 33836609 PMCID: PMC7980416 DOI: 10.1073/pnas.2024679118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Affiliation(s)
- Shinjini Kundu
- Department of Biomedical Engineering, Carnegie Mellon University, Pittsburgh, PA 15213;
- Medical Scientist Training Program, University of Pittsburgh, Pittsburgh, PA 15213
| | - Beth G Ashinsky
- Laboratory of Clinical Investigation, Magnetic Resonance Imaging and Spectroscopy Section, National Institute on Aging, National Institutes of Health, Baltimore, MD 21224
| | - Mustapha Bouhrara
- Laboratory of Clinical Investigation, Magnetic Resonance Imaging and Spectroscopy Section, National Institute on Aging, National Institutes of Health, Baltimore, MD 21224
| | - Erik B Dam
- Department of Computer Science, University of Copenhagen, 2100 Copenhagen, Denmark
| | - Shadpour Demehri
- Department of Radiology, The Johns Hopkins Hospital, Baltimore, MD 21287
| | - M Shifat-E-Rabbi
- Department of Biomedical Engineering, University of Virginia, Charlottesville, VA 22904
| | - Richard G Spencer
- Laboratory of Clinical Investigation, Magnetic Resonance Imaging and Spectroscopy Section, National Institute on Aging, National Institutes of Health, Baltimore, MD 21224
| | - Kenneth L Urish
- Department of Biomedical Engineering, Carnegie Mellon University, Pittsburgh, PA 15213
- Arthritis and Arthroplasty Design Group, The Bone and Joint Center, Magee Womens Hospital of the University of Pittsburgh Medical Center, Pittsburgh, PA 15213
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, PA 15213
- Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA 15261
- Clinical and Translational Science Institute, University of Pittsburgh, Pittsburgh, PA 15261
| | - Gustavo K Rohde
- Department of Biomedical Engineering, University of Virginia, Charlottesville, VA 22904
- Department of Electrical and Computer Engineering, University of Virginia, Charlottesville, VA 22904
| |
Collapse
|
20
|
Yagi H, Kihara S, Mittwede PN, Maher PL, Rothenberg AC, Falcione ADCM, Chen A, Urish KL, Tuan RS, Alexander PG. Development of a large animal rabbit model for chronic periprosthetic joint infection. Bone Joint Res 2021; 10:156-165. [PMID: 33641351 PMCID: PMC8005337 DOI: 10.1302/2046-3758.103.bjr-2019-0193.r3] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [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] [Indexed: 12/27/2022] Open
Abstract
Aims Periprosthetic joint infections (PJIs) and osteomyelitis are clinical challenges that are difficult to eradicate. Well-characterized large animal models necessary for testing and validating new treatment strategies for these conditions are lacking. The purpose of this study was to develop a rabbit model of chronic PJI in the distal femur. Methods Fresh suspensions of Staphylococcus aureus (ATCC 25923) were prepared in phosphate-buffered saline (PBS) (1 × 109 colony-forming units (CFUs)/ml). Periprosthetic osteomyelitis in female New Zealand white rabbits was induced by intraosseous injection of planktonic bacterial suspension into a predrilled bone tunnel prior to implant screw placement, examined at five and 28 days (n = 5/group) after surgery, and compared to a control aseptic screw group. Radiographs were obtained weekly, and blood was collected to measure ESR, CRP, and white blood cell (WBC) counts. Bone samples and implanted screws were harvested on day 28, and processed for histological analysis and viability assay of bacteria, respectively. Results Intraosseous periprosthetic introduction of planktonic bacteria induced an acute rise in ESR and CRP that subsided by day 14, and resulted in radiologically evident periprosthetic osteolysis by day 28 accompanied by elevated WBC counts and histological evidence of bacteria in the bone tunnels after screw removal. The aseptic screw group induced no increase in ESR, and no lysis developed around the implants. Bacterial viability was confirmed by implant sonication fluid culture. Conclusion Intraosseous periprosthetic introduction of planktonic bacteria reliably induces survivable chronic PJI in rabbits. Cite this article: Bone Joint Res 2021;10(3):156–165.
Collapse
Affiliation(s)
- Haruyo Yagi
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Shinsuke Kihara
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Peter N Mittwede
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Patrick L Maher
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Adam C Rothenberg
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Alyssa D C M Falcione
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Antonia Chen
- Department of Orthopaedic Surgery, Center for Cellular and Molecular Engineering, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.,Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Kenneth L Urish
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA.,Arthritis and Arthroplasty Design Group, Magee Womens Hospital of UPMC, Pittsburgh, Pennsylvania, USA
| | - Rocky S Tuan
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | | |
Collapse
|
21
|
Shah NB, Hersh BL, Kreger A, Sayeed A, Bullock AG, Rothenberger SD, Klatt B, Hamlin B, Urish KL. Reply to Courjon and Del Giudice. Clin Infect Dis 2021; 72:177-178. [PMID: 32518947 DOI: 10.1093/cid/ciaa392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Neel B Shah
- Division of Infectious Disease, Department of Internal Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Beverly L Hersh
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Alex Kreger
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Aatif Sayeed
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Andrew G Bullock
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Scott D Rothenberger
- Center for Research on Health Care Data Center, Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Brian Klatt
- Department of Orthopedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Brian Hamlin
- The Bone and Joint Center, Magee Womens Hospital of the University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Kenneth L Urish
- Arthritis and Arthroplasty Design Group, the Bone and Joint Center, Magee Womens Hospital of the University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA.,Department of Orthopedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA.,Department of Biomedical Engineering, Carnegie Mellon University, Pittsburgh, Pennsylvania, USA
| |
Collapse
|
22
|
Shah NB, Hersh BL, Kreger A, Sayeed A, Bullock AG, Rothenberger SD, Klatt B, Hamlin B, Urish KL. Benefits and Adverse Events Associated With Extended Antibiotic Use in Total Knee Arthroplasty Periprosthetic Joint Infection. Clin Infect Dis 2021; 70:559-565. [PMID: 30944931 DOI: 10.1093/cid/ciz261] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [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: 10/15/2018] [Accepted: 03/26/2019] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Total knee arthroplasty (TKA) periprosthetic joint infection (PJI) can be managed with debridement, antibiotic therapy, and implant retention (DAIR). Oral antibiotics can be used after DAIR for an extended time period to improve outcomes. The objective of this study was to compare DAIR failure rates and adverse events between an initial course of intravenous antibiotic therapy and the addition of extended treatment with oral antibiotics. METHODS A multicenter observational study of patients diagnosed with a TKA PJI who underwent DAIR was performed. The primary outcome of interest was the failure rate derived from the survival time between the DAIR procedure and future treatment failure. RESULTS One hundred eight patients met inclusion criteria; 47% (n = 51) received an extended course of oral antibiotics. These patients had a statistically significant lower failure rate compared to those who received only intravenous antibiotics (hazard ratio, 2.47; P = .009). Multivariable analysis demonstrated that extended antibiotics independently predicted treatment success, controlling for other variables. There was no significant difference in failure rates between an extended course of oral antibiotics less or more than 12 months (P = .23). No significant difference in the rates of adverse events was observed between patients who received an initial course of antibiotics alone and those who received a combination of initial and extended antibiotic therapy (P = .59). CONCLUSIONS Extending therapy with oral antibiotics had superior infection-free survival for TKA PJI managed with DAIR. There was no increase in adverse events, demonstrating safety. After 1 year, there appears to be no significant benefit associated with continued antibiotic therapy.
Collapse
Affiliation(s)
- Neel B Shah
- Division of Infectious Disease, Department of Internal Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Beverly L Hersh
- School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Alex Kreger
- School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Aatif Sayeed
- School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Andrew G Bullock
- School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Scott D Rothenberger
- Center for Research on Health Care Data Center, Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Brian Klatt
- Department of Orthopedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Brian Hamlin
- Bone and Joint Center, Magee-Womens Hospital of the University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Kenneth L Urish
- Department of Orthopedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania.,Arthritis and Arthroplasty Design Group, Bone and Joint Center, Magee-Womens Hospital of the University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.,Department of Bioengineering, and Clinical and Translational Science Institute, University of Pittsburgh, Pittsburgh, Pennsylvania.,Department of Biomedical Engineering, Carnegie Mellon University, Pittsburgh, Pennsylvania
| |
Collapse
|
23
|
Gobao VC, Alfishawy M, Smith C, Byers KE, Yassin M, Urish KL, Shah NB. Risk Factors, Screening, and Treatment Challenges in Staphylococcus aureus Native Septic Arthritis. Open Forum Infect Dis 2020; 8:ofaa593. [PMID: 33511230 PMCID: PMC7813160 DOI: 10.1093/ofid/ofaa593] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Accepted: 12/15/2020] [Indexed: 01/29/2023] Open
Abstract
Background Staphylococcus aureus is the most common cause of native septic arthritis. Few studies have characterized this disease during the US opioid epidemic. The role of methicillin-resistant Staphylococcus aureus (MRSA) nasal screening in this disease has not been elucidated. We sought to identify risk factors and outcomes for S. aureus native septic arthritis and to evaluate MRSA screening in this disease. Methods A retrospective cohort study of native septic arthritis patients (2012–2016) was performed. Demographics, risk factors, and outcomes were compared between Staphylococcus aureus and other native septic arthritis infections. Sensitivity, specificity, and predictive values of MRSA screening were assessed. Results Two hundred fifteen cases of native septic arthritis were included. S. aureus was cultured in 64% (138/215). MRSA was cultured in 23% (50/215). S. aureus was associated with injection drug use (odds ratio [OR], 4.33; 95% CI, 1.74–10.81; P = .002) and switching antibiotics (OR, 3.92; 95% CI, 1.01–21.38; P = .032). For every 10-year increase in age, the odds of S. aureus decreased (OR, 0.72; 95% CI, 0.60–0.87; P = .001). For 1-unit increases in Charlson comorbidity index score, the odds of S. aureus decreased (OR, 0.82; 95% CI, 0.73–0.91; P = .0004). MRSA screening during admission demonstrated a sensitivity of 0.59, specificity of 0.96, positive predictive value of 0.85, and negative predictive value of 0.84 for MRSA native septic arthritis. Conclusions The opioid epidemic may be contributing to a demographic shift in native septic arthritis to younger, healthier individuals. S. aureus native septic arthritis has unique risks, including injection drug use. MRSA screening may be useful to rule in MRSA native septic arthritis.
Collapse
Affiliation(s)
- Valerie C Gobao
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | | | - Clair Smith
- Department of Orthopaedic Surgery and Department of Physical Therapy, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Karin E Byers
- Division of Infectious Disease, Department of Internal Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Mohamed Yassin
- Division of Infectious Disease, Department of Internal Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Kenneth L Urish
- Arthritis and Arthroplasty Design Group, The Bone and Joint Center, Magee Womens Hospital of the University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA.,Departments of Orthopaedic Surgery and Bioengineering, Clinical and Translational Science Institute, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Department of Biomedical Engineering, Carnegie Mellon University, Pittsburgh, Pennsylvania, USA
| | - Neel B Shah
- Division of Infectious Disease, Department of Internal Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| |
Collapse
|
24
|
Mandell JB, Koch J, Deslouches B, Urish KL. Direct antimicrobial activity of cationic amphipathic peptide WLBU2 against Staphylococcus aureus biofilms is enhanced in physiologic buffered saline. J Orthop Res 2020; 38:2657-2663. [PMID: 32484998 PMCID: PMC7665995 DOI: 10.1002/jor.24765] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [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: 01/04/2020] [Revised: 04/30/2020] [Accepted: 05/25/2020] [Indexed: 02/04/2023]
Abstract
Periprosthetic joint infection of total knee arthroplasties represents a major challenge to the field of orthopedic surgery. These infections are commonly associated with antibiotic-tolerant Staphylococcus aureus biofilms. Engineered cationic amphipathic peptide WLBU2 has shown the ability to kill antibiotic-resistant pathogens and drug-tolerant bacterial biofilms. The novelty of using WLBU2 during the direct irrigation and debridement of periprosthetic joint infections led our group to investigate the optimal washout conditions for treatment of S. aureus biofilms. S. aureus mature biofilms were grown on metal implant material and treated with WLBU2 dissolved in differing irrigation solvents. Mature biofilms were treated both in vitro as well as in a periprosthetic joint infection murine model. WLBU2 activity against S. aureus biofilms was increased when dissolved in diphosphate-buffered saline (dPBS) with pH of 7.0 compared with normal saline with pH of 5.5. WLBU2 activity was decreased in acidic dPBS and increased in alkaline dPBS. WLBU2 activity could be decreased in hypertonic dPBS and increased in hypotonic dPBS. WLBU2 dissolved in less acidic dPBS displayed increased efficacy in treating periprosthetic joint infection (PJI) implants ex vivo. WLBU2 demonstrated the ability to eliminate PJI associated S. aureus biofilms on arthroplasty material. The efficacy of engineered cationic amphipathic peptide WLBU2 for intraoperative elimination of S. aureus biofilms can be further optimized when kept in a less acidic and more physiologic pH adjusted saline. Understanding optimal physical washout conditions are vital for the success of WLBU2 in treating S. aureus biofilms in PJI clinical trials going forward.
Collapse
Affiliation(s)
- Jonathan B. Mandell
- Arthritis and Arthroplasty Design Group, Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania,Department of Infectious Diseases and Microbiology, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - John Koch
- Arthritis and Arthroplasty Design Group, Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Berthony Deslouches
- Department of Environmental and Occupational Health, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Kenneth L. Urish
- Arthritis and Arthroplasty Design Group, Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania,The Bone and Joint Center, Magee Womens Hospital of the University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania,Department of Bioengineering, University of Pittsburgh, Pittsburgh, Pennsylvania,Clinical and Translational Science Institute, University of Pittsburgh, Pittsburgh, Pennsylvania,Department of Biomedical Engineering, Carnegie Mellon University, Pittsburgh, Pennsylvania
| |
Collapse
|
25
|
Budge MD, Koch JA, Mandell JB, Cappellini AJ, Orr S, Patel S, Ma D, Nourie O, Brothers KM, Urish KL. The In Vitro Efficacy of Doxycycline over Vancomycin and Penicillin in the Elimination of Cutibacterium Acnes Biofilm. Antimicrob Comb Devices (2019) 2020; STP1630:53-64. [PMID: 35529525 PMCID: PMC9070841 DOI: 10.1520/stp163020200019] [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] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
Cutibacterium acnes (formerly Propionibacterium acnes) is a significant pathogen in periprosthetic joint infections (PJIs) in total shoulder arthroplasty. Poor outcomes seen in PJIs are due to the established C. acnes bacterial biofilms. The prolonged nature of C. acnes infections makes them difficult to treat with antibiotics. The goal of this study was to determine the relative efficacy of vancomycin compared with penicillin and doxycycline against planktonic and mature biofilms. Clinical isolates from PJI patients as well as a laboratory strain of C. acnes were tested. Planktonic minimum inhibitory concentrations (MICs) and minimum bactericidal concentrations (MBCs) were obtained using modified clinical laboratory standard index assays. Biofilm MICs and MBCs were also obtained. The MIC was determined for both using the PrestoBlue viability stain. The MBC was determined using differential reinforced clostridial medium agar plates for colony-forming unit analysis. Using the PrestoBlue viability reagent, the planktonic MIC values for vancomycin were significantly higher than doxycycline. Across 10 strains of C. acnes, all three antibiotics had decreased efficacy when comparing planktonic and biofilm cultures. Although effective antibiotic doses ranged from 1 to 1,000 μg/mL, only doxycycline achieved inhibitory and bactericidal concentrations in all tested strains. Penicillin failed to achieve the minimum biofilm inhibitory concentration (MBIC) in 60% of tested strains, whereas vancomycin failed in 80% of tested strains. Penicillin, doxycycline, and vancomycin have similar abilities in inhibiting C. acnes growth planktonically. The MBIC for doxycycline was within the clinical dosing range, suggesting C. acnes biofilm offers minimal tolerance to these antibiotics. The MBIC for penicillin was within clinical dosing ranges in only 60% of trials, suggesting the relative tolerance of C. acnes to penicillin. The minimum biofilm bactericidal concentration (MBBC) of doxycycline showed efficacy in 90% of trials, whereas penicillin and vancomycin achieved MBBC in 15% of samples.
Collapse
Affiliation(s)
- Matthew D Budge
- NW Perrnanente, 5125 Skyline Rd. S., Salem, OR 97306-9427, USA
| | - John A Koch
- NW Perrnanente, 5125 Skyline Rd. S., Salem, OR 97306-9427, USA
- Arthritis and Arthroplasty Design Group, Dept. of Orthopaedic Surgery, 100 Technology Dr., Pittsburgh, PA 15219, USA
| | - Jonathan B Mandell
- Arthritis and Arthroplasty Design Group, Dept. of Orthopaedic Surgery, 100 Technology Dr., Pittsburgh, PA 15219, USA
| | - Alex J Cappellini
- Arthritis and Arthroplasty Design Group, Dept. of Orthopaedic Surgery, 100 Technology Dr., Pittsburgh, PA 15219, USA
| | - Sara Orr
- Arthritis and Arthroplasty Design Group, Dept. of Orthopaedic Surgery, 100 Technology Dr., Pittsburgh, PA 15219, USA
| | - Samik Patel
- Arthritis and Arthroplasty Design Group, Dept. of Orthopaedic Surgery, 100 Technology Dr., Pittsburgh, PA 15219, USA
| | - Dongzhu Ma
- Arthritis and Arthroplasty Design Group, Dept. of Orthopaedic Surgery, 100 Technology Dr., Pittsburgh, PA 15219, USA
| | - Olivia Nourie
- NW Perrnanente, 5125 Skyline Rd. S., Salem, OR 97306-9427, USA
| | - Kimberly M Brothers
- Arthritis and Arthroplasty Design Group, Dept. of Orthopaedic Surgery, 100 Technology Dr., Pittsburgh, PA 15219, USA
| | - Kenneth L Urish
- Arthritis and Arthroplasty Design Group, The Bone and Joint Center, MageeWomens Hospital of the University of Pittsburgh Medical Center, 300 Halket St., Pittsburgh, PA 15213, USA; and Dept. of Orthopaedic Surgery, Dept. of Bioengineering, and Clinical and Translational Science Institute, University of Pittsburgh, 100 Technology Dr., Pittsburgh, PA 15219, USA
| |
Collapse
|
26
|
Urish KL, Qin Y, Salka B, Li BY, Borza T, Sessine M, Kirk P, Hollenbeck BK, Helm JE, Lavieri MS, Skolarus TA, Jacobs BL. Comparison of readmission and early revision rates as a quality metric in total knee arthroplasty using the Nationwide Readmission Database. Ann Transl Med 2020; 8:687. [PMID: 32617307 PMCID: PMC7327322 DOI: 10.21037/atm-19-3463] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Background After release of the Comprehensive Care for Joint Replacement bundle, there has been increased emphasis on reducing readmission rates for total knee arthroplasty (TKA). The potential for a separate, clinically-relevant metric, TKA revision rates within a year following surgery, has not been fully explored. Based on this, we compared rates and payments for TKA readmission and revision procedures as metrics for improving quality and cost. Methods We utilized the 2013 Nationwide Readmission Database (NRD) to examine national readmission and revision rates, the reasons for revision procedures, and associated costs for elective TKA procedures. As data are not linked across years, we examined revision rates for TKA completed in the month of January by capturing revision procedures in the subsequent following 11-month period to approximate a 1-year revision rate. Diagnosis and procedure codes for revision procedures were collected. Average readmission and revision procedure costs were then calculated, and the cost distributed across the entire TKA population. Results We identified 20,851 patients having TKA surgery. The mean unadjusted 30- and 90-day TKA readmission rates were 3.4% and 5.8%, respectively. In contrast, the mean unadjusted 3-month and approximate 1-year reoperation rates were 1.0% and 1.6%, respectively. The most common cause for revision was periprosthetic joint infection, which accounting for 62% of all reported revision procedures. The mean payment for 90-day readmission was roughly half ($10,589±$11,084) of the mean inpatient payment for single reoperation procedure at 90 days ($20,222±$17,799). Importantly, nearly half (46%) of all 90-day readmissions were associated with a reoperation event within the first year. Conclusions Readmission following TKA is associated with a 1-year reoperation in approximately half of patients. These reoperations represent a significant patient burden and have a higher per episode cost. Early reoperation may represent a more clinically relevant target for quality improvement and cost containment.
Collapse
Affiliation(s)
- Kenneth L Urish
- Arthritis and Arthroplasty Design Group, The Bone and Joint Center, Magee Womens Hospital, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.,Department of Orthopaedic Surgery, Department of Bioengineering, and Clinical and Translational Science Institute, University of Pittsburgh, Pittsburgh, PA, USA.,Department of Biomedical Engineering, Carnegie Mellon University, Pittsburgh, PA, USA
| | - Yongmei Qin
- Department of Urology, Division of Oncology, Dow Division for Urologic Health Service Research, University of Michigan, Ann Arbor, MI, USA
| | - Bassel Salka
- Department of Urology, Division of Oncology, Dow Division for Urologic Health Service Research, University of Michigan, Ann Arbor, MI, USA
| | - Benjamin Y Li
- Department of Urology, Division of Oncology, Dow Division for Urologic Health Service Research, University of Michigan, Ann Arbor, MI, USA
| | - Tudor Borza
- Department of Urology, University of Wisconsin School of Medicine and Public Health, William S. Middleton Memorial Veterans Hospital, Madison, WI, USA
| | - Michael Sessine
- Department of Urology, Division of Oncology, Dow Division for Urologic Health Service Research, University of Michigan, Ann Arbor, MI, USA
| | - Peter Kirk
- Department of Urology, Division of Oncology, Dow Division for Urologic Health Service Research, University of Michigan, Ann Arbor, MI, USA
| | - Brent K Hollenbeck
- Department of Urology, Division of Oncology, Dow Division for Urologic Health Service Research, University of Michigan, Ann Arbor, MI, USA
| | - Jonathan E Helm
- Health Services Research & Development, Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Mariel S Lavieri
- Department of Industrial and Operations Engineering, University of Michigan, Ann Arbor, MI, USA
| | - Ted A Skolarus
- Department of Urology, Division of Oncology, Dow Division for Urologic Health Service Research, Health Services Research & Development, Center for Clinical Management Research, VA Ann Arbor Healthcare System, University of Michigan, Ann Arbor, MI, USA
| | - Bruce L Jacobs
- Department of Urology, University of Pittsburgh, Pittsburgh, PA, USA
| |
Collapse
|
27
|
Abstract
➤Artificial intelligence (AI) provides machines with the ability to perform tasks using algorithms governed by pattern recognition and self-correction on large amounts of data to narrow options in order to avoid errors. ➤The 4 things necessary for AI in medicine include big data sets, powerful computers, cloud computing, and open source algorithmic development. ➤The use of AI in health care continues to expand, and its impact on orthopaedic surgery can already be found in diverse areas such as image recognition, risk prediction, patient-specific payment models, and clinical decision-making. ➤Just as the business of medicine was once considered outside the domain of the orthopaedic surgeon, emerging technologies such as AI warrant ownership, leverage, and application by the orthopaedic surgeon to improve the care that we provide to the patients we serve. ➤AI could provide solutions to factors contributing to physician burnout and medical mistakes. However, challenges regarding the ethical deployment, regulation, and the clinical superiority of AI over traditional statistics and decision-making remain to be resolved.
Collapse
Affiliation(s)
- Thomas G. Myers
- Divisions of Adult Reconstruction (T.G.M. and B.F.R.) and Hand and Upper Extremity Surgery (C.K.), Department of Orthopaedics and Rehabilitation, University of Rochester Medical Center, Rochester, New York
| | - Prem N. Ramkumar
- Machine Learning Arthroplasty Laboratory, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Benjamin F. Ricciardi
- Divisions of Adult Reconstruction (T.G.M. and B.F.R.) and Hand and Upper Extremity Surgery (C.K.), Department of Orthopaedics and Rehabilitation, University of Rochester Medical Center, Rochester, New York
| | - Kenneth L. Urish
- Department of Orthopaedics and The Bone and Joint Center, Magee Women’s Hospital of the University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Jens Kipper
- Department of Philosophy, University of Rochester, Rochester, New York
| | - Constantinos Ketonis
- Divisions of Adult Reconstruction (T.G.M. and B.F.R.) and Hand and Upper Extremity Surgery (C.K.), Department of Orthopaedics and Rehabilitation, University of Rochester Medical Center, Rochester, New York
| |
Collapse
|
28
|
Shah NB, Hersh BL, Kreger A, Sayeed A, Bullock AG, Rothenberger SD, Klatt B, Hamlin B, Urish KL. Reply to Wouthuyzen-Bakker et al. Clin Infect Dis 2020; 70:1260-1261. [PMID: 31292620 PMCID: PMC7931842 DOI: 10.1093/cid/ciz632] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Neel B Shah
- Division of Infectious Disease, Department of Internal Medicine, University of Pittsburgh Medical Center, Carnegie Mellon University, Pittsburgh, Pennsylvania
| | - Beverly L Hersh
- University of Pittsburgh School of Medicine, Carnegie Mellon University, Pittsburgh, Pennsylvania
| | - Alex Kreger
- University of Pittsburgh School of Medicine, Carnegie Mellon University, Pittsburgh, Pennsylvania
| | - Aatif Sayeed
- University of Pittsburgh School of Medicine, Carnegie Mellon University, Pittsburgh, Pennsylvania
| | - Andrew G Bullock
- University of Pittsburgh School of Medicine, Carnegie Mellon University, Pittsburgh, Pennsylvania
| | - Scott D Rothenberger
- Center for Research on Health Care Data Center, Division of General Internal Medicine, University of Pittsburgh School of Medicine, Carnegie Mellon University, Pittsburgh, Pennsylvania
| | - Brian Klatt
- Department of Orthopaedic Surgery, University of Pittsburgh, Carnegie Mellon University, Pittsburgh, Pennsylvania
| | - Brian Hamlin
- Bone and Joint Center, and, Carnegie Mellon University, Pittsburgh, Pennsylvania
| | - Kenneth L Urish
- Arthritis and Arthroplasty Design Group, Bone and Joint Center, Magee-Womens Hospital of the University of Pittsburgh Medical Center, Carnegie Mellon University, Pittsburgh, Pennsylvania
- Department of Orthopaedic Surgery, Department of Bioengineering, Carnegie Mellon University, Pittsburgh, Pennsylvania and Clinical and Translational Science Institute, University of Pittsburgh
- Department of Biomedical Engineering, Carnegie Mellon University, Pittsburgh, Pennsylvania
| |
Collapse
|
29
|
Li BY, Urish KL, Jacobs BL, He C, Borza T, Qin Y, Min HS, Dupree JM, Ellimoottil C, Hollenbeck BK, Lavieri MS, Helm JE, Skolarus TA. Inaugural Readmission Penalties for Total Hip and Total Knee Arthroplasty Procedures Under the Hospital Readmissions Reduction Program. JAMA Netw Open 2019; 2:e1916008. [PMID: 31755949 PMCID: PMC6902819 DOI: 10.1001/jamanetworkopen.2019.16008] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
IMPORTANCE The Hospital Readmissions Reduction Program (HRRP) is a Centers for Medicare and Medicaid Services policy that levies hospital reimbursement penalties based on excess readmissions of patients with 4 medical conditions and 3 surgical procedures. A greater understanding of factors associated with the 3 surgical reimbursement penalties is needed for clinicians in surgical practice. OBJECTIVE To investigate the first year of HRRP readmission penalties applied to 2 surgical procedures-elective total hip arthroplasty (THA) and total knee arthroplasty (TKA)-in the context of hospital and patient characteristics. DESIGN, SETTING, AND PARTICIPANTS Fiscal year 2015 HRRP penalization data from Hospital Compare were linked with the American Hospital Association Annual Survey and with the Healthcare Cost and Utilization Project State Inpatient Database for hospitals in the state of Florida. By using a case-control framework, those hospitals were separated based on HRRP penalty severity, as measured with the HRRP THA and TKA excess readmission ratio, and compared according to orthopedic volume as well as hospital-level and patient-level characteristics. The first year of HRRP readmission penalties applied to surgery in Florida Medicare subsection (d) hospitals was examined, identifying 60 663 Medicare patients who underwent elective THA or TKA in 143 Florida hospitals. The data analysis was conducted from February 2016 to January 2017. EXPOSURES Annual hospital THA and TKA volume, other hospital-level characteristics, and patient factors used in HRRP risk adjustment. MAIN OUTCOMES AND MEASURES The HRRP penalties with HRRP excess readmission ratios were measured, and their association with annual THA and TKA volume, a common measure of surgical quality, was evaluated. The HRRP penalties for surgical care according to hospital and readmitted patient characteristics were then examined. RESULTS Among 143 Florida hospitals, 2991 of 60 663 Medicare patients (4.9%) who underwent THA or TKA were readmitted within 30 days. Annual hospital arthroplasty volume seemed to follow an inverse association with both unadjusted readmission rates (r = -0.16, P = .06) and HRRP risk-adjusted readmission penalties (r = -0.12, P = .14), but these associations were not statistically significant. Other hospital characteristics and readmitted patient characteristics were similar across HRRP orthopedic penalty severity. CONCLUSIONS AND RELEVANCE This study's findings suggest that higher-volume hospitals had less severe, but not significantly different, rates of readmission and HRRP penalties, without systematic differences across readmitted patients.
Collapse
MESH Headings
- Aged
- Arthroplasty, Replacement, Hip/adverse effects
- Arthroplasty, Replacement, Hip/statistics & numerical data
- Arthroplasty, Replacement, Knee/adverse effects
- Arthroplasty, Replacement, Knee/statistics & numerical data
- Case-Control Studies
- Centers for Medicare and Medicaid Services, U.S./economics
- Centers for Medicare and Medicaid Services, U.S./standards
- Female
- Florida
- Humans
- Male
- Patient Readmission/economics
- Patient Readmission/statistics & numerical data
- Reimbursement Mechanisms/economics
- Reimbursement Mechanisms/organization & administration
- Risk Adjustment
- United States
Collapse
Affiliation(s)
- Benjamin Y. Li
- Dow Division for Urologic Health Services Research, Department of Urology, University of Michigan, Ann Arbor
| | - Kenneth L. Urish
- Magee Bone and Joint Center, Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Bruce L. Jacobs
- Department of Urology, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Chang He
- Dow Division for Urologic Health Services Research, Department of Urology, University of Michigan, Ann Arbor
- Michigan Society of Thoracic and Cardiovascular Surgeons Quality Collaborative, University of Michigan, Ann Arbor
| | - Tudor Borza
- Dow Division for Urologic Health Services Research, Department of Urology, University of Michigan, Ann Arbor
- Department of Urology, University of Wisconsin, Madison
| | - Yongmei Qin
- Dow Division for Urologic Health Services Research, Department of Urology, University of Michigan, Ann Arbor
| | - Hye Sung Min
- Dow Division for Urologic Health Services Research, Department of Urology, University of Michigan, Ann Arbor
| | - James M. Dupree
- Dow Division for Urologic Health Services Research, Department of Urology, University of Michigan, Ann Arbor
| | - Chad Ellimoottil
- Dow Division for Urologic Health Services Research, Department of Urology, University of Michigan, Ann Arbor
| | - Brent K. Hollenbeck
- Dow Division for Urologic Health Services Research, Department of Urology, University of Michigan, Ann Arbor
| | - Mariel S. Lavieri
- Department of Industrial and Operations Engineering, University of Michigan, Ann Arbor
| | - Jonathan E. Helm
- Operations and Decision Technologies, Indiana University Kelley School of Business, Bloomington
| | - Ted A. Skolarus
- Dow Division for Urologic Health Services Research, Department of Urology, University of Michigan, Ann Arbor
- Health Services Research and Development, Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
| |
Collapse
|
30
|
Hersh BL, Shah NB, Rothenberger SD, Zlotnicki JP, Klatt BA, Urish KL. Do Culture Negative Periprosthetic Joint Infections Remain Culture Negative? J Arthroplasty 2019; 34:2757-2762. [PMID: 31327645 PMCID: PMC6801070 DOI: 10.1016/j.arth.2019.06.050] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [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: 04/15/2019] [Revised: 06/19/2019] [Accepted: 06/22/2019] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Diagnosis and treatment of culture negative total knee arthroplasty (TKA) periprosthetic joint infection (PJI) is challenging. There is debate over whether culture negative PJI confers increased risk of failure and which organisms are responsible. It is also unclear as to what factors predict conversion from culture negative to culture positivity. To address these issues, we performed an observational study to detect factors associated with transition from culture negative to culture positive TKA PJI in those patients that failed irrigation and debridement (I&D), determine the incidence of this transition, and identify those organisms that were associated with treatment failure. METHODS A multicenter observational cohort study was performed on patients with TKA PJI as defined by Musculoskeletal Infection Society criteria without cultured organisms and treated with I&D. Primary outcome was failure defined as any subsequent surgical procedure. Secondary outcome included cultured organism within 2 years of initial I&D. RESULTS Two hundred sixteen TKA I&D procedures were performed for PJI, and 36 met inclusion criteria. The observed treatment failure rate for culture negative PJI treated with I&D was 41.67%. Of those culture negative I&Ds that failed, 53.33% became culture positive after failure. Of those that converted to culture positive, 62.5% were Staphylococcus species. The odds ratio associated with becoming culture positive following culture negative treatment failure in the setting of antibiotic administration prior to the initial I&D procedure was 0.69 (95% confidence interval 0.14-3.47, P = .65). CONCLUSION Many cases of culture negative TKA PJI treated with I&D eventually fail and become culture positive. Staphylococci are common organisms identified after culture negative PJI.
Collapse
Affiliation(s)
| | - Neel B. Shah
- Division of Infectious Disease, Department of Internal Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Scott D. Rothenberger
- Division of General Internal Medicine, Center for Research on Health Care Data Center, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Jason P. Zlotnicki
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Brian A. Klatt
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Kenneth L. Urish
- Arthritis and Arthroplasty Design Group, The Bone and Joint Center, Magee Womens Hospital of the University of Pittsburgh Medical Center,
Pittsburgh, PA,Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, PA,Department of Bioengineering, Clinical and Translational Science Institute, University of Pittsburgh, Pittsburgh, PA,Department of Biomedical Engineering, Carnegie Mellon University, Pittsburgh, PA,Reprint requests: Kenneth L. Urish, MD, PhD,Arthritis and Arthroplasty Design Group, The Bone and Joint Center, Magee Womens Hospital of the University of Pittsburgh Medical Center, 300 Halket Street, Suite 1601, Pittsburgh, PA 15232
| |
Collapse
|
31
|
Abstract
Modern total hip arthroplasty implants have incorporated modularity into their designs, providing the benefits of intraoperative flexibility and the ability to exchange the femoral heads in the future if necessary. However, this feature has unfortunately predisposed patients to the effects of corrosion, potentially resulting in adverse local tissue reactions (ALTR) and even systemic effects. A thorough understanding of the science of corrosion is important for the treating surgeon so that they can understand the underlying pathology, quickly diagnose the condition of ALTR, and risk stratify their patients to determine the best method of treatment. Revision surgery is not always necessary in cases of trunnionosis or ALTR, but the results of revision surgery are generally favorable.
Collapse
Affiliation(s)
- Richard A Wawrose
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Kaufmann Medical Building, 3471 Fifth Ave., Suite 1010, Pittsburgh, PA 15213
| | - Kenneth L Urish
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Kaufmann Medical Building, 3471 Fifth Ave., Suite 1010, Pittsburgh, PA 15213
| |
Collapse
|
32
|
Khare R, Jaramaz B, Hamlin B, Urish KL. Implant orientation accuracy of a hand-held robotic partial knee replacement system over conventional technique in a cadaveric test. Comput Assist Surg (Abingdon) 2019; 23:8-13. [PMID: 29932791 DOI: 10.1080/24699322.2018.1484167] [Citation(s) in RCA: 5] [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] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Unicondylar Knee Arthroplasty (UKA) is a minimally-invasive surgical procedure for treating isolated compartmental knee osteoarthritis. Accurate implant placement is crucial for a successful UKA procedure. Previous work has shown the improvement in UKA by using robotic systems. Here, we present the implant alignment accuracy of a hand-held robotic UKA system compared with a conventional manual UKA system for 12 cadaver specimens. Two surgeons carried out equal number of medial UKAs with robotic UKA on one knee and the manual UKA on the other knee. Preoperative and postoperative computed tomography (CT) scans were obtained for each cadaveric model. The final implant positions were identified in the postoperative CT scan. The implant orientations were compared with the planned implant positions to obtain femoral and tibial implant alignment errors. Our results show that the femoral flexion, varus, and rotation root mean square errors for the robotic and conventional approach were 1.23°, 2.81°, 1.62° and 7.52°, 6.25°, 5.0°, respectively. The tibial slope and varus errors for the robotic and conventional approaches were 2.41°, 2.96° and 4.06°, 1.8°, respectively. We did not find any statistical significant difference (p = .05) in the performance of the two surgeons. We conclude that the hand-held robotic UKA system offers significant improvement in the final implant placement.
Collapse
Affiliation(s)
- Rahul Khare
- a Smith & Nephew Inc. , Pittsburgh , PA , USA
| | | | - Brian Hamlin
- b Department of Orthopaedic Surgery, The Bone and Joint Center, Magee Womens Hospital of the University of Pittsburgh Medical Center , Pittsburgh , PA , USA
| | - Kenneth L Urish
- c Arthritis and Arthroplasty Design Group, The Bone and Joint Center , Magee Womens Hospital of the University of Pittsburgh Medical Center , Pittsburgh , PA , USA.,d Department of Orthopaedic Surgery, Department of Bioengineering, Clinical and Translational Science Institute , University of Pittsburgh , Pittsburgh , PA , USA.,e Department of Biomedical Engineering , Carnegie Mellon University, University of Pittsburgh , Pittsburgh , PA , USA
| |
Collapse
|
33
|
Abstract
There has been increased interest in the role of corrosion in early implant failures and adverse local tissue reaction in total hip arthroplasty. We review the relationship between the different types of corrosion in orthopaedic surgery including uniform, pitting, crevice, and fretting or mechanically assisted crevice corrosion (MACC). Passive layer dynamics serves a critical role in each of these processes. The femoral head-neck trunnion creates an optimal environment for corrosion to occur because of the limited fluid diffusion, acidic environment, and increased bending moment.
Collapse
Affiliation(s)
- Kenneth L. Urish
- Corresponding Author: Arthritis and Arthroplasty Design Group, The Bone and Joint Center, Magee Womens Hospital of the University of Pittsburgh Medical Center; Department of Orthopaedic Surgery, Department of Bioengineering, and Clinical and Translational Science Institute, University of Pittsburgh; Department of Biomedical Engineering, Carnegie Mellon University, Pittsburgh, PA. .
| | - Nicholas John Giori
- VA Palo Alto Health Care System, Palo Alto, CA and Department of Orthopaedic Surgery, Stanford University, Stanford, CA, 450 Broadway Street, Pavilion C, 4th Floor, Redwood City, CA 94063-6342
| | - Jack E. Lemons
- Department of Orthopaedic Surgery, University of Alabama at Birmingham. Birmingham, AL, 1313 13th Street South, Birmingham, AL 35205-5327
| | - William M. Mihalko
- Campbell Clinic Department of Orthopaedic Surgery & Biomedical Engineering, University of Tennessee Health Science Center, Memphis, TN 1211 Union Avenue, Suite 510, Memphis TN 38104
| | - Nadim Hallab
- Department of Orthopaedic Surgery, Rush University, Chicago, IL 1653 W. Congress Parkway, Chicago, IL 60612
| |
Collapse
|
34
|
Mandell JB, Orr S, Koch J, Nourie B, Ma D, Bonar DD, Shah N, Urish KL. Large variations in clinical antibiotic activity against Staphylococcus aureus biofilms of periprosthetic joint infection isolates. J Orthop Res 2019; 37:1604-1609. [PMID: 30919513 PMCID: PMC7141781 DOI: 10.1002/jor.24291] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [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: 10/26/2018] [Accepted: 03/02/2019] [Indexed: 02/04/2023]
Abstract
Staphylococcus aureus biofilms have a high tolerance to antibiotics, making the treatment of periprosthetic joint infection (PJI) challenging. From a clinical perspective, bacteria from surgical specimens are cultured in a planktonic state to determine antibiotic sensitivity. However, S. aureus exists primarily as established biofilms in PJI. To address this dichotomy, we developed a prospective registry of total knee and hip arthroplasty PJI S. aureus isolates to quantify the activity of clinically important antibiotics against isolates grown as biofilms. S. aureus planktonic minimum inhibitory concentration (MIC) and minimum bactericidal concentration (MBC) were assessed using clinical laboratory standard index assays for 10 antibiotics (cefazolin, clindamycin, vancomycin, rifampin, linezolid, nafcillin, gentamicin, trimethoprim/sulfamethoxazole, doxycycline, and daptomycin). Mature biofilms of each strain were grown in vitro, after which biofilm MIC (MBIC) and biofilm MBC (MBBC) were determined. Overall, isolates grown as biofilms displayed larger variations in antibiotic MICs as compared to planktonic MIC values. Only rifampin, doxycycline, and daptomycin had measurable biofilm MIC values across all S. aureus isolates tested. Biofilm MBC observations complemented biofilm MIC observations; rifampin, doxycycline, and daptomycin were the only antibiotics with measurable biofilm MBC values. 90% of S. aureus biofilms could be killed by rifampin, 50% by doxycycline, and only 15% by daptomycin. Biofilm formation increased bacterial antibiotic tolerance nonspecifically across all antibiotics, in both MSSA and MRSA samples. Rifampin and doxycycline were the most effective antibiotics at killing established S. aureus biofilms. © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 37:1604-1609, 2019.
Collapse
Affiliation(s)
- Jonathan B. Mandell
- Arthritis and Arthroplasty Design Group, Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania,Department of Infectious Diseases and Microbiology, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Sara Orr
- Arthritis and Arthroplasty Design Group, Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - John Koch
- Arthritis and Arthroplasty Design Group, Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Blake Nourie
- Arthritis and Arthroplasty Design Group, Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Dongzhu Ma
- Arthritis and Arthroplasty Design Group, Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Daniel D. Bonar
- Department of Mathematics, Denison University, Granville, Ohio
| | - Neel Shah
- Division of Infectious Disease, Department of Internal Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Kenneth L. Urish
- Arthritis and Arthroplasty Design Group, Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania,The Bone and Joint Center, Magee Womens Hospital of the University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania,Department of Bioengineering, University of Pittsburgh, Pittsburgh, Pennsylvania,Clinical and Translational Science Institute, University of Pittsburgh, Pittsburgh, Pennsylvania,Department of Biomedical Engineering, Carnegie Mellon University, Pittsburgh, Pennsylvania
| |
Collapse
|
35
|
Urish KL, Hamlin BR, Plakseychuk AY, Levison TJ, Kurtz S, DiGioia AM. Letter to the Editor on "Trunnion Failure of the Recalled Low Friction Ion Treatment Cobalt Chromium Alloy Femoral Head". J Arthroplasty 2019; 34:190. [PMID: 30342953 DOI: 10.1016/j.arth.2018.09.048] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Accepted: 09/17/2018] [Indexed: 02/01/2023] Open
Affiliation(s)
- Kenneth L Urish
- Bone and Joint Center, Magee-Womens Hospital of the University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Brian R Hamlin
- Bone and Joint Center, Magee-Womens Hospital of the University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Anton Y Plakseychuk
- Bone and Joint Center, Magee-Womens Hospital of the University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Timothy J Levison
- Bone and Joint Center, Magee-Womens Hospital of the University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Steven Kurtz
- Implant Research Center, Drexel Univeristy, Philadelphia, PA
| | - Anthony M DiGioia
- Bone and Joint Center, Magee-Womens Hospital of the University of Pittsburgh Medical Center, Pittsburgh, PA
| |
Collapse
|
36
|
Abstract
Additive manufacturing (AM) has demonstrated the potential to revolutionize manufacturing for various applications across the medical, aerospace, automobile, and energy sectors. It is a layer-by-layer manufacturing process in which the computer-aided design model is sliced into layers and each layer is deposited successively to realize the final product. This article provides a general overview of AM and discusses current state-of-the-art AM methodologies as they apply to total joint arthroplasty. Specifically, details on their applications and current challenges are summarized to provide orthopedic surgeons with a basic understanding of current and potential applications of AM in total joint arthroplasty.
Collapse
Affiliation(s)
- Sneha Prabha Narra
- NextManufacturing Center, College of Engineering, Carnegie Mellon University, 5000 Forbes Avenue, Pittsburgh, PA 15213, USA,Corresponding author.
| | - Peter N. Mittwede
- Department of Orthopaedic Surgery, University of Pittsburgh School of Medicine, 3471 Fifth Avenue, Suite 1010, Pittsburgh, PA 15213, USA
| | - Sandra DeVincent Wolf
- NextManufacturing Center, College of Engineering, Carnegie Mellon University, 5000 Forbes Avenue, Pittsburgh, PA 15213, USA
| | - Kenneth L. Urish
- Department of Orthopaedic Surgery, Arthritis and Arthroplasty Design Group, Magee-Womens Hospital, University of Pittsburgh School of Medicine, 300 Halket Street, Pittsburgh, PA 15213, USA,The Bone and Joint Center, Magee-Womens Hospital, University of Pittsburgh School of Medicine, 300 Halket Street, Pittsburgh, PA 15213, USA
| |
Collapse
|
37
|
Lee AJ, Liu X, Borza T, Qin Y, Li BY, Urish KL, Kirk PS, Gilbert S, Hollenbeck BK, Helm JE, Lavieri MS, Skolarus TA, Jacobs BL. Role of Post-Acute Care on Hospital Readmission After High-Risk Surgery. J Surg Res 2018; 234:116-122. [PMID: 30527462 DOI: 10.1016/j.jss.2018.08.053] [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] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2018] [Revised: 07/31/2018] [Accepted: 08/24/2018] [Indexed: 11/17/2022]
Abstract
BACKGROUND Payment models, including the Hospital Readmissions Reduction Program and bundled payments, place pressures on hospitals to limit readmissions. Against this backdrop, we sought to investigate the association of post-acute care after major surgery and readmission rates. METHODS We identified patients undergoing high-risk surgery (abdominal aortic aneurysm repair, coronary bypass grafting, aortic valve replacement, carotid endarterectomy, esophagectomy, pancreatectomy, lung resection, and cystectomy) from 2005 to 2010 using the Healthcare Cost and Utilization Project's State Inpatient Database. The primary outcome was readmission rates after major surgery. Secondary outcome was readmission length of stay. RESULTS We identified 135,523 patients of whom 56,720 (42%) received post-acute care. Patients receiving post-acute care had higher readmission rates than those who were discharged home (16% versus 10%, respectively; P < 0.001). The risk-adjusted readmission length of stay was greatest for patients who received care from a skilled nursing facility, followed by those who received home care, and lowest for those who did not receive post-acute care (7.1 versus 5.4 versus 4.8 d, respectively; P < 0.001). CONCLUSIONS The use of post-acute care was associated with higher readmission rates and higher readmission lengths of stay. Improving the support of patients in post-acute care settings may help reduce readmissions and readmission intensity.
Collapse
Affiliation(s)
- Austin J Lee
- School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania.
| | - Xiang Liu
- Department of Industrial and Operations Engineering, University of Michigan, Ann Arbor, Michigan
| | - Tudor Borza
- Divisions of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, Michigan; Divisions of Health Services Research and Oncology, Department of Urology, University of Michigan, Ann Arbor, Michigan
| | - Yongmei Qin
- Divisions of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, Michigan
| | - Benjamin Y Li
- Divisions of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, Michigan
| | - Kenneth L Urish
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Peter S Kirk
- Divisions of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, Michigan
| | - Scott Gilbert
- Department of Urology, H. Lee Moffitt Cancer Center, Tampa, Florida
| | - Brent K Hollenbeck
- Divisions of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, Michigan; Divisions of Health Services Research and Oncology, Department of Urology, University of Michigan, Ann Arbor, Michigan
| | - Jonathan E Helm
- W.P. Carey School of Business, Arizona State University, Tempe, Arizona
| | - Mariel S Lavieri
- Department of Industrial and Operations Engineering, University of Michigan, Ann Arbor, Michigan
| | - Ted A Skolarus
- Divisions of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, Michigan; Divisions of Health Services Research and Oncology, Department of Urology, University of Michigan, Ann Arbor, Michigan; Center for Clinical Management Research, VA Ann Arbor Healthcare System, Tempe, Arizona
| | - Bruce L Jacobs
- Department of Urology, University of Pittsburgh, Pittsburgh, Pennsylvania
| |
Collapse
|
38
|
Li BY, Zhu KY, Urish KL, Jacobs BL, Qin Y, Borza T, Hollenbeck BK, Helm JE, Lavieri MS, Skolarus TA. Understanding Readmission Policy Implications for US Hospitals Performing Major Surgery. J Am Coll Surg 2018. [DOI: 10.1016/j.jamcollsurg.2018.08.459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
|
39
|
Urish KL, Qin Y, Li BY, Borza T, Sessine M, Kirk P, Hollenbeck BK, Helm JE, Lavieri MS, Skolarus TA, Jacobs BL. Predictors and Cost of Readmission in Total Knee Arthroplasty. J Arthroplasty 2018; 33:2759-2763. [PMID: 29753618 PMCID: PMC6103832 DOI: 10.1016/j.arth.2018.04.008] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [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: 02/23/2018] [Revised: 03/25/2018] [Accepted: 04/02/2018] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND The Comprehensive Care for Joint Replacement bundle was created to decrease total knee arthroplasty (TKA) cost. To help accomplish this, there is a focus on reducing TKA readmissions. However, there is a lack of national representative sample of all-payer hospital admissions to direct strategy, identify risk factors for readmission, and understand actual readmission cost. METHODS We used the Nationwide Readmission Database to examine national readmission rates, predictors of readmission, and associated readmission costs for elective TKA procedures. We fit a multivariable logistic regression model to examine factors associated with readmission. Then, we determined mean readmission costs and calculated the readmission cost when distributed across the entire TKA population. RESULTS We identified 224,465 patients having TKA across all states participating in the Nationwide Readmission Database. The mean unadjusted 30-day TKA readmission rate was 4%. The greatest predictors of readmission were congestive heart failure (odds ratio [OR] 2.51, 95% confidence interval [CI] 2.62-2.80), renal disease (OR 2.19, 95% CI 2.03-2.37), and length of stay greater than 4 days (OR 2.4, 95% CI 2.25-2.61). The overall median cost for each readmission was $6753 ± 175. Extrapolating the readmission cost for the entire TKA population resulted in the readmission cost being 2% of the overall 30-day procedure cost. CONCLUSIONS A major focus of the Comprehensive Care for Joint Replacement bundle is improving cost and quality by limiting readmission rates. TKA readmissions are low and comprise a small percentage of total TKA cost, suggesting that they may not be the optimal measure of quality care or a significant driver of overall cost.
Collapse
Affiliation(s)
- Kenneth L. Urish
- Arthritis and Arthroplasty Design Group, The Bone and Joint Center, Magee Womens Hospital of the University of Pittsburgh Medical Center; Department of Orthopaedic Surgery, Department of Bioengineering, and Clinical and Translational Science Institute, University of Pittsburgh; Department of Biomedical Engineering, Carnegie Mellon University, 300 Halket Street, Suite 1601, Pittsburgh, PA 15232
| | - Yongmei Qin
- Department of Urology, Division of Oncology; Dow Division for Urologic Health Service Research, University of Michigan, Ann Arbor, MI
| | - Benjamin Y. Li
- Department of Urology, Division of Oncology, MI; Dow Division for Urologic Health Service Research, University of Michigan, Ann Arbor
| | - Tudor Borza
- Department of Urology, Division of Oncology; Dow Division for Urologic Health Service Research, University of Michigan, Ann Arbor, MI
| | - Michael Sessine
- Department of Urology, Division of Oncology; Dow Division for Urologic Health Service Research, University of Michigan, Ann Arbor, MI
| | - Peter Kirk
- Department of Urology, Division of Oncology; Dow Division for Urologic Health Service Research, University of Michigan, Ann Arbor, MI
| | - Brent K. Hollenbeck
- Department of Urology, Division of Oncology; Dow Division for Urologic Health Service Research, University of Michigan, Ann Arbor, MI
| | - Jonathan E. Helm
- Health Services Research & Development, Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI
| | - Mariel S. Lavieri
- Department of Industrial and Operations Engineering, University of Michigan, Ann Arbor, MI
| | - Ted A. Skolarus
- Department of Urology, Division of Oncology; Dow Division for Urologic Health Service Research, Health Services Research & Development, Center for Clinical Management Research, VA Ann Arbor Healthcare System, University of Michigan, Ann Arbor, MI
| | - Bruce L. Jacobs
- Department of Urology, University of Pittsburgh, Pittsburgh, PA
| |
Collapse
|
40
|
Urish KL, Bullock AG, Kreger A, Shah NB, Jeong K, Rothenberger SD. A Multicenter Study of Irrigation and Debridement in Total Knee Arthroplasty Periprosthetic Joint Infection: Treatment Failure Is High. J Arthroplasty 2018; 33:1154-1159. [PMID: 29221840 PMCID: PMC5858958 DOI: 10.1016/j.arth.2017.11.029] [Citation(s) in RCA: 98] [Impact Index Per Article: 16.3] [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: 06/23/2017] [Revised: 11/07/2017] [Accepted: 11/08/2017] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND In total knee arthroplasty (TKA) periprosthetic joint infection (PJI), irrigation and debridement (I&D) with component retention is a treatment option with a wide variation in reported failure rates. The purpose of this study was to determine failure rates, outcomes, and factors that predict failure in I&D for TKA PJI. METHODS A multicenter observational study of patients with a TKA PJI and subsequently undergoing an I&D with retention of components was conducted. The primary outcome was failure rate of I&D, where failure was defined as any subsequent surgical procedures. RESULTS Two hundred sixteen cases of I&D with retention of components performed on 206 patients met inclusion criteria. The estimated long-term failure rate at 4 years was 57.4%. Time-to-event analyses revealed that the median survival time was 14.32 months. Five-year mortality was 19.9%. Multivariable modeling revealed that time symptomatic and organism were independent predictors of I&D failure. Culture-negative status had a higher hazard for failure than culture-positive patients. When primary organism and time symptomatic were selected to produce an optimized scenario for an I&D, the estimated failure rate was 39.6%. CONCLUSION I&D with retention of components has a high failure rate, and there is a high incidence of more complex procedures after this option is chosen. The patient comorbidities we investigated did not predict I&D success. Our results suggest that I&D has a limited ability to control infection in TKA and should be used selectively under optimum conditions.
Collapse
Affiliation(s)
- Kenneth L. Urish
- Arthritis and Arthroplasty Design Group, The Bone and Joint Center, Magee Womens Hospital of the University of Pittsburgh Medical Center; Department of Orthopaedic Surgery, Department of Bioengineering, and Clinical and Translational Science Institute, University of Pittsburgh; Department of Biomedical Engineering, Carnegie Mellon University, Pittsburgh, PA, 15219
| | | | - Alex Kreger
- University of Pittsburgh School of Medicine, Pittsburgh, PA 15261
| | - Neel B. Shah
- Division of Infectious Disease, Department of Internal Medicine; University of Pittsburgh Medical Center, Pittsburgh, PA 15219
| | - Kwonho Jeong
- Clinical and Translation Science Institute; Department of Medicine, University of Pittsburgh, Pittsburgh, PA 15213
| | - Scott D. Rothenberger
- Clinical and Translation Science Institute; Department of Medicine, University of Pittsburgh, Pittsburgh, PA 15213
| | | |
Collapse
|
41
|
Ma D, Shanks RMQ, Davis CM, Craft DW, Wood TK, Hamlin BR, Urish KL. Viable bacteria persist on antibiotic spacers following two-stage revision for periprosthetic joint infection. J Orthop Res 2018; 36:452-458. [PMID: 28543707 PMCID: PMC5694702 DOI: 10.1002/jor.23611] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2017] [Accepted: 05/11/2017] [Indexed: 02/04/2023]
Abstract
Treatment in periprosthetic joint infection (PJI) remains challenging. The failure rate of two-stage revision and irrigation and debridement with component retention in PJI suggests that biofilm cells have a high tolerance to antibiotic chemotherapy. Previous work has demonstrated that biofilm cells have high antibiotic tolerance in vitro, but there is little clinical evidence to support these observations. The aim of this study was to determine if retrieved antibiotic spacers from two-stage revision total knee arthroplasty for PJI have evidence of remaining viable bacteria. Antibiotic poly (methyl methacrylate) (PMMA) spacers from two-stage revision total knee arthroplasty for PJI were prospectively collected and analyzed for bacterial 16s rRNA using polymerase chain reaction (PCR), reverse transcription (RT)-PCR, quantitative RT-PCR (qRT-PCR), and single genome analysis (SGA). PCR and RT-PCR identified bacterial species on 53.8% (7/13) of these samples. When initial culture negative cases are excluded, 68% (6/9) samples were identified with bacterial species. A more rigorous qRT-PCR analysis showed a strong positive signal for bacterial contamination in 30.7% (4/13) of cases. These patients did not show any clinical evidence of PJI recurrence after 15 months of follow-up. Because the half-life of bacterial rRNA is approximately a few days, the identification of bacteria rRNA on antibiotic PMMA spacers suggests that viable bacteria were present after conclusion of antibiotic therapy. This study provides evidence for the high tolerance of biofilm cells to antibiotics in vivo and the important role of bacterial persisters in PJI. © 2017 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 36:452-458, 2018.
Collapse
Affiliation(s)
- Dongzhu Ma
- Arthritis and Arthroplasty Design Group, Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, PA 15219
| | | | - Charles M. Davis
- Department of Orthopaedics and Rehabilitation, Pennsylvania State University, PA
| | - David W. Craft
- Department of Pathology, College of Medicine, Pennsylvania State University, PA
| | - Thomas K. Wood
- Department of Chemical Engineering, Pennsylvania State University, University Park, PA
| | - Brian R Hamlin
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, PA
| | - Kenneth L. Urish
- The Bone and Joint Center, Magee Womens Hospital of the University of Pittsburgh Medical Center; Department of Orthopaedic Surgery, Department of Bioengineering, and Clinical and Translational Science Institute, University of Pittsburgh; Department of Biomedical Engineering, Carnegie Mellon University, Pittsburgh, PA, USA
| |
Collapse
|
42
|
Mandell JB, Deslouches B, Montelaro RC, Shanks RMQ, Doi Y, Urish KL. Elimination of Antibiotic Resistant Surgical Implant Biofilms Using an Engineered Cationic Amphipathic Peptide WLBU2. Sci Rep 2017; 7:18098. [PMID: 29273750 PMCID: PMC5741726 DOI: 10.1038/s41598-017-17780-6] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2017] [Accepted: 11/28/2017] [Indexed: 01/31/2023] Open
Abstract
Antibiotics are unable to remove biofilms from surgical implants. This high antibiotic tolerance is related to bacterial persisters, a sub-population of bacteria phenotypically tolerant to antibiotics secondary to a reduced metabolic state. WLBU2 is an engineered cationic amphipathic peptide designed to maximize antimicrobial activity with minimal mammalian cell toxicity. The objective of this study was to test the ability of WLBU2 to remove Staphylococcus aureus surgical implant biofilms. WLBU2 effectively treated S. aureus biofilms formed by a variety of clinical MSSA and MRSA strains and created culture-negative implants in the in vitro biofilm model. Blocking bacterial metabolism by inhibiting oxidative phosphorylation did not affect WLBU2 killing compared to decreased killing by cefazolin. In the surgical implant infection animal model, WLBU2 decreased biofilm mass as compared to control, untreated samples. WLBU2 could rapidly eliminate implants in vitro and had sufficient efficacy in vivo with minimal systemic toxicity.
Collapse
Affiliation(s)
- Jonathan B Mandell
- Arthritis and Arthroplasty Design Group, Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Berthony Deslouches
- Department of Microbiology and Molecular Genetics, University of Pittsburgh, Pittsburgh, PA, USA
| | - Ronald C Montelaro
- Department of Microbiology and Molecular Genetics, University of Pittsburgh, Pittsburgh, PA, USA
| | - Robert M Q Shanks
- Department of Ophthalmology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Yohei Doi
- Division of Infectious Diseases, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Kenneth L Urish
- Arthritis and Arthroplasty Design Group, Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, PA, USA.
- The Magee Bone and Joint Center, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
- Clinical & Translational Science Institute, University of Pittsburgh, Pittsburgh, PA, USA.
- Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA, USA.
- Department of Biomedical Engineering, Carnegie Mellon University, Pittsburgh, PA, USA.
| |
Collapse
|
43
|
Ashinsky BG, Bouhrara M, Coletta CE, Lehallier B, Urish KL, Lin PC, Goldberg IG, Spencer RG. Predicting early symptomatic osteoarthritis in the human knee using machine learning classification of magnetic resonance images from the osteoarthritis initiative. J Orthop Res 2017; 35:2243-2250. [PMID: 28084653 PMCID: PMC5969573 DOI: 10.1002/jor.23519] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2016] [Accepted: 01/06/2017] [Indexed: 02/06/2023]
Abstract
The purpose of this study is to evaluate the ability of a machine learning algorithm to classify in vivo magnetic resonance images (MRI) of human articular cartilage for development of osteoarthritis (OA). Sixty-eight subjects were selected from the osteoarthritis initiative (OAI) control and incidence cohorts. Progression to clinical OA was defined by the development of symptoms as quantified by the Western Ontario and McMaster Universities Arthritis (WOMAC) questionnaire 3 years after baseline evaluation. Multi-slice T2 -weighted knee images, obtained through the OAI, of these subjects were registered using a nonlinear image registration algorithm. T2 maps of cartilage from the central weight bearing slices of the medial femoral condyle were derived from the registered images using the multiple available echo times and were classified for "progression to symptomatic OA" using the machine learning tool, weighted neighbor distance using compound hierarchy of algorithms representing morphology (WND-CHRM). WND-CHRM classified the isolated T2 maps for the progression to symptomatic OA with 75% accuracy. CLINICAL SIGNIFICANCE Machine learning algorithms applied to T2 maps have the potential to provide important prognostic information for the development of OA. © 2017 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 35:2243-2250, 2017.
Collapse
Affiliation(s)
- Beth G Ashinsky
- Laboratory of Clinical Investigation, Magnetic Resonance Imaging and Spectroscopy Section, National Institute on Aging, NIH, 251 Bayview Boulevard, Baltimore 21224, Maryland
| | - Mustapha Bouhrara
- Laboratory of Clinical Investigation, Magnetic Resonance Imaging and Spectroscopy Section, National Institute on Aging, NIH, 251 Bayview Boulevard, Baltimore 21224, Maryland
| | - Christopher E Coletta
- Image Informatics and Computational Biology Unit, National Institute on Aging, NIH, Baltimore, Maryland
| | - Benoit Lehallier
- Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Stanford, California
| | - Kenneth L Urish
- Bone and Joint Center, Magee Women's Hospital, Department of Orthopaedic Surgery, Pittsburgh, Pennsylvania
| | - Ping-Chang Lin
- Department of Radiology, College of Medicine, Howard University, Washington, DC, Washington
| | - Ilya G Goldberg
- Image Informatics and Computational Biology Unit, National Institute on Aging, NIH, Baltimore, Maryland
| | - Richard G Spencer
- Laboratory of Clinical Investigation, Magnetic Resonance Imaging and Spectroscopy Section, National Institute on Aging, NIH, 251 Bayview Boulevard, Baltimore 21224, Maryland
| |
Collapse
|
44
|
MacLachlan RA, Hollis RL, Jaramaz B, Riviere CN, Martel JN, Urish KL. Multirate Kalman Filter Rejects Impulse Noise in Frequency-Domain-Multiplexed Tracker Measurements. Proc IEEE Sens 2017; 2017:10.1109/ICSENS.2017.8234073. [PMID: 30147815 PMCID: PMC6105314 DOI: 10.1109/icsens.2017.8234073] [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] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Frequency domain multiplexing (FDM) is a useful for making multiple measurements simultaneously, such as in optical and electromagnetic position trackers. Much interference is periodic (e.g., AC power harmonics), and is rejected well by FDM, but impulse disturbances are also common. Impulses corrupt the entire spectrum for a short period, and are better rejected in the time domain. Nonlinear blanking is a simple way to suppress impulses, but cannot be easily realized when the required dynamic range is large, and problematic noise may be far smaller than the signal. The described multi-rate Kalman filter upsamples the prediction to the input rate so that impulse departures from the predicted signal are easily detected and blanked out. Also, noise levels in unused adjacent channels are used to estimate measurement noise so that the Kalman filter adapts more slowly when noise is high, keeping output noise roughly constant even in the presence of longer noise bursts.
Collapse
Affiliation(s)
- Robert A MacLachlan
- The Robotics Institute, Carnegie Mellon University, Pittsburgh, Pennsylvania, USA
| | - Ralph L Hollis
- The Robotics Institute, Carnegie Mellon University, Pittsburgh, Pennsylvania, USA
| | - Branislav Jaramaz
- The Robotics Institute, Carnegie Mellon University, Pittsburgh, Pennsylvania, USA
| | - Cameron N Riviere
- The Robotics Institute, Carnegie Mellon University, Pittsburgh, Pennsylvania, USA
| | - Joseph N Martel
- School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Kenneth L Urish
- School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| |
Collapse
|
45
|
Urish KL, Hamlin BR, Plakseychuk AY, Levison TJ, Higgs G, Kurtz S, DiGioia AM. Trunnion Failure of the Recalled Low Friction Ion Treatment Cobalt Chromium Alloy Femoral Head. J Arthroplasty 2017; 32:2857-2863. [PMID: 28478184 PMCID: PMC5572503 DOI: 10.1016/j.arth.2017.03.075] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [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: 12/21/2016] [Revised: 03/11/2017] [Accepted: 03/31/2017] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Gross trunnion failure (GTF) is a rare complication in total hip arthroplasty (THA) reported across a range of manufacturers. Specific lots of the Stryker low friction ion treatment (LFIT) anatomic cobalt chromium alloy (CoCr) V40 femoral head were recalled in August 2016. In part, the recall was based out of concerns for disassociation of the femoral head from the stem and GTF. METHODS We report on 28 patients (30 implants) with either GTF (n = 18) or head-neck taper corrosion (n = 12) of the LFIT CoCr femoral head and the Accolade titanium-molybdenum-zirconium-iron alloy femoral stems. All these cases were associated with adverse local tissue reactions requiring revision of the THA. RESULTS In our series, a conservative estimate of the incidence of failure was 4.7% (n = 636 total implanted) at 8.0 ± 1.4 years from the index procedure. Failures were associated with a high-offset 127° femoral stem neck angle and increased neck lengths; 43.3% (13 of 30) of the observed failures included implant sizes outside the voluntary recall (27.8% [5 of 18] of the GTF and 75.0% [8 of 12] of the taper corrosion cases). Serum cobalt and chromium levels were elevated (cobalt: 8.4 ± 7.0 μg/mL; chromium: 3.4 ± 3.3 μ/L; cobalt/chromium ratio: 3.7). The metal artifact reduction sequence magnetic resonance imaging demonstrated large cystic fluid collections typical with adverse local tissue reactions. During revision, a pseudotumor was observed in all cases. Pathology suggested a chronic inflammatory response. Impending GTF could be diagnosed based on aspiration of black synovial fluid and an oblique femoral head as compared with the neck taper on radiographs. CONCLUSION In our series of the recalled LFIT CoCr femoral head, the risk of impending GTF or head-neck taper corrosion should be considered as a potential diagnosis in a painful LFIT femoral head and Accolade titanium-molybdenum-zirconium-iron alloy THA with unknown etiology. Almost half of the failures we observed included sizes outside of the voluntary recall.
Collapse
Affiliation(s)
- Kenneth L. Urish
- The Bone & Joint Center, Magee Womens Hospital of the University of Pittsburgh Medical Center, Pittsburgh, PA 15212. Phone: 412.736.4261; Fax: 717.531.7583,Corresponding Author: The Bone & Joint Center, Magee Womens Hospital of the University of Pittsburgh Medical Center; Department of Orthopaedic Surgery, College of Medicine, University of Pittsburgh, Pittsburgh, PA 15212.
| | - Brian R. Hamlin
- The Bone & Joint Center, Magee Womens Hospital of the University of Pittsburgh Medical Center, Pittsburgh, PA 15212. Phone: 412.736.4261; Fax: 717.531.7583
| | - Anton Y. Plakseychuk
- The Bone & Joint Center, Magee Womens Hospital of the University of Pittsburgh Medical Center, Pittsburgh, PA 15212. Phone: 412.736.4261; Fax: 717.531.7583
| | - Timothy J. Levison
- The Bone & Joint Center, Magee Womens Hospital of the University of Pittsburgh Medical Center, Pittsburgh, PA 15212. Phone: 412.736.4261; Fax: 717.531.7583
| | - Genymphas Higgs
- Implant Research Center, 3401 Market St., Suite 345, Philadelphia, PA. Phone: 215-901-4520
| | - Steven Kurtz
- Implant Research Center, 3401 Market St., Suite 345, Philadelphia, PA. Phone: 215-901-4520
| | - Anthony M. DiGioia
- The Bone & Joint Center, Magee Womens Hospital of the University of Pittsburgh Medical Center, Pittsburgh, PA 15212. Phone: 412.736.4261; Fax: 717.531.7583
| |
Collapse
|
46
|
Urish KL, Conditt M, Roche M, Rubash HE. Robotic Total Knee Arthroplasty: Surgical Assistant for a Customized Normal Kinematic Knee. Orthopedics 2016; 39:e822-7. [PMID: 27398788 DOI: 10.3928/01477447-20160623-13] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [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] [Received: 04/27/2015] [Accepted: 11/11/2015] [Indexed: 02/03/2023]
Abstract
Although current total knee arthroplasty (TKA) is considered a highly successful surgical procedure, patients undergoing TKA can still experience substantial functional impairment and increased revision rates as compared with those undergoing total hip arthroplasty. Robotic-assisted surgery has been available clinically for almost 15 years and was developed, in part, to address these concerns. Robotic-assisted surgery aims to improve TKA by enhancing the surgeon's ability to optimize soft tissue balancing, reproduce alignment, and restore normal knee kinematics. Current systems include a robotic arm with a variety of different navigation systems with active, semi-active, or passive control. Semi-active systems have become the dominant strategy, providing a haptic window through which the surgeon consistently prepares a TKA based on preoperative planning. A review of previous designs and clinical studies demonstrates that these robotic systems decrease variability and increase precision, primarily with the mechanical axis and restoration of the joint line. Future design objectives include precise planning and consistent intraoperative execution. Preoperative planning, intraoperative sensors, augmenting surgical instrumentation, and biomimetic surfaces will be used to re-create the 4-bar linkage system in the knee. Implants will be placed so that the knee functions with a medial pivot, lateral rollback, screw home mechanism, and patellar femoral tracking. Soft tissue balancing will become more than equalizing the flexion and extension gaps and will match the kinematics to a normal knee. Together, coupled with advanced knee designs, they may be the key to a patient stating, "My knee feels like my natural knee." [Orthopedics. 2016; 39(5):e822-e827.].
Collapse
|
47
|
Liow MHL, Urish KL, Preffer FI, Nielson GP, Kwon YM. Metal Ion Levels Are Not Correlated With Histopathology of Adverse Local Tissue Reactions in Taper Corrosion of Total Hip Arthroplasty. J Arthroplasty 2016; 31:1797-802. [PMID: 26923497 DOI: 10.1016/j.arth.2016.01.041] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [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: 11/16/2015] [Revised: 01/21/2016] [Accepted: 01/26/2016] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND The underlying biological mechanism in the formation of adverse local tissue reaction in taper corrosion of total hip arthroplasty (THA) remains unknown. This study evaluated whether there was a dose-dependent relationship between metal ion levels, intraoperative tissue damage and ALVAL (aseptic lymphocyte-dominated vasculitis-associated lesion) scores in dual taper THA patients who underwent revisions for taper corrosion. METHODS We performed a retrospective review of 31 dual taper THA patients who underwent revision surgery from May 2013 to October 2013. Preoperative serum metal ion levels, intraoperative tissue damage grading, and ALVAL scores were reviewed. Multivariate analysis was performed to determine if an association existed between metal ion levels, intraoperative tissue damage, and ALVAL scores. RESULTS Findings consistent with adverse local tissue reaction were found in all cases. We noted 10 patients with low, 8 with moderate, and 13 with high ALVAL scores, respectively. For intraoperative tissue damage, we recorded 2 (grade 1), 22 (grade 2) and 7 (grade 3) cases. Preoperatively, there was preferential elevation of serum cobalt (3.8 ng/mL, 2.3-17.0) compared to serum chromium (1.0 ng/mL, 0.2-5.8). There was no correlation between preoperative metal ion levels and intraoperative tissue damage (R = -0.06, P = .74) or ALVAL scores (R = -0.04, P = .481). There was also no correlation between intraoperative tissue damage and ALVAL score (R = -0.06, P = .73). CONCLUSION There was no significant correlation between ALVAL scores and prerevision surgery metal ion levels or intraoperative tissue damage, suggesting that the biological mechanism of histologic morphology cannot be solely attributed to elevated metal ion levels and is likely multifactorial, reflecting a complex interplay between implant and patient factors.
Collapse
Affiliation(s)
- Ming Han Lincoln Liow
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Kenneth L Urish
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Frederic I Preffer
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Gunnlaugur P Nielson
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Young-Min Kwon
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| |
Collapse
|
48
|
Urish KL, DeMuth PW, Kwan BW, Craft DW, Ma D, Haider H, Tuan RS, Wood TK, Davis CM. Antibiotic-tolerant Staphylococcus aureus Biofilm Persists on Arthroplasty Materials. Clin Orthop Relat Res 2016; 474:1649-56. [PMID: 26831479 PMCID: PMC4887357 DOI: 10.1007/s11999-016-4720-8] [Citation(s) in RCA: 67] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND The continued presence of biofilm may be one cause of the high risk of failure observed with irrigation and débridement with component retention in acute periprosthetic joint infection (PJI). There is a poor understanding of the role of biofilm antibiotic tolerance in PJI. QUESTIONS/PURPOSES (1) Do increasing doses of cefazolin result in decreased viable biofilm mass on arthroplasty materials? (2) Is cefazolin resistance phenotypic or genotypic? (3) Is biofilm viability a function of biofilm depth after treatment with cefazolin? (4) Is the toxin-antitoxin system, yoeB expression, associated with antibiotic stress? METHODS Methicillin-sensitive Staphylococcus aureus biofilm was cultured on total knee arthroplasty (TKA) materials and exposed to increasing doses of cefazolin (control, 0.5, 1.0, 10.0, 100.0 μg/mL). Quantitative confocal microscopy and quantitative culture were used to measure viable biofilm cell density. To determine if cefazolin resistance was phenotypic or genotypic, we measured minimum inhibitory concentration (MIC) after exposure to different cefazolin concentrations; changes in MIC would suggest genotypic features, whereas unchanged MIC would suggest phenotypic behavior. Finally, quantitative reverse transcription-polymerase chain reaction was used to quantify expression of yoeB levels between biofilm and planktonic bacteria after exposure to 1 μg/mL cefazolin for 3 hours. RESULTS Although live biofilm mass was reduced by exposure to cefazolin when compared with biofilm mass in controls (39.2 × 10(3) ± 26.4 × 10(3) pixels), where the level after 0.5 µg/mL exposure also showed reduced mass (20.3 × 10(3) ± 11.9 × 10(3) pixels), no further reduction was seen after higher doses (mass at 1.0 µg/mL: 5.0 × 10(3) pixels ± 1.1 × 10(3) pixels; at 10.0 µg/mL: 6.4 × 10(3) ± 9.6 × 10(3) pixels; at 100.0 µg/mL: 6.4 × 10(3) ± 3.9 × 10(3)). At the highest concentration tested (100 µg/mL), residual viable biofilm was present on all three materials, and there were no differences in percent biofilm survival among cobalt-chromium (18.5% ± 15.1%), polymethylmethacrylate (22.8% ± 20.2%), and polyethylene (14.7% ± 10.4%). We found that tolerance was a phenotypic phenomenon, because increasing cefazolin exposure did not result in changes in MIC as compared with controls (MIC in controls: 0.13 ± 0.02; at 0.5 µg/mL: 0.13 ± 0.001, p = 0.96; at 1.0 µg/m: 0.14 ± 0.04, p = 0.95; at 10.0 µg/m: 0.11 ± 0.016, p = 0.47; at 100.0 µg/m: 0.94 ± 0.047, p = 0.47). Expression of yoeB after 1 µg/mL cefazolin for 3 hours in biofilm cells was greater in biofilm but not in planktonic cells (biofilm: 62.3-fold change, planktonic cells: -78.8-fold change, p < 0.001). CONCLUSIONS Antibiotics are inadequate at complete removal of the biofilm from the surface of TKA materials. Results suggest that bacterial persisters are responsible for this phenotypic behavior allowing biofilm high tolerance to antibiotics. CLINICAL RELEVANCE Antibiotic-tolerant biofilm suggests a mechanism behind the poor results in irrigation and débridement for acute TKA PJI.
Collapse
Affiliation(s)
- Kenneth L Urish
- The Magee Bone & Joint Center, Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, PA, 15212, USA.
| | - Peter W DeMuth
- Department of Orthopaedics and Rehabilitation, Penn State Hershey Medical Center, Hershey, PA, USA
| | - Brian W Kwan
- Department of Chemical Engineering, The Pennsylvania State University, University Park, PA, USA
| | - David W Craft
- Department of Pathology, Penn State Hershey Medical Center and College of Medicine, Hershey, PA, USA
| | - Dongzhu Ma
- Department of Orthopaedic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Hani Haider
- Orthopaedics Biomechanics & Advanced Surgical Technologies Laboratory, Department of Orthopaedic Surgery and Rehabilitation, University of Nebraska Medical Center, Omaha, NE, USA
| | - Rocky S Tuan
- Center for Cellular and Molecular Engineering, Department of Orthopaedic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Thomas K Wood
- Department of Chemical Engineering, The Pennsylvania State University, University Park, PA, USA
| | - Charles M Davis
- Department of Orthopaedics and Rehabilitation, Penn State Hershey Medical Center, Hershey, PA, USA
| |
Collapse
|
49
|
Urish KL, DeMuth PW, Craft DW, Haider H, Davis CM. Pulse lavage is inadequate at removal of biofilm from the surface of total knee arthroplasty materials. J Arthroplasty 2014; 29:1128-32. [PMID: 24439797 DOI: 10.1016/j.arth.2013.12.012] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.3] [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: 08/27/2013] [Revised: 11/27/2013] [Accepted: 12/08/2013] [Indexed: 02/01/2023] Open
Abstract
In acute periprosthetic infection, irrigation and debridement with component retention has a high failure rate in some studies. We hypothesize that pulse lavage irrigation is ineffective at removing biofilm from total knee arthroplasty (TKA) components. Staphylococcus aureus biofilm mass and location was directly visualized on arthroplasty materials with a photon collection camera and laser scanning confocal microscopy. There was a substantial reduction in biofilm signal intensity, but the reduction was less than a ten-fold decrease. This suggests that irrigation needs to be further improved for the removal of biofilm mass below the necessary bioburden level to prevent recurrence of acute infection in total knee arthroplasty.
Collapse
Affiliation(s)
- Kenneth L Urish
- Department of Orthopaedics and Rehabilitation, Division of Musculoskeletal Sciences, College of Medicine, The Pennsylvania State University, Hershey, Pennsylvania
| | - Peter W DeMuth
- College of Medicine, The Pennsylvania State University, Hershey, Pennsylvania
| | - David W Craft
- Department of Pathology, College of Medicine, The Pennsylvania State University, Hershey, Pennsylvania
| | - Hani Haider
- Orthopaedics Biomechanics & Advanced Surgical Technologies Laboratory, Department of Orthopaedic Surgery and Rehabilitation, University of Nebraska Medical Center, Omaha, Nebrasca
| | - Charles M Davis
- Department of Orthopaedics and Rehabilitation, College of Medicine, The Pennsylvania State University, Hershey, Pennsylvania
| |
Collapse
|
50
|
Urish KL, Keffalas MG, Durkin JR, Miller DJ, Chu CR, Mosher TJ. T2 texture index of cartilage can predict early symptomatic OA progression: data from the osteoarthritis initiative. Osteoarthritis Cartilage 2013; 21:1550-7. [PMID: 23774471 PMCID: PMC3779506 DOI: 10.1016/j.joca.2013.06.007] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2012] [Revised: 05/10/2013] [Accepted: 06/05/2013] [Indexed: 02/02/2023]
Abstract
OBJECTIVE There is an interest in using Magnetic Resonance Imaging (MRI) to identify pre-radiographic changes in osteoarthritis (OA) and features that indicate risk for disease progression. The purpose of this study is to identify image features derived from MRI T2 maps that can accurately predict onset of OA symptoms in subjects at risk for incident knee OA. METHODS Patients were selected from the Osteoarthritis Initiative (OAI) control cohort and incidence cohort and stratified based on the change in total Western Ontario and McMaster Universities Arthritis (WOMAC) score from baseline to 3-year follow-up (80 non-OA progression and 88 symptomatic OA progression patients). For each patient, a series of image texture features were measured from the baseline cartilage T2 map. A linear discriminant function and feature reduction method was then trained to quantify a texture metric, the T2 texture index of cartilage (TIC), based on 22 image features, to identify a composite marker of T2 heterogeneity. RESULTS Statistically significant differences were seen in the baseline T2 TIC between the non-progression and symptomatic OA progression populations. The baseline T2 TIC differentiates subjects that develop worsening of their WOMAC score OA with an accuracy between 71% and 76%. The T2 TIC differences were predominantly localized to a dominant knee compartment that correlated with the mechanical axis of the knee. CONCLUSION Baseline heterogeneity in cartilage T2 as measured with the T2 TIC index is able to differentiate and predict individuals that will develop worsening of their WOMAC score at 3-year follow-up.
Collapse
Affiliation(s)
- Kenneth L. Urish
- Corresponding Author: Department of Orthopaedics and Rehabilitation, Division of Musculoskeletal Sciences, College of Medicine, The Pennsylvania State University, 30 Hope Drive EC089, Hershey, PA 17033. . Phone: 412.736.4261; Fax: 717.531.7583
| | - Matthew G Keffalas
- Department of Electrical Engineering, The Pennsylvania State University, 227C Electrical Engineering West, University Park, PA
| | - John R. Durkin
- School of Medicine, University of Pittsburgh, 533 Scaife Hall, Pittsburgh, PA, 15260
| | - David J. Miller
- Department of Electrical Engineering, The Pennsylvania State University, 227C Electrical Engineering West, University Park, PA
| | - Constance R. Chu
- Cartilage Restoration Laboratory, Department of Orthopaedic Surgery, University of Pittsburgh, 3471 5 Avenue, Suite 911, Pittsburgh, PA, 15260
| | - Timothy J Mosher
- Department of Radiology, Penn State Milton S. Hershey Medical Center, 500 University Drive, MC, H066, Hershey PA 17033
| |
Collapse
|