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Parel PM, Kuyl EV, Haft M, Silverman R, Ramesh A, Agarwal AR, Quan T, Ranson RA, Zimmer ZR, Srikumaran U. Anti-osteoporotic treatment reduces risk of revision following total shoulder arthroplasty in patients with osteoporosis. J Shoulder Elbow Surg 2025; 34:e348-e354. [PMID: 39542235 DOI: 10.1016/j.jse.2024.09.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Revised: 08/22/2024] [Accepted: 09/05/2024] [Indexed: 11/17/2024]
Abstract
BACKGROUND Osteoporosis, a prevalent bone density disorder, introduces a complex dynamic in the context of total shoulder arthroplasty (TSA). However, despite the well-established association between osteoporosis and an elevated risk of revision, the existing literature lacks comprehensive insights into the impact of anti-osteoporotic therapy on surgical outcomes in the setting of TSA. Thus, the purpose of this study was to investigate whether anti-osteoporotic therapy correlates with improved revision outcomes following TSA. METHODS A retrospective cohort analysis was performed using a national all payer's claims database. Patients who underwent TSA were identified using Current Procedural Terminology and International Classification of Diseases procedure codes. Patients with a preoperative diagnosis of osteoporosis were included and stratified into 2 groups: (1) patients with osteoporosis who underwent anti-osteoporotic therapy within 6 months prior to surgery (anti-OP cohort) and (2) patients with osteoporosis who never received anti-osteoporotic treatment (no anti-OP cohort). Primary outcomes included the incidence of 2-year all-cause revision, periprosthetic fracture, periprosthetic joint infection, and mechanical loosening. Univariate and multivariable regression analysis was conducted to compare outcomes between the 2 cohorts. RESULTS In total, 40,532 osteoporotic patients were included in this study, with 11,577 (28.5%) having undergone anti-osteoporotic treatment. Patients who did not receive anti-osteoporotic treatment had significantly higher odds of 2-year all-cause revision (odds ratio: 1.31; P < .001) and mechanical loosening (odds ratio: 1.25; P < .001) following TSA when compared to those treated for osteoporosis. DISCUSSION This study demonstrates a significant association between anti-osteoporotic therapy and reduced rates of 2-year revision following TSA. Orthopedic surgeons should recognize the heightened risk of early implant failure in the absence of osteoporosis therapy. This underscores the imperative for increased screening initiatives given the high prevalence of undiagnosed or untreated osteoporosis in the TSA population. These results also emphasize the importance of integrating osteoporosis management strategies into the broader context of surgical decision-making, thereby contributing to enhanced patient outcomes and quality of care in shoulder surgery.
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Affiliation(s)
- Philip M Parel
- The George Washington University School of Medicine and Health Sciences, Washington, DC, USA.
| | - Emile-Victor Kuyl
- The George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Mark Haft
- Department of Orthopaedic Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Rachel Silverman
- The George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Abhisri Ramesh
- The George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Amil R Agarwal
- The George Washington University School of Medicine and Health Sciences, Washington, DC, USA; Department of Orthopaedic Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Theodore Quan
- The George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Rachel A Ranson
- The George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Zachary R Zimmer
- The George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Uma Srikumaran
- Department of Orthopaedic Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Lin L, Li J, Zhang C, Li J, Wu B, Huang Z, Lv J, Liu M, Li W, Zhang W, Fang X. Comprehensive analysis of culture-negative periprosthetic joint infection with metagenomic next-generation sequencing. Front Cell Infect Microbiol 2025; 15:1564488. [PMID: 40415958 PMCID: PMC12098451 DOI: 10.3389/fcimb.2025.1564488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2025] [Accepted: 04/11/2025] [Indexed: 05/27/2025] Open
Abstract
Objective This study aimed to identify the risk factors and microbial profiles of patients with culture-negative periprosthetic joint infection (PJI) using metagenomic next generation sequencing (mNGS) and to compare the clinical characteristics and treatment outcomes of culture-negative PJI (CN PJI) with culture-positive PJI (CP PJI). Methods A retrospective analysis was conducted on 223 patients who met the International Consensus Meeting criteria for PJI and underwent surgical treatment at our hospital between February 2013 and January 2023. Clinical and follow-up data, including microbiological culture results and mNGS findings, were collected. Based on culture results, patients were divided into the CP PJI and CN PJI groups. Risk factors and microbial profiles of CN PJI patients were summarized with the aid of mNGS results. Differences in clinical characteristics and treatment outcomes between the two groups were also analyzed. Results Among the 223 patients, 168 were in the CP PJI group, and 55 were in the CN PJI group. Risk factors for negative cultures included polymicrobial infections, infections caused by rare pathogens, and prolonged antibiotic use prior to sampling. In the CN PJI group, over a quarter of cases involved polymicrobial infections (25.5%) or rare pathogen infections (38.2%), with Mycoplasma sp. being the most frequently identified rare pathogen (7.2%). Compared to the CP PJI group, the CN PJI group exhibited distinctly longer hospital stays (P<0.001), extended antibiotic use (P=0.02), and a higher rate of antibiotic-related complications (P=0.026). However, no significant difference was noted in reinfection rates between the two groups (P=0.412). Conclusion CN PJI presents a unique microbial spectrum and distinct clinical therapeutic characteristics. mNGS offers a more comprehensive understanding of infecting microorganisms, particularly those often missed by conventional culture techniques. With advancements in sample collection, optimized culture methods, molecular diagnostic tools, and early targeted therapies, CN PJI may achieve clinical outcomes comparable to CP PJI.
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Affiliation(s)
- Lan Lin
- Department of Orthopaedic Surgery, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
- Department of Orthopaedic Surgery, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, China
- Fujian Provincial Institute of Orthopedics, the First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Jiayu Li
- Department of Orthopaedic Surgery, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
- Department of Orthopaedic Surgery, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, China
- Fujian Provincial Institute of Orthopedics, the First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Canhong Zhang
- Department of Orthopedic Surgery, Quanzhou First Affiliated Hospital of Fujian Medical University, Quanzhou, China
| | - Juncheng Li
- Department of Orthopaedic Surgery, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
- Department of Orthopaedic Surgery, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, China
- Fujian Provincial Institute of Orthopedics, the First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Baijian Wu
- Department of Orthopaedic Surgery, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
- Department of Orthopaedic Surgery, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, China
- Fujian Provincial Institute of Orthopedics, the First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Zida Huang
- Department of Orthopaedic Surgery, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
- Department of Orthopaedic Surgery, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, China
- Fujian Provincial Institute of Orthopedics, the First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Jianhua Lv
- Department of Orthopedic Surgery, Affiliated Hospital of Putian University, Putian, China
| | - Mingzhong Liu
- Department of Orthopedic Surgery, Quanzhou First Affiliated Hospital of Fujian Medical University, Quanzhou, China
| | - Wenbo Li
- Department of Orthopaedic Surgery, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
- Department of Orthopaedic Surgery, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, China
- Fujian Provincial Institute of Orthopedics, the First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Wenming Zhang
- Department of Orthopaedic Surgery, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
- Department of Orthopaedic Surgery, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, China
- Fujian Provincial Institute of Orthopedics, the First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Xinyu Fang
- Department of Orthopaedic Surgery, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
- Department of Orthopaedic Surgery, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, China
- Fujian Provincial Institute of Orthopedics, the First Affiliated Hospital, Fujian Medical University, Fuzhou, China
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Parr J, Thai-Paquette V, Paranjape P, McLaren A, Deirmengian C, Toler K. Probability Score for the Diagnosis of Periprosthetic Joint Infection: Development and Validation of a Practical Multi-analyte Machine Learning Model. Cureus 2025; 17:e84055. [PMID: 40371186 PMCID: PMC12074866 DOI: 10.7759/cureus.84055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/13/2025] [Indexed: 05/16/2025] Open
Abstract
Background and objective The diagnosis of periprosthetic joint infection (PJI) relies on established criteria-based systems requiring interpretation and combination of multiple laboratory tests into scoring systems. In routine clinical care, clinicians implement these algorithms to diagnose PJI. Existing literature indicates suboptimal adoption and implementation of these criteria in clinical practice, even among experts. Recognizing the need for accurate PJI diagnosis through proper synthesis of multiple laboratory parameters, this study aimed to develop and validate a machine learning (ML) model that generates a preoperative PJI probability score based solely on synovial fluid (SF) biomarkers within 24 hours. Materials and methods A two-stage ML model was constructed using 104,090 SF samples from 2,923 institutions (2018-2024). First, unsupervised learning identified natural clusters in the data to label samples as "infected" or "not infected." Then, these labels trained a supervised logistic regression model that generated PJI scores (0-100), categorizing cases as PJI positive (> 80), PJI negative (< 20), or equivocal (20-80). The model incorporated 10 SF biomarkers: specimen integrity markers (absorbance at 280 nm, red blood cell count), inflammatory markers (white blood cell count, percentage of neutrophils, SF C-reactive protein), a PJI-specific biomarker (alpha-defensin), and microbial antigen markers (Staphylococcus, Enterococcus, Candida, and Cutibacterium acnes). Notably, culture results were excluded to allow for a 24-hour diagnosis. After splitting data into training (n = 83,272) and validation (n = 20,818) cohorts, performance was assessed against modified 2018 International Consensus Meeting criteria, including evaluation with probabilistically reclassified "inconclusive" cases. Results The ML model and resulting PJI score showed high diagnostic accuracy in the validation cohort. The PJI score achieved 99.3% sensitivity and 99.5% specificity versus the clinical reference before reclassification of inconclusive cases and 98.1% sensitivity and 97.6% specificity after probabilistic reclassification. With a disease prevalence of 20.7%, the positive predictive value reached 91.5% and the negative predictive value 99.5%. The model resolved 95% (1,363/1,442) of samples deemed inconclusive by the clinical standard. The analysis identified alpha defensin, percentage of neutrophils, and white blood cell count as the most influential model features. The model performed well in culture-negative infections. Conclusions The ML model and resulting PJI score demonstrated exceptional diagnostic accuracy by leveraging unsupervised SF biomarker pattern clustering. The model substantially reduced diagnostic uncertainty by definitively classifying most inconclusive cases, revealing their natural alignment with infected or non-infected patterns. This performance was achieved without SF culture results, enabling definitive diagnostic information within 24 hours based solely on biomarkers. The clinical significance demonstrates that an ML algorithm can match the diagnostic accuracy of complex clinical standards while transferring analytical complexity from clinicians to laboratories, minimizing the implementation gap that hinders current criteria-based approaches.
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Affiliation(s)
- Jim Parr
- Data Science and Machine Learning, Zimmer Biomet, Swindon, GBR
| | | | - Pearl Paranjape
- Diagnostics Research and Development, Zimmer Biomet, Claymont, USA
| | - Alex McLaren
- Orthopedic Surgery, University of Arizona College of Medicine - Phoenix, Phoenix, USA
| | - Carl Deirmengian
- Orthopedic Surgery, Rothman Orthopaedic Institute, Philadelphia, USA
- Orthopedic Surgery, Thomas Jefferson University, Philadelphia, USA
| | - Krista Toler
- Diagnostics Research and Development, Zimmer Biomet, Claymont, USA
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Maman D, Liba G, Hirschmann MT, Ben Zvi L, Fournier L, Steinfeld Y, Berkovich Y. Predictive analysis of economic and clinical outcomes in total knee arthroplasty: Identifying high-risk patients for increased costs and length of stay. Knee Surg Sports Traumatol Arthrosc 2025; 33:1754-1762. [PMID: 39629972 PMCID: PMC12022826 DOI: 10.1002/ksa.12547] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2024] [Revised: 11/06/2024] [Accepted: 11/10/2024] [Indexed: 04/26/2025]
Abstract
PURPOSE The purpose of this study was to predict high-risk patients who experience significant increases in hospital charges and length of stay (LOS) following specific postoperative complications. METHODS This study analyzed over two million patients from the Nationwide Inpatient Sample database undergoing elective total knee arthroplasty (TKA) for primary osteoarthritis. Baseline demographics, clinical characteristics and incidence of postoperative complications were examined. A neural network model was utilized to predict high-risk patients who fall into the top 25% for both LOS and total hospital charges after complications such as sepsis or surgical site infection (SSI). RESULTS The most common complications were blood loss anaemia (14.6%), acute kidney injury (1.6%) and urinary tract infection (0.9%). Patients with complications incurred significantly higher total charges (mean $66,804) and longer LOS (mean 2.9 days) compared to those without complications (mean $58,545 and 2.1 days, respectively). The neural network model demonstrated strong predictive performance, with an area under the curve of 0.83 for the training set and 0.78 for the testing set. Key complications like sepsis and SSIs significantly impacted hospital charges and LOS. For example, a 57-year-old patient with diabetes and sepsis had a 100% probability of being in the top 25% for both total charges and LOS. CONCLUSION Postoperative complications in TKA patients significantly increase hospital charges and LOS. The neural network model effectively predicted high-risk patients after specific complications occurred, offering a potential tool for improving patient management and resource allocation. LEVELS OF EVIDENCE Level III.
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Affiliation(s)
- David Maman
- Israel Institute of Technology, Technion University Hospital, Rappaport Faculty of MedicineHaifaIsrael
- Department of OrthopedicsCarmel Medical CenterHaifaIsrael
| | - Guy Liba
- Israel Institute of Technology, Technion University Hospital, Rappaport Faculty of MedicineHaifaIsrael
- Department of OrthopedicsCarmel Medical CenterHaifaIsrael
| | | | - Lior Ben Zvi
- Israel Institute of Technology, Technion University Hospital, Rappaport Faculty of MedicineHaifaIsrael
- Department of OrthopedicsCarmel Medical CenterHaifaIsrael
| | - Linor Fournier
- Israel Institute of Technology, Technion University Hospital, Rappaport Faculty of MedicineHaifaIsrael
- Pediatric DepartmentCarmel Medical CenterHaifaIsrael
| | - Yaniv Steinfeld
- Israel Institute of Technology, Technion University Hospital, Rappaport Faculty of MedicineHaifaIsrael
- Department of OrthopedicsCarmel Medical CenterHaifaIsrael
| | - Yaron Berkovich
- Israel Institute of Technology, Technion University Hospital, Rappaport Faculty of MedicineHaifaIsrael
- Department of OrthopedicsCarmel Medical CenterHaifaIsrael
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Saraiva ACM, Mozella ADP, Cobra HADAB, Sandes Kimura OD, Guimarães JAM, Defino H, Leal AC. Alterations in coagulation profile of patients with periprosthetic joint infections. INTERNATIONAL ORTHOPAEDICS 2025:10.1007/s00264-025-06537-w. [PMID: 40298954 DOI: 10.1007/s00264-025-06537-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/19/2024] [Accepted: 04/09/2025] [Indexed: 04/30/2025]
Abstract
PURPOSE This study aims to evaluate changes in the coagulation profile of patients with knee periprosthetic infections (PJI) and determine its diagnostic value in this complication. METHODS A prospective study was conducted with 112 patients who underwent revision surgery for total knee arthroplasty in a single tertiary hospital between January 2021 and December 2022. RESULTS 51 patients were diagnosed with PJI. D-dimer (p = 0.001), fibrinogen (p = 0.0007), platelets (0.01), and international normalized ratio (p = 0.01) were significantly higher in patients with PJI. CONCLUSIONS Patients with PJI display altered coagulation profile. The evaluation of coagulation-related markers has limited value for diagnosing PJI. Further studies are needed to understand the impact of such alterations on patients' outcomes.
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Affiliation(s)
| | - Alan de Paula Mozella
- Center for Surgery of Knee, National Institute of Traumatology and Orthopaedics, Rio de Janeiro, Brazil
- Medical Sciences University, State University of Rio de Janeiro (UERJ), Rio de Janeiro, Brasil
| | | | - Osamu de Sandes Kimura
- Center for Surgery of Hip, National Institute of Traumatology and Orthopaedics, Rio de Janeiro, Brazil
| | - João Antonio Matheus Guimarães
- Teaching and Research Division, National Institute of Traumatology and Orthopaedics, Avenida Brasil, 500, Rio de Janeiro, RJ, 20940-070, Brasil
| | - Helton Defino
- Department of Orthopaedics and Anaesthesiology, Ribeirão Preto Medical School, University of São Paulo, São Paulo, Brazil
| | - Ana Carolina Leal
- Teaching and Research Division, National Institute of Traumatology and Orthopaedics, Avenida Brasil, 500, Rio de Janeiro, RJ, 20940-070, Brasil.
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Aslani H, Gholipour M, Mahrooz MH, Alizadeh A, Bonakdar S. Use of vancomycin powder under polyethylene in total knee arthroplasty: a technical note. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2025; 35:163. [PMID: 40272561 DOI: 10.1007/s00590-025-04195-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/02/2024] [Accepted: 02/09/2025] [Indexed: 04/25/2025]
Abstract
Periprosthetic joint infections (PJI) remain a significant complication in total knee arthroplasty (TKA), often necessitating complex revisions. Vancomycin powder has been used intra-articularly to reduce PJI rates, but conflicting evidence suggests potential complications. This technical note introduces a novel approach: applying vancomycin powder beneath the polyethylene component during TKA, rather than directly into the joint space. We hypothesize that this technique could enhance infection prevention efficacy while minimizing complications associated with intra-articular vancomycin. We detail the indications, procedural steps, and potential complications of this method. Vancomycin powder is applied to the tibial surface before inserting the polyethylene component, maintaining the drug's proximity to potential infection sites without direct exposure to joint tissues. This approach aims to balance infection prevention with safety concerns, providing an alternative for patients at high risk for PJI. Further clinical validation is necessary to confirm the efficacy and safety of this technique.
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Affiliation(s)
| | | | | | - Amin Alizadeh
- Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Sona Bonakdar
- Shahid Beheshti University of Medical Sciences, Tehran, Iran
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Şahin R, Budin M, Suero EM, Gehrke T, Çıtak M. Differences in Microorganism Profile in Periprosthetic Joint Infections of the Knee in Patients Affected by Chronic Kidney Disease. J Arthroplasty 2025; 40:1034-1039. [PMID: 39756590 DOI: 10.1016/j.arth.2024.12.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2024] [Revised: 12/20/2024] [Accepted: 12/30/2024] [Indexed: 01/07/2025] Open
Abstract
BACKGROUND Periprosthetic joint infections (PJIs) are one of the most devastating complications of total knee arthroplasty (TKA). Patients who have chronic kidney disease (CKD) are more vulnerable to PJI. We aimed to answer the following questions: 1) What are the commonly observed pathogens in PJI after TKA in CKD patients, and do they differ from those in non-CKD patients? and 2) What are the risk factors for PJI after TKA in CKD patients? METHODS Patients who underwent surgery due to a chronic PJI of the TKA were retrospectively enrolled. The patients were divided into two groups as follows: patients those who had and those who did not have CKD. Demographic data and comorbidities of the patients were recorded. The microorganisms responsible for PJI were identified based on the biopsy results, and comparisons were made between the two groups. There were 331 patients in the CKD group and 2,238 in the control group. Patients who had CKD were significantly older (P < 0.001) and had higher Charlson Comorbidity Index scores (P < 0.001). RESULTS Binary logistic regression identified multiple microorganisms within the CKD group. The most common microorganisms in PJI were as follows: Staphylococcus epidermidis (odds ratio [OR] 1.38; P = 0.030; 95% confidence intervals (CI) 1.03 to 1.86), Staphylococcus aureus (OR 1.88; P < 0.001; 95% CI 1.36 to 2.61), Enterococcus faecalis (OR 2.39; P < 0.001; 95% CI 1.44 to 3.94), Escherichia coli (OR 1.76; P = 0.028; 95% CI 1.06 to 2.94), methicillin-resistant Staphylococcus aureus (OR 3.04; P = 0.024; 95% CI 1.15 to 8.02), polymicrobial infections (OR 1.52; P < 0.001; 95% CI 1.12 to 2.06). CONCLUSION Patients who had PJI and CKD demonstrated a higher incidence of infections with specific microorganisms, including Staphylococci, enterococci, gram-negative bacteria, and methicillin-resistant Staphylococcus aureus. To mitigate the high PJI risk in CKD patients, a treatment plan based on this microbial profile and a multidisciplinary assessment of CKD comorbidities before TKA is recommended.
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Affiliation(s)
- Rıfat Şahin
- Department of Orthopaedic Surgery, Helios ENDO-Klinik, Hamburg, Germany; Department of Orthopaedics and Traumatology, Faculty of Medicine, Recep Tayyip Erdogan University, Rize, Turkey
| | - Maximilian Budin
- Department of Orthopaedic Surgery, Helios ENDO-Klinik, Hamburg, Germany
| | - Eduardo M Suero
- Department of Orthopaedics and Trauma Surgery, Musculoskeletal University Center LMU Munich, Munich, Germany
| | - Thorsten Gehrke
- Department of Orthopaedic Surgery, Helios ENDO-Klinik, Hamburg, Germany
| | - Mustafa Çıtak
- Department of Orthopaedic Surgery, Helios ENDO-Klinik, Hamburg, Germany
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Guo D, Shen D, Dong Y. The Predictive Value of Heparin-Binding Protein in Total Joint Arthroplasty Prosthesis Infections. Surg Infect (Larchmt) 2025; 26:135-142. [PMID: 39602249 DOI: 10.1089/sur.2024.122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2024] Open
Abstract
Objective: This study aims to explore the predictive value of heparin-binding protein (HBP) in diagnosing prosthesis infections after total joint arthroplasty (TJA), in order to provide a new biomarker for early identification and management of prosthetic joint infections (PJI) post-TJA. Methods: A retrospective analysis of data from 168 patients who underwent TJA revision at Lianyungang First People's Hospital from October 2020 to March 2024 was conducted. The participants were divided into an infection group (38 cases) and a non-infection group (94 cases). Inclusion criteria included all patients undergoing joint prosthesis revision who had preoperative HBP levels measured. Primary assessment parameters included HBP, C-reactive protein (CRP), white blood cell (WBC) count, and erythrocyte sedimentation rate (ESR). Univariate analysis and multivariate regression analysis were used to evaluate the correlation of these factors with PJI, and the performance of HBP in predicting PJI was analyzed using the receiver operating characteristic (ROC) curve. Results: There were significant statistical differences in HBP, CRP, WBC, and ESR between the infection and non-infection groups (p < 0.05). Multivariate regression analysis showed that HBP is an independent predictive factor for the risk of PJI. The area under the ROC curve was 0.856, indicating that HBP has good predictive performance. The optimal cutoff value for HBP was 51.3, with a sensitivity of 69.2% and a specificity of 89.5%. Conclusion: The study found that HBP levels are significantly associated with the occurrence of PJI following TJA, serving as an effective independent predictive factor for PJI risk. HBP has high predictive value and can be considered an important biomarker for predicting PJI post-TJA in clinical settings, aiding in the early identification and management of PJI, thereby improving patient treatment outcomes and quality of life.
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Affiliation(s)
- Dongsheng Guo
- The First People's Hospital of Lianyungang, Lianyungang City, China
| | - Dahui Shen
- Lianyungang Clinical College of Nanjing Medical University, Lianyungang City, China
| | - Yuefu Dong
- The First People's Hospital of Lianyungang, Lianyungang City, China
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Incesoy MA, Demirkiran CB, Kaya HB, Geckalan MA, Tak AY, Elmali N, Yildiz F, Uzer G. Natural course of postoperative C-reactive protein and erythrocyte sedimentation rate in unilateral and simultaneous bilateral total knee arthroplasty. BMC Musculoskelet Disord 2025; 26:260. [PMID: 40087715 PMCID: PMC11907866 DOI: 10.1186/s12891-025-08523-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2025] [Accepted: 03/12/2025] [Indexed: 03/17/2025] Open
Abstract
BACKGROUND C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) are valuable markers for detecting periprosthetic joint infection (PJI) post-total knee arthroplasty (TKA). However, their prolonged elevation after TKA diminishes diagnostic reliability. This study investigates CRP and ESR trends in unilateral (U-TKA) and simultaneous bilateral TKA (SB-TKA) patients, comparing their patterns. METHODS Between 2017 and 2023, preoperative and postoperative (weeks 2, 4, 6) CRP and ESR levels were assessed in U-TKA (32 patients) and SB-TKA (29 patients) groups for gonarthrosis. RESULTS Median preoperative CRP levels were 1.13 mg/dL (U-TKA) and 0.2 mg/dL (SB-TKA), with corresponding ESR levels of 13.50 mm/h and 10 mm/h. While CRP and ESR increased more in SB-TKA, differences were statistically insignificant (p > 0.05). Both groups showed significant differences in CRP and ESR values at all time points (p < 0.05). U-TKA patients reached CRP < 5 mg/dL and ESR < 30 mm/h by the 6th postoperative week. SB-TKA patients did not exhibit significantly higher CRP and ESR levels at various intervals compared to U-TKA patients (p > 0.05). CONCLUSION This study delineates postoperative CRP and ESR trends in U-TKA and SB-TKA for osteoarthritis. CRP values decreased below 5 mg/dL, and ESR values below 30 mm/h within 6 weeks in both groups. Statistically significant differences in CRP and ESR values were observed at all time points. No significant differences were found in CRP and ESR trends between both groups. These findings aid physicians in interpreting laboratory reports for PJI determination. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Mustafa Alper Incesoy
- Department of Orthopedics, Faculty of Medicine, Bezmialem Vakif University, Istanbul, Turkey.
| | - Cemil Burak Demirkiran
- Department of Orthopedics, Kilis Prof. Dr. Alaeddin Yavaşca State Hospital, Kilis, Turkey
| | - Hakan Batuhan Kaya
- Department of Orthopedics, Faculty of Medicine, Bezmialem Vakif University, Istanbul, Turkey
| | - Muhammed Ali Geckalan
- Department of Orthopedics, Faculty of Medicine, Bezmialem Vakif University, Istanbul, Turkey
| | - Aysegul Yabaci Tak
- Department of Biostatistics and Medical Informatics, Faculty of Medicine, Bezmialem Vakif University, Istanbul, Turkey
| | - Nurzat Elmali
- Department of Orthopedics, Faculty of Medicine, Bezmialem Vakif University, Istanbul, Turkey
| | - Fatih Yildiz
- Department of Orthopedics, Faculty of Medicine, Bezmialem Vakif University, Istanbul, Turkey
| | - Gokcer Uzer
- Department of Orthopedics, Faculty of Medicine, Bezmialem Vakif University, Istanbul, Turkey
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Dilger OB, Owen AR, Bedard NA, Mabry TM, Berry DJ, Abdel MP. Repeat Two-Stage Exchange Arthroplasty for Recurrent Periprosthetic Knee Infection: Results of 87 Cases. J Arthroplasty 2025:S0883-5403(25)00217-7. [PMID: 40089122 DOI: 10.1016/j.arth.2025.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2024] [Revised: 03/04/2025] [Accepted: 03/05/2025] [Indexed: 03/17/2025] Open
Abstract
BACKGROUND Despite the success of two-stage exchange total knee arthroplasties (TKAs), a subset of patients become reinfected and may be considered for a repeat two-stage exchange TKAs. A small, prior study from our institution demonstrated a 50% re-revision rate in such a cohort. The purpose of the present study was to evaluate a contemporary and larger cohort of repeat two-stage exchange TKAs with an emphasis on implant survivorship, risk factors, and clinical outcomes. METHODS We retrospectively identified 87 repeat two-stage exchange TKAs performed between 2014 and 2021. The mean patient age was 66 years, 32% were women, and the mean body mass index was 29. At the time of resection, 98% of patients were treated with a high-dose antibiotic spacer (58 nonarticulating and 27 articulating). The mean time from resection arthroplasty to reimplantation was 22 weeks. Kaplan-Meier survivorship analyses were performed, and risk factors (including the McPherson staging system) were assessed. The mean follow-up was five years (range, two to nine). RESULTS The 5-year survivorships free of rerevision for reinfection, any rerevision, and any reoperation were 88, 67, and 54%, respectively. Leading causes for rerevision were periprosthetic joint infection (36%) and aseptic loosening (27%). There were no statistically significant independent risk factors identified. However, patients who had McPherson host grade C trended toward higher rates of reoperation (hazard ratio: 2, P = 0.057). Despite the high reoperation rate, at the final follow-up (mean five years), 91% of patients had a TKA in situ, 8% had been treated with above-knee amputation, and 1% with a definitive resection arthroplasty. CONCLUSIONS Despite its challenges, including a 54% reoperation rate, repeat two-stage exchange TKAs may be considered in a subset of patients given 91% of patients had a TKA in situ at a mean of five years, and the 5-year survivorship free of rerevision for infection was 88%. Notably, patients who were McPherson host grade C trended toward failure. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Oliver B Dilger
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Aaron R Owen
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | | | - Tad M Mabry
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Daniel J Berry
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Matthew P Abdel
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
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Chong YY, Lau CML, Jiang T, Wen C, Zhang J, Cheung A, Luk MH, Leung KCT, Cheung MH, Fu H, Chiu KY, Chan PK. Predicting periprosthetic joint infection in primary total knee arthroplasty: a machine learning model integrating preoperative and perioperative risk factors. BMC Musculoskelet Disord 2025; 26:241. [PMID: 40069724 PMCID: PMC11895328 DOI: 10.1186/s12891-025-08296-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2024] [Accepted: 01/06/2025] [Indexed: 03/15/2025] Open
Abstract
BACKGROUND Periprosthetic joint infection leads to significant morbidity and mortality after total knee arthroplasty. Preoperative and perioperative risk prediction and assessment tools are lacking in Asia. This study developed the first machine learning model for individualized prediction of periprosthetic joint infection following primary total knee arthroplasty in this demographic. METHODS A retrospective analysis was conducted on 3,483 primary total knee arthroplasty (81 with periprosthetic joint infection) from 1998 to 2021 in a Chinese tertiary and quaternary referral academic center. We gathered 60 features, encompassing patient demographics, operation-related variables, laboratory findings, and comorbidities. Six of them were selected after univariate and multivariate analysis. Five machine learning models were trained with stratified 10-fold cross-validation and assessed by discrimination and calibration analysis to determine the optimal predictive model. RESULTS The balanced random forest model demonstrated the best predictive capability with average metrics of 0.963 for the area under the receiver operating characteristic curve, 0.920 for balanced accuracy, 0.938 for sensitivity, and 0.902 for specificity. The significant risk factors identified were long operative time (OR, 9.07; p = 0.018), male gender (OR, 3.11; p < 0.001), ASA > 2 (OR, 1.68; p = 0.028), history of anemia (OR, 2.17; p = 0.023), and history of septic arthritis (OR, 4.35; p = 0.030). Spinal anesthesia emerged as a protective factor (OR, 0.55; p = 0.022). CONCLUSION Our study presented the first machine learning model in Asia to predict periprosthetic joint infection following primary total knee arthroplasty. We enhanced the model's usability by providing global and local interpretations. This tool provides preoperative and perioperative risk assessment for periprosthetic joint infection and opens the potential for better individualized optimization before total knee arthroplasty.
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Affiliation(s)
- Yuk Yee Chong
- Department of Orthopedics and Traumatology, The University of Hong Kong, Hong Kong SAR, China
| | - Chun Man Lawrence Lau
- Department of Orthopedics and Traumatology, The University of Hong Kong, Hong Kong SAR, China.
| | - Tianshu Jiang
- Department of Biomedical Engineering, The Hong Kong Polytechnic University, Hong Kong SAR, China
| | - Chunyi Wen
- Department of Biomedical Engineering, The Hong Kong Polytechnic University, Hong Kong SAR, China
| | - Jiang Zhang
- Department of Health Technology and Informatics, The Hong Kong Polytechnic University, Hong Kong SAR, China
| | - Amy Cheung
- Department of Orthopedics and Traumatology, Queen Mary Hospital, Hong Kong SAR, China
| | - Michelle Hilda Luk
- Department of Orthopedics and Traumatology, Queen Mary Hospital, Hong Kong SAR, China
| | - Ka Chun Thomas Leung
- Department of Orthopedics and Traumatology, Queen Mary Hospital, Hong Kong SAR, China
| | - Man Hong Cheung
- Department of Orthopedics and Traumatology, The University of Hong Kong, Hong Kong SAR, China
| | - Henry Fu
- Department of Orthopedics and Traumatology, The University of Hong Kong, Hong Kong SAR, China
| | - Kwong Yuen Chiu
- Department of Orthopedics and Traumatology, The University of Hong Kong, Hong Kong SAR, China
| | - Ping Keung Chan
- Department of Orthopedics and Traumatology, The University of Hong Kong, Hong Kong SAR, China.
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12
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Chen P, Wu L, Zhang S, Jin Q, Sun K. Combining TNF-α silencing with Wnt3a overexpression: a promising gene therapy for particle-induced periprosthetic osteolysis. Front Cell Dev Biol 2025; 13:1511577. [PMID: 40114968 PMCID: PMC11922860 DOI: 10.3389/fcell.2025.1511577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2024] [Accepted: 02/12/2025] [Indexed: 03/22/2025] Open
Abstract
Wear particle-induced periprosthetic osteolysis is a prevalent issue that frequently leads to the failure of joint replacements, necessitating the development of effective therapeutic strategies. In this study, we established a mouse model of prosthetic loosening and evaluated the therapeutic effects of targeting tumor necrosis factor-alpha (TNF-α) and wingless-type MMTV integration site family, member 3A (Wnt3a) on osteolysis. TNF-α knockdown reduced inflammation and osteoclast-related gene expression, while Wnt3a overexpression increased osteoblast-related gene expression. Notably, the combination of these interventions showed superior efficacy in inhibiting osteolysis compared to monotherapy. Biomechanical imaging and histological staining revealed that combined therapy enhanced bone density and minimized the gaps between the peri-prosthetic bone and the prosthesis, reducing fibrous connective tissue proliferation. Adeno-associated virus-mediated gene therapy was found to be safe, with no adverse effects observed in liver, brain, spleen, and kidney tissues. Our findings suggest that combining TNF-α silencing with Wnt3a overexpression may be a promising approach for treating particle-induced peri-implant osteolysis and warrants further clinical investigation.
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Affiliation(s)
- Ping Chen
- Medical Experiment Center, General Hospital of Ningxia Medical University, Yinchuan, China
- Ningxia Key Laboratory of Clinical and Pathogenic Microbiology, General Hospital of Ningxia Medical University, Yinchuan, China
| | - Long Wu
- Orthopedics Ward 3, The General Hospital of Ningxia Medical University, Yinchuan, China
| | - Shuai Zhang
- Orthopedics Ward 3, The General Hospital of Ningxia Medical University, Yinchuan, China
| | - Qunhua Jin
- Orthopedics Ward 3, The General Hospital of Ningxia Medical University, Yinchuan, China
| | - Kening Sun
- Orthopedics Ward 3, The General Hospital of Ningxia Medical University, Yinchuan, China
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13
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Porteous A, Wagenaar FC, Price A, Phillips J, van Hellemondt G. Consensus statement on problematic knee replacement and revision knee replacement: A collaboration between EKS and BASK. Knee 2025; 53:86-92. [PMID: 39689381 DOI: 10.1016/j.knee.2024.11.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2024] [Accepted: 11/18/2024] [Indexed: 12/19/2024]
Abstract
BACKGROUND Up to 20% of primary total knee arthroplasty (TKA) patients are not satisfied with their outcome. Both the analysis of these patients and revision surgery can be complex, expensive and outcomes can vary widely. AIM The aim of this study was to deliver consensus recommendations regarding outpatient analysis, surgical treatment and arrangement of clinical services concerning patients with a problematic TKA or revision knee replacement (RTKA). METHODS Members of BASK and EKS were invited to attend a joint meeting in London, UK (December 2019). A formal consensus process was undertaken at the meeting incorporating a multiple round Delphi exercise, with group discussion of areas of agreement and disagreement between rounds. Eighty delegates attended the meeting and five consensus statements were considered, with a threshold level of 80% agreement required as the definition consensus. A further consensus meeting of EKS members in Kitzbuhl, Austria (January 2023) followed similar methodology and considered a further four statements on this topic. RESULTS From the first meeting, 5 consensus statements with accompanying supporting evidence and text were agreed. 1) In suspected infection, a recognised diagnostic pathway and definition should be used (e.g. MSIS, ICM, EBJIS) and documented; 2) Revision of an infected TKA should be treated in units with a multidisciplinary team; 3) Initial investigation of a problematic TKA should include a minimum of: clinical investigation, X-Rays and blood tests, with further discussion with the MDT if required; 4) Units providing RTKA should have surgeons with evidence of specific training or experience, and on-going minimum unit numbers; 5) National Orthopaedic/Knee Societies should develop a strategy on Revision TKA provision taking into account: workforce, revision burden, location, hospital infrastructure. From the second meeting a further 4 consensus statements were agreed. Two statements were agreed text content answering the questions: 1) What should be included in the basic diagnostic workup of a painful TKA? and 2) Which are the key factors for surgeons to consider before offering the patient revision surgery? The two other agreed statements are: 3) Pre-operative diagnosis is related to outcome in RTKA and 4) RTKA for pain, without a surgically treatable diagnosis, is unpredictable. CONCLUSIONS The agreed joint BASK-EKS consensus statements and the EKS consensus statements on the assessment of problematic RTKA are recommended as the contemporary basis of optimal care for these patients and should inform future training and service developments.
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Affiliation(s)
- Andrew Porteous
- European Knee Society (EKS), Europe; British Association for Surgery of the Knee (BASK), Europe.
| | | | - Andrew Price
- European Knee Society (EKS), Europe; British Association for Surgery of the Knee (BASK), Europe.
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Laver L, Maman D, Hirschmann MT, Mahamid A, Bar O, Steinfeld Y, Berkovich Y. Big data analysis reveals significant increases in complications, costs, and hospital stay in revision total knee arthroplasty compared to primary TKA. Knee Surg Sports Traumatol Arthrosc 2025; 33:1015-1024. [PMID: 39382040 PMCID: PMC11848982 DOI: 10.1002/ksa.12499] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2024] [Revised: 09/21/2024] [Accepted: 09/22/2024] [Indexed: 10/10/2024]
Abstract
INTRODUCTION Despite significant advancements in total knee arthroplasty (TKA), some patients require revision surgery (R-TKA) due to complications such as infection, mechanical loosening, instability, periprosthetic fractures, and persistent pain. This study aimed to explore the specific causes leading to R-TKA, associated complications, including infection, mechanical failure, and wound issues, as well as costs, mortality rates, and hospital length of stay (LOS) using data from a large national database. METHODS Data from the nationwide inpatient sample (NIS), the largest publicly available all-payer inpatient care database in the United States were analysed from 1 January 2016 to 31 December 2019. The study included 44,649 R-TKA cases, corresponding to 223,240 patients, with exclusions for nonelective admissions. Various statistical analyses were used to assess clinical outcomes, including in-hospital mortality, postoperative complications, LOS, and hospitalization costs. RESULTS Among 2,636,880 TKA patients, 8.4% underwent R-TKA. R-TKA patients had higher rates of chronic conditions, including mental disorders (36.4%) and renal disease (9.9%). Additionally, these patients often experienced instability, necessitating revision surgery. Infection (22.3%) was the primary reason for R-TKA, followed by mechanical loosening (22.9%) and instability. Compared to primary TKA patients, R-TKA patients exhibited higher in-hospital mortality (0.085% vs. 0.025%), longer LOS (3.1 vs. 2.28 days), and higher total charges ($97,815 vs. $62,188). Postoperative complications, including blood transfusion (4.6% vs. 1.3%), acute kidney injury (4.4% vs. 1.8%), venous thromboembolism (0.55% vs. 0.29%), infection, and wound problems, were significantly higher in R-TKA patients. CONCLUSIONS This study provides detailed insights into t LOS, costs, and complications associated with specific etiologies of revision TKA. Our findings emphasize the need for targeted preoperative optimization and patient education. This approach can help reduce the incidence and burden of R-TKA, improve patient care, optimize resource allocation, and potentially decrease the overall rates of complications in revision surgeries. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Lior Laver
- Department of OrthopedicsHillel Yaffe Medical CenterHaderaIsrael
- Rappaport Faculty of MedicineTechnion University Hospital (Israel Institute of Technology)HaifaIsrael
| | - David Maman
- Rappaport Faculty of MedicineTechnion University Hospital (Israel Institute of Technology)HaifaIsrael
- Department of OrthopedicsCarmel Medical CenterHaifaIsrael
| | - Michael T. Hirschmann
- Department of Orthopaedic Surgery and TraumatologyKantonsspital BasellandLiestalSwitzerland
| | - Assil Mahamid
- Department of OrthopedicsHillel Yaffe Medical CenterHaderaIsrael
| | - Ofek Bar
- Faculty of MedicineLithuanian University of Health SciencesKaunasLithuania
| | - Yaniv Steinfeld
- Rappaport Faculty of MedicineTechnion University Hospital (Israel Institute of Technology)HaifaIsrael
- Department of OrthopedicsCarmel Medical CenterHaifaIsrael
| | - Yaron Berkovich
- Rappaport Faculty of MedicineTechnion University Hospital (Israel Institute of Technology)HaifaIsrael
- Department of OrthopedicsCarmel Medical CenterHaifaIsrael
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15
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Mederake M, Hofmann UK, Eleftherakis G. Prognostic Value of C-Reactive Protein in Primary Total Hip Arthroplasty. Antibiotics (Basel) 2025; 14:205. [PMID: 40001448 PMCID: PMC11851395 DOI: 10.3390/antibiotics14020205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2024] [Revised: 02/09/2025] [Accepted: 02/14/2025] [Indexed: 02/27/2025] Open
Abstract
Background/Objectives: Periprosthetic joint infections (PJIs) are feared complications in arthroplasty and are associated with an increased mortality rate. PJI prevention is of paramount importance since treatment is difficult. In case of an infection, it is crucial to diagnose it at an early stage in order to initiate adequate therapy. The Musculoskeletal Infection Society (MSIS) proposed a catalog of different major and minor diagnostic criteria in 2011 to define a PJI. They were adapted in the following years. One of these criteria is the blood level of C-reactive protein (CRP). CRP is a non-specific acute-phase protein that also increases in response to various non-infectious inflammatory responses. CRP is also routinely obtained prior to total hip arthroplasty (THA) to screen for possible contraindications for arthroplasty such as an acute infection. The validity of this approach has rarely been investigated. The aim of this study was to evaluate the diagnostic value of perioperative CRP in patients receiving a THA. Methods: A total of 239 patients were included in this study and retrospectively analyzed. CRP values were obtained preoperatively and three values postoperatively. Sensitivity, specificity, area under the curve (AUC) and optimal thresholds were calculated. Results: In the whole group, 10 patients developed a PJI. No significance was demonstrated between patients without and with later PJI in terms of preoperative CRP (p = 0.182), postoperative CRP (p = 0.167), relative CRP increase (p = 0.684) and respective CRP differences (p = 0.456). We were not able to find cut-off values with adequate sensitivity and specificity. Conclusions: Perioperative CRP values do not seem to be helpful in predicting further PJI. Rather, they should be used as a screening tool to detect ongoing infections in the individual patient prior to THA. This trial should encourage studies with more statistical power due to the small effect sizes.
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Affiliation(s)
- Moritz Mederake
- Department of Trauma and Reconstructive Surgery, Berufsgenossenschaftliche Unfallklinik, University of Tübingen, 72076 Tübingen, Germany
| | - Ulf Krister Hofmann
- Department of Orthopaedic, Trauma, and Reconstructive Surgery, Division of Arthroplasty, Rheinisch-Westfälische Technische Hochschule University Hospital, 52074 Aachen, Germany
| | - Georgios Eleftherakis
- Department of Orthopaedic Surgery, Diakonie-Klinikum Stuttgart, 70176 Stuttgart, Germany
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16
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Yazdi H, Talebi S, Razi M, Sarzaeem MM, Moshirabadi A, Mohammadpour M, Seiri S, Ghaeini M, Alaeddini S, Abolghasemian M. Effect of Adding Stem Extension to a Short-Keeled Knee Implant on the Risk of Tibial Loosening: a Historical Cohort Study. J Am Acad Orthop Surg 2025; 33:187-193. [PMID: 39186613 DOI: 10.5435/jaaos-d-23-00833] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Accepted: 06/06/2024] [Indexed: 08/28/2024] Open
Abstract
BACKGROUND Short-keeled tibial implants may be at higher risk of aseptic loosening. Stem augmentation has been suggested to improve its fixation. We aimed to assess whether this technique could decrease the loosening rate of such tibial implants. METHODS We retrospectively studied the knees receiving stemmed versus nonstemmed versions of a short-keeled prosthesis. A total of 932 patients undergoing total knee arthroplasty using a Persona prosthesis with >24-month follow-up (mean 53.7) were included, of whom 212 were at high risk of loosening due to osteoporosis or high body mass index (BMI). The rate of tibial aseptic loosening in high-risk patients and in the whole cohort was compared between those with and without stem extension. Multivariable analysis was conducted to identify the risk factors of loosening. RESULTS In the whole cohort, in 203 knees (21.8%), a cemented short stem was used, versus 729 knees (78.2%) without. The tibial implant revision rates for loosening were 2.06% and 0.99% for nonstemmed and stemmed cases, respectively ( P = 0.551). When the cohort was categorized based on the loosening risk factors, the loosening risk was significantly higher in the high-risk than in the low-risk group, regardless of stem status (log-rank test = 8.1, hazard ratio = 2.17, 95% CI = 1.78, 2.57, P = 0.005). 212 patients were at high risk of loosening, due to high BMI or osteoporosis, among whom the risk of aseptic loosening was higher when a stem was not used (log-rank = 32.1, hazard ratio = 4.95, 95% CI = 4.05, 5.86, P < 0.001). In multivariate analysis, osteoporosis, BMI ≥35, and smoking were correlated with loosening. CONCLUSION The failure rate was markedly lower in the stemmed group of the patients at elevated risk of aseptic loosening due to osteoporosis and/or high BMI. In the entire cohort, the risk of loosening in stemmed tibial implants was similar to the nonstemmed group. The findings support a protective role for the stem in patients at high risk of failure of the cemented tibial implant. LEVEL OF EVIDENCE III therapeutic.
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Affiliation(s)
- Hamidreza Yazdi
- From the Department of Orthopedics, School of Medicine, Bone and Joint Reconstruction Research Center, Iran University of Medical Sciences, Tehran, Iran (Yazdi, Talebi, Razi, Mohammadpour, Seiri, Ghaeini, Alaeddini, and Abolghasemian), the Neuromusculoskeletal Research Center, School of Medicine, Iran University of Medical Sciences, Tehran, Iran (Yazdi), Department of Orthopedics, Imam Hossein Medical Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran (Sarzaeem), and the Department of Orthopedic Surgery, Atieh Private Hospital, Tehran, Iran (Moshirabadi)
- Division of Orthopedic Surgery, Department of Surgery, University of Alberta, Alberta, Canada
| | - Sina Talebi
- From the Department of Orthopedics, School of Medicine, Bone and Joint Reconstruction Research Center, Iran University of Medical Sciences, Tehran, Iran (Yazdi, Talebi, Razi, Mohammadpour, Seiri, Ghaeini, Alaeddini, and Abolghasemian), the Neuromusculoskeletal Research Center, School of Medicine, Iran University of Medical Sciences, Tehran, Iran (Yazdi), Department of Orthopedics, Imam Hossein Medical Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran (Sarzaeem), and the Department of Orthopedic Surgery, Atieh Private Hospital, Tehran, Iran (Moshirabadi)
- Division of Orthopedic Surgery, Department of Surgery, University of Alberta, Alberta, Canada
| | - Mohammad Razi
- From the Department of Orthopedics, School of Medicine, Bone and Joint Reconstruction Research Center, Iran University of Medical Sciences, Tehran, Iran (Yazdi, Talebi, Razi, Mohammadpour, Seiri, Ghaeini, Alaeddini, and Abolghasemian), the Neuromusculoskeletal Research Center, School of Medicine, Iran University of Medical Sciences, Tehran, Iran (Yazdi), Department of Orthopedics, Imam Hossein Medical Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran (Sarzaeem), and the Department of Orthopedic Surgery, Atieh Private Hospital, Tehran, Iran (Moshirabadi)
- Division of Orthopedic Surgery, Department of Surgery, University of Alberta, Alberta, Canada
| | - Mohammad Mahdi Sarzaeem
- From the Department of Orthopedics, School of Medicine, Bone and Joint Reconstruction Research Center, Iran University of Medical Sciences, Tehran, Iran (Yazdi, Talebi, Razi, Mohammadpour, Seiri, Ghaeini, Alaeddini, and Abolghasemian), the Neuromusculoskeletal Research Center, School of Medicine, Iran University of Medical Sciences, Tehran, Iran (Yazdi), Department of Orthopedics, Imam Hossein Medical Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran (Sarzaeem), and the Department of Orthopedic Surgery, Atieh Private Hospital, Tehran, Iran (Moshirabadi)
- Division of Orthopedic Surgery, Department of Surgery, University of Alberta, Alberta, Canada
| | - Ataollah Moshirabadi
- From the Department of Orthopedics, School of Medicine, Bone and Joint Reconstruction Research Center, Iran University of Medical Sciences, Tehran, Iran (Yazdi, Talebi, Razi, Mohammadpour, Seiri, Ghaeini, Alaeddini, and Abolghasemian), the Neuromusculoskeletal Research Center, School of Medicine, Iran University of Medical Sciences, Tehran, Iran (Yazdi), Department of Orthopedics, Imam Hossein Medical Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran (Sarzaeem), and the Department of Orthopedic Surgery, Atieh Private Hospital, Tehran, Iran (Moshirabadi)
- Division of Orthopedic Surgery, Department of Surgery, University of Alberta, Alberta, Canada
| | - Mehdi Mohammadpour
- From the Department of Orthopedics, School of Medicine, Bone and Joint Reconstruction Research Center, Iran University of Medical Sciences, Tehran, Iran (Yazdi, Talebi, Razi, Mohammadpour, Seiri, Ghaeini, Alaeddini, and Abolghasemian), the Neuromusculoskeletal Research Center, School of Medicine, Iran University of Medical Sciences, Tehran, Iran (Yazdi), Department of Orthopedics, Imam Hossein Medical Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran (Sarzaeem), and the Department of Orthopedic Surgery, Atieh Private Hospital, Tehran, Iran (Moshirabadi)
- Division of Orthopedic Surgery, Department of Surgery, University of Alberta, Alberta, Canada
| | - Sina Seiri
- From the Department of Orthopedics, School of Medicine, Bone and Joint Reconstruction Research Center, Iran University of Medical Sciences, Tehran, Iran (Yazdi, Talebi, Razi, Mohammadpour, Seiri, Ghaeini, Alaeddini, and Abolghasemian), the Neuromusculoskeletal Research Center, School of Medicine, Iran University of Medical Sciences, Tehran, Iran (Yazdi), Department of Orthopedics, Imam Hossein Medical Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran (Sarzaeem), and the Department of Orthopedic Surgery, Atieh Private Hospital, Tehran, Iran (Moshirabadi)
- Division of Orthopedic Surgery, Department of Surgery, University of Alberta, Alberta, Canada
| | - Moein Ghaeini
- From the Department of Orthopedics, School of Medicine, Bone and Joint Reconstruction Research Center, Iran University of Medical Sciences, Tehran, Iran (Yazdi, Talebi, Razi, Mohammadpour, Seiri, Ghaeini, Alaeddini, and Abolghasemian), the Neuromusculoskeletal Research Center, School of Medicine, Iran University of Medical Sciences, Tehran, Iran (Yazdi), Department of Orthopedics, Imam Hossein Medical Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran (Sarzaeem), and the Department of Orthopedic Surgery, Atieh Private Hospital, Tehran, Iran (Moshirabadi)
- Division of Orthopedic Surgery, Department of Surgery, University of Alberta, Alberta, Canada
| | - Soroush Alaeddini
- From the Department of Orthopedics, School of Medicine, Bone and Joint Reconstruction Research Center, Iran University of Medical Sciences, Tehran, Iran (Yazdi, Talebi, Razi, Mohammadpour, Seiri, Ghaeini, Alaeddini, and Abolghasemian), the Neuromusculoskeletal Research Center, School of Medicine, Iran University of Medical Sciences, Tehran, Iran (Yazdi), Department of Orthopedics, Imam Hossein Medical Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran (Sarzaeem), and the Department of Orthopedic Surgery, Atieh Private Hospital, Tehran, Iran (Moshirabadi)
- Division of Orthopedic Surgery, Department of Surgery, University of Alberta, Alberta, Canada
| | - Mansour Abolghasemian
- Division of Orthopedic Surgery, Department of Surgery, University of Alberta, Alberta, Canada
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Pioger C, Marmor S, Bouché PA, Kerroumi Y, Lhotellier L, Graff W, Mouton A, Heym B, Zeller V. One-stage exchange strategy with extensive debridement for chronic periprosthetic joint infection following total knee arthroplasty is associated with a low relapse rate in non-selected patients: a prospective single-center analysis. Orthop Traumatol Surg Res 2025; 111:104019. [PMID: 39393489 DOI: 10.1016/j.otsr.2024.104019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Revised: 08/05/2024] [Accepted: 10/08/2024] [Indexed: 10/13/2024]
Abstract
PURPOSE This prospective clinical cohort was undertaken to determine the long-term risks of reinfection and all-cause aseptic failure after 1-stage exchange total knee arthroplasties (TKA) in a large series of consecutive patients with periprosthetic joint infection (PJI) following TKA. HYPOTHESIS One-stage exchange for chronic PJI is an effective strategy, even in a non-selected population. PATIENTS AND METHODS Non-selected patients (152 with 154 PJI) undergoing 1-stage-exchange TKA for PJI (January 2003-August 2015) were prospectively included and monitored for ≥2 years. PJI following TKA satisfying Musculoskeletal Infection Society diagnostic criteria were documented by microbiological culture results of preoperative joint aspirates and/or intraoperative samples. The cumulative incidences of total reinfections (i.e., relapses or new infections) and aseptic revisions were assessed. The mean follow-up (FU) duration was 7.5 years post-reimplantation. RESULTS At the last follow-up, 35 knees had developed reinfections: 7 relapses and 28 new infections, with respective 14-year cumulative incidences of 4.8% and 20.6%. The 2-, 5- and 14-year cumulative total reinfection incidences were 12.3%, 21.3% and 24.3%, respectively. Respective 2-, 5-, 10- and 14-year aseptic component-revision incidences were 0.7%, 3.2%, 5.4% and 13.4%. Multivariate analysis retained male sex (HR 3.27, p < 0.01) and preoperative atrial fibrillation (HR 3.03; p = 0.01) as being significantly associated with greater risk of reinfection. CONCLUSIONS One-stage-exchange TKA with aggressive debridement for chronic PJI is apparently a valid strategy, even for non-selected patients. It was associated with a low relapse rate, prevented morbidity and avoided economic social costs of 2-stage exchange. New infections with a different microorganism were observed more frequently and occurred even after years of FU. LEVEL OF EVIDENCE II; Therapeutic.
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Affiliation(s)
- Charles Pioger
- Department of Orthopaedic Surgery, Hospital La Croix-Saint Simon, 125, Rue d'Avron, 75020, Paris, France; Department of Orthopaedic Surgery, Ambroise Paré Hospital, Paris Saclay University, 9, Avenue Charles de Gaulle, 92100, Boulogne-Billancourt, France.
| | - Simon Marmor
- Department of Orthopaedic Surgery, Hospital La Croix-Saint Simon, 125, Rue d'Avron, 75020, Paris, France
| | - Pierre-Alban Bouché
- Department of Orthopaedic Surgery, Hospital La Croix-Saint Simon, 125, Rue d'Avron, 75020, Paris, France; Department of Orthopaedic Surgery, Lariboisière Hospital, Paris University, Paris, France
| | - Younes Kerroumi
- Department of Orthopaedic Surgery, Hospital La Croix-Saint Simon, 125, Rue d'Avron, 75020, Paris, France
| | - Luc Lhotellier
- Department of Orthopaedic Surgery, Hospital La Croix-Saint Simon, 125, Rue d'Avron, 75020, Paris, France
| | - Wilfrid Graff
- Department of Orthopaedic Surgery, Hospital La Croix-Saint Simon, 125, Rue d'Avron, 75020, Paris, France
| | - Antoine Mouton
- Department of Orthopaedic Surgery, Hospital La Croix-Saint Simon, 125, Rue d'Avron, 75020, Paris, France
| | - Beate Heym
- Department of Orthopaedic Surgery, Hospital La Croix-Saint Simon, 125, Rue d'Avron, 75020, Paris, France
| | - Valérie Zeller
- Department of Orthopaedic Surgery, Hospital La Croix-Saint Simon, 125, Rue d'Avron, 75020, Paris, France
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18
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Rosenberg N. Walking Ability After Total Knee Arthroplasty: A Comprehensive Review. Cureus 2025; 17:e79577. [PMID: 40151712 PMCID: PMC11947503 DOI: 10.7759/cureus.79577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/24/2025] [Indexed: 03/29/2025] Open
Abstract
Total knee arthroplasty (TKA) is a highly effective surgical intervention for alleviating pain and restoring function in patients with end-stage knee osteoarthritis. Walking ability, a critical measure of post-operative success, directly impacts patients' independence, mobility, and quality of life. This review comprehensively examines the factors influencing walking ability after TKA, encompassing pre-operative, surgical, and post-operative considerations. Pre-operative factors, such as patient demographics, functional status, psychological well-being, and comorbidities, significantly shape post-operative outcomes. Surgical techniques, including the choice of approach, implant design, alignment, and minimally invasive or robotic-assisted methods, also play a pivotal role in determining walking ability. Post-operative rehabilitation, particularly early mobilization, physical therapy, and exercise protocol adherence, is essential for optimizing recovery. Long-term outcomes reveal that, while most patients experience significant improvements in walking ability, some face persistent limitations due to age, comorbidities, or suboptimal surgical results. Emerging technologies, such as wearable devices, robotic-assisted surgery, and personalized rehabilitation programs, offer promising avenues for enhancing post-operative walking ability. Biological augmentation techniques, like platelet-rich plasma and stem cell therapy, are also being explored to improve tissue healing and functional recovery. This review underscores the importance of a multidisciplinary, patient-centered approach to maximize walking ability and overall satisfaction after TKA, synthesizing evidence from clinical studies, meta-analyses, and systematic reviews. Future research should focus on refining surgical techniques, advancing rehabilitation strategies, and integrating personalized medicine to improve outcomes.
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Affiliation(s)
- Nahum Rosenberg
- Specialists Center, National Insurance Institute - Israel, Haifa, ISR
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19
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Chiu AK, Agarwal AR, Peagler C, Fraychineaud T, Gu A, Parel PM, Golladay GJ, Thakkar SC. Declining Trends in Septic Revision Following Total Knee Arthroplasty From 2010 to 2019: A National Cohort Analysis. J Arthroplasty 2025; 40:480-485.e1. [PMID: 39389236 DOI: 10.1016/j.arth.2024.08.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2024] [Revised: 08/04/2024] [Accepted: 08/05/2024] [Indexed: 10/12/2024] Open
Abstract
BACKGROUND Periprosthetic joint infections (PJIs) following total knee arthroplasty (TKA) are associated with high patient morbidity, mortality, and health care costs. Methods to reduce the burden of PJI have been shown to be efficacious on a small scale. On a national scale, it is unknown whether these methods have reduced PJI rates. METHODS A retrospective trend analysis was conducted using a national database. The incidence of 2-year septic revision was observed for the entire cohort in patients who had high-risk comorbidities from 2010 to 2019. A multivariable logistic regression was performed to compare the odds ratios of 2-year septic revision rates from 2011 to 2019 to the reference year of 2010. Linear regression was used to compare the change in the overall and high-risk subanalysis groups. RESULTS Among the 860,185 patients, 5,589 underwent septic revision within 2 years. The 2-year septic revision rate decreased from 0.75% in 2010 to 0.69% in 2019 (compounded annual growth rate = -0.94%, P = 0.049). Multivariable logistic regressions demonstrated that the odds of septic revision in 2019 were significantly lower than those in 2010 (odds ratio: 0.83, 95% CI [confidence interval]: [0.70 to 0.96], P = 0.017). In high-risk patients, the septic revision rate decreased from 1.04 to 0.80% (compounded annual growth rate = -2.80%, P = 0.004), specifically in those who had a history of psychoses, Medicaid insurance, anemia, heart failure, obesity, liver disease, tobacco use, and drug abuse (P < 0.05 for all). CONCLUSIONS This study demonstrated a national reduction in the 2-year septic revision rate in all TKA patients, including patients considered at high risk for PJI. This suggests that current preventative methods may be efficacious on a national scale in TKA. Further research is needed to identify more modalities to reduce the national incidence of this morbid and costly complication.
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Affiliation(s)
- Anthony K Chiu
- Department of Orthopaedic Surgery, George Washington University Hospital, Washington, District of Columbia
| | - Amil R Agarwal
- Department of Orthopaedic Surgery, George Washington University Hospital, Washington, District of Columbia
| | - Correggio Peagler
- Department of Orthopaedic Surgery, George Washington University Hospital, Washington, District of Columbia
| | - Thomas Fraychineaud
- Department of Orthopaedic Surgery, George Washington University Hospital, Washington, District of Columbia
| | - Alex Gu
- Department of Orthopaedic Surgery, George Washington University Hospital, Washington, District of Columbia
| | - Philip M Parel
- Department of Orthopaedic Surgery, George Washington University Hospital, Washington, District of Columbia
| | - Gregory J Golladay
- Department of Orthopaedic Surgery, Virginia Commonwealth University Hospital, Richmond, Virginia
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20
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Giraldo-Osorno PM, Turner AB, Barros SM, Büscher R, Guttau S, Asa'ad F, Trobos M, Palmquist A. Anodized Ti6Al4V-ELI, electroplated with copper is bactericidal against Staphylococcus aureus and enhances macrophage phagocytosis. JOURNAL OF MATERIALS SCIENCE. MATERIALS IN MEDICINE 2025; 36:14. [PMID: 39853447 PMCID: PMC11761993 DOI: 10.1007/s10856-024-06853-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/31/2024] [Accepted: 12/10/2024] [Indexed: 01/26/2025]
Abstract
Implants aim to restore skeletal dysfunction associated with ageing and trauma, yet infection and ineffective immune responses can lead to failure. This project characterized the microbiological and host cell responses to titanium alloy with or without electroplated metallic copper. Bacterial viability counting and scanning electron microscopy quantified and visualized the direct and indirect bactericidal effects of the Cu-electroplated titanium (Cu-Ep-Ti) against two different Staphylococcus aureus strains. Human THP-1 macrophage adhesion and viability was analyzed, along with phagocytosis. Results showed potent antimicrobial activity alongside promising host-immunomodulatory properties. Direct and indirect exposure to Cu-Ep-Ti produced potent bactericidal effects resulting in 94-100% reductions in bacterial viability at 24 h, with complete eradication in some cases. As expected, cytotoxicity was observed in THP-1 macrophages without media exchange, though when media was exchanged at 8, 24 and 48 h cell viability was equivalent to Control-Ti. Interestingly macrophages adhered to the copper material or grown in the presence of copper ions showed 7-fold increase in phagocytosis of S. aureus bioparticles compared to Control-Ti, suggesting a dual bactericidal and host immunomodulatory mechanism. In conclusion, this Cu-electroplated Ti biomaterial can limit bacterial contamination on the implant surface, whilst simultaneously promoting a beneficial antimicrobial immune response.
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Affiliation(s)
- Paula Milena Giraldo-Osorno
- Department of Biomaterials, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Centre for Antibiotic Resistance Research in Gothenburg (CARe), University of Gothenburg, Gothenburg, Sweden
| | - Adam Benedict Turner
- Department of Biomaterials, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Centre for Antibiotic Resistance Research in Gothenburg (CARe), University of Gothenburg, Gothenburg, Sweden
| | - Sebastião Mollet Barros
- Stryker Trauma Gmbh, Schönkirchen, Germany
- Faculty of Medicine, Centre for Translational Bone, Joint and Soft Tissue Research, Technische Universität Dresden, Dresden, Germany
| | | | | | - Farah Asa'ad
- Department of Biomaterials, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Oral Biochemistry, Institute of Odontology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Margarita Trobos
- Department of Biomaterials, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
- Centre for Antibiotic Resistance Research in Gothenburg (CARe), University of Gothenburg, Gothenburg, Sweden.
| | - Anders Palmquist
- Department of Biomaterials, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
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21
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Kohring A, Parikh N, Hobbs J, Lowitz S, Gold P, Krueger CA. The Effect of Cemented Implants Placed During Initial TKA on Surgical Time and Expenses in Revision TKA. J Am Acad Orthop Surg 2025; 33:75-82. [PMID: 38759227 DOI: 10.5435/jaaos-d-23-01184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Accepted: 04/18/2024] [Indexed: 05/19/2024] Open
Abstract
INTRODUCTION Revision total knee arthroplasty (rTKA) is a complex procedure that often requires the removal of previous implants. There is little information evaluating the difference between removing cemented or noncemented knee prostheses in revision surgeries. The purpose of this study was to determine whether removing cemented or noncemented implants would affect surgical time and expenses incurred during revision procedures. METHODS This retrospective cohort study used a single-institution database to identify 300 patients who underwent femoral and tibial implant rTKA from 2016 to 2022 because of mechanical complications (infection cases excluded). Radiographs and surgical reports were used to confirm whether the fixation technique was cemented (N = 243) or noncemented (N = 57). The primary outcomes were surgical time and surgery costs. Secondary outcomes included readmission rates, revision implants used, stem usage, and insurance type. RESULTS The average surgical time was 121 minutes for noncemented and 128 minutes for cemented procedures ( P = 0.118). The 90-day readmission rates for each group were similar at 7.00% for the cemented cohort and 8.77% for the noncemented cohort ( P = 0.643). For patients with Medicare Advantage, the respective surgery costs were $1,966 for noncemented and $1,968 for cemented TKA ( P = 0.988). For patients with commercial insurance, the respective surgery costs were $4,854 for noncemented and $5,660 for cemented TKA ( P = 0.330). CONCLUSION Primary knee fixation type, cemented or noncemented, did not appear to influence the surgical duration or surgical costs of both-implant revision knee surgery indicated for mechanical complications.
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Affiliation(s)
- Adam Kohring
- From the Jefferson Health New Jersey (Kohring), Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA (Parikh, Hobbs, and Krueger), Midwestern University, Downers Grove, IL (Lowitz), and Panorama Orthopedic & Spine Center, Golden, CO (Gold)
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22
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Kurtz MA, Aslani S, Smith JA, Klein GR, Spece H, Kurtz SM. Titanium-Titanium Junctions in the Knee Corrode, Generating Damage Similar to the Hip. J Arthroplasty 2025; 40:227-235. [PMID: 39053666 DOI: 10.1016/j.arth.2024.07.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2024] [Revised: 07/13/2024] [Accepted: 07/17/2024] [Indexed: 07/27/2024] Open
Abstract
BACKGROUND Previous studies identified corrosion between the modular tibial components of total knee arthroplasty devices. However, gaps persist. Compared to the hip, damage modes that occur within taper junctions in the knee remain poorly understood. In this study, we investigated corrosion on total knee arthroplasty components with titanium-titanium junctions. We asked the following question: under typical in vivo cyclic loading conditions, will the same alloy damage modes from total knee arthroplasty devices resemble those documented in the hip? METHODS A total of 50 paired titanium alloy tibial baseplates and stems were collected and semiquantitatively analyzed using Goldberg corrosion scoring. To characterize damage, a subsection of moderately and severely corroded components was sectioned and imaged using scanning electron and digital optical microscopy. RESULTS Of the 100 device components, 95% showed visual evidence of corrosion. The initial contact area between the stem and bore generally occurred 3 mm from the stem taper base. Scanning electron microscopy revealed 4 damage modes, including oxide film formation, crevice corrosion, selective dissolution, and pitting. CONCLUSIONS Each of the damage modes identified in modular titanium-titanium tibial junctions was previously reported by total hip arthroplasty retrieval studies. Cumulatively, our results suggest that mechanically assisted crevice corrosion promoted this damage in vivo.
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Affiliation(s)
- Michael A Kurtz
- Implant Research Core, School of Biomedical Engineering, Science, and Health Systems, Drexel University, Philadelphia, Pennsylvania
| | - Shabnam Aslani
- Implant Research Core, School of Biomedical Engineering, Science, and Health Systems, Drexel University, Philadelphia, Pennsylvania
| | - James A Smith
- Implant Research Core, School of Biomedical Engineering, Science, and Health Systems, Drexel University, Philadelphia, Pennsylvania
| | - Gregg R Klein
- Department of Orthopaedic Surgery, Hackensack University Medical Center, Hackensack, New Jersey
| | - Hannah Spece
- Implant Research Core, School of Biomedical Engineering, Science, and Health Systems, Drexel University, Philadelphia, Pennsylvania
| | - Steven M Kurtz
- Implant Research Core, School of Biomedical Engineering, Science, and Health Systems, Drexel University, Philadelphia, Pennsylvania
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23
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Hsu YC, Hsu AHS, Wu CT, Tan TL, Wang JW, Kuo FC. Association between IV and topical tranexamic acid use and periprosthetic joint infections in hip and knee arthroplasty: a retrospective study. BMC Musculoskelet Disord 2024; 25:1033. [PMID: 39702243 DOI: 10.1186/s12891-024-08080-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Accepted: 11/14/2024] [Indexed: 12/21/2024] Open
Abstract
BACKGROUND Anemia and blood transfusions are recognized as risk factors for periprosthetic joint infections (PJI). Tranexamic acid (TXA) is established in reducing perioperative blood loss and transfusion requirements. Our study investigates the impact of perioperative TXA administration on the incidence of PJI in patients undergoing total joint arthroplasty (TJA) and evaluates the association of intravenous (IV) and topical applications with PJI occurrence. METHODS A retrospective review was performed on 8042 patients who underwent primary total hip arthroplasty (THA) and knee arthroplasty (TKA) from January 2009 to December 2020, with a minimum one-year follow-up at our institution. We compared patients who received TXA (n = 3664, with 2345 receiving it IV and 1319 topically) to those who did not (n = 4378). 0.5-1.25 g of IV TXA was administered before skin incision, and 1.5-3 g of topical TXA was injected intra-articularly or into the drainage tube during surgery. The primary outcome was PJI development within one year, defined by the 2013 International Consensus Meeting criteria. Secondary outcomes included blood transfusion, hospital length of stay (LOS), venous thromboembolism (VTE), and 90-day readmission. We employed multivariate logistic regression and propensity score weighting to adjust for potential confounders and conducted subgroup analyses to assess PJI odds in TKA and THA patients treated with IV and topical TXA. RESULTS The TXA group demonstrated a lower PJI occurrence (1.1% vs. 2.1%, p < 0.001), less blood transfusion (14.4% vs. 22.7%, p < 0.001) and shorter LOS (5.6 ± 1.6 vs. 6.5 ± 2.5, p < 0.001) compared to those without TXA. There was no difference between the two groups with regards to VTE and 90-day readmission. Perioperative TXA administration demonstrated lower PJI in multivariate analysis (OR 0.54, 95% CI 0.36-0.80, p = 0.002), and in propensity score weighting (OR 0.53, 95% CI 0.36-0.80, p = 0.002). In the subgroup analysis, both IV and topical administration of TXA resulted in decreased PJI (IV group: OR 0.53, 95% CI, 0.33-0.84, p = 0.007, topical group: OR 0.51, 95% CI, 0.29-0.89, p = 0.018), especially in primary TKA (IV TXA, OR 0.49, 95% CI, 0.29-0.83, p = 0.008; Topical TXA, OR, 0.56, 95% CI, 0.32-0.98, p = 0.042). CONCLUSION Perioperative TXA administration in primary hip and knee arthroplasty is significantly associated with a reduced PJI occurrence. Both IV and topical TXA routes showed similar association with reduced PJI occurrence, with a notable correlation observed in primary TKA.
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Affiliation(s)
- Yun-Chen Hsu
- Department of Orthopaedic Surgery, Kaohsiung Chang Gung Memorial Hospital, No. 123, Dapi Road, Niaosong District, Kaohsiung, 833, Taiwan
| | - Allen Herng Shouh Hsu
- Department of Orthopaedic Surgery, Kaohsiung Chang Gung Memorial Hospital, No. 123, Dapi Road, Niaosong District, Kaohsiung, 833, Taiwan
| | - Cheng-Ta Wu
- Department of Orthopaedic Surgery, Kaohsiung Chang Gung Memorial Hospital, No. 123, Dapi Road, Niaosong District, Kaohsiung, 833, Taiwan
| | - Timothy L Tan
- Sequoia Institute for Surgical Service, Visalia, CA, USA
- Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco, CA, USA
| | - Jun-Wen Wang
- Department of Orthopaedic Surgery, Kaohsiung Chang Gung Memorial Hospital, No. 123, Dapi Road, Niaosong District, Kaohsiung, 833, Taiwan.
- College of Medicine, Chang Gung University, Kaohsiung, Taiwan.
| | - Feng-Chih Kuo
- Department of Orthopaedic Surgery, Kaohsiung Chang Gung Memorial Hospital, No. 123, Dapi Road, Niaosong District, Kaohsiung, 833, Taiwan.
- College of Medicine, Chang Gung University, Kaohsiung, Taiwan.
- Center for General Education, Cheng Shiu University, Kaohsiung, Taiwan.
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24
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R S, P S, Gh S, S B, M E, Ja B. Analysis of systemic serum vancomycin levels following intraarticular application in primary total joint arthroplasty. Arch Orthop Trauma Surg 2024; 145:60. [PMID: 39694929 DOI: 10.1007/s00402-024-05688-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Accepted: 10/08/2024] [Indexed: 12/20/2024]
Abstract
INTRODUCTION Periprosthetic joint infection (PJI) is a serious complication following primary total joint arthroplasty (TJA). PJI accounts for 15-25% of revision surgeries, therefore it is associated with PJI is associated with substantial patient morbidity and mortality as well as increased healthcare expenditures due to complex treatment strategies. Recently, intraoperative local application of vancomycin powder is increasingly being used in primary total hip and knee arthroplasty (THA, TKA) as an additive strategy for PJI prevention. Whereas local vancomycin concentrations have already been investigated in prior studies, evidence on systemic vancomycin levels and potential adverse drug reactions (ADR) is limited. Purpose of this study was to investigate systemic vancomycin levels following intraarticular application in primary TJA. MATERIALS AND METHODS This pilot study is a prospective analysis of patients undergoing primary THA and TKA between April and July 2023. One gram of vancomycin powder was applied to the prosthesis prior to wound closure. Serum vancomycin levels were measured at two standardised time points, 24 and 48 h postoperatively. RESULTS In total, 103 patients were included, and the patient collective was further stratified by surgical procedure into a THA subgroup (n = 52) and a TKA subgroup (n = 51). Mean serum vancomycin levels showed a significant group difference at both time points (24 h: p < 0.001; 48 h: p = 0.044) with higher serum vancomycin concentrations in the THA cohort. Mean serum vancomycin levels in THA patients were 1.25 μg/ml (range 0.00-7.00 μg/ml) after 24 h and 0.34 μg/ml (range 0.00-4.80 μg/ml) 48 h postoperatively. In TKA, no systemic vancomycin levels were detected. Vancomycin concentrations did not reach therapeutic levels in any patient. No ADR was detected in the whole study collective. CONCLUSION Following intraarticular administration of vancomycin powder, no systemic vancomycin levels within the therapeutic range were detected, thus it may serve as a safe and cost-effective adjunct to strategies for prevention of PJI.
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Affiliation(s)
- Stauss R
- School of Medicine and Health Sciences, Division of Orthopaedics at Campus Pius-Hospital, Carl von Ossietzky Universität Oldenburg, Georgstraße 12, 26121, Oldenburg, Germany.
| | - Savov P
- School of Medicine and Health Sciences, Division of Orthopaedics at Campus Pius-Hospital, Carl von Ossietzky Universität Oldenburg, Georgstraße 12, 26121, Oldenburg, Germany
| | - Seeber Gh
- School of Medicine and Health Sciences, Division of Orthopaedics at Campus Pius-Hospital, Carl von Ossietzky Universität Oldenburg, Georgstraße 12, 26121, Oldenburg, Germany
- Department of Orthopedics, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Brand S
- School of Medicine and Health Sciences, Division of Orthopaedics at Campus Pius-Hospital, Carl von Ossietzky Universität Oldenburg, Georgstraße 12, 26121, Oldenburg, Germany
| | - Ettinger M
- School of Medicine and Health Sciences, Division of Orthopaedics at Campus Pius-Hospital, Carl von Ossietzky Universität Oldenburg, Georgstraße 12, 26121, Oldenburg, Germany
| | - Beheshty Ja
- School of Medicine and Health Sciences, Division of Orthopaedics at Campus Pius-Hospital, Carl von Ossietzky Universität Oldenburg, Georgstraße 12, 26121, Oldenburg, Germany
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Weis S, Seifert L, Oltmanns M, Khury F, Bieger R, Faschingbauer M. The Etiology of Total Knee Arthroplasty Failure Influences on Improvement in Knee Function: A Follow-Up Study. J Clin Med 2024; 13:7672. [PMID: 39768594 PMCID: PMC11677656 DOI: 10.3390/jcm13247672] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2024] [Revised: 11/21/2024] [Accepted: 11/28/2024] [Indexed: 01/11/2025] Open
Abstract
Background: Outcomes following total knee arthroplasty (TKA) revisions are variable, and it is hypothesized that the underlying cause of primary TKA failure impacts postoperative outcomes. This study analyzes the results of TKA revisions seven years after surgery, in relation to the etiology of primary failure and other influencing factors. A previous study conducted in 2013 examined the same cohort of patients three months after revision surgery. Methods: From the original study, 97 patients were followed up, and 49 patients were eligible for inclusion. Patients were classified into four groups: "periprosthetic infection" (PPI), "aseptic loosening," "instability," and "arthrofibrosis." Outcomes were analyzed using established scores (the Knee Society Score (KSS), New Knee Society Score (nKSS), and the Western Ontario and McMaster Universities (WOMAC) index) and considering factors such as age, gender, BMI, and ASA classification. The outcomes were analyzed using three time intervals: "Outcome Short" (preoperative to 3 months postoperative); "Outcome Long" (preoperative to 7 years postoperative); and "Delta PostOP" (3 months postoperative to 7 years postoperative). Results: Significant improvements were observed in all time intervals, especially in the "Outcome Short" (p < 0.001) and "Delta PostOP" (p < 0.001) periods. The "instability" and "aseptic loosening" groups showed better outcomes in terms of range of motion and knee scores than the "arthrofibrosis" and "infection" groups (p < 0.05). A lower BMI and an ASA status of II were associated with better outcomes (p < 0.05). Women also showed superior results in the nKSS (p < 0.05). Discussion: Patients with "aseptic loosening" and "instability" had the best long-term outcomes. Lower BMI and better ASA status also correlated with improved results. These findings can inform patients of the potential outcomes of revision surgery, thereby facilitating informed decision-making.
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Affiliation(s)
- Sandy Weis
- Department of Orthopedic Surgery, University of Augsburg, 86159 Augsburg, Germany
| | - Lisa Seifert
- Clinic for Anesthesiology, University of Augsburg, 86159 Augsburg, Germany
| | - Moritz Oltmanns
- Department of Orthopedic Surgery, University of Ulm, 89081 Ulm, Germany;
| | - Farouk Khury
- Rambam Health Care Campus, Orthopedic Surgery, Haifa 3109601, Israel
| | - Ralf Bieger
- Schön Klinik München Harlaching, 81547 Munich, Germany;
| | - Martin Faschingbauer
- Department of Orthopedics, Klinik Penzing, Wiener Gesundheitsverbund, 1140 Vienna, Austria
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26
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Raval P, Coolican M. Preoperative, intraoperative, and postoperative concepts to prevent infection for unicompartmental knee arthroplasty. J ISAKOS 2024; 9:100345. [PMID: 39427820 DOI: 10.1016/j.jisako.2024.100345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2024] [Accepted: 10/08/2024] [Indexed: 10/22/2024]
Abstract
Periprosthetic joint infection (PJI) is a complication that occurs in less than 1% of patients after unicompartmental knee arthroplasty (UKA). Though infrequent, it may potentially lead to revision while placing a significant financial burden on the healthcare system. Preoperative, intra-operative, and postoperative strategies should be implemented to minimize the risk of PJI. Patient optimization prior to surgery can help to identify patients at risk for PJI and also maximize the health of the patient prior to surgery. Intraoperative and postoperative strategies can also mitigate the risk of postoperative infection. This article will summarize the evidence for preoperative, intra-operative, and postoperative strategies to prevent PJI in UKA. This will include topics on malnutrition and obesity, Staphylococcus aureus, smoking, human immunodeficiency virus, rheumatoid arthritis, as well as skin preparation, laminar air flow, preoperative antibiotic administration antimicrobial incision drapes, pulsatile lavage, vancomycin powder, wound closure method, thromboprophylactic agents, and closed incisional negative pressure wound therapy dressings.
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Affiliation(s)
| | - Myles Coolican
- Sydney Orthopaedic Research Institute, Sydney Australia.
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27
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Egerci OF, Yapar A, Dogruoz F, Selcuk H, Kose O. Preventive strategies to reduce the rate of periprosthetic infections in total joint arthroplasty; a comprehensive review. Arch Orthop Trauma Surg 2024; 144:5131-5146. [PMID: 38635048 PMCID: PMC11602800 DOI: 10.1007/s00402-024-05301-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2023] [Accepted: 03/24/2024] [Indexed: 04/19/2024]
Abstract
The increasing frequency of total hip (THA) and knee arthroplasties (TKA) is marred by the rise in periprosthetic joint infections (PJIs) and surgical site infections (SSIs), with PJIs incurring costs over $1.62 billion as of 2020 and individual case management averaging $90,000. SSIs additionally burden the U.S. healthcare economy with billions in expenses annually. PJI prevalence in primary THA and TKA ranges from 0.5% to 2.4%, spiking to 20% in revisions and representing 25% of TKA revision causes. Projections estimate up to 270,000 annual PJI cases by 2030. Often caused by gram-positive bacteria, particularly methicillin-resistant staphylococci, these infections demand preventive measures. This review dissects PJI prevention across preoperative, intraoperative, and perioperative phases, aligning with evidence-based CDC and WHO guidelines. Preoperative measures include managing diabetes, obesity, tobacco use, Staphylococcus aureus screening and nasal decolonization, nutritional optimization, and management of inflammatory arthropathies. Intraoperatively, antibiotic prophylaxis, skin preparation, operative room environmental controls, surgical technique precision, and irrigation options are scrutinized. Perioperative concerns focus on anticoagulation, blood management, and infection risk mitigation. Integrating these strategies promotes a patient-centric care model, aiming to reduce PJI incidence, improve patient outcomes, and increase care cost-effectiveness in joint arthroplasty.
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Affiliation(s)
- Omer Faruk Egerci
- Department of Orthopedics and Traumatology, Antalya Training and Research Hospital, Antalya, Turkey
| | - Aliekber Yapar
- Department of Orthopedics and Traumatology, Antalya Training and Research Hospital, Antalya, Turkey
| | - Fırat Dogruoz
- Department of Orthopedics and Traumatology, Antalya Training and Research Hospital, Antalya, Turkey
| | - Huseyin Selcuk
- Department of Orthopedics and Traumatology, Antalya Training and Research Hospital, Antalya, Turkey
| | - Ozkan Kose
- Department of Orthopedics and Traumatology, Antalya Training and Research Hospital, Antalya, Turkey.
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Röhrl A, Klawonn F, Füchtmeier B, Wulbrand C, Gessner A, Zustin J, Ambrosch A. Results of a monocentric field study: value of histology compared to sonication method and conventional tissue culture in the diagnosis of periprosthetic joint infection (PJI). Infection 2024; 52:2287-2296. [PMID: 38730201 DOI: 10.1007/s15010-024-02278-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Accepted: 04/21/2024] [Indexed: 05/12/2024]
Abstract
BACKGROUND To confirm the diagnosis of periprosthetic joint infection (PJI), the Infectious Diseases Society of America (IDSA) and the International Consensus Meeting (ICM) have defined criteria that include histology as a minor criterion and the sonication method only as an additional criterion. The aim of this monocentric, retrospective study was to investigate the value of histology and whether sonication leads to a more accurate diagnosis. MATERIALS AND METHODS All revision surgeries for knee and hip arthroplasty between 2017 and 2020 were included. With regard to microbiological diagnostic, conventional culture of periprosthetic biopsies and sonication of explant material were performed. In addition, histology and non-specific inflammatory markers (CRP, leukocytes) were recorded. RESULTS A total of 78 patients with PJI and 62 aseptic controls were included. From both microbiological methods (conventional culture / sonication), Staphyloccus (S.) epidermidis and S. aureus were detected most frequently. However, compared to the conventional microbiology, a higher sensitivity was calculated for sonication, albeit with a lower specificity in relation to a PJI. In two logistic regression models for the significance of all diagnostic parameters in PJI, the AUC was 0.92 and 0.96 with histology in particular making the decisive contribution in both models (p < 0. 001, both models). CONCLUSION Since histology showed the highest accuracy in the current study, its importance in the PJI criteria should be reevaluated. Sonication shows a high sensitivity for germ detection with a lower specificity and should only be used in combination with the conventional culture for microbiolgical diagnostics.
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Affiliation(s)
- Alexander Röhrl
- Department of Trauma Surgery, Orthopaedics & Sports Medicine, Hospital of Brothers of Mercy, Regensburg, Germany
| | - Frank Klawonn
- Biostatistics, Helmholtz Centre for Infection Research, Brunswick, Germany
- Institute for Information Engineering, Ostfalia University, Wolfenbüttel, Germany
| | - Bernd Füchtmeier
- Department of Trauma Surgery, Orthopaedics & Sports Medicine, Hospital of Brothers of Mercy, Regensburg, Germany
| | - Christian Wulbrand
- Department of Trauma Surgery, Orthopaedics & Sports Medicine, Hospital of Brothers of Mercy, Regensburg, Germany
| | - Andre Gessner
- Institute of Clinical Microbiology and Infection Prevention, University Hospital, Regensburg, Germany
| | - Jozef Zustin
- Private Histopathology Service, Regensburg, Germany
- Gerhard Domagk Institute of Pathology, University Medical Center, Münster, Germany
| | - Andreas Ambrosch
- Institute of Laboratory Medicine, Microbiology and Infection Prevention, Hospital of Brothers of Mercy, Prüfeninger Straße 86, 93049, Regensburg, Germany.
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Derr T, MacDonald DW, Malkani AL, Mont MA, Piuzzi NS, Kurtz SM. Oxidation and Damage Mechanisms of Second-Generation Highly Cross-Linked Polyethylene Tibial Inserts. J Arthroplasty 2024; 39:3084-3091. [PMID: 38906197 DOI: 10.1016/j.arth.2024.06.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Revised: 06/11/2024] [Accepted: 06/13/2024] [Indexed: 06/23/2024] Open
Abstract
BACKGROUND After clinical introduction in 2005, sequentially annealed, highly cross-linked polyethylene (SA HXLPE) was studied for retrievals with short implantation times; however, long-term follow-ups are lacking. The objective of this study was to examine and compare the revision reasons, damage mechanisms, and oxidation indices of SA HXLPE and conventional gamma inert-sterilized (Gamma Inert) ultra-high-molecular-weight polyethylene tibial inserts implanted for >5 years. METHODS There were 74 total knee arthroplasty tibial inserts (46 SA HXLPEs, 28 Gamma Inerts) implanted for >5 years (mean 7 ± 2 years) retrieved as part of a multicenter retrieval program. Cruciate-retaining implants comprised 44% of the SA HXLPEs and 14% of the Gamma Inerts. Patient factors and revision reasons were collected from revision operating notes. A semiquantitative scoring method was used to assess surface damage mechanisms. Oxidation was measured using Fourier transform infrared microscopy according to American Society for Testing and Materials 2102. Differences between cohorts were assessed with Mann-Whitney U-tests. RESULTS Loosening (Gamma Inert: 17 of 28, SA HXLPE: 15 of 46) and instability (Gamma Inert: 6 of 28, SA HXLPE: 15 of 46) were the most common revision reasons for both cohorts. The most prevalent surface damage mechanisms were burnishing, pitting, and scratching, with burnishing of the condyles being higher in Gamma Inert components (P = .022). Mean oxidation was higher in the SA HXLPE inserts at the articulating surface (P = .002) and anterior-posterior faces (P = .023). No difference was observed at the backside surface (P = .060). CONCLUSIONS Revision reasons and surface damage mechanisms were comparable in the Gamma Inert and SA cohorts. Further studies are needed to continue to assess the in vivo damage and clinical relevance, if any, of oxidation in SA HXLPE over longer implantation times, particularly for implants implanted for more than 10 years.
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Affiliation(s)
- Tabitha Derr
- Implant Research Core, Drexel University, Philadelphia, Pennsylvania
| | | | - Arthur L Malkani
- Department of Orthopaedic Surgery, University of Louisville, Louisville, Kentucky
| | - Michael A Mont
- Department of Orthopaedic Surgery, Sinai Hospital of Baltimore, Rubin Institute for Advanced Orthopedics, Baltimore, Maryland
| | - Nicolas S Piuzzi
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Steven M Kurtz
- Implant Research Core, Drexel University, Philadelphia, Pennsylvania
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Karlidag T, Dasci MF, Steinhoff J, Gehrke T, Citak M. What is the diagnostic accuracy of neutrophil to lymphocyte ratio and monocyte to lymphocyte ratio in detecting acute periprosthetic joint infections? A gender-specific analysis. Arch Orthop Trauma Surg 2024; 144:5071-5078. [PMID: 38147079 DOI: 10.1007/s00402-023-05162-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2023] [Accepted: 11/26/2023] [Indexed: 12/27/2023]
Abstract
PURPOSE The accurate and timely diagnosis of periprosthetic joint infection (PJI) is critical for guiding optimal treatment management and success, highlighting the requirement of readily available inexpensive serum biomarkers to increase the diagnostic accuracy for PJI. Many studies have investigated the diagnostic accuracy of neutrophil to lymphocyte ratio (NLR) and monocyte to lymphocyte ratio (MLR). However, there is a lack of existing literature regarding optimal thresholds for acute PJI. The purpose of this study was to reveal the most appropriate cut-off values for MLR and NLR in detecting acute PJI with a gender specific analysis. METHODS Patients were classified as having an acute PJI if they met the International Consensus Meeting (ICM) 2018 modified criteria. Patients who had a negative clinical and diagnostic workup for a PJI and the presence of erythema on the index surgical area were included in the erysipelas group (control group). Data obtained from all patients included age, sex, body mass index (BMI), Charlson Comorbidity Index (CCI), procedure type (THA or TKA), serum C-reactive protein (CRP), and blood studies at the admission and culture results were retrieved from the electronic medical record. RESULTS ROC curve analysis was used to determine the gender-specific optimal threshold values for CRP, NLR, and MLR. Comparing the sensitivities and specificities of NLR and MLR at the identified best thresholds in males and females, the study found similar sensitivities of NLR in males and females with 0.84 and 0.84, respectively. On the other hand, an MLR of 0.67 or more reported a notably higher specificity in male patients [0.90 (95% CI 0.75-0.96) versus 0.70 (95% CI 0.56-0.80)]. CONCLUSION NLR and MLR represent commonly ordered, low-cost, simple, and readily available complete cell count laboratory values and should be used as adjunct tests with reasonable diagnostic accuracy in detecting acute PJIs. Moreover, with its excellent specificity and PPV, MLR could provide valuable insight in diagnosing acute PJI, particularly in male patients. LEVEL OF EVIDENCE Level III Retrospective Cohort analysis.
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Affiliation(s)
- Taner Karlidag
- Department of Orthopedics and Traumatology, Helios ENDO-Klinik Hamburg, Holstenstr. 2, 22767, Hamburg, Germany
- Department of Orthopedics and Traumatology, Gaziantep City Hospital, Gaziantep, Turkey
| | - Mustafa Fatih Dasci
- Department of Orthopedics and Traumatology, Helios ENDO-Klinik Hamburg, Holstenstr. 2, 22767, Hamburg, Germany
| | - Julian Steinhoff
- Department of Orthopedics and Traumatology, Helios ENDO-Klinik Hamburg, Holstenstr. 2, 22767, Hamburg, Germany
| | - Thorsten Gehrke
- Department of Orthopedics and Traumatology, Helios ENDO-Klinik Hamburg, Holstenstr. 2, 22767, Hamburg, Germany
| | - Mustafa Citak
- Department of Orthopedics and Traumatology, Helios ENDO-Klinik Hamburg, Holstenstr. 2, 22767, Hamburg, Germany.
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Jones CM, Acuna AJ, Forlenza EM, Serino J, Della Valle CJ. Trends and Epidemiology in Revision Total Knee Arthroplasty: A Large Database Study. J Arthroplasty 2024:S0883-5403(24)01268-3. [PMID: 39622423 DOI: 10.1016/j.arth.2024.11.051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2024] [Revised: 11/22/2024] [Accepted: 11/26/2024] [Indexed: 12/24/2024] Open
Abstract
BACKGROUND As the volume of primary total knee arthroplasty (TKA) continues to grow, the clinical and financial burden of revision total knee arthroplasty (rTKA) is expected to increase. The purpose of this investigation was to characterize contemporary indications and complications for rTKA. METHODS Patients undergoing rTKA between 2010 and 2021 were identified within an administrative claims database. Adjusted rTKA incidence was calculated by dividing the annual rTKA volume by the annual primary TKA and multiplying by 100,000. Mann-Kendall trend tests were utilized to trend revision volume, etiology, 90-day postoperative complications, and patient demographics. RESULTS A total of 397,367 rTKA were identified over our study period, of which 287,492 (72.4%) had coding regarding revision etiology. The volume of annual rTKA (31,091 to 33,850; P = 0.451) did not change over the study period. The adjusted incidence of rTKA decreased (25,568.3 to 19,272.2 per 100,000 annual TKA; P = 0.011). The leading causes of revision TKA were infection (21.2%), aseptic implant loosening (19.3%), and instability (9.8%). The rate of septic revision (4,710.5 to 4,426.1 per 100,000 annual TKAs) and aseptic implant loosening (4,502.5 to 3,636.4 per 100,000 annual TKAs) did not change (both P values > 0.05). The rates of instability increased (1,369.2 to 2,609.85 per 100,000 annual TKAs; P = 0.007). The rates of postrevision surgical site infection, periprosthetic joint infection, deep vein thrombosis, and transfusion decreased over the study period, while rates of emergency department visits and readmission increased (all P values <0.05). CONCLUSIONS The incidence of revision TKA may be slowing. While the risk of revision for infection and aseptic loosening remains unchanged, revision for instability has increased. The rates of postoperative complications appear to have decreased. Improved surgical technique, implant design, and perioperative protocols may have contributed to these findings. Continued work is necessary to reduce the risk of failure and postoperative complications.
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Affiliation(s)
- Conor M Jones
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois
| | - Alexander J Acuna
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois
| | - Enrico M Forlenza
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois
| | - Joseph Serino
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois
| | - Craig J Della Valle
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois
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Suzuki Y, Iwasaki K, Joutoku Z, Onodera T, Matsuoka M, Hishimura R, Hamasaki M, Kondo E, Iwasaki N. High-concentration continuous local antibacterial perfusion therapy: safety and potential efficacy for acute and chronic periprosthetic knee joint infection. SICOT J 2024; 10:51. [PMID: 39589098 PMCID: PMC11590478 DOI: 10.1051/sicotj/2024048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2024] [Accepted: 10/18/2024] [Indexed: 11/27/2024] Open
Abstract
BACKGROUND Periprosthetic joint infections (PJIs) following total knee arthroplasty (TKA) are among the most challenging pathologies to manage. Recently, continuous local antibiotic perfusion (CLAP) therapy has been introduced for treating musculoskeletal infections in orthopedics. This study aimed to determine the outcomes and risks of CLAP therapy combined with conventional treatment for PJIs after TKA. METHODS We retrospectively evaluated 14 patients with PJIs. For acute PJIs, CLAP therapy was performed alongside debridement, intravenous antibiotics, and implant retention. For chronic PJIs, a two-stage revision with CLAP therapy and intravenous antibiotics was performed. Implants were replaced with a cement mold incorporating CLAP therapy, followed by revision surgery after 3 months. For all patients, 120 mg/day of gentamicin (GM) was locally administered into the knee joint for 2 weeks as part of CLAP therapy, in combination with perioperative intravenous antibiotics. RESULTS Five patients developed acute PJIs, and nine developed chronic PJIs after TKA. The mean follow-up period was 18.4 (15.2-21.1) months. All five patients with PJIs treated with one-stage surgery (debridement and insert exchange only) successfully preserved their implants. Among the nine patients with chronic PJIs, seven underwent CLAP therapy combined with two-stage revision surgery, resulting in successful treatment without relapse, whereas the remaining two patients were initially treated with one-stage surgery and CLAP therapy but failed to retain their implants, and subsequently required additional two-stage revision surgery, which ultimately succeeded. No adverse effects from GM were reported. CONCLUSIONS Our results suggest that CLAP therapy is safe and may be effective for treating acute and most chronic PJIs after TKA.
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Affiliation(s)
- Yuki Suzuki
- Department of Orthopaedic Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University Kita 15 jo, Nishi 7 chome, Kita-ku Sapporo Hokkaido 060-8638 Japan
| | - Koji Iwasaki
- Department of Functional Reconstruction for the Knee Joint, Graduate School of Medicine, Hokkaido University Kita 15 jo, Nishi 7 chome, Kita-ku Sapporo Hokkaido 060-8638 Japan
| | - Zenta Joutoku
- Department of Orthopaedic Surgery, Obihiro Kosei Hospital Nishi 14 jo, Minami 10 chome 1 Obihiro Hokkaido 080-0024 Japan
| | - Tomohiro Onodera
- Department of Orthopaedic Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University Kita 15 jo, Nishi 7 chome, Kita-ku Sapporo Hokkaido 060-8638 Japan
| | - Masatake Matsuoka
- Department of Orthopaedic Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University Kita 15 jo, Nishi 7 chome, Kita-ku Sapporo Hokkaido 060-8638 Japan
| | - Ryosuke Hishimura
- Department of Orthopaedic Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University Kita 15 jo, Nishi 7 chome, Kita-ku Sapporo Hokkaido 060-8638 Japan
| | - Masanari Hamasaki
- Department of Orthopaedic Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University Kita 15 jo, Nishi 7 chome, Kita-ku Sapporo Hokkaido 060-8638 Japan
| | - Eiji Kondo
- Centre for Sports Medicine, Hokkaido University Hospital Kita 14 jo Nishi 5 chome, Kita-ku Sapporo Hokkaido 060-8648 Japan.
| | - Norimasa Iwasaki
- Department of Orthopaedic Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University Kita 15 jo, Nishi 7 chome, Kita-ku Sapporo Hokkaido 060-8638 Japan
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Fernández-Torres J, Zamudio-Cuevas Y, Martínez-Flores K, López-Macay A, Rosas-Alquicira G, Martínez-Zavaleta MG, López-Jácome LE, Franco-Cendejas R, Roldan-Valadez E. β-Defensin versus conventional markers of inflammation in periprosthetic joint infection: a retrospective study. PeerJ 2024; 12:e18560. [PMID: 39575176 PMCID: PMC11580661 DOI: 10.7717/peerj.18560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2024] [Accepted: 10/31/2024] [Indexed: 11/24/2024] Open
Abstract
Background Diagnosing periprosthetic joint infection (PJI) remains a significant challenge for healthcare professionals. Commonly utilized inflammatory markers include erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), and white blood cells (WBC). Human β-defensin 1 (β-defensin) is an antimicrobial peptide elevated in infection, yet its diagnostic value for PJI has not been explored. The purpose of this study was to evaluate the efficacy of synovial β-defensin as a diagnostic marker for PJI and to compare its performance with ESR, serum CRP, and WBC. Methods We conducted a single-center retrospective study from October 2022 to June 2023. A total of 105 joint fluid samples from revision patients at the Instituto Nacional de Rehabilitación Luis Guillermo Ibarra Ibarra were collected intraoperatively (71 hips, 34 knees) and frozen. According to MSIS criteria, 64 patients were defined as positive for PJI and the remaining 41 were negative. Synovial β-defensin levels were quantified using ELISA, serum CRP levels by immunoturbidimetry, and blood ESR and WBC were analyzed. Sensitivity and specificity were determined using ROC curves, and diagnostic performance was compared using the area under the curve (AUC). Cut-off values for diagnosing PJI were established. Results Levels of synovial β-defensin, ESR, serum CRP, and WBC were significantly higher in the PJI group compared to the non-PJI (P < 0.0001). The AUCs were 0.948 for β-defensin, 0.884 for ESR, 0.902 for CRP, and 0.767 for WBC, with a combined AUC of 0.994. Sensitivity/specificity for β-defensin, ESR, CRP, and WBC were 0.966/0.830, 0.887/0.791, 0.930/0.771, and 0.820/0.682, respectively. Optimal predictive cut-off values were 1105.8 pg/mL for β-defensin, 11.5 mm/h for ESR, 5.55 mg/L for CRP, and 7.3 × 103/mm3 for WBC. Conclusion The synovial β-defensin assay demonstrated greater sensitivity and specificity for the diagnosis of PJI compared to ESR, serum CRP and WBC. Therefore, β-defensin shows promise as a diagnostic marker for PJI. Simultaneous determination of all markers may increase diagnostic confidence.
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Affiliation(s)
- Javier Fernández-Torres
- Laboratorio de Líquido Sinovial, Instituto Nacional de Rehabilitación Luis Guillermo Ibarra Ibarra, Mexico City, Mexico
- Departamento de Biología, Facultad de Química, Universidad Nacional Autónoma de México, Mexico, Mexico
| | - Yessica Zamudio-Cuevas
- Laboratorio de Líquido Sinovial, Instituto Nacional de Rehabilitación Luis Guillermo Ibarra Ibarra, Mexico City, Mexico
| | - Karina Martínez-Flores
- Laboratorio de Líquido Sinovial, Instituto Nacional de Rehabilitación Luis Guillermo Ibarra Ibarra, Mexico City, Mexico
| | - Ambar López-Macay
- Laboratorio de Líquido Sinovial, Instituto Nacional de Rehabilitación Luis Guillermo Ibarra Ibarra, Mexico City, Mexico
| | - Graciela Rosas-Alquicira
- Clinical Microbiology Laboratory, Instituto Nacional de Rehabilitación Luis Guillermo Ibarra Ibarra, Mexico City, Mexico
| | | | - Luis Esaú López-Jácome
- Clinical Microbiology Laboratory, Instituto Nacional de Rehabilitación Luis Guillermo Ibarra Ibarra, Mexico City, Mexico
| | - Rafael Franco-Cendejas
- Biomedical Research Subdirection, Instituto Nacional de Rehabilitación Luis Guillermo Ibarra Ibarra, Mexico City, Mexico
| | - Ernesto Roldan-Valadez
- División de Investigación, Instituto Nacional de Rehabilitación Luis Guillermo Ibarra Ibarra, Mexico City, Mexico
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Oleo-Taltavull R, Vicente Gomà-Camps M, Joshi Jubert N, Corona PS. Efficacy of the preformulated irrigation solution Bactisure® in acute periprosthetic joint infection debridement surgery: study protocol for a randomized controlled trial. Trials 2024; 25:775. [PMID: 39550574 PMCID: PMC11568522 DOI: 10.1186/s13063-024-08637-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2024] [Accepted: 11/12/2024] [Indexed: 11/18/2024] Open
Abstract
BACKGROUND Despite significant progress in orthopaedic surgery, the prevalence of periprosthetic joint infections (PJIs) remains persistent, and future increases are expected due to the increasing number of joint arthroplasties. PJIs are intricately connected to biofilm-producing bacteria, which encase infected prostheses, impairing the effectiveness of antibiotics and the immune system. Acute PJIs with immature biofilms are traditionally managed with debridement, antibiotics, and implant retention (DAIR). However, to date, there has not been a conclusive direct clinical comparison (in vivo) demonstrating the superiority of one irrigation solution over others. Recently, there has been a growing interest in irrigation solutions with antibiofilm properties demonstrated in in vitro studies, exemplified by the preformulated Bactisure® irrigation solution, which contains ethanol, acetic acid, sodium acetate, benzalkonium chloride, and sterile water. The main objective of this study was to evaluate the effectiveness (infection cure rate) of preformulated Bactisure® irrigation solution in vivo compared with saline solution in a control group of patients with acute knee and/or hip periprosthetic infections treated with DAIR. METHODS Prospective single-centre randomized controlled trial involving patients with acute haematogenous PJI who received standard DAIR surgery from December 2022 to December 2024. The type of irrigation solution used during surgery will include two groups allocated at a 1:1 ratio: a control group (n = 25) with saline solution and an experimental group (n = 25) receiving the Bactisure® preformulated solution. The sample size was calculated based on an expected reduction in reinfection rates from 45% in the control group to 10% in the experimental group. Data on baseline patient characteristics, clinical and radiological information, and healthcare questionnaires will be recorded. All patients will be followed for minimum of 12 months. The infection cure rate at 1 year will be the primary outcome. DISCUSSION This study is the first to compare the effectiveness of preformulated Bactisure® irrigation solution with that of saline solution in real clinical practice (in vivo) in patients with acute knee and/or hip periprosthetic infections treated with DAIR. Our main hypothesis is that, compared with saline solution, Bactisure® provides a better infection cure rate at 1 year post-DAIR. TRIAL REGISTRATION International Standard Randomized Controlled Trial Number (ISRCTN): https://doi.org/10.1186/ISRCTN10873696 . Registered on December 19, 2023.
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Affiliation(s)
- Rafael Oleo-Taltavull
- Orthopaedic Surgery Department, Vall d'Hebron University Hospital, Universitat Autonoma de Barcelona (UAB), Barcelona, Spain.
- Department of Surgery, Universitat Autònoma de Barcelona (UAB), Barcelona, Spain.
- Septic and Reconstructive Surgery Unit (UCSO), Orthopaedic Surgery Department, Vall d'Hebron University Hospital, Barcelona, Spain.
| | - Matías Vicente Gomà-Camps
- Orthopaedic Surgery Department, Vall d'Hebron University Hospital, Universitat Autonoma de Barcelona (UAB), Barcelona, Spain
- Department of Surgery, Universitat Autònoma de Barcelona (UAB), Barcelona, Spain
- Septic and Reconstructive Surgery Unit (UCSO), Orthopaedic Surgery Department, Vall d'Hebron University Hospital, Barcelona, Spain
- Musculoskeletal Tissue Engineering Group, Vall d'Hebron Research Institute, Universitat Autonoma de Barcelona (UAB), Barcelona, Spain
| | - Nayana Joshi Jubert
- Orthopaedic Surgery Department, Vall d'Hebron University Hospital, Universitat Autonoma de Barcelona (UAB), Barcelona, Spain
- Department of Surgery, Universitat Autònoma de Barcelona (UAB), Barcelona, Spain
- Musculoskeletal Tissue Engineering Group, Vall d'Hebron Research Institute, Universitat Autonoma de Barcelona (UAB), Barcelona, Spain
- Knee Surgery Unit, Orthopaedic Surgery Department, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Pablo S Corona
- Orthopaedic Surgery Department, Vall d'Hebron University Hospital, Universitat Autonoma de Barcelona (UAB), Barcelona, Spain
- Department of Surgery, Universitat Autònoma de Barcelona (UAB), Barcelona, Spain
- Septic and Reconstructive Surgery Unit (UCSO), Orthopaedic Surgery Department, Vall d'Hebron University Hospital, Barcelona, Spain
- Musculoskeletal Tissue Engineering Group, Vall d'Hebron Research Institute, Universitat Autonoma de Barcelona (UAB), Barcelona, Spain
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Chang CN, Chung JJ, Jiang HY, Ding SJ. Calcium Silicate Promoting the Upcycling Potential of Polysulfone Medical Waste in Load-Bearing Applications. J Funct Biomater 2024; 15:323. [PMID: 39590527 PMCID: PMC11595709 DOI: 10.3390/jfb15110323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2024] [Revised: 10/22/2024] [Accepted: 10/29/2024] [Indexed: 11/28/2024] Open
Abstract
Polysulfone (PSF) medical waste can be effectively repurposed due to its excellent mechanical properties. Due to the increasing need for load-bearing bone implants, it is crucial to prioritize the development of biocompatible polymer-matrix composites. Calcium silicate (CaSi), known for its osteogenesis and antibacterial properties, is widely used in medical applications. In this study, recycled PSF plastics in fiber or nanoparticle forms and commercial PSF products were used to create PSF-based composites filled with three different amounts (10, 20, and 30 vol%) of CaSi. The green compact was heat-treated at various temperatures. Experimental results showed that the mechanical interlocking of the PSF matrix and CaSi filler occurred due to the liquefaction of PSF fibers or nanoparticles during heat treatment. When the composite contained 20% CaSi, the obtained three-point bending strength exceeded 60 MPa, falling within the reported strength of compact bone. There was a concurrent improvement in the biocompatibility and antibacterial activity of the PSF-based composites with the increasing amount of CaSi. Considering their mechanical properties and antibacterial activity, the 20% CaSi-containing PSF-based composites treated at 240 °C emerged as a promising candidate for bone implant applications. This study demonstrated the feasibility of upcycling medical waste such as PSF as a matrix, opening doors for its potential usage in the medical field.
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Affiliation(s)
- Chi-Nan Chang
- Institute of Oral Science, Chung Shan Medical University, Taichung City 402, Taiwan; (C.-N.C.)
| | - Jia-Jia Chung
- Institute of Oral Science, Chung Shan Medical University, Taichung City 402, Taiwan; (C.-N.C.)
| | - Huei-Yu Jiang
- Institute of Oral Science, Chung Shan Medical University, Taichung City 402, Taiwan; (C.-N.C.)
| | - Shinn-Jyh Ding
- Institute of Oral Science, Chung Shan Medical University, Taichung City 402, Taiwan; (C.-N.C.)
- School of Dentistry, Chung Shan Medical University, Taichung City 402, Taiwan
- Department of Stomatology, Chung Shan Medical University Hospital, Taichung City 402, Taiwan
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Longo UG, Papalia R, De Salvatore S, Intermesoli G, Piergentili I, Zaffagnini S, Samuelsson K, D'Hooghe P, Denaro V. Trends of hip arthroscopy in Italy show an increase over the years: A nationwide study from 2001 to 2016. J Exp Orthop 2024; 11:e70099. [PMID: 39703834 PMCID: PMC11656223 DOI: 10.1002/jeo2.70099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2024] [Revised: 10/08/2024] [Accepted: 10/21/2024] [Indexed: 12/21/2024] Open
Abstract
Purpose Hip arthroscopy has gained popularity among orthopaedic procedures over the last decade. The present study aims to evaluate the trends of hip arthroscopy procedures in Italy analysing data recorded by the Italian Ministry of Health, reporting demographics, length of hospitalisation (LOS), diagnosis and the economic impact of the procedure. Methods The National Hospital Discharge records reported by the Italian Ministry of Health were used, analysing the data regarding hip arthroscopy procedures performed in Italy between 2001 and 2016. A total of 4022 hip arthroscopies were performed in Italy in the adult population. Results The present study shows more males being exposed to the procedure, while the mean age of females was always higher than that of males during the 16-year study period. The mean LOS was 2.6 ± 3.2 days, and every procedure had a mean Italian hospital reimbursement from 1361€ to 1512€. Hip arthroscopy procedures have increased substantially between the years 2001 and 2016, as well as the costs related to the surgery. Conclusions The findings of this study constitute valuable clinical and scientific evidence for the healthcare system, which is useful not only for the formulation and improvement of national healthcare policies but also to improve awareness and accessibility of hip arthroscopy. Level of Evidence Level II.
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Affiliation(s)
- Umile Giuseppe Longo
- Department of OrthopaedicsFondazione Policlinico Universitario Campus Bio‐MedicoRomaItaly
- Research Unit of Orthopaedic and Trauma Surgery, Department of Medicine and SurgeryUniversità Campus Bio‐Medico di RomaRomaItaly
| | - Rocco Papalia
- Department of OrthopaedicsFondazione Policlinico Universitario Campus Bio‐MedicoRomaItaly
- Research Unit of Orthopaedic and Trauma Surgery, Department of Medicine and SurgeryUniversità Campus Bio‐Medico di RomaRomaItaly
| | | | - Giovanni Intermesoli
- Research Unit of Orthopaedic and Trauma Surgery, Department of Medicine and SurgeryUniversità Campus Bio‐Medico di RomaRomaItaly
| | - Ilaria Piergentili
- Department of BiomathematicsCNR‐IASI, Laboratorio di Biomatematica, Consiglio Nazionale delle Ricerche, Istituto di Analisi dei Sistemi ed InformaticaRomeItaly
| | - Stefano Zaffagnini
- Department of OrthopaedicsClinica Ortopedica e Traumatologica II IRCCS Istituto Ortopedico Rizzoli BolognaBolognaItaly
| | - Kristian Samuelsson
- Department of OrthopaedicsSahlgrenska Sports Medicine CenterGothenburgSweden
- Department of OrthopaedicsInstitute of Clinical Sciences, Sahlgrenska AcademyUniversity of GothenburgGothenburgSweden
- Department of OrthopaedicsSahlgrenska University HospitalMölndalSweden
| | | | - Vincenzo Denaro
- Department of OrthopaedicsFondazione Policlinico Universitario Campus Bio‐MedicoRomaItaly
- Research Unit of Orthopaedic and Trauma Surgery, Department of Medicine and SurgeryUniversità Campus Bio‐Medico di RomaRomaItaly
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Mozella ADP, Cobra HADAB, Minamoto STN, Salim R, Leal AC. Causes of Revision of Total Knee Arthroplasties in a Tertiary Hospital in Brazil. Rev Bras Ortop 2024; 59:e696-e701. [PMID: 39649045 PMCID: PMC11624922 DOI: 10.1055/s-0042-1757304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Accepted: 08/17/2022] [Indexed: 12/10/2024] Open
Abstract
Objective To identify the causes of revision of total knee arthroplasty in a referral center in Brazil. Methods This is a case series, with 80 patients undergoing revision surgery for total knee arthroplasty (RTKA) at a referral center for knee surgery, between August 2019 and November 2021, with a mean age of 69.6 years. Of these patients, 60.23% were female and 39.77% were male. The average body mass index (BMI) was 30.23 kg/m 2 . The causes of TKA failure were defined as: periprosthetic infection according to the 2018 International Consensus Meeting criteria, ligament instability, range of motion limitation, periprosthetic fracture, malalignment, aseptic loosening, pain due to non-replacement of the patellar cartilage, polyethylene wear, fracture of implants, insufficiency of the extensor mechanism. Results Periprosthetic joint infection (PJI) was the main cause of revision total knee arthroplasty (TKA), corresponding to 47.73% of cases. Aseptic loosening of one or more components represented the second most frequent reason for TKA failure, accounting for 35.23% of revisions. Range of motion limitation represented the third most frequent cause, accounting for 5.68% of surgeries. Instability was the fourth most frequent reason for RTKA, occurring in 4.55% of patients. The other causes of revision were: periprosthetic fracture (3.41%), failure due to rupture of the extensor mechanism (2.27%), and pain attributed to non-replacement of the patellar cartilage (1.14%). Conclusions Periprosthetic joint infection was the most frequent cause of TKA revision in our series. Other reasons for TKA failures were, in descending order: aseptic loosening, limited range of motion, and instability.
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Affiliation(s)
- Alan de Paula Mozella
- Departamento de Ortopedia e Traumatologia, Centro de Cirurgia do Joelho, Instituto Nacional de Traumatologia e Ortopedia (INTO), Rio de Janeiro, RJ, Brasil.
| | - Hugo Alexandre de Araújo Barros Cobra
- Departamento de Ortopedia e Traumatologia, Centro de Cirurgia do Joelho, Instituto Nacional de Traumatologia e Ortopedia (INTO), Rio de Janeiro, RJ, Brasil.
| | - Sandra Tie Nishibe Minamoto
- Departamento de Ortopedia e Traumatologia, Centro de Cirurgia do Joelho, Instituto Nacional de Traumatologia e Ortopedia (INTO), Rio de Janeiro, RJ, Brasil.
| | - Rodrigo Salim
- Departamento de Ortopedia e Anestesiologia, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo (USP), São Paulo, SP, Brasil.
| | - Ana Carolina Leal
- Divisão de Ensino e Pesquisa, Instituto Nacional de Traumatologia e Ortopedia (INTO), Rio de Janeiro, RJ, Brasil.
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Cavagnaro L, Mosconi L, Providenti V, Formica M. "Is every revision the same?" definition of complexity in knee revision surgery. INTERNATIONAL ORTHOPAEDICS 2024; 48:2609-2616. [PMID: 39052030 DOI: 10.1007/s00264-024-06259-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/07/2024] [Accepted: 07/12/2024] [Indexed: 07/27/2024]
Abstract
PURPOSE The purpose of this paper is to define a subset of complex rTKA in terms of preoperative, intraoperative, and postoperative outcomes and complications. The secondary outcome of the authors is to propose a simple and easy-to-use guide for clinical network in rTKA management. METHODS Complex rTKAs were defined according to the presence of at least two of the following features: periprosthetic joint infection, re- revision, femoral and/or tibial massive bone defects, soft tissue impairment, stiffness, fracture requiring fixed component revision. RESULTS Twenty-six patients underwent a standard rTKA (group A) while 24 had a complex rTKA (group B). The mean follow-up was 50.2 ± 16.4 months in group A and 49.5 ± 16.8 in group B (p = 0.44). The operative time was longer in group B (200.4 ± 131.4 min vs 110.2 ± 59.8 min). A greater intraoperative total blood loss (3014.2 ± 740.0 vs 2328.5 ± 620.6 ml, p < 0.001), intra and postoperative blood infusion (3.6 ± 1.2 vs 2.1 ± 1.2 units, p < 0.001) was reported in group B. Significant difference was obtained for global complication rate (11.5% group A vs 37.5% group B, p = 0.04), reoperation (7.7% group A vs 33.3% group B, p = p = 0.03) and re-revision (3.8% group A vs 25% group B, p = p = 0.04). CONCLUSION This study describes a specific entity of rTKA that require higher surgical effort and increased surgical challenge (measured as increased surgical time, need of transfusions and complications). The proposed classification could provide an easy-to-use tool for quick grading of complexity in rTKA.
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Affiliation(s)
- Luca Cavagnaro
- Joint Replacement Unit / Bone Infection Unit - Ospedale Santa Maria Di Misericordia, Via Martiri Della Foce 40, 17031, Albenga, SV, Italy.
| | - Lorenzo Mosconi
- Joint Replacement Unit / Bone Infection Unit - Ospedale Santa Maria Di Misericordia, Via Martiri Della Foce 40, 17031, Albenga, SV, Italy
| | - Valentina Providenti
- Joint Replacement Unit / Bone Infection Unit - Ospedale Santa Maria Di Misericordia, Via Martiri Della Foce 40, 17031, Albenga, SV, Italy
| | - Matteo Formica
- Orthopaedic Department - Policlinico San Martino, Largo Rosanna Benzi 10, 16132, Genoa, GE, Italy
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Lodge CJ, Adlan A, Nandra RS, Kaur J, Jeys L, Stevenson JD. Staged revision of the infected knee arthroplasty and endoprosthesis. Bone Joint J 2024; 106-B:1067-1073. [PMID: 39348917 DOI: 10.1302/0301-620x.106b10.bjj-2023-0432.r1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/02/2024]
Abstract
Aims Periprosthetic joint infection (PJI) is a challenging complication of any arthroplasty procedure. We reviewed our use of static antibiotic-loaded cement spacers (ABLCSs) for staged management of PJI where segmental bone loss, ligamentous instability, or soft-tissue defects necessitate a static construct. We reviewed factors contributing to their failure and techniques to avoid these complications when using ABLCSs in this context. Methods A retrospective analysis was conducted of 94 patients undergoing first-stage revision of an infected knee prosthesis between September 2007 and January 2020 at a single institution. Radiographs and clinical records were used to assess and classify the incidence and causes of static spacer failure. Of the 94 cases, there were 19 primary total knee arthroplasties (TKAs), ten revision TKAs (varus-valgus constraint), 20 hinged TKAs, one arthrodesis (nail), one failed spacer (performed elsewhere), 21 distal femoral endoprosthetic arthroplasties, and 22 proximal tibial arthroplasties. Results A total of 35/94 patients (37.2%) had spacer-related complications, of which 26/35 complications (74.3%) were because of mechanical failure of the spacer construct, while 9/35 (25.7%) were due to recurrence of infection. Risk factors for internal failure were a construct where the total intramedullary spacer length was less than twice the length of the central osseous defect (p = 0.009), where proximal or distal intraosseous spacer contact was < 10%, and after tibial tubercle osteotomy (p = 0.005). The incidence of spacer complications significantly increased the time to second stage: mean 157 days (42 to 458) in those without complications versus 227 days (11 to 528) with complications (p = 0.014). Conclusion The failure rate of static antibiotic-loaded cement spacers is much higher than anticipated. Complications of the spacer significantly increased the time to second-stage revision. The risk of mechanical failure is significantly increased if the spacer is less than double the size of the segmental defect, or if inadequate reinforcement is inserted into the residual bone. These findings serve as a guide for surgeons to avoid mechanical complications with static spacers.
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Affiliation(s)
- Christopher J Lodge
- Royal Orthopaedic Hospital NHS Foundation Trust, Birmingham, UK
- York Teaching Hospital NHS Foundation Trust, York, UK
| | - Amirul Adlan
- Royal Orthopaedic Hospital NHS Foundation Trust, Birmingham, UK
| | - Rajpal S Nandra
- Royal Orthopaedic Hospital NHS Foundation Trust, Birmingham, UK
| | - Jasprit Kaur
- Royal Orthopaedic Hospital NHS Foundation Trust, Birmingham, UK
| | - Lee Jeys
- Royal Orthopaedic Hospital NHS Foundation Trust, Birmingham, UK
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Campagna G, Lauri C, Manta R, Ottaviani R, Vella WD, Signore A. Intra and Inter-Rater Variability in the Interpretation of White Blood Cell Scintigraphy of Hip and Knee Prostheses. Diagnostics (Basel) 2024; 14:2043. [PMID: 39335722 PMCID: PMC11431631 DOI: 10.3390/diagnostics14182043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2024] [Revised: 09/10/2024] [Accepted: 09/13/2024] [Indexed: 09/30/2024] Open
Abstract
Background: White blood cell (WBC) scintigraphy plays a major role in the diagnostic approach to periprosthetic infections. Although the procedure has been standardized by the publication of several guidelines, the interpretation of this technique may be susceptible to intra and inter-variability. We aimed to assess the reproducibility of interpretation between nuclear medicine physicians and by the same physician and to demonstrate that Cohen's coefficient is more unstable than Gwet's coefficient, as the latter is influenced by the prevalence rates. Methods: We enrolled 59 patients who performed a Technetium-99m WBC (99mTc-WBC) scintigraphy for suspected hip or knee prosthesis infection. Three physicians, blinded to all patient clinical data, performed two image readings. Each WBC study was assessed both visually and semi-quantitatively according to the guidelines of the European Association of Nuclear Medicine (EANM). For semi-quantitative analysis, readers drew an irregular Region of Interest (ROI) over the suspected infectious lesion and copied it to the normal contralateral bone. The mean counts per ROI were used to calculate lesion-to-reference tissue (LR) ratios for both late and delayed images. An increase in LR over time (LRlate> LRdelayed) of more than 20% was considered indicative of infection. Agreement between readers and between readings was assessed by the first-order agreement coefficient (Gwet's AC1). Reading time for each scan was compared between the three readers in both the first and the second reading, using the Generalized Linear Mixed Model. Results: An excellent agreement was found among all three readers: 0.90 for the first reading and 0.94 for the second reading. Both inter- and intra-variability showed values ≥0.86. Gwet's method demonstrated greater robustness than the Cohen coefficient when assessing the intra and inter-rater variability, since it is not influenced by the prevalence rate. Conclusions: These studies can contribute to improving the reliability of nuclear medicine imaging techniques and to evaluating the effectiveness of trainee preparation.
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Affiliation(s)
- Giuseppe Campagna
- Department of Medical-Surgical Sciences and of Translational Medicine, Sant’Andrea Hospital, “Sapienza” University of Rome, 00161 Rome, Italy; (C.L.); (R.O.); (A.S.)
| | - Chiara Lauri
- Department of Medical-Surgical Sciences and of Translational Medicine, Sant’Andrea Hospital, “Sapienza” University of Rome, 00161 Rome, Italy; (C.L.); (R.O.); (A.S.)
| | - Ringo Manta
- Department of Nuclear Medicine, Université Libre de Bruxelles, 1050 Brussels, Belgium;
| | - Roberta Ottaviani
- Department of Medical-Surgical Sciences and of Translational Medicine, Sant’Andrea Hospital, “Sapienza” University of Rome, 00161 Rome, Italy; (C.L.); (R.O.); (A.S.)
| | - Walter Davide Vella
- Nuclear Medicine Unit, Sant’Andrea Hospital, Via di Grottarossa 1035, 00189 Rome, Italy;
| | - Alberto Signore
- Department of Medical-Surgical Sciences and of Translational Medicine, Sant’Andrea Hospital, “Sapienza” University of Rome, 00161 Rome, Italy; (C.L.); (R.O.); (A.S.)
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Dasari SP, Kanumuri SD, Yang J, Manner PA, Fernando ND, Hernandez NM. Extended Prophylactic Antibiotics for Primary and Aseptic Revision Total Joint Arthroplasty: A Meta-Analysis. J Arthroplasty 2024; 39:S476-S487. [PMID: 38237874 DOI: 10.1016/j.arth.2024.01.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 12/24/2023] [Accepted: 01/07/2024] [Indexed: 02/08/2024] Open
Abstract
BACKGROUND There is growing interest in extended antibiotic prophylaxis (EAP) following total joint arthroplasty (TJA); however, the benefit of EAP remains controversial. For this investigation, both oral and intravenous antibiotic protocols were included in the EAP group. METHODS The Cochrane Database of Systematic Reviews, Cochrane Register of Controlled Trials, PubMed, MEDLINE, Web of Science, Ovid Embase, Elton B. Stephens CO, and Cumulative Index to Nursing and Allied Health Literature were queried for literature comparing outcomes of primary and aseptic revision total hip arthroplasty (THA) and total knee arthroplasty (TKA) patients who were treated with either ≤24 hours of postoperative antibiotic prophylaxis (standard of care [SoC]) or >24 hours of EAP. The primary outcome was periprosthetic joint infection (PJI). A pooled relative-risk random-effects Mantel-Haenszel model was implemented to compare cohorts. RESULTS There were 18 studies with a total of 19,153 patients included. There was considerable variation in antibiotic prophylaxis protocols with first-generation cephalosporins being the most commonly implemented antibiotic for both groups. Patients treated with EAP were 35% less likely to develop PJI relative to the SoC (P = .0004). When examining primary TJA, patients treated with EAP were 39% and 40% less likely to develop a PJI for TJA (P = .0008) and THA (P = .02), respectively. There was no significant difference for primary TKA (P = .17). When examining aseptic revision TJA, EAP led to a 36% and 47% reduction in the probability of a PJI for aseptic revision TJA (P = .007) and aseptic revision TKA (P = .008), respectively; there was no observed benefit for aseptic revision THA (P = .36). CONCLUSIONS This meta-analysis demonstrated that patients treated with EAP were less likely to develop a PJI relative to those treated with the SoC for all TJA, primary TJA, primary THA, aseptic revision TJA, and aseptic revision TKA. There was no significant difference observed between EAP and SoC for primary TKA or aseptic revision THA.
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Affiliation(s)
- Suhas P Dasari
- Department of Orthopaedic Surgery, University of Washington, Seattle, Washington
| | - Sanjana D Kanumuri
- Department of Orthopaedic Surgery, University of Washington, Seattle, Washington
| | - JaeWon Yang
- Department of Orthopaedic Surgery, University of Washington, Seattle, Washington
| | - Paul A Manner
- Department of Orthopaedic Surgery, University of Washington, Seattle, Washington
| | - Navin D Fernando
- Department of Orthopaedic Surgery, University of Washington, Seattle, Washington
| | - Nicholas M Hernandez
- Department of Orthopaedic Surgery, University of Washington, Seattle, Washington
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Chen TLW, RezazadehSaatlou M, Buddhiraju A, Seo HH, Shimizu MR, Kwon YM. Predicting extended hospital stay following revision total hip arthroplasty: a machine learning model analysis based on the ACS-NSQIP database. Arch Orthop Trauma Surg 2024; 144:4411-4420. [PMID: 39294531 DOI: 10.1007/s00402-024-05542-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2024] [Accepted: 09/03/2024] [Indexed: 09/20/2024]
Abstract
INTRODUCTION Prolonged length of stay (LOS) following revision total hip arthroplasty (THA) can lead to increased healthcare costs, higher rates of readmission, and lower patient satisfaction. In this study, we investigated the predictive power of machine learning (ML) models for prolonged LOS after revision THA using patient data from a national-scale patient repository. MATERIALS AND METHODS We identified 11,737 revision THA cases from the American College of Surgeons National Surgical Quality Improvement Program database from 2013 to 2020. Prolonged LOS was defined as exceeding the 75th value of all LOSs in the study cohort. We developed four ML models: artificial neural network (ANN), random forest, histogram-based gradient boosting, and k-nearest neighbor, to predict prolonged LOS after revision THA. Each model's performance was assessed during training and testing sessions in terms of discrimination, calibration, and clinical utility. RESULTS The ANN model was the most accurate with an AUC of 0.82, calibration slope of 0.90, calibration intercept of 0.02, and Brier score of 0.140 during testing, indicating the model's competency in distinguishing patients subject to prolonged LOS with minimal prediction error. All models showed clinical utility by producing net benefits in the decision curve analyses. The most significant predictors of prolonged LOS were preoperative blood tests (hematocrit, platelet count, and leukocyte count), preoperative transfusion, operation time, indications for revision THA (infection), and age. CONCLUSIONS Our study demonstrated that the ML model accurately predicted prolonged LOS after revision THA. The results highlighted the importance of the indications for revision surgery in determining the risk of prolonged LOS. With the model's aid, clinicians can stratify individual patients based on key factors, improve care coordination and discharge planning for those at risk of prolonged LOS, and increase cost efficiency.
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Affiliation(s)
- Tony Lin-Wei Chen
- Bioengineering Laboratory, Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA, 02114, USA
- Department of Biomedical Engineering, The Hong Kong Polytechnic University, Yuk Choi Rd 11, 999077, Hong Kong SAR, China
| | - MohammadAmin RezazadehSaatlou
- Bioengineering Laboratory, Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA, 02114, USA
| | - Anirudh Buddhiraju
- Bioengineering Laboratory, Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA, 02114, USA
| | - Henry Hojoon Seo
- Bioengineering Laboratory, Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA, 02114, USA
| | - Michelle Riyo Shimizu
- Bioengineering Laboratory, Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA, 02114, USA
| | - Young-Min Kwon
- Bioengineering Laboratory, Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA, 02114, USA.
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Ekhtiari S, Worthy T, Rubinger L, Valdivielso AA, Puri L, de Beer J, Citak M, Wood TJ. A novel radiological index uses the inner canal diameter and the Citak classification index to predict risk factor for aseptic loosening following hinged total knee arthroplasty. Arch Orthop Trauma Surg 2024; 144:4385-4390. [PMID: 39259311 DOI: 10.1007/s00402-024-05538-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2024] [Accepted: 09/03/2024] [Indexed: 09/13/2024]
Abstract
INTRODUCTION It remains unclear if distal femoral morphology should be a key consideration when selecting the implant or fixation strategy. A novel radiological index has been proposed to classify patients' distal femoral morphology. This study aims to evaluate the validity of this classification system in a cohort of patients undergoing hinged Total Knee Arthroplasty (TKA), and to determine if distal femoral morphology is a risk factor for aseptic loosening or all cause revision following hinged TKA. MATERIALS AND METHODS This study was a retrospective analysis of our institutional database. Fifty-nine patients having undergone hinged TKA with adequate radiographs for examination were eligible for inclusion. Radiographic measurements were performed using the Citak radiological index criteria. The proportion of aseptic loosening and all-cause revisions were compared between the different classification groups. RESULTS The analysis included 41 females (69.5%) and 18 males (30.5%). The mean age of the participants was 71.2 years (SD = 12.6). For inner canal diameter patients were classified as: Type A (31/59, 53%), Type B (19/59, 32%), and Type C (9/59, 15%). For the Index Classification Group, patients were classified as: Group A (26/59, 44%), Group B (20/59, 34%), and Group C (13/59, 22%). There was no significant difference in overall revision rate between the three groups (χ2 = 3.25, P = .197 from a Chi-square test). There was a significantly higher rate of aseptic loosening in Group C compared to Groups A and B, with no significant difference between Groups A and B in terms of aseptic loosening rates (χ2 = 8.72, P = .013 from a Chi-square test). CONCLUSIONS Distal femoral morphology plays an important role in the risk of aseptic loosening following hinged knee replacement, and should be considered when deciding implant type and fixation in these patients.
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Affiliation(s)
| | - Tanis Worthy
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, ON, Canada
| | - Luc Rubinger
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, ON, Canada
| | | | - Laura Puri
- Hamilton Arthroplasty Group, Hamilton Health Sciences, McMaster University, 711 Concession Street B3, Hamilton, ON, L8V 1C3, Canada.
| | - Justin de Beer
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, ON, Canada
- Hamilton Arthroplasty Group, Hamilton Health Sciences, McMaster University, 711 Concession Street B3, Hamilton, ON, L8V 1C3, Canada
| | | | - Thomas J Wood
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, ON, Canada
- Hamilton Arthroplasty Group, Hamilton Health Sciences, McMaster University, 711 Concession Street B3, Hamilton, ON, L8V 1C3, Canada
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Treanor A, Shimizu M, Barrett A, Byram S, Schmitt D, Brown N. Outcomes of Regional Block in Revision Total Joint Arthroplasty for Prosthetic Joint Infection. J Am Acad Orthop Surg Glob Res Rev 2024; 8:01979360-202409000-00009. [PMID: 39288290 PMCID: PMC11410322 DOI: 10.5435/jaaosglobal-d-24-00180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2024] [Accepted: 07/06/2024] [Indexed: 09/19/2024]
Abstract
INTRODUCTION Infection is among the most common reasons for revision after a total joint arthroplasty (TJA) and is associated with notable morbidity and mortality rates. As the demand for TJA increases, a concurrent increase in the prevalence of periprosthetic joint infection (PJI) is also expected to rise. While previous studies have explored differences in postoperative outcomes between general and spinal anesthesia, there is limited data on the use of regional blocks in patients undergoing revision joint arthroplasty for PJI. This study evaluated the postoperative outcomes of patients undergoing revision TJA for PJI using regional blocks. METHODS Data from 518 patients were retrospectively collected. Patients included in the study had undergone revision TJA for PJI from January 2004 to January 2023 at a single institution. Patients undergoing same-day bilateral revisions, above-knee amputations, and aseptic revisions were excluded. Postoperative complications investigated included local complications, postoperative transfusion, wound complication, readmission, sepsis, systemic infection, spinal infection, death, persistent PJI, periprosthetic fracture, and unplanned revision surgery. Chi-square analysis was used to compare postoperative complications between procedures that used spinal or general anesthesia with regional blocks and those with spinal or general anesthesia without regional blocks. RESULTS Of the 518 patients who underwent revision TJA, 63 (12.2%) used a regional block. After surgery, 12.7% (n = 8) of patients with regional block and 23.5% (n = 107) of patients without regional block experienced persistent PJI (P = 0.076). No significant differences in wound complication (P = 0.333), readmission (P = 0.998), revision surgery (P = 0.783), and death (P = 0.588) were found between those with and without regional block use. Sepsis (P = 0.224), systemic infection (P = 0.220), and spinal infection (P = 0.998) rates within 1 year after revision TJA for PJI surgery were comparable between the two groups. No local infections were observed at the block site. A subanalysis comparing spinal and general anesthesia demonstrated comparable persistent PJI postoperatively and complication rates; however, spinal anesthesia use was associated with shorter length of stay (P = 0.003) and lower transfusion rates (P = 0.002). CONCLUSION The results of this study suggest that the use of regional block is not associated with an increased probability of postoperative persistent PJI, local wound complication, readmission, spinal/systemic/other infections, death, or revision surgery. Surgeons can comfortably choose regional block as a safe option for revision surgery for PJI. Consistent with previous research, patients who received spinal anesthesia had shorter hospital stays and lower transfusion rates when compared with those who received general anesthesia.
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Affiliation(s)
- Ashley Treanor
- From the Loyola University Chicago Stritch School of Medicine, Maywood, IL (Ms. Treanor, Ms. Shimizu, and Ms. Barrett); the Department of Anesthesiology and Perioperative Medicine, Loyola University Medical Center, Maywood, IL (Dr. Byram); and the Department of Orthopaedic Surgery, Loyola University Medical Center, Maywood, IL (Dr. Schmitt and Dr. Brown)
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Hannon CP, Browne JA, Schwarzkopf R, Berry DJ, Abdel MP. Tips and Tricks to Save You During Revision Total Knee Arthroplasty. J Arthroplasty 2024; 39:S26-S31. [PMID: 38823514 DOI: 10.1016/j.arth.2024.05.066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2024] [Revised: 05/22/2024] [Accepted: 05/23/2024] [Indexed: 06/03/2024] Open
Abstract
The number of revision total knee arthroplasties (TKAs) performed annually continues to rise. This article is a summary of a symposium on revision TKAs presented at the 2023 American Association of Hip and Knee Surgeons annual meeting. It will provide an overview of the surgical tips and tricks for exposure and component removal, use of metaphyseal fixation and stems to manage bone loss and optimize fixation, constraint in TKA, as well as how to manage extensor mechanism disruptions with a synthetic mesh reconstruction. LEVEL OF EVIDENCE: V.
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Affiliation(s)
- Charles P Hannon
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | - James A Browne
- Department of Orthopedic Surgery, University of Virginia, Charlottesville, Virginia
| | - Ran Schwarzkopf
- Department of Orthopedic Surgery, New York University Langone Health, New York, New York
| | - Daniel J Berry
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Matthew P Abdel
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
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Flynn JB, Yokhana SS, Wilson JM, Schultz JD, Hymel AM, Martin JR. Not so Fast: Extended Oral Antibiotic Prophylaxis Does Not Reduce 90-Day Infection Rate Following Joint Arthroplasty. J Arthroplasty 2024; 39:S122-S128. [PMID: 38685337 DOI: 10.1016/j.arth.2024.04.064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Revised: 04/19/2024] [Accepted: 04/21/2024] [Indexed: 05/02/2024] Open
Abstract
BACKGROUND Periprosthetic joint infection (PJI) is a devastating complication following both total hip (THA) and knee (TKA) arthroplasty. Extended oral antibiotic (EOA) prophylaxis has been reported to reduce PJI following TJA in high-risk patients. The purpose of this study was to determine if EOA reduces PJI in all-comers and high-risk THA and TKA populations. METHODS This is a retrospective cohort study, including 4,576 patients undergoing primary THA or TKA at a single institution from 2018 to 2022. Beginning in 2020, EOA prophylaxis was administered for 10 days following THA or TKA at our institution. Patients were separated into 2 cohorts (1,769 EOA, 2,807 no EOA) based on whether they received postoperative EOA. The 90-day and 1-year outcomes, with a focus on PJI, were then compared between groups. A subgroup analysis of high-risk patients was also performed. RESULTS There was no difference in 90-day PJI rates between cohorts (EOA 1 versus no EOA 0.8%; P = .6). The difference in the rate of PJI remained insignificant at 1 year (EOA 1 versus no EOA 1%; P = .9). Similarly, our subgroup analysis of high-risk patients demonstrated no difference in postoperative PJI between EOA (n = 254) and no EOA (n = 396) (0.8 versus 2.3%, respectively; P = .2). Reassuringly, we also found no differences in the incidence of Clostridium difficile infection (EOA 0.1 versus no EOA 0.1%; P > .9) or in antibiotic resistance among those who developed PJI within 90 days (EOA 59 versus no EOA 83%; P = .2). CONCLUSIONS With the numbers available for analysis, EOA prophylaxis was not associated with PJI risk reduction following primary TJA when universally deployed. Furthermore, among high-risk patients, there was no statistically significant difference. While we did not identify increased antibiotic resistance or Clostridium difficile infection, we cannot recommend wide-spread adoption of EOA prophylaxis, and clarification regarding the role of EOA, even in high-risk patients, is needed.
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Affiliation(s)
- Jade B Flynn
- Department of Pharmaceutical Services, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Sanar S Yokhana
- Department of Orthopedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jacob M Wilson
- Department of Orthopedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jacob D Schultz
- Department of Orthopedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Alicia M Hymel
- Vanderbilt University Medical Center, Nashville, Tennessee
| | - John R Martin
- Department of Orthopedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
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Kwong JW, Abramowicz M, Kühn KD, Foelsch C, Hansen EN. High and Low Dosage of Vancomycin in Polymethylmethacrylate Cements: Efficacy and Mechanical Properties. Antibiotics (Basel) 2024; 13:818. [PMID: 39334991 PMCID: PMC11428212 DOI: 10.3390/antibiotics13090818] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2024] [Revised: 08/14/2024] [Accepted: 08/21/2024] [Indexed: 09/30/2024] Open
Abstract
INTRODUCTION Prosthetic joint infections (PJIs) are difficult to treat and represent a significant burden to the healthcare system. Two-stage revision surgery with placement of an antibiotic-loaded cement spacer is currently the gold standard for treatment in the United States for late-onset infections. We evaluate the efficacy of varying doses of vancomycin added to antibiotic-containing acrylic cement spacers and discuss the biomechanical and antimicrobial properties of using high versus low doses of vancomycin in cement spacers in the hip and knee. MATERIALS AND METHODS Commercially available Copal cement containing either gentamicin and clindamycin (G + C) or gentamicin and vancomycin (G + V) was prepared with the manual addition of low (2 g) and high (6 g) doses of vancomycin. In vitro mechanical testing was then carried out according to ISO 5833 and DIN 53435, as well as inhibition zone assays against common PJI pathogens. Additionally, inhibition zone assays were conducted on two commercially available prefabricated spacers containing gentamicin: Copal Exchange G and Cemex Spacer-K. RESULTS In biomechanical testing, Copal G + V with the addition of 6 g of vancomycin failed to meet the ISO standard. Copal G + C and Copal G + V with low and high dosages of vancomycin were all effective against the tested pathogens and displayed constant efficacy for a duration of 42 days. High doses of vancomycin showed significantly lower mechanical stability. Moreover, Copal Exchange G showed significantly larger inhibition zones across 42 days. DISCUSSION While higher concentrations of vancomycin appear to improve the antimicrobial efficacy of cement, they also reduce its mechanical stability. Despite its smoother surface, the Copal Exchange G spacer exhibits large inhibition zones after 1 day and maintains consistently large inhibition zones over 6 weeks. Thus, it may be preferred for use in two-stage revision surgery. CONCLUSION Copal Exchange G is more effective than Cemex Spacer K against S. aureus and E. coli. The manual addition of vancomycin to cement containing double antibiotics is very effective. The influence on ISO compression is low, the ISO bending modulus is increased, and ISO bending, DIN bending, and DIN impact, are reduced.
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Affiliation(s)
- Jeffrey W. Kwong
- Department of Orthopaedic Surgery, University of California San Francisco, San Francisco, CA 94143, USA; (J.W.K.); (E.N.H.)
| | | | - Klaus Dieter Kühn
- Department of Orthopaedics and Trauma, Medical University of Graz, 8036 Graz, Austria
| | - Christian Foelsch
- Department of Orthopaedics and Orthopaedic Surgery, University Hospital Gießen and Marburg (UKGM), Justus-Liebig-University, Klinikstraße 33, 35392 Gießen, Germany;
| | - Erik N. Hansen
- Department of Orthopaedic Surgery, University of California San Francisco, San Francisco, CA 94143, USA; (J.W.K.); (E.N.H.)
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Miao H, Zhu Z, Wang H, Bai X, Li X. Predictive Accuracy Analysis of a Novel Robotic-Assisted System for Total Knee Arthroplasty:A Prospective Observational Study. Ther Clin Risk Manag 2024; 20:473-482. [PMID: 39135983 PMCID: PMC11318605 DOI: 10.2147/tcrm.s468598] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2024] [Accepted: 07/21/2024] [Indexed: 08/15/2024] Open
Abstract
Background Robotic-assisted total knee arthroplasty (RATKA) has been reported to enhance operative decision-making. The purpose of this study was intended to assess the predictive accuracy of bone cuts, lower limb alignment, and component size of a novel system for RATKA preoperatively and intraoperatively. Methods Preoperatively planned bone cuts, limb alignment, and component size were projected using a reconstructed 3D model. Intraoperative bone cuts and postoperative limb alignment were measured. Errors between planned and real bone cuts, limb alignment, and component size were compared. Results The mean absolute errors for bone cuts and alignment were within 1.40mm/1.30° with a standard deviation (SD) of 0.96mm/1.12°. For all errors of bone cuts and alignment compared with the plan, there were no statistically significant differences except for the lateral distal of femoral cuts (P=0.004). The accuracy for predicting the femoral, tibial, and polyethylene component sizes was 100% (48/48), 90% (43/48), and 88% (42/48), respectively. Regarding all mean absolute errors of bone cuts and alignments, no significant differences were observed among surgeons. Conclusion The novel robotically-assisted system for RATKA donated reliable operative decision-making based on the predictive accuracy regardless of the surgeon's level of experience.
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Affiliation(s)
- Haichuan Miao
- Dalian Medical University, Dalian, 116044, People’s Republic of China
- Department of Sports Medicine and Joint Surgery, The People’s Hospital of Liaoning Province, The People’s Hospital of China Medical University, Shenyang, 110000, People’s Republic of China
| | - Zhiyong Zhu
- Department of Sports Medicine and Joint Surgery, The People’s Hospital of Liaoning Province, The People’s Hospital of China Medical University, Shenyang, 110000, People’s Republic of China
| | - Huisheng Wang
- Department of Sports Medicine and Joint Surgery, The People’s Hospital of Liaoning Province, The People’s Hospital of China Medical University, Shenyang, 110000, People’s Republic of China
| | - Xizhuang Bai
- Department of Sports Medicine and Joint Surgery, The People’s Hospital of Liaoning Province, The People’s Hospital of China Medical University, Shenyang, 110000, People’s Republic of China
| | - Xi Li
- Department of Sports Medicine and Joint Surgery, The People’s Hospital of Liaoning Province, The People’s Hospital of China Medical University, Shenyang, 110000, People’s Republic of China
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Sasaki R, Nagashima M, Tanaka K, Takeshima K. Relationship between cement penetration and incidence of a radiolucent line around the tibia 2 years after total knee arthroplasty: A retrospective study. J ISAKOS 2024; 9:609-614. [PMID: 38825183 DOI: 10.1016/j.jisako.2024.05.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2023] [Revised: 05/17/2024] [Accepted: 05/29/2024] [Indexed: 06/04/2024]
Abstract
OBJECTIVES Cement penetration (CP) plays a key role in implant stability for cemented total knee arthroplasty (TKA), and the radiolucent line (RLL) >2 mm is a preliminary sign for loosening of components. However, the direct relationship between CP and the frequency of RLL >2 mm is unclear, and the best cut-off value for CP to prevent RLL >2 mm also remains unclear. This study aimed to investigate this relationship between CP and RLL and to determine the clinical cut-off value for tibial CP in patients 2 years after TKA. METHODS This retrospective study investigated 157 knees from 123 patients with osteoarthritis who underwent cemented TKA. The CP and RLL immediately after TKA and the RLL 2 years after TKA were measured for the medial, lateral, anterior, and posterior tibial baseplate zones. Receiver operating characteristic (ROC) curves were constructed to determine the best cut-off values for CP. RESULTS RLL >2 mm was not observed just after TKA. An RLL >2 mm was observed in any tibial baseplate zone in 22 knees from 20 patients (RLL+ group) and was not observed in the remaining (RLL- group) 2 years after TKA. The mean CP for all zones was significantly higher in the RLL- group (2.5 ± 1.1 mm) than in the RLL+ group (1.7 ± 0.6 mm; P < 0.001). An RLL >2 mm was seen in 21 knees in the medial zone, 9 knees in the lateral zone, 8 knees in the anterior zone, and 3 knees in the posterior zone. CP values with RLL >2 mm were significantly lower than those without the RLL at the medial, anterior, and posterior tibial baseplate zones. The best cut-off values from the ROC curve of CP in each zone were between 1.1 mm and 2.1 mm. CONCLUSIONS The depth of the CP directly affects the incidence of an RLL >2 mm. The best cut-off value for tibial CP to prevent an RLL >2 mm is 2.1 mm.
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Affiliation(s)
- Ryo Sasaki
- Department of Orthopaedic Surgery, International University of Health and Welfare Mita Hospital, 1-4-3 Mita, Minato-ku, Tokyo 108-8329, Japan; Department of Orthopaedic Surgery, School of Medicine, International University of Health and Welfare, 852, Hatakeda, Narita City, Chiba 286-8520, Japan; Department of Orthopaedic Surgery, NHO Tokyo Medical Center, 2-5-1 Higashigaoka, Meguro-ku, Tokyo 152-8902, Japan
| | - Masaki Nagashima
- Department of Orthopaedic Surgery, International University of Health and Welfare Mita Hospital, 1-4-3 Mita, Minato-ku, Tokyo 108-8329, Japan; Department of Orthopaedic Surgery, School of Medicine, International University of Health and Welfare, 852, Hatakeda, Narita City, Chiba 286-8520, Japan.
| | - Kentaro Tanaka
- Department of Orthopaedic Surgery, International University of Health and Welfare Mita Hospital, 1-4-3 Mita, Minato-ku, Tokyo 108-8329, Japan; Department of Orthopaedic Surgery, School of Medicine, International University of Health and Welfare, 852, Hatakeda, Narita City, Chiba 286-8520, Japan
| | - Kenichiro Takeshima
- Department of Orthopaedic Surgery, School of Medicine, International University of Health and Welfare, 852, Hatakeda, Narita City, Chiba 286-8520, Japan; Department of Orthopaedic Surgery, International University of Health and Welfare Narita Hospital, 852, Hatakeda, Narita City, Chiba 286-8520, Japan
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Jimenez AM, Cook JJ, Reihl AM, Patel NK. Assessment of the Potential Role of Preoperative Dental Clearance in Total Joint Arthroplasty Optimization: A Pilot Study. Cureus 2024; 16:e68022. [PMID: 39347338 PMCID: PMC11430491 DOI: 10.7759/cureus.68022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/27/2024] [Indexed: 10/01/2024] Open
Abstract
AIMS AND OBJECTIVES Periprosthetic joint infection (PJI) is a serious complication after total joint arthroplasty (TJA) and is associated with significant morbidity, mortality, and cost. This pilot study primarily aimed to investigate if preoperative dental screenings would impact the rate of PJI following TJA when compared to historical controls. Secondarily, this study aimed to evaluate the prevalence of dental pathology in patients undergoing TJA. METHODS Charts from 103 consecutive patients undergoing primary or revision total hip arthroplasty (THA, rTHA) or total knee arthroplasty (TKA, rTKA) by a single surgeon at a single academic institution over a two-year period were reviewed and selected for inclusion. All patients were referred to a dentist for preoperative clearance using a standardized form. The rate of dental pathology before surgery, details of the dental intervention required, and any dental work performed within six months postoperatively were evaluated. The demographic and comorbidity composition of our patient population was also collected. Finally, rates of PJI following each type of TJA were obtained for demographic- and comorbidity-matched historical controls from similar study designs to examine the potential impact of preoperative dental intervention. RESULTS Of the 103 patients, 31 (30.1%) were found to have preoperative dental pathology. Twenty-eight of these 31 patients (90.3%) required dental intervention prior to surgery. Based on demographic- and comorbidity-matched historical data, we expected two (95% CI (0, 6)) PJI cases for the THA group, 0 (95% CI (0, 2)) PJI cases for the TKA group, two (95% CI (0, 5)) PJI cases for the rTHA group, and two (95% CI (0, 5)) PJI cases for the rTKA group. However, in our study, there were no PJIs after any TJA up to the latest follow-up, which was unlikely for THA, rTHA, and rTKA groups given the calculated Poisson probabilities (9.39%, 15.11%, and 11.26%, respectively). Finding 0 cases was likely for the TKA group given the calculated Poisson probability of 72.61%. CONCLUSIONS This pilot study demonstrated that preoperative dental screening, which aims to decrease the chance of PJI due to bacteremia, may have an impact on the rate of PJI following THA, rTKA, and rTHA but not TKA based on Poisson probabilities calculated from demographic- and comorbidity-matched historical controls that lacked preoperative dental screening. For THA, rTKA, and rTHA, the Poisson probabilities of observing 0 cases of PJI postoperatively, as was the case in our study, were unlikely, suggesting that some variable in our cohort was decreasing the PJI rate for these groups. However, in the case of TKA, the Poisson probability of observing 0 cases was likely and matched the results of our study, suggesting that no variable in our cohort was affecting the PJI rate for this group. We cannot draw direct conclusions from this retrospective observational study, but the preliminary findings prompt further investigation through an appropriately controlled, blinded, multi-centered, and powered prospective randomized controlled trial.
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Affiliation(s)
| | - Joshua J Cook
- Department of Biology, University of West Florida, Pensacola, USA
| | - Alec M Reihl
- Department of Orthopedics, Virginia Commonwealth University (VCU) Health, Richmond, USA
| | - Nirav K Patel
- Department of Hip and Knee Surgery, The Johns Hopkins University School of Medicine, Bethesda, USA
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