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Batailler C, Cance N, Lustig S. Spacers in two-stage strategy for periprosthetic infection. Orthop Traumatol Surg Res 2025; 111:104074. [PMID: 39608638 DOI: 10.1016/j.otsr.2024.104074] [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: 12/04/2023] [Revised: 05/15/2024] [Accepted: 05/15/2024] [Indexed: 11/30/2024]
Abstract
In two-stage revision of infected implants, the first stage involves removing the implant and implanting a joint spacer, and the second stage involves implanting a new prosthesis at least 6 weeks later. Spacers have two main functions: local administration of high-dose antibiotics, and preservation of the joint space by reducing soft tissue retraction and improving patient comfort until reimplantation. The present review aims to detail the necessary characteristics of antibiotics added to cement to achieve good joint diffusion, to describe the steps of two-stage revision, and to present the types of spacer available according to the joint and complications. The antibiotic used in the spacer must be heat-resistant, water-soluble and chemically stable in the cement. Gentamicin and vancomycin are generally preferred. We recommend at least 3 months' systematic antibiotic therapy for periprosthetic joint infection. Reimplantation is performed either at 6 weeks without antibiotic washout or 3 months after 2 weeks' washout Spacers may be static (non-articulating) or dynamic (articulating). Static spacers are mainly used in the knee or hip in cases of severe bone defect or risk of soft-tissue lesions. An articulating spacer enables some joint functions to be preserved in the knee, hip or shoulder. The most frequent complications are the dislocation of dynamic spacers and the breakage of static or dynamic spacers. To optimize efficacy and minimize complications, the biomechanical and bacteriological characteristics of spacers must be considered. LEVEL OF EVIDENCE: Expert opinion.
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Affiliation(s)
- Cécile Batailler
- Service de Chirurgie Orthopédique et Médecine du Sport, Centre d'Excellence FIFA, Hôpital de la Croix Rousse, Hospices Civils de Lyon, Lyon, France; Univ Lyon, Université Claude Bernard Lyon 1, IFSTTAR, LBMC UMR_T9406, 69622 Villeurbanne, France.
| | - Nicolas Cance
- Service de Chirurgie Orthopédique et Médecine du Sport, Centre d'Excellence FIFA, Hôpital de la Croix Rousse, Hospices Civils de Lyon, Lyon, France
| | - Sébastien Lustig
- Service de Chirurgie Orthopédique et Médecine du Sport, Centre d'Excellence FIFA, Hôpital de la Croix Rousse, Hospices Civils de Lyon, Lyon, France; Univ Lyon, Université Claude Bernard Lyon 1, IFSTTAR, LBMC UMR_T9406, 69622 Villeurbanne, France
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Oe K, Iida H, Saito T. The 'Japanese paradox' of total hip arthroplasty: where are we going? Expert Rev Med Devices 2025; 22:31-48. [PMID: 39748157 DOI: 10.1080/17434440.2024.2448741] [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: 08/18/2024] [Accepted: 12/16/2024] [Indexed: 01/04/2025]
Abstract
INTRODUCTION There is a worldwide trend toward 'revisiting' cemented total hip arthroplasty (THA). In Japan, however, cemented THAs accounts for 11%, and the percentage of cemented hemiarthroplasty is estimated to be less than 10%. This review was designed to reconsider the option of cemented THA and to encourage policy changes in Japan to support the best possible care for patients. AREA COVERED In this article, we reviewed the history of THA and the current situations of the world, based on past reports and nationwide registries. Merits and demerits of cemented THA were evaluated from various perspectives. EXPERT OPINION Cemented THA had great advantages, including establishment of the acetabular cup, diversity of the femoral stem, antibiotic-loaded acrylic cement, revision, low incidence of periprosthetic fracture, and hemiarthroplasty. In patients older than 75 years of age, cemented THA resulted in the lowest risk of revision. Guidelines for femoral neck fracture recommended the use of cemented hemiarthroplasty in many countries because of low incidence of periprosthetic fracture. Numerous contradictions regarding implant price and cost of operations have also been noted in Japan. For the patients, we need to rethink what is truth and what is fiction.
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Affiliation(s)
- Kenichi Oe
- Department of Orthopaedic Surgery, Kansai Medical University, Hirakata, Osaka, Japan
| | - Hirokazu Iida
- Department of Orthopaedic Surgery, Kansai Medical University, Hirakata, Osaka, Japan
| | - Takanori Saito
- Department of Orthopaedic Surgery, Kansai Medical University, Hirakata, Osaka, Japan
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Romanò CL, Bonomo L, Bonomo G, Viale G, Del Sel H, Tezval M. What Is the Role of Local Antimicrobial Protection for One-Stage Revision for Peri-Prosthetic Hip Infection? Antibiotics (Basel) 2024; 13:1060. [PMID: 39596754 PMCID: PMC11590878 DOI: 10.3390/antibiotics13111060] [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: 09/29/2024] [Revised: 10/27/2024] [Accepted: 11/05/2024] [Indexed: 11/29/2024] Open
Abstract
The aim of this review is to investigate the effective role of local antimicrobial protection for one-stage cemented and cementless hip revision surgery. Twelve studies reporting the results of cemented single-stage procedures with a minimum two-year follow-up were reviewed. When pooling together the data, no infection recurrence was observed on average in 83.3% of the patients (a range of 75.0% to 100%). Only two papers included patients treated without the use of antibiotic-loaded bone cement, with an average infection control of 95.9% in a total of 195 patients. This figure appears to be better than the 80.7% infection control obtained by pooling together all the remaining studies. Concerning cementless one-stage revision, a total of 17 studies, reporting on 521 patients, showed an average of 90.0% (range 56.8% to 100%) no infection recurrence at a minimum two-year follow-up. No comparative study investigated cementless revision with or without local antibacterial protection. The pooled data showed an average infection control of 86.7%, without the application of local antibacterials, compared to 90.1% to 100% with local antimicrobial protection, depending on the technology used. No statistical difference could be found, either considering local antibacterial strategies alone or pooled together. No side effects had been reported by any local antibacterial technique. Local antibacterial protection for one-stage hip revision surgery, although safe and largely performed in the clinical setting, appears to still rely mainly on experts' opinions with no prospective or comparative trial, hence no definitive conclusion can be drawn concerning its effective role in one-stage hip revision surgery.
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Affiliation(s)
| | - Luigi Bonomo
- Universitatea de Medicina si Farmacie Victor Babes din Timisoara, 300041 Timișoara, Romania; (L.B.); (G.B.)
| | - Giulio Bonomo
- Universitatea de Medicina si Farmacie Victor Babes din Timisoara, 300041 Timișoara, Romania; (L.B.); (G.B.)
| | - German Viale
- Department Orthopaedics and Traumatology, British Hospital of Buenos Aires, Buenos Aires 1280, Argentina; (G.V.); (H.D.S.)
| | - Hernán Del Sel
- Department Orthopaedics and Traumatology, British Hospital of Buenos Aires, Buenos Aires 1280, Argentina; (G.V.); (H.D.S.)
| | - Mohammad Tezval
- Klinikum Vest GmbH, Dorstener Str. 151, 45657 Recklinghausen, Germany;
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Lizcano JD, Fernández-Rodríguez D, Goh GS, DeMik DE, Hughes AJ, Parvizi J, Courtney PM, Purtill JJ, Austin MS. In Vivo Intra-Articular Antibiotic Concentrations at 24 Hours After TKA Fall Below the Minimum Inhibitory Concentration for Most Bacteria: A Randomized Study of Commercially Available Bone Cement. J Bone Joint Surg Am 2024; 106:1664-1672. [PMID: 39052763 DOI: 10.2106/jbjs.23.01412] [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: 07/27/2024]
Abstract
BACKGROUND The use of antibiotic-loaded bone cement (ALBC) to help reduce the risk of infection after primary total knee arthroplasty (TKA) is controversial. There is a paucity of in vivo data on the elution characteristics of ALBC. We aimed to determine whether the antibiotic concentrations of 2 commercially available ALBCs met the minimum inhibitory concentration (MIC) and minimum biofilm eradication concentration (MBEC) for common infecting organisms. METHODS Forty-five patients undergoing TKA were randomized to receive 1 of the following: bone cement without antibiotic (the negative control; n = 5), a commercially available formulation containing 1 g of tobramycin (n = 20), or a commercially available formulation containing 0.5 g of gentamicin (n = 20). Intra-articular drains were placed, and fluid was collected at 4 and 24 hours postoperatively. An automated immunoassay measuring antibiotic concentration was performed, and the results were compared against published MIC and MBEC thresholds. RESULTS The ALBC treatment groups were predominantly of White (65%) or Black (32.5%) race and were 57.5% female and 42.4% male. The mean age (and standard deviation) was 72.6 ± 7.2 years in the gentamicin group and 67.6 ± 7.4 years in the tobramycin group. The mean antibiotic concentration in the tobramycin group was 55.1 ± 37.7 μg/mL at 4 hours and 19.5 ± 13.0 μg/mL at 24 hours, and the mean concentration in the gentamicin group was 38.4 ± 25.4 μg/mL at 4 hours and 17.7 ± 15.4 μg/mL at 24 hours. Time and antibiotic concentration had a negative linear correlation coefficient (r = -0.501). Most of the reference MIC levels were reached at 4 hours. However, at 24 hours, a considerable percentage of patients had concentrations below the MIC for many common pathogens, including Staphylococcus epidermidis (gentamicin: 65% to 100% of patients; tobramycin: 50% to 85%), methicillin-sensitive Staphylococcus aureus (gentamicin: 5% to 90%; tobramycin: 5% to 50%), methicillin-resistant S . aureus (gentamicin: 5% to 65%; tobramycin: 50%), Streptococcus species (gentamicin: 10% to 100%), and Cutibacterium acnes (gentamicin: 10% to 65%; tobramycin: 100%). The aforementioned ranges reflect variation in the MIC among different strains of each organism. Gentamicin concentrations reached MBEC threshold values at 4 hours only for the least virulent strains of S . aureus and Escherichia coli. Tobramycin concentrations did not reach the MBEC threshold for any of the bacteria at either time point. CONCLUSIONS The elution of antibiotics from commercially available ALBC decreased rapidly following TKA, and only at 4 hours postoperatively did the mean antibiotic concentrations exceed the MIC for most of the pathogens. Use of commercially available ALBC may not provide substantial antimicrobial coverage following TKA. LEVEL OF EVIDENCE Therapeutic Level I . See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Juan D Lizcano
- Rothman Orthopaedic Institute, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
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Bundschuh KE, Muffly BT, Ayeni AM, Heo KY, Khawaja SR, Tocio AJ, Karzon AL, Premkumar A, Guild GN. Should All Patients Receive Extended Oral Antibiotic Prophylaxis? Defining Its Role in Patients Undergoing Primary and Aseptic Revision Total Joint Arthroplasty. J Arthroplasty 2024; 39:S117-S121.e4. [PMID: 38218558 DOI: 10.1016/j.arth.2024.01.012] [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: 07/01/2023] [Revised: 12/28/2023] [Accepted: 01/07/2024] [Indexed: 01/15/2024] Open
Abstract
BACKGROUND Prior studies have demonstrated reduced periprosthetic joint infection (PJI) rates following extended oral antibiotics (EOAs) for high-risk patients undergoing primary total joint arthroplasty (TJA). This study compared 3-month PJI rates in all patients undergoing primary or aseptic revision TJA with or without EOA prophylaxis. METHODS In total, 2,982 consecutive primary (n = 2,677) and aseptic revision (n = 305) TJAs were performed by a single, fellowship-trained arthroplasty surgeon from 2016 to 2022 were retrospectively reviewed. Beginning January 2020, all patients received 7 days of 300 mg oral cefdinir twice daily immediately postoperatively. Rates of PJI at 3 months were compared between patients who received or did not receive EOA. RESULTS Rates of PJI at 3 months in patients undergoing primary and aseptic revision TJA were significantly lower in those receiving EOA prophylaxis compared to those who did not (0.41 versus 1.13%, respectively; P = .02). After primary TJA, lower PJI rates were observed with EOA prophylaxis utilization (0.23 versus 0.74%, P = .04; odds ratio [OR] 3.85). Following aseptic revision TJA, PJI rates trended toward a significant decrease with the EOA compared to without (1.88 versus 4.83%, respectively; P = .16; OR 2.71). CONCLUSIONS All patients undergoing primary or aseptic revision TJA who received EOA prophylaxis were 3.85 and 2.71 times less likely, respectively, to develop PJI at 3 months compared to those without EOA. Future studies are needed to determine if these results are maintained at postoperative time periods beyond 3 months following primary TJA. LEVEL OF EVIDENCE III, Retrospective review.
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Affiliation(s)
- Kyle E Bundschuh
- Department of Orthopaedic Surgery, Investigation performed at Emory University, Atlanta, Georgia
| | - Brian T Muffly
- Department of Orthopaedic Surgery, Investigation performed at Emory University, Atlanta, Georgia
| | - Ayomide M Ayeni
- Department of Orthopaedic Surgery, Investigation performed at Emory University, Atlanta, Georgia
| | - Kevin Y Heo
- Department of Orthopaedic Surgery, Investigation performed at Emory University, Atlanta, Georgia
| | - Sameer R Khawaja
- Department of Orthopaedic Surgery, Investigation performed at Emory University, Atlanta, Georgia
| | - Adam J Tocio
- Department of Orthopaedic Surgery, Investigation performed at Emory University, Atlanta, Georgia
| | - Anthony L Karzon
- Department of Orthopaedic Surgery, Investigation performed at Emory University, Atlanta, Georgia
| | - Ajay Premkumar
- Department of Orthopaedic Surgery, Investigation performed at Emory University, Atlanta, Georgia
| | - George N Guild
- Department of Orthopaedic Surgery, Investigation performed at Emory University, Atlanta, Georgia
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Nourie BO, Cozzarelli NF, Krueger CA, Donnelly PC, Fillingham YA. Antibiotic Laden Bone Cement Does Not Reduce Acute Periprosthetic Joint Infection Risk in Primary Total Knee Arthroplasty. J Arthroplasty 2024; 39:S229-S234. [PMID: 38703925 DOI: 10.1016/j.arth.2024.04.068] [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: 09/28/2023] [Revised: 04/22/2024] [Accepted: 04/23/2024] [Indexed: 05/06/2024] Open
Abstract
BACKGROUND Periprosthetic joint infection (PJI) can be a serious complication of total knee arthroplasty (TKA). A method believed to decrease the incidence of PJI is antibiotic-laden bone cement (ALBC). Current clinical practice guidelines do not recommend ALBC in primary TKA. The purpose of this study was to compare ALBC to plain cement (PC) in preventing PJI in primary TKA. METHODS This retrospective analysis included 109,242 Medicare patients in the American Joint Replacement Registry who underwent a cemented primary TKA from January 2017 to March 2021, and had at least 1 year of follow-up. Patients who received ALBC were compared to patients who received PC. Demographic and case-specific variables such as age, sex, race, body mass index, Charlson Comorbidity Index, anesthesia type, and operative time were used to create propensity scores. A logistic regression was run to predict the probability of receiving ALBC. Also, a multivariate model was run on the full unstratified population, using the same covariates as were used to create the propensity model. The primary outcome was differences in PJI rates. RESULTS Logistic regression analysis showed that a higher preoperative diagnosis of osteoarthritis, higher Charlson Comorbidity Index, higher body mass index, women, race, and anesthesia requirements increased a patient's probability of receiving ALBC. In the full unstratified multivariate model, ALBC did not show a statistically significant difference in risk of revision for infection compared to PC. CONCLUSIONS The use of ALBC in primary TKA has not been shown to be more efficacious in preventing PJI within the population of Medicare patients in the United States. However, this study is limited given it is a retrospective database study that may inherently have biases and the large dataset has a potential for overpowering the findings.
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Affiliation(s)
- Blake O Nourie
- Department of Orthopedic Surgery, Albany Medical Center, Albany, New York
| | - Nicholas F Cozzarelli
- Department of Orthopedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Chad A Krueger
- Department of Orthopedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | | | - Yale A Fillingham
- Department of Orthopedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
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Pardo-Pol A, Fontanellas-Fes A, Pérez-Prieto D, Sorli L, Hinarejos P, Monllau JC. The Use of Erythromycin and Colistin Cement in Total Knee Arthroplasty Does Not Reduce the Incidence of Infection: A Randomized Study in 2,893 Knees With a 9-year Average Follow-Up. J Arthroplasty 2024; 39:2280-2284. [PMID: 38640967 DOI: 10.1016/j.arth.2024.04.039] [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: 03/25/2023] [Revised: 04/09/2024] [Accepted: 04/11/2024] [Indexed: 04/21/2024] Open
Abstract
BACKGROUND One of the most severe complications of primary total knee arthroplasty (TKA) is prosthetic joint infection. Currently, the use of antibiotic-loaded cement for the prevention of infection is still controversial. The aim of the present study was to evaluate if the use of antibiotic-loaded cement reduces the infection rate in primary TKA in long-term follow-up (more than 5 years average follow-up). METHODS This study is the follow-up extension of a prospective randomized study, with 2,893 cemented TKA performed between 2005 and 2010 at our institution. There were 2 different cohorts depending on which bone cement was used: without antibiotics (control group) or those loaded with erythromycin and colistin (study group). All patients received the same systemic prophylactic antibiotics. The patients were followed for a minimum of twelve months. The diagnosis of prosthetic joint infection was done according to Zimmerli criteria. RESULTS In 1,452 patients, the prosthetic components were fixed using bone cement without antibiotics, whereas in 1,441 patients, bone cement was loaded with erythromycin and colistin. Both groups were comparable in terms of all the possible risk factors studied. We found a total of 53 deep infections, with a mean rate of 1.8%. There were no differences between the groups as to whether bone cement with or without antibiotics had been used (P = .58). The average duration of follow-up was 8.7 years. In terms of prosthetic revision due to aseptic loosening, there were no differences between groups (P = .32), with 33 revision arthroplasties in the control group and 37 in the study group. Moreover, we analyzed the erythromycin resistance rate, with no differences between both groups (P = .6). CONCLUSIONS The use of erythromycin and colistin-loaded bone cement in TKA did not lead to a decrease in the rate of infection in long-term follow-up, a finding that suggests that its use would not be indicated in the general population.
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Affiliation(s)
- Albert Pardo-Pol
- Department of Orthopedics, Parc de Salut Mar, Universitat Autònoma de Barcelona (UAB), Barcelona, Spain; Institut Catala de Traumatologiai Medicina de l'Esport (ICATME)-Hospital Universitari Quiron-Dexeus, Universitat Autonoma de Barcelona, Barcelona, Spain
| | - Albert Fontanellas-Fes
- Department of Orthopedics, Parc de Salut Mar, Universitat Autònoma de Barcelona (UAB), Barcelona, Spain
| | - Daniel Pérez-Prieto
- Department of Orthopedics, Parc de Salut Mar, Universitat Autònoma de Barcelona (UAB), Barcelona, Spain; Institut Catala de Traumatologiai Medicina de l'Esport (ICATME)-Hospital Universitari Quiron-Dexeus, Universitat Autonoma de Barcelona, Barcelona, Spain
| | - Lluïsa Sorli
- Department of Infectious Diseases, Parc de Salut Mar, Universitat Autònoma de Barcelona (UAB), Barcelona, Spain
| | - Pedro Hinarejos
- Department of Orthopedics, Parc de Salut Mar, Universitat Autònoma de Barcelona (UAB), Barcelona, Spain
| | - Joan Carles Monllau
- Department of Orthopedics, Parc de Salut Mar, Universitat Autònoma de Barcelona (UAB), Barcelona, Spain; Institut Catala de Traumatologiai Medicina de l'Esport (ICATME)-Hospital Universitari Quiron-Dexeus, Universitat Autonoma de Barcelona, Barcelona, Spain
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8
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Leta TH, Lie SA, Fenstad AM, Lygre SHL, Lindberg-Larsen M, Pedersen AB, W-Dahl A, Rolfson O, Bülow E, van Steenbergen LN, Nelissen RGHH, Harries D, de Steiger R, Lutro O, Mäkelä K, Venäläinen MS, Willis J, Wyatt M, Frampton C, Grimberg A, Steinbrück A, Wu Y, Armaroli C, Gentilini MA, Picus R, Bonetti M, Dragosloveanu S, Vorovenci AE, Dragomirescu D, Dale H, Brand C, Christen B, Shapiro J, Wilkinson JM, Armstrong R, Wooster K, Hallan G, Gjertsen JE, Chang RN, Prentice HA, Sedrakyan A, Paxton EW, Furnes O. Periprosthetic Joint Infection After Total Knee Arthroplasty With or Without Antibiotic Bone Cement. JAMA Netw Open 2024; 7:e2412898. [PMID: 38780939 PMCID: PMC11117087 DOI: 10.1001/jamanetworkopen.2024.12898] [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: 12/27/2023] [Accepted: 03/20/2024] [Indexed: 05/25/2024] Open
Abstract
Importance Despite increased use of antibiotic-loaded bone cement (ALBC) in joint arthroplasty over recent decades, current evidence for prophylactic use of ALBC to reduce risk of periprosthetic joint infection (PJI) is insufficient. Objective To compare the rate of revision attributed to PJI following primary total knee arthroplasty (TKA) using ALBC vs plain bone cement. Design, Setting, and Participants This international cohort study used data from 14 national or regional joint arthroplasty registries in Australia, Denmark, Finland, Germany, Italy, New Zealand, Norway, Romania, Sweden, Switzerland, the Netherlands, the UK, and the US. The study included primary TKAs for osteoarthritis registered from January 1, 2010, to December 31, 2020, and followed-up until December 31, 2021. Data analysis was performed from April to September 2023. Exposure Primary TKA with ALBC vs plain bone cement. Main Outcomes and Measures The primary outcome was risk of 1-year revision for PJI. Using a distributed data network analysis method, data were harmonized, and a cumulative revision rate was calculated (1 - Kaplan-Meier), and Cox regression analyses were performed within the 10 registries using both cement types. A meta-analysis was then performed to combine all aggregated data and evaluate the risk of 1-year revision for PJI and all causes. Results Among 2 168 924 TKAs included, 93% were performed with ALBC. Most TKAs were performed in female patients (59.5%) and patients aged 65 to 74 years (39.9%), fully cemented (92.2%), and in the 2015 to 2020 period (62.5%). All participating registries reported a cumulative 1-year revision rate for PJI of less than 1% following primary TKA with ALBC (range, 0.21%-0.80%) and with plain bone cement (range, 0.23%-0.70%). The meta-analyses based on adjusted Cox regression for 1 917 190 TKAs showed no statistically significant difference at 1 year in risk of revision for PJI (hazard rate ratio, 1.16; 95% CI, 0.89-1.52) or for all causes (hazard rate ratio, 1.12; 95% CI, 0.89-1.40) among TKAs performed with ALBC vs plain bone cement. Conclusions and Relevance In this study, the risk of revision for PJI was similar between ALBC and plain bone cement following primary TKA. Any additional costs of ALBC and its relative value in reducing revision risk should be considered in the context of the overall health care delivery system.
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Affiliation(s)
- Tesfaye H. Leta
- The Norwegian Arthroplasty Register, Department of Orthopedic Surgery, Haukeland University Hospital, Bergen, Norway
- Faculty of Health Science, VID Specialized University, Oslo, Norway
- Department of Population Health Sciences, Weill Medical College of Cornell University, New York, New York
- Medical Device Surveillance and Assessment, Kaiser Permanente, San Diego, California
| | - Stein Atle Lie
- The Norwegian Arthroplasty Register, Department of Orthopedic Surgery, Haukeland University Hospital, Bergen, Norway
- Center for Translational Oral Research, Department of Dentistry, University of Bergen, Bergen, Norway
| | - Anne Marie Fenstad
- The Norwegian Arthroplasty Register, Department of Orthopedic Surgery, Haukeland University Hospital, Bergen, Norway
| | - Stein Håkon L. Lygre
- The Norwegian Arthroplasty Register, Department of Orthopedic Surgery, Haukeland University Hospital, Bergen, Norway
- Department of Occupational Medicine, Haukeland University Hospital, Bergen, Norway
| | - Martin Lindberg-Larsen
- The Danish Knee Arthroplasty Register, Odense, Denmark
- Department of Orthopaedic Surgery and Traumatology, Odense University Hospital, Odense, Denmark
| | - Alma B. Pedersen
- The Danish Knee Arthroplasty Register, Odense, Denmark
- Department of Clinical Epidemiology, Aarhus University Hospital and Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Annette W-Dahl
- The Swedish Arthroplasty Register, Gothenburg, Sweden
- Department of Clinical Sciences Lund, Orthopedics, Lund University, Lund, Sweden
| | - Ola Rolfson
- The Swedish Arthroplasty Register, Gothenburg, Sweden
- Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Erik Bülow
- Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Centre of Registers Västra Götaland, Gothenburg, Sweden
| | | | - Rob G. H. H. Nelissen
- The Dutch Arthroplasty Register, ‘s-Hertogenbosch, the Netherlands
- Department Orthopaedics, Leiden University Medical Center, Leiden, the Netherlands
| | - Dylan Harries
- South Australian Health and Medical Research Institute, Adelaide, Australia
| | - Richard de Steiger
- The Australian Orthopaedic Association National Joint Replacement Registry, Adelaide, Australia
| | - Olav Lutro
- Department of Medicine, Stavanger University Hospital, Stavanger, Norway
| | - Keijo Mäkelä
- The Finnish Arthroplasty Register, Helsinki, Finland
- Turku University Hospital and University of Turku, Turku, Finland
| | | | - Jinny Willis
- The New Zealand Joint Registry, Christchurch, New Zealand
| | - Michael Wyatt
- The New Zealand Joint Registry, Christchurch, New Zealand
| | - Chris Frampton
- The New Zealand Joint Registry, Christchurch, New Zealand
| | | | | | - Yinan Wu
- German Arthroplasty Registry, Berlin, Germany
| | - Cristiana Armaroli
- Arthroplasty Registry of the Autonomous Province of Trento, Clinical Epidemiology Service, Provincial Agency for Health Services of Trento, Trento, Italy
| | - Maria Adalgisa Gentilini
- Arthroplasty Registry of the Autonomous Province of Trento, Clinical Epidemiology Service, Provincial Agency for Health Services of Trento, Trento, Italy
| | - Roberto Picus
- Arthroplasty Register of Autonomous Province of Bolzano, Observatory of Health, Health Department AP of Bolzano, Bolzano, Italy
| | - Mirko Bonetti
- Arthroplasty Register of Autonomous Province of Bolzano, Observatory of Health, Health Department AP of Bolzano, Bolzano, Italy
| | - Serban Dragosloveanu
- Romanian Arthroplasty Registry, Bucharest, Romania
- University of Medicine and Pharmacy–Carol Davila, Bucharest, Romania
- Foisor Orthopaedic Hospital, Bucharest, Romania
| | - Andreea E. Vorovenci
- Romanian Arthroplasty Registry, Bucharest, Romania
- Economic Cybernetics and Statistics Doctoral School, Bucharest University of Economic Studies, Bucharest, Romania
| | - Dan Dragomirescu
- Romanian Arthroplasty Registry, Bucharest, Romania
- Economic Cybernetics and Statistics Doctoral School, Bucharest University of Economic Studies, Bucharest, Romania
| | - Håvard Dale
- The Norwegian Arthroplasty Register, Department of Orthopedic Surgery, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, Faculty of Medicine, University of Bergen, Bergen, Norway
| | - Christian Brand
- Swiss National Hip and Knee Joint Registry, Bern, Switzerland
- Institute of Social and Preventive Medicine, SwissRDL, University of Bern, Bern, Switzerland
| | - Bernhard Christen
- Swiss National Hip and Knee Joint Registry, Bern, Switzerland
- Articon, Bern, Switzerland
| | - Joanne Shapiro
- The National Joint Registry for England, Wales, Northern Ireland, The Isle of Man and Guernsey, London, United Kingdom
- NEC Software Solutions, Hemel Hempstead, United Kingdom
| | - J. Mark Wilkinson
- The National Joint Registry for England, Wales, Northern Ireland, The Isle of Man and Guernsey, London, United Kingdom
- Division of Clinical Medicine, School of Medicine and Population Health, University of Sheffield, Sheffield, United Kingdom
| | - Richard Armstrong
- The National Joint Registry for England, Wales, Northern Ireland, The Isle of Man and Guernsey, London, United Kingdom
- NEC Software Solutions, Hemel Hempstead, United Kingdom
| | - Kate Wooster
- The National Joint Registry for England, Wales, Northern Ireland, The Isle of Man and Guernsey, London, United Kingdom
- NEC Software Solutions, Hemel Hempstead, United Kingdom
| | - Geir Hallan
- The Norwegian Arthroplasty Register, Department of Orthopedic Surgery, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, Faculty of Medicine, University of Bergen, Bergen, Norway
| | - Jan-Erik Gjertsen
- The Norwegian Arthroplasty Register, Department of Orthopedic Surgery, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, Faculty of Medicine, University of Bergen, Bergen, Norway
| | - Richard N. Chang
- Medical Device Surveillance and Assessment, Kaiser Permanente, San Diego, California
| | - Heather A. Prentice
- Medical Device Surveillance and Assessment, Kaiser Permanente, San Diego, California
| | - Art Sedrakyan
- Department of Population Health Sciences, Weill Medical College of Cornell University, New York, New York
| | - Elizabeth W. Paxton
- Medical Device Surveillance and Assessment, Kaiser Permanente, San Diego, California
| | - Ove Furnes
- The Norwegian Arthroplasty Register, Department of Orthopedic Surgery, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, Faculty of Medicine, University of Bergen, Bergen, Norway
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9
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Ganta A, Merrell LA, Adams J, Konda SR, Egol KA. Retention of Antibiotic Cement Delivery Implants in Orthopedic Infection Associated With United Fractures Does Not Increase Recurrence Risk. J Orthop Trauma 2024; 38:190-195. [PMID: 38206770 DOI: 10.1097/bot.0000000000002771] [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] [Accepted: 01/08/2024] [Indexed: 01/13/2024]
Abstract
OBJECTIVES To evaluate whether retention of antibiotic cement delivery devices after resolution of orthopaedic infection is associated with recurrence. METHODS DESIGN Retrospective cohort. SETTING Academic medical center. PATIENT SELECTION CRITERIA Patients with a fracture definitively treated with internal fixation that went on to unite and develop a confirmed fracture-related infection or osteomyelitis after a remote fracture surgery and had implantation of antibiotic-impregnated cement for infection management. OUTCOME MEASURES AND COMPARISONS Patients were divided into whom the antibiotic implants were retained (Retained Cohort) and whom the antibiotic implants were removed (Removed Cohort). Outcome measures included clinical infection resolution, infection recurrence, time to resolution of infection signs, symptoms and laboratory values, reoperation and readmission rates, and need for soft tissue coverage (local flap vs. free tissue transfer) because of recurrence. RESULTS Of 98 patients treated for fracture-related infection in united fractures or osteomyelitis after a remote fracture surgery, 39 (39.8%) underwent implantation of antibiotic-impregnated cement delivery devices: 21 (21.4%) beads, 7 (7.1%) rods, and 11 (11.2%) blocks. Twenty patients (51.3%) comprised the Retained Cohort and 19 patients (48.7%) comprised the Removed Cohort. There were few differences in demographics ([American Society of Anesthesiology Score, P = 0.026] and [diabetes, P = 0.047]), infection location, and pathogenic profiles. The cohorts demonstrated no difference in eventual resolution of infection (100% in the Retained Cohort, 95% in the Removed Cohort, P = 0.487) and experienced similar time to clinical infection resolution, based on signs, symptoms, and laboratory values ( P = 0.360). There was no difference in incidence of subsequent infection recurrence after clinical infection resolution (1 recurrence Retained vs. 2 recurrences Removed, P = 0.605) for those considered "cured." Compared with the Retained Cohort, the Removed Cohort underwent more reoperations (0.40 vs. 1.84 reoperations, P < 0.001) and admissions after implantation ( P < 0.001). CONCLUSIONS Retention of antibiotic-impregnated cement delivery devices in patients with orthopaedic infection after fractured bones that have healed was not associated with infection recurrence. Additional surgical intervention with the sole purpose of removing antibiotic delivery devices may not be warranted. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Abhishek Ganta
- Department of Orthopedic Surgery, NYU Langone Health, NYU Langone Orthopedic Hospital, New York, NY; and
- Department of Orthopedic Surgery, Jamaica Hospital Medical Center, Queens, NY
| | - Lauren A Merrell
- Department of Orthopedic Surgery, NYU Langone Health, NYU Langone Orthopedic Hospital, New York, NY; and
| | - Jack Adams
- Department of Orthopedic Surgery, NYU Langone Health, NYU Langone Orthopedic Hospital, New York, NY; and
| | - Sanjit R Konda
- Department of Orthopedic Surgery, NYU Langone Health, NYU Langone Orthopedic Hospital, New York, NY; and
- Department of Orthopedic Surgery, Jamaica Hospital Medical Center, Queens, NY
| | - Kenneth A Egol
- Department of Orthopedic Surgery, NYU Langone Health, NYU Langone Orthopedic Hospital, New York, NY; and
- Department of Orthopedic Surgery, Jamaica Hospital Medical Center, Queens, NY
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10
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Nandi S, Doub JB, De Palma BJ, Potter GR, Stronach BM, Stambough JB, Brilliant ZR, Mears SC. Suppressive Antibiotic Therapy After Debridement, Antibiotics, and Implant Retention is Well-Tolerated Without Inducing Resistance: A Multicenter Study. J Arthroplasty 2024; 39:795-800. [PMID: 37717831 DOI: 10.1016/j.arth.2023.09.004] [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: 10/31/2022] [Revised: 08/25/2023] [Accepted: 09/03/2023] [Indexed: 09/19/2023] Open
Abstract
BACKGROUND Suppressive antibiotic therapy (SAT) after total joint arthroplasty (TJA) debridement, antibiotics, and implant retention (DAIR) maximizes reoperation-free survival. We evaluated SAT after DAIR of acutely infected primary TJA regarding: 1) adverse drug reaction (ADR)/intolerance; 2) reoperation for infection; and 3) antibiotic resistance. METHODS Patients who underwent total knee arthroplasty (TKA) or total hip arthroplasty (THA) DAIR for acute periprosthetic joint infection at two academic medical centers from 2015 to 2020 were identified (n = 115). Data were collected on patient demographics, infecting organisms, antibiotics, ADR/intolerances, reoperations, and antibiotic resistances. Median SAT duration was 11 months. Stepwise multivariate logistic regressions were used to identify covariates significantly associated with outcomes of interest. RESULTS There were 11.1 and 16.3% of TKA and THA DAIR patients, respectively, who had ADR/intolerance to SAT. Patients prescribed trimethoprim/sulfamethoxazole (P = .0014) or combination antibiotic therapy (P = .0169) after TKA DAIR had increased risk of ADR/intolerance. There was no difference in reoperation-free survival between TKA (83.3%) and THA (65.1%) DAIR (P = .5900) at mean 2.8-year follow-up. Risk of reoperation for infection was higher among TKA Staphylococcus aureus infections (P = .0004) and lower with increased SAT duration (P < .0450). The optimal duration of SAT was nearly 2 years. No cases of antibiotic resistance developed due to SAT. CONCLUSIONS Consider SAT after TJA DAIR due to improved reoperation-free survival and favorable safety profile. Prolonged SAT did not induce antibiotic resistance. Use trimethoprim/sulfamethoxazole with caution because of the increased likelihood of ADR/intolerance. LEVEL OF EVIDENCE Therapeutic Level III.
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Affiliation(s)
- Sumon Nandi
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, Maryland
| | - James B Doub
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, Maryland
| | - Brian J De Palma
- Department of Orthopaedics, University of Maryland Medical Center, Baltimore, Maryland
| | - Genna R Potter
- Department of Orthopaedic Surgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Benjamin M Stronach
- Department of Orthopaedic Surgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Jeffrey B Stambough
- Department of Orthopaedic Surgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Zachary R Brilliant
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, Maryland
| | - Simon C Mears
- Department of Orthopaedic Surgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas
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11
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Bos PK, Spekenbrink-Spooren A, Croughs P, Bierma-Zeinstra SMA, Reijman M, Van Oldenrijk J. Risk for re-revision and type of antibiotic-loaded bone cement in hip or knee arthroplasty revisions: report of the Dutch Arthroplasty Register. Acta Orthop 2023; 94:471-476. [PMID: 37728200 PMCID: PMC10510150 DOI: 10.2340/17453674.2023.18645] [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: 01/01/2023] [Accepted: 08/17/2023] [Indexed: 09/21/2023] Open
Abstract
BACKGROUND AND PURPOSE High-dose dual antibiotic-loaded bone cement (ALBC) may reduce the risk of revision after total hip and knee replacements. The aim of our study therefore was to determine the risk of re-revision following first time aseptic hip or knee revision using single versus dual ALBC. PATIENTS AND METHODS Patients from the Dutch Arthroplasty Register treated from 2007 to 2018 with first time cemented aseptic hip (n = 2,529) or knee revisions (n = 7,124) were incorporated into 2 datasets. The primary endpoint of this observational cohort study was subsequent all-cause re-revision. Multivariable Cox proportional hazard and competing risk was analyzed for both groups. RESULTS There was no difference in re-revision rate (any reason) with single versus dual ALBC (hazard ratio 1.06, 95% confidence interval [CI] 0.83-1.35 for hip and 0.93, CI 0.80-1.07 for knee revisions). The 10-year crude cumulative re-revision rate also showed no differences for single versus dual ALBC use. The crude cumulative 7-year THA re-revision and 9-year TKA re-revision rates did not show any difference in implant survival for common cement types used. CONCLUSION We could not confirm the potential benefit of using dual ALBC compared with single ALBC for aseptic hip and knee revisions.
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Affiliation(s)
- Pieter K Bos
- Department of Orthopedics and Sports Medicine, Erasmus MC University Medical Center, Rotterdam.
| | | | - Peter Croughs
- Department of Medical Microbiology and Infectious Diseases, Erasmus MC University Medical Center, Rotterdam
| | - Sita M A Bierma-Zeinstra
- Department of Orthopedics and Sports Medicine, Erasmus MC University Medical Center, Rotterdam; Department of General Practice, Erasmus MC University Center Rotterdam, Rotterdam, the Netherlands
| | - Max Reijman
- Department of Orthopedics and Sports Medicine, Erasmus MC University Medical Center, Rotterdam
| | - Jakob Van Oldenrijk
- Department of Orthopedics and Sports Medicine, Erasmus MC University Medical Center, Rotterdam
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12
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Jiamton C, Apivatgaroon A, Aunaramwat S, Chawalitrujiwong B, Chuaychoosakoon C, Suwannaphisit S, Jirawison C, Iamsumang C, Kongmalai P, Sukvanich P, Nakorn PN, Ongbumrungphan W, Rattanasumrit P, Tharakulphan S, Thongtanworapat T, Thammarakcharoen F, Srion A, Suwanprateeb J, Chernchujit B. Efficacy and Safety of Antibiotic Impregnated Microporous Nanohydroxyapatite Beads for Chronic Osteomyelitis Treatment: A Multicenter, Open-Label, Prospective Cohort Study. Antibiotics (Basel) 2023; 12:1049. [PMID: 37370370 DOI: 10.3390/antibiotics12061049] [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: 04/16/2023] [Revised: 06/02/2023] [Accepted: 06/05/2023] [Indexed: 06/29/2023] Open
Abstract
Chronic osteomyelitis is still a serious health problem that causes disabling conditions and has an impact on the quality of life. The objective of this study was to determine the clinical efficacy and safety of localized antibiotics delivery via impregnated microporous nanohydroxyapatite (nHA-ATB) beads for chronic osteomyelitis treatment. A total of 62 patients were enrolled in this study. After radical surgical debridement, the bone defect was filled with three types of antibiotics (vancomycin or gentamicin or fosfomycin) impregnated HA beads. The follow-up period was 48 weeks. It was found that the success rate was approximately 98% with a re-infection in only one patient. Quality of life of all patients after treatment improved significantly over time. Systemic exposure to vancomycin and gentamicin after beads implantation was limited and high local antibiotics concentrations were found in wound drainage fluid at 24, 48 and 72 h. Blood biochemistry measurements did not show any nephrotoxic or hepatotoxic effects. 20 adverse events were reported, but 90% of the events were resolved without having to remove the beads and the patients recovered. Satisfactory outcomes were observed in terms of success rate, quality of life and adverse effect. nHA-ATB beads impregnated by vancomycin or gentamicin or fosfomycin could potentially be employed as an alternative product of choice for localized antibiotics delivery in chronic osteomyelitis treatment.
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Affiliation(s)
- Chittawee Jiamton
- Institute of Orthopaedics, Lerdsin Hospital, Silom Road, Bang Rak, Bangkok 10500, Thailand
- Queen Savang Vadhana Memorial Hospital, Jerm Jom Phon Road, Tambon Si Racha, Si Racha, Chonburi 20110, Thailand
| | - Adinun Apivatgaroon
- Department of Orthopaedics, Faculty of Medicine, Thammasat University, Paholyothin Road, Klong Nueng, Klong Luang, Pathum Thani 12121, Thailand
| | - Saree Aunaramwat
- Paholpolpayuhasena Hospital, Sangchuto Road, Pak Phraek, Mueang, Kanchanaburi 71000, Thailand
| | - Banchai Chawalitrujiwong
- Suppasitthiprasong Hospital, Sappasit Road, Nai Mueang, Mueang, Ubon Ratchathani 34000, Thailand
| | - Chaiwat Chuaychoosakoon
- Department of Orthopedics, Faculty of Medicine, Prince of Songkla University, Karnjanavanich Road, Kho Hong, Hat Yai, Songkhla 90110, Thailand
| | - Sitthiphong Suwannaphisit
- Department of Orthopedics, Faculty of Medicine, Prince of Songkla University, Karnjanavanich Road, Kho Hong, Hat Yai, Songkhla 90110, Thailand
| | - Choen Jirawison
- Bhudasothon Hospital, Marupong Road, Na Mueang, Mueang, Chachoengsao 24000, Thailand
| | | | - Pinkawas Kongmalai
- Department of Orthopedics, Faculty of Medicine, Srinakharinwirot University, Rangsit-Nakhon Nayok Road, Baan na, Ongkharak, Nakhon Nayok 26120, Thailand
| | - Pawaris Sukvanich
- Department of Orthopedics, Faculty of Medicine, Srinakharinwirot University, Rangsit-Nakhon Nayok Road, Baan na, Ongkharak, Nakhon Nayok 26120, Thailand
| | - Pongtep Na Nakorn
- Hatyai Hospital, Ratthakan, Tambon Hat Yai, Hat Yai, Songkhla 90110, Thailand
| | | | - Pawin Rattanasumrit
- Bhumibol Adulyadej Hospital, Phahonyothin Road, Sai Mai, Bangkok 10220, Thailand
| | - Suthee Tharakulphan
- Khon Kaen Hospital, Sri Chant Road, Nai Mueang, Mueang, Khon Kaen 40000, Thailand
| | | | - Faungchat Thammarakcharoen
- National Metal and Materials Technology Center (MTEC), National Science and Technology Development Agency (NSTDA), 111 Phahonyothin Road, Khlong Nueng, Khlong Luang, Pathum Thani 12120, Thailand
| | - Autcharaporn Srion
- National Metal and Materials Technology Center (MTEC), National Science and Technology Development Agency (NSTDA), 111 Phahonyothin Road, Khlong Nueng, Khlong Luang, Pathum Thani 12120, Thailand
| | - Jintamai Suwanprateeb
- National Metal and Materials Technology Center (MTEC), National Science and Technology Development Agency (NSTDA), 111 Phahonyothin Road, Khlong Nueng, Khlong Luang, Pathum Thani 12120, Thailand
- Thammasat University Center of Excellence in Computational Mechanics and Medical Engineering, Thammasat University, Phahonyothin Road, Khlong Nueng, Khlong Luang, Pathum Thani 12121, Thailand
| | - Bancha Chernchujit
- Department of Orthopaedics, Faculty of Medicine, Thammasat University, Paholyothin Road, Klong Nueng, Klong Luang, Pathum Thani 12121, Thailand
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13
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Szymski D, Walter N, Krull P, Melsheimer O, Lang S, Grimberg A, Alt V, Steinbrück A, Rupp M. The Prophylactic Effect of Single vs. Dual Antibiotic-Loaded Bone Cement against Periprosthetic Joint Infection Following Hip Arthroplasty for Femoral Neck Fracture: An Analysis of the German Arthroplasty Registry. Antibiotics (Basel) 2023; 12:antibiotics12040732. [PMID: 37107094 PMCID: PMC10135143 DOI: 10.3390/antibiotics12040732] [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: 03/26/2023] [Revised: 03/31/2023] [Accepted: 04/07/2023] [Indexed: 04/29/2023] Open
Abstract
BACKGROUND Antibiotic-loaded bone cement in arthroplasties is currently experiencing increased usage. Therefore, single and double antibiotic-loaded bone cements are commercially available and used in orthopedic surgery. The aim of this investigation was to compare the clinical use of single compared to dual antibiotic-loaded bone cement for implant fixation after femoral neck fracture. Further infection rates were to be compared in (partial) arthroplasty for the treatment of femoral neck fracture for both treatment options. METHODS On the basis of the German Arthroplasty Registry (EPRD), all cases of femoral neck fracture treated with hemiarthroplasty (HA), or total hip arthroplasty (THA) with single and dual antibiotic-loaded bone cement, were included into the data analysis. The infection risk was compared using Kaplan-Meier estimates. RESULTS In total, 26,845 cases (HA 76.3%-THA: 23.7%) with femoral neck fracture were included. Within recent years, an increasing usage of dual antibiotic-loaded cement in Germany, with a current proportion of 7.30% in arthroplasty procedures for femoral neck fracture treatment, has been observed. In patients treated with HA, the proportion of dual antibiotic-loaded cement was 7.86%, while in those treated with THA, 5.46% of all prostheses were fixated with a two antibiotic component cement. For all arthroplasty procedures using single antibiotic-loaded bone cement after six months 1.8%, after one year 1.9%, and after five years 2.3%, of the cases failed due to periprosthetic joint infection (PJI), while in the same time period, in cases with dual antibiotic-loaded bone cement 1.5%, 1.5% and 1.5% suffered from infection (p = 0.34). A infection rate of 1.1% after HA with dual antibiotic-loaded bone cement was reported, compared to a 2.1% infection rate whilst using single antibiotic-loaded bone cement after five years (p = 0.098). The number required for treatment when using HA was 91. CONCLUSIONS The use of dual antibiotic-loaded bone cement is increasingly used in arthroplasty procedures after femoral neck fractures. It demonstrates a reduction of PJI after HA and seems, therefore, to be a useful method for the prevention of infection, especially in patients with increased risk factors for PJI.
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Affiliation(s)
- Dominik Szymski
- Department for Trauma Surgery, University Hospital Regensburg, 93053 Regensburg, Germany
| | - Nike Walter
- Department for Trauma Surgery, University Hospital Regensburg, 93053 Regensburg, Germany
| | - Paula Krull
- Deutsches Endoprothesenregister (EPRD) gGmbH, 10623 Berlin, Germany
| | | | - Siegmund Lang
- Department for Trauma Surgery, University Hospital Regensburg, 93053 Regensburg, Germany
| | | | - Volker Alt
- Department for Trauma Surgery, University Hospital Regensburg, 93053 Regensburg, Germany
| | - Arnd Steinbrück
- Deutsches Endoprothesenregister (EPRD) gGmbH, 10623 Berlin, Germany
- Orthopädisch Chirurgisches Kompetenzzentrum Augsburg (OCKA), 86152 Augsburg, Germany
| | - Markus Rupp
- Department for Trauma Surgery, University Hospital Regensburg, 93053 Regensburg, Germany
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14
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Sabater-Martos M, Verdejo MA, Morata L, Muñoz-Mahamud E, Guerra-Farfan E, Martinez-Pastor JC, Soriano A. Antimicrobials in polymethylmethacrylate: from prevention to prosthetic joint infection treatment: basic principles and risk of resistance. ARTHROPLASTY 2023; 5:12. [PMID: 36864538 PMCID: PMC9983184 DOI: 10.1186/s42836-023-00166-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Accepted: 01/16/2023] [Indexed: 03/04/2023] Open
Abstract
BACKGROUND Excellent revisions about antibiotic-loaded bone cement (ALBC) have been recently published. In the present article, we review the principles and limitations of local antibiotic delivery in the context of recent advances in the pathogenesis of prosthetic joint infections (PJI), with particular attention paid to the potential association between ALBC and antimicrobial resistance. MAIN BODY Recalcitrance of PJI is related to the ability of pathogens to adapt to particular environments present in bone tissue and protect themselves from host immunity in different ways. Accordingly, delivery of high local antimicrobial concentrations using ALBC is needed. Most relevant clinical data showing the efficacy of ALBC for PJI prophylaxis and treatment are reviewed, and we dissected the limitations on the basis of the recent findings from animal models and suggested that aminoglycosides, in particular, could not be the best option. One of the major concerns associated with ALBC is the emergence of resistance because of theoretical prolonged exposure to low antibiotic concentrations. We summarize the mechanisms for the selection of resistant microorganisms, and we critically reviewed the evidence from animal models and clinical data from observational and registry studies and concluded that there is no evidence to support this association. CONCLUSION While waiting for better evidence from well-designed clinical trials, ALBC shows a beneficial effect as a prophylaxis in arthroplasty, and to avoid the colonization of spacers used for two-stage revision in patients with PJI. Experimental models and clinical evidence suggest the need to achieve high local antimicrobial concentrations to obtain the highest prophylactic and therapeutic effect. The current evidence does not support the risk of increasing resistance with use of ALBC. In the future, it is necessary to evaluate new carriers and different antimicrobials to improve clinical outcomes.
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Affiliation(s)
- Marta Sabater-Martos
- Department of Orthopedics and Traumatology, Hospital Clínic of Barcelona, Carrer Villarroel 170, 08036, Barcelona, Spain.
| | - Miguel A. Verdejo
- grid.410458.c0000 0000 9635 9413Department of Infectious Diseases, Hospital Clínic of Barcelona, Carrer Villarroel 170, 08036 Barcelona, Spain
| | - Laura Morata
- grid.410458.c0000 0000 9635 9413Department of Infectious Diseases, Hospital Clínic of Barcelona, Carrer Villarroel 170, 08036 Barcelona, Spain
| | - Ernesto Muñoz-Mahamud
- grid.410458.c0000 0000 9635 9413Department of Orthopedics and Traumatology, Hospital Clínic of Barcelona, Carrer Villarroel 170, 08036 Barcelona, Spain
| | - Ernesto Guerra-Farfan
- grid.411083.f0000 0001 0675 8654Department of Orthopedics and Traumatology, Hospital Vall d’Hebron of Barcelona, Passeig de la Vall d’Hebron 119, 08035 Barcelona, Spain
| | - Juan C. Martinez-Pastor
- grid.410458.c0000 0000 9635 9413Department of Orthopedics and Traumatology, Hospital Clínic of Barcelona, Carrer Villarroel 170, 08036 Barcelona, Spain
| | - Alex Soriano
- Department of Infectious Diseases, Hospital Clínic of Barcelona, Carrer Villarroel 170, 08036, Barcelona, Spain. .,University of Barcelona, CIBERINF, Carrer Casanova 143, 08036, Barcelona, Spain.
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15
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Xu T, Wu KL, Jie K. Comprehensive meta-analysis of antibiotic-impregnated bone cement versus plain bone cement in primary total knee arthroplasty for preventing periprosthetic joint infection. Chin J Traumatol 2022; 25:325-330. [PMID: 35717367 PMCID: PMC9751532 DOI: 10.1016/j.cjtee.2022.06.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2021] [Revised: 03/28/2022] [Accepted: 05/21/2022] [Indexed: 02/04/2023] Open
Abstract
PURPOSE Antibiotic-loaded bone cement (ALBC) was usually used to prevent periprosthetic joint infection (PJI) in primary total knee arthroplasty (PTKA), but whether to use ALBC or plain bone cement in PTKA remains unclear. We aimed to compare the occurrence rate of PJI using two different cements, and to investigate the efficacy of different antibiotic types and doses administered in preventing surgical site infection (SSI) with ALBC. METHODS The availability of ALBC for preventing PJI was evaluated by using a systematic review and meta-analysis referring to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Existing articles until December 2021 involving PTKA patients with both ALBC and plain bone cement cohorts were scanned by searching "total knee arthroplasty", "antibiotic-loaded cement", "antibiotic prophylaxis", "antibiotic-impregnated cement" and "antibiotic-laden cement" in the database of PubMed/MEDLINE, Embase, Web of Science and the Cochrane Library. Subgroup analysis included the effectiveness of different antibiotic types and doses in preventing SSI with ALBC. The modified Jadad scale was employed to score the qualities of included articles. RESULTS Eleven quantitative studies were enrolled, including 34,159 knees undergoing PTKA. The meta-analysis results demonstrated that the use of prophylactic ALBC could significantly reduce the prevalence of deep incisional SSI after PTKA, whereas there was no significant reduction in the rate of superficial incisional SSI. Moreover, gentamicin-loaded cement was effective in preventing deep incisional SSI, and the use of high-dose ALBC significantly reduced the rate of deep incisional SSI after PTKA. Besides, no significant adverse reactions and complications were stated during the use of ALBC in PTKA. CONCLUSION The preventive application of ALBC during PTKA could reduce the rates of deep PJI. Furthermore, bone cement containing gentamicin and high-dose ALBC could even better prevent deep infection after PTKA. However, the existing related articles are mostly single-center and retrospective studies, and further high-quality ones are needed for confirmation.
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Affiliation(s)
- Ting Xu
- Foshan Hospital of Traditional Chinese Medicine, Foshan, 528000, Guangdong Province, China
| | - Ke-Liang Wu
- Shenzhen Traditional Chinese Medicine Hospital, Shenzhen, 518000, Guangdong Province, China
| | - Ke Jie
- Foshan Hospital of Traditional Chinese Medicine, Foshan, 528000, Guangdong Province, China,Corresponding author.
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Berberich C, Josse J, Ruiz PS. Patients at a high risk of PJI: Can we reduce the incidence of infection using dual antibiotic-loaded bone cement? ARTHROPLASTY 2022; 4:41. [PMID: 36068617 PMCID: PMC9450350 DOI: 10.1186/s42836-022-00142-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Accepted: 06/26/2022] [Indexed: 11/10/2022] Open
Abstract
AbstractProsthetic joint infection (PJI) is one of the most devastating complications of orthopedic surgery. However, not all patients are equally at the risk of severe infection. The incidences of PJI vary with the host and surgery-related risk factors. It is now generally accepted that some important medical comorbidities may predispose the patients to a high risk of PJI. Time-consuming and invasive surgical procedures, such as revision arthroplasties, are also associated with a high incidence of PJI, presumably due to the increased risk of surgical site contamination. Effective infection-preventing strategies should begin with identifying and optimizing the patients at a high risk of infection prior to surgery. Optimizing the operating room environment and antibiotic prophylaxis are also essential strategies that help minimize the overall incidence of infection in orthopedic surgery. The ideal antibiotic prophylaxis is still under debate, and discussions have emerged about whether variations or adjustments to the standard protocol are justified in patients at a high risk of infection. This also includes evaluating the possible benefits and risks of using high-dose dual antibiotic-loaded bone cement instead of low-dose single antibiotic-loaded bone cement in arthroplasty. This review summarizes the evidence showing that the combination of two local antibiotics in bone cement exerts a strong and longer-lasting antimicrobial effect against PJI-associated pathogens. This conclusion is consistent with the preliminary clinical studies showing a low incidence of PJI in high-risk patients undergoing cemented hemiarthroplasty, cemented revision, and primary arthroplasty if dual ALBC is used. These results may encourage clinicians to consolidate this hypothesis in a wider clinical range.
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17
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Mohamed NS, Dávila Castrodad IM, Etcheson JI, George NE, Aitken JS, Kelemen MN, Nace J, Delanois RE. Utilisation of calcium sulphate beads in one-stage aseptic revision total hip arthroplasty. Hip Int 2022; 32:656-660. [PMID: 33241953 DOI: 10.1177/1120700020973973] [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] [Indexed: 02/04/2023]
Abstract
INTRODUCTION Periprosthetic joint infection (PJI) affects many revision total hip arthroplasty (THA) patients, contributing to a concomitant rise in revision costs. Means of decreasing the risk of PJI include the use of antibiotic adjuncts, such as calcium sulphate beads (CSBs). Mixed with antibiotics, the potential benefits of CSBs include dissolvability and antibiotic drug elution. However, information comparing them in aseptic revision is scarce. Therefore, this study investigated CSB utilisation for infection prevention in aseptic revision THA. Specifically, we compared (1) infection rates; (2) lengths of stay; (3) subsequent infection procedures; and (4) final surgical outcome in 1-stage aseptic revision THA patients who did received CSBs to 1-stage aseptic revision THA patients who did not. METHODS A retrospective chart review was performed to identify all patients who underwent an aseptic revision THA between January 2013 and December 2017. Patients who received CSBs (n = 48) were compared to non-CSB patients (n = 58) on the following outcomes: postoperative infections, lengths of stay (LOS), subsequent irrigation and debridements (I+Ds), and final surgical outcome, classified as successful THA reimplantation, retained antibiotic spacer, or Girdlestone procedure. Chi-square and t-testing were used to analyse the variables. RESULTS There was no significant differences found between CSB patients and non-CSB patients in postoperative infections (p = 0.082), LOS (p = 0.179), I+Ds (p = 0.068), and final surgical outcome (p = 0.211). CONCLUSION This study did not find any statistical difference between CSBs and standard of care in infection rates and surgical outcomes. The advantage of these beads for 1-stage aseptic revisions is questionable.
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Affiliation(s)
- Nequesha S Mohamed
- Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, MD, USA
| | - Iciar M Dávila Castrodad
- Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, MD, USA
| | - Jennifer I Etcheson
- Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, MD, USA
| | - Nicole E George
- Department of Graduate Medical Education, Aultman Hospital, Canton, OH, USA
| | - James S Aitken
- Department of Orthopaedic Surgery, Philadelphia College of Osteopathic Medicine, Philadelphia, PA, USA
| | - Margaret N Kelemen
- Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, MD, USA
| | - James Nace
- Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, MD, USA
| | - Ronald E Delanois
- Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, MD, USA
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18
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Systematic Review and Meta-Analysis of Intrawound Vancomycin in Total Hip and Total Knee Arthroplasty: A Continued Call for a Prospective Randomized Trial. J Arthroplasty 2022; 37:1405-1415.e1. [PMID: 35314283 DOI: 10.1016/j.arth.2022.03.047] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Accepted: 03/12/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Periprosthetic joint injection (PJI) is a rare, but life-altering complication of total joint arthroplasty (TJA). Though intrawound vancomycin powder (IVP) has been studied in other orthopedic subspecialties, its efficacy and safety in TJA has not been established. METHODS PubMed and MEDLINE databases were used to identify studies utilizing IVP in primary and revision total hip (THA) and knee arthroplasty (TKA). Postoperative PJI data were pooled using random effect models with results reported as odds ratios (ORs) and 95% confidence intervals (CIs). Studies were weighted by the inverse variance of their effect estimates. RESULTS Overall, 16 of the 1871 studies identified were pooled for final analysis, yielding 33,731 patients totally. Of these, 17 164 received IVP. In aggregate, patients who received IVP had a decreased rate of PJI (OR 0.46, P < .05). Separately, TKA and THA patients who received IVP had lower rates of PJI (OR 0.41, P < .05 and OR 0.45, P < .05, respectively). Aggregate analysis of primary TKA and THA patients also revealed a decreased PJI rate (OR 0.44, P < .05). Pooled revision TKA and THA patients had a similar decrease in PJI rates (OR 0.30, P < .05). Although no publication bias was appreciated, these findings are limited by the low-quality evidence available. CONCLUSION While IVP may reduce the risk of PJI in primary and revision TJA, its widespread use cannot be recommended until higher-quality data, such as that obtained from randomized control trials, are available. This study underscores the continued need for more rigorous studies before general adoption of this practice by arthroplasty surgeons.
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19
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Lewis G. Antibiotic-free antimicrobial poly (methyl methacrylate) bone cements: A state-of-the-art review. World J Orthop 2022; 13:339-353. [PMID: 35582158 PMCID: PMC9048499 DOI: 10.5312/wjo.v13.i4.339] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Revised: 11/30/2021] [Accepted: 03/04/2022] [Indexed: 02/06/2023] Open
Abstract
Prosthetic joint infection (PJI) is the most serious complication following total joint arthroplasty, this being because it is associated with, among other things, high morbidity and low quality of life, is difficult to prevent, and is very challenging to treat/manage. The many shortcomings of antibiotic-loaded poly (methyl methacrylate) (PMMA) bone cement (ALBC) as an agent for preventing and treating/managing PJI are well-known. One is that microorganisms responsible for most PJI cases, such as methicillin-resistant S. aureus, have developed or are developing resistance to gentamicin sulfate, which is the antibiotic in the vast majority of approved ALBC brands. This has led to many research efforts to develop cements that do not contain gentamicin (or, for that matter, any antibiotic) but demonstrate excellent antimicrobial efficacy. There is a sizeable body of literature on these so-called "antibiotic-free antimicrobial" PMMA bone cements (AFAMBCs). The present work is a comprehensive and critical review of this body. In addition to summaries of key trends in results of characterization studies of AFAMBCs, the attractive features and shortcomings of the literature are highlighted. Shortcomings provide motivation for future work, with some ideas being formulation of a new generation of AFAMBCs by, example, adding a nanostructured material and/or an extract from a natural product to the powder and/or liquid of the basis cement, respectively.
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Affiliation(s)
- Gladius Lewis
- Department of Mechanical Engineering, University of Memphis, Memphis, TN 38152, United States
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20
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Bansal D, Khatri K, Dahuja A, Lakhani A, Malhotra N. Comparison Between Vancomycin and Gentamicin for Intraoperative Presoaking of Hamstring Graft in Primary Anterior Cruciate Ligament Reconstruction. Cureus 2022; 14:e22550. [PMID: 35345679 PMCID: PMC8956929 DOI: 10.7759/cureus.22550] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/23/2022] [Indexed: 11/15/2022] Open
Abstract
Introduction Postoperative infection is an uncommon complication with grave consequences following anterior cruciate ligament reconstruction (ACLR). Presoaking of the hamstring graft with antibiotics results in a lower rate of infection. The purpose of the current study was to compare the efficacy of two commonly used antibiotics, vancomycin and gentamicin, in reducing infection rates following anterior cruciate ligament reconstruction. Methods The retrospective study included a total of 578 patients who underwent arthroscopic anterior cruciate ligament reconstruction between June 2015 and October 2021. The timeline was categorized as the period between June 2015 to October 2018 (Vancomycin presoaking of hamstring graft) and November 2018 to October 2021 (Gentamicin presoaking of hamstring graft). All patients were examined for the development of infection, causative organism, and treatment received. Patients with intravenous drug abuse, alcoholism, steroid use, revision cases, and a prior history of infection in the knee were excluded from the study. Fisher’s exact test was used for comparison of categorical data, and Poisson regression analysis was carried out to calculate incidence rate ratios after adjusting for confounding variables. Results Presoaking of hamstring grafts with vancomycin was carried out in 224 patients, and gentamicin was used in 354 patients. In total, three patients in the vancomycin and four patients in the gentamicin groups developed an intraarticular infection, and the difference in infection rate between the two groups was not statistically significant (p=0.919). Coagulase-negative Staphylococcus aureus was isolated in four cases, Enterobacter cloacae in one, and no organism was seen in two cases. The groups were comparable in terms of age (p=0.563), smoking (p=0.84), sex (p=0.359), and operative time (p=0.09). Conclusion Presoaking of hamstring autografts with gentamicin intraoperatively is a good alternative to vancomycin in the prevention of infection following arthroscopic anterior cruciate ligament reconstruction.
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21
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Samelis PV, Papagrigorakis E, Sameli E, Mavrogenis A, Savvidou O, Koulouvaris P. Current Concepts on the Application, Pharmacokinetics and Complications of Antibiotic-Loaded Cement Spacers in the Treatment of Prosthetic Joint Infections. Cureus 2022; 14:e20968. [PMID: 35154947 PMCID: PMC8815820 DOI: 10.7759/cureus.20968] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/04/2022] [Indexed: 01/15/2023] Open
Abstract
Prosthetic joint infection (PJI) is a devastating complication of total joint replacement surgery. It affects about 2% of primary total joint replacements. Treatment aims at infection eradication and restoration of patient's mobility. Two-stage revision arthroplasty with an interim application of an antibiotic-loaded cement spacer (ALCS) is the widely accepted treatment for PJI. Spacers are powerful local carriers of antibiotics at the site of infection, effective against biofilm-protected microbes. On the other hand, spacers permit some mobility of the patient and facilitate final prosthesis implantation. ALCS's are either commercially available or prepared intraoperatively on prefabricated or improvised molds. Antibiotic elution from the spacer depends on the amount of the antibiotic used for cement impregnation, at the expense of mechanical stiffness of the spacer. The antibiotic should not exceed 4g per 40g of bone cement to preserve the mechanical properties of the cement. Spacers are frequently accompanied by local or systemic complications. The spacer may break, dislocate and compress vessels or nerves of the limb. Systemic complications are the result of excess elution of antibiotic and include nephrotoxicity, hepatotoxicity, ototoxicity, allergic reactions or neutropenia. Elderly patients with comorbidities are at risk to present such complications. Microbial resistance is a potential risk of long-lasting spacer retention. Persisting infection may require multiple spacer replacements.
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22
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The use of antibiotic-loaded bone cement does not increase antibiotic resistance after primary total joint arthroplasty. Knee Surg Sports Traumatol Arthrosc 2022; 30:3208-3214. [PMID: 34244827 PMCID: PMC9418265 DOI: 10.1007/s00167-021-06649-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Accepted: 06/21/2021] [Indexed: 11/11/2022]
Abstract
PURPOSE One of the preventive strategies for periprosthetic joint infection (PJI) is the use of antibiotic-loaded bone cement (ALBC) in primary total joint arthroplasty (TJA). Even though it is widely used, there are concerns about the development of antibacterial resistance. The aim of the study was to investigate whether using ALBC in primary TJA increases the antibiotic-resistant PJI. The hypothesis was that the regular use of ALBC does not increase the rate of resistant PJI. METHODS Patients with confirmed PJI who had revision surgery from year 2010 to 2019 were included in this international multicenter study. The ALBC group was compared to the non-ALBC TJA group from the same time period. Medical records were used to collect clinical (age, gender, body mass index, comorbidities), TJA-related (type of operation, implant type and survival) and PJI-related (cultured microorganism, antibiogram) data. Resistance to gentamicin, clindamycin and vancomycin were recorded from the antibiograms. Multiple logistic regression model was used to identify risk factors and account for the potential confounders. RESULTS 218 patients with PJI were included in the study: 142 with gentamicin-loaded bone cement and 76 in the non-ALBC group. The average age in the ALBC group was 71 ± 10 years and 62 ± 12 years in the comparison group (p < 0.001). Coagulase negative Staphylococci (CONS) were the most common (49%) isolated pathogens. The use of ALBC did not increase the rate of any resistant bacteria significantly (OR = 0.79 (0.42-1.48), p = 0.469). The presence of CONS was associated with higher risk of antibiotic resistance. CONCLUSIONS The current study demonstrates no increase in antibiotic resistance due to ALBC after primary TJA. Thus, the use of ALBC during primary TJA should not be feared in the context of antimicrobial resistance. LEVEL OF EVIDENCE III.
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23
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Cobra HADAB, Mozella ADP, Labronici PJ, Cavalcanti AS, Guimarães JAM. Infection after primary total knee arthroplasty: a randomized controlled prospective study of the addition of antibiotics to bone cement. Rev Bras Ortop 2021; 56:621-627. [PMID: 34733434 PMCID: PMC8558932 DOI: 10.1055/s-0041-1729941] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Accepted: 12/01/2020] [Indexed: 11/21/2022] Open
Abstract
Objective
The present prospective, randomized and controlled study was conducted with 286 patients submitted to primary total knee arthroplasty (TKA) with the objective of evaluating the efficacy of the addition of antibiotics to bone cement as a way to prevent post arthroplasty infection (PAI).
Methods
The patients were randomized into two groups: bone cement without antibiotic (No ATB,
n
= 158) or cement with antibiotic (ATB,
n
= 128), in which 2 g of vancomycin was added to 40 g of cement. The patients were followed up for 24 months after surgery.
Results
Regarding preoperative demographic data, the distribution of patients between groups was homogeneous (
p
< 0.05). In the 24-month period, the overall infection rate was of 2.09% (6/286), with no difference (odds ratio [OR] = 1.636; 95% confidence interval [CI]: 0.294–9.080;
p
= 0.694) between the ATB group (1.56%; 2/128) and the No ATB group (2.53%; 4/158). In the No ATB group, the infection was caused by methicillin-resistant
Staphylococcus aureus
(MRSA) (
n
= 2), methicillin-sensitive
S. aureus
(MSSA) (
n
= 1) and
Eschirichia coli
(
n
= 1).
Proteus mirabilis
and MSSA were isolated from patients in the ATB group. Among the comorbidities, all patients with PAI were hypertensive and nondiabetic. Two rheumatoid arthritis patients who developed PAI were from the ATB group.
Conclusion
The use of cement with ATB reduced the absolute number of infections, but without statistical difference between the groups; thus, routine use should not be encouraged.
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Affiliation(s)
| | - Alan de Paula Mozella
- Centro de Atenção Especializada em Cirurgia do Joelho, Instituto Nacional de Traumatologia e Ortopedia, Rio de Janeiro, RJ, Brasil
| | - Pedro José Labronici
- Departamento de Ortopedia e Traumatologia, Universidade Federal Fluminense, Niterói, RJ, Brasil
| | - Amanda S Cavalcanti
- Divisão de Pesquisa, Instituto Nacional de Traumatologia e Ortopedia, Rio de Janeiro, RJ, Brasil
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24
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Lawrie CM, Kazarian GS, Barrack T, Nunley RM, Barrack RL. Intra-articular administration of vancomycin and tobramycin during primary cementless total knee arthroplasty : determination of intra-articular and serum elution profiles. Bone Joint J 2021; 103-B:1702-1708. [PMID: 34719272 DOI: 10.1302/0301-620x.103b11.bjj-2020-2453.r1] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
AIMS Intra-articular administration of antibiotics during primary total knee arthroplasty (TKA) may represent a safe, cost-effective strategy to reduce the risk of acute periprosthetic joint infection (PJI). Vancomycin with an aminoglycoside provides antimicrobial cover for most organisms isolated from acute PJI after TKA. However, the intra-articular doses required to achieve sustained therapeutic intra-articular levels while remaining below toxic serum levels is unknown. The purpose of this study is to determine the intra-articular and serum levels of vancomycin and tobramycin over the first 24 hours postoperatively after intra-articular administration in primary cementless TKA. METHODS A prospective cohort study was performed. Patients were excluded if they had poor renal function, known allergic reaction to vancomycin or tobramycin, received intravenous vancomycin, or were scheduled for same-day discharge. All patients received 600 mg tobramycin and 1 g of vancomycin powder suspended in 25 cc of normal saline and injected into the joint after closure of the arthrotomy. Serum from peripheral venous blood and drain fluid samples were collected at one, four, and 24 hours postoperatively. All concentrations are reported in µg per ml. RESULTS A total of 22 patients were included in final analysis. At one, four, and 24 hours postoperatively, mean (95% confidence interval (CI)) serum concentrations were 2.4 (0.7 to 4.1), 5.0 (3.1 to 6.9), and 4.8 (2.8 to 6.9) for vancomycin and 4.9 (3.4 to 6.3), 7.0 (5.8 to 8.2), and 1.3 (0.8 to 1.8) for tobramycin; intra-articular concentrations were 1,900.6 (1,492.5 to 2,308.8), 717.9 (485.5 to 950.3), and 162.2 (20.5 to 304.0) for vancomycin and 2,105.3 (1,389.9 to 2,820.6), 403.2 (266.6 to 539.7), and 98.8 (0 to 206.5) for tobramycin. CONCLUSION Intra-articular administration of 1 g of vancomycin and 600 mg of tobramycin as a solution after closure of the arthrotomy in primary cementless TKA achieves therapeutic intra-articular concentrations over the first 24 hours postoperatively and does not reach sustained toxic levels in peripheral blood. Cite this article: Bone Joint J 2021;103-B(11):1702-1708.
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Affiliation(s)
- Charles Murray Lawrie
- Miami Orthopedics and Sports Medicine Institute, Baptist Health South Florida, Miami, Florida, USA
| | - Gregory S Kazarian
- Department of Orthopedic Surgery, Hospital for Special Surgery, Weill-Cornell Medical School, New York, New York, USA
| | - Toby Barrack
- Department of Orthopedic Surgery, Washington University in Saint Louis School of Medicine, Saint Louis, Missouri, USA
| | - Ryan M Nunley
- Department of Orthopedic Surgery, Washington University in Saint Louis School of Medicine, Saint Louis, Missouri, USA
| | - Robert L Barrack
- Department of Orthopedic Surgery, Washington University in Saint Louis School of Medicine, Saint Louis, Missouri, USA
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25
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Titanium implant coating based on dopamine-functionalized sulphated hyaluronic acid: in vivo assessment of biocompatibility and antibacterial efficacy. MATERIALS SCIENCE & ENGINEERING. C, MATERIALS FOR BIOLOGICAL APPLICATIONS 2021; 128:112286. [PMID: 34474837 DOI: 10.1016/j.msec.2021.112286] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Revised: 06/11/2021] [Accepted: 06/25/2021] [Indexed: 11/20/2022]
Abstract
The number of total knee and/or hip replacements are expected to exceed 5 million a year by 2030; the incidence of biofilm-associated complications can vary from 1% in primary implants to 5.6% in case of revision. The purpose of this study was to test the ability of sHA-DA, a partially sulphated hyaluronic acid (sHA) functionalized with a dopamine (DA) moiety, to prevent acute bacterial growth in an in vivo model of an intra-operatively highly contaminated implant. Previously, in vitro studies showed that the DA moiety guarantees good performance as binding agent for titanium surface adhesion, while the negatively charged sHA has both a high efficiency in electrostatic binding of positively charged antibiotics, and bone regenerative effects. The in vitro testing also highlighted the effectiveness of the sHA-DA system in inhibiting bacterial spreading through a sustained release of the antibiotic payload from the implant coating. In this study the chemical stability of the sHA-DA to β-ray sterilization was demonstrated, based on evaluation by NMR, SEC-TDA Omnisec and HPLC-MS analysis, thus supporting the approach of terminal sterilization of the coated implant with no loss of efficacy. Furthermore, an in vivo study in rabbits was performed according to UNI EN ISO 10993-6 to assess the histocompatibility of titanium nails pre-coated with sHA-DA. The implants, placed in the femoral medullary cavity and harvested after 12 weeks, proved to be histocompatible and to allow bone growth in adhesion to the metal surface. Finally, an in vivo model of bacterial contamination was set up by injecting 1 mL of bacterial suspension containing 104 or 106 CFU of methicillin-resistant Staphylococcus aureus (MRSA) into the femoral medullary cavity of 30 rabbits. Titanium nails either uncoated or pre-coated with sHA-DA and loaded directly by the surgeon with 5% vancomycin were implanted in the surgical site. After 1 week, only the animals treated with pre-coated nails did not show the presence of systemic or local bacterial infection, as confirmed by microbiology and histology (Smeltzer score). Further insights into the animal model setup are crucial, however the results obtained suggest that the system can be effective in preventing the onset of the bacterial infective process.
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26
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Brooks JR, Dusane DH, Moore K, Gupta T, Delury C, Aiken SS, Laycock PA, Sullivan AC, Granger JF, Dipane MV, McPherson EJ, Stoodley P. Pseudomonas aeruginosa biofilm killing beyond the spacer by antibiotic-loaded calcium sulfate beads: an in vitro study. J Bone Jt Infect 2021; 6:119-129. [PMID: 34084700 PMCID: PMC8137860 DOI: 10.5194/jbji-6-119-2021] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Accepted: 03/04/2021] [Indexed: 12/11/2022] Open
Abstract
Introduction: Bacterial biofilms are an important virulence factor in
chronic periprosthetic joint infection (PJI) and other orthopedic infection
since they are highly tolerant to antibiotics and host immunity. Antibiotics
are mixed into carriers such as bone cement and calcium sulfate bone void
fillers to achieve sustained high concentrations of antibiotics required to
more effectively manage biofilm infections through local release. The effect
of antibiotic diffusion from antibiotic-loaded calcium sulfate beads
(ALCS-B) in combination with PMMA bone cement spacers on the spread and
killing of Pseudomonas aeruginosa Xen41 (PA-Xen41) biofilm was investigated using a “large agar
plate” model scaled for clinical relevance. Methods: Bioluminescent
PA-Xen41 biofilms grown on discs of various orthopedic materials were placed within a large agar plate containing a PMMA full-size mock “spacer”
unloaded or loaded with vancomycin and tobramycin, with or without ALCS-B.
The amount of biofilm spread and log reduction on discs at varying distances
from the spacer was assessed by bioluminescent imaging and viable cell
counts. Results: For the unloaded spacer control, PA-Xen41 spread from the
biofilm to cover the entire plate. The loaded spacer generated a 3 cm zone of
inhibition and significantly reduced biofilm bacteria on the discs
immediately adjacent to the spacer but low or zero reductions on those further away. The combination of ALCS-B and a loaded PMMA spacer greatly
reduced bacterial spread and resulted in significantly greater biofilm
reductions on discs at all distances from the spacer. Discussion: The
addition of ALCS-B to an antibiotic-loaded spacer mimic increased the area of antibiotic coverage and efficacy against biofilm, suggesting that a
combination of these depots may provide greater physical antibiotic coverage
and more effective dead space management, particularly in zones where the
spread of antibiotic is limited by diffusion (zones with little or no fluid
motion).
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Affiliation(s)
- Jacob R Brooks
- Department of Microbial Infection and Immunity, The Ohio State University, Wexner Medical Center, Columbus, Ohio, USA
| | - Devendra H Dusane
- Department of Microbial Infection and Immunity, The Ohio State University, Wexner Medical Center, Columbus, Ohio, USA
| | - Kelly Moore
- Department of Microbial Infection and Immunity, The Ohio State University, Wexner Medical Center, Columbus, Ohio, USA
| | - Tripti Gupta
- Department of Microbial Infection and Immunity, The Ohio State University, Wexner Medical Center, Columbus, Ohio, USA
| | - Craig Delury
- Biocomposites Ltd., Keele Science Park, Keele, Staffordshire, ST5 5NL, UK
| | - Sean S Aiken
- Biocomposites Ltd., Keele Science Park, Keele, Staffordshire, ST5 5NL, UK
| | - Phillip A Laycock
- Biocomposites Ltd., Keele Science Park, Keele, Staffordshire, ST5 5NL, UK
| | - Anne C Sullivan
- Department of Orthopaedics, The Ohio State University, Wexner Medical Center, Columbus, Ohio, USA
| | - Jeffrey F Granger
- Department of Orthopaedics, The Ohio State University, Wexner Medical Center, Columbus, Ohio, USA
| | - Matthew V Dipane
- Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, Santa Monica, California, USA
| | - Edward J McPherson
- Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, Santa Monica, California, USA
| | - Paul Stoodley
- Department of Microbial Infection and Immunity, The Ohio State University, Wexner Medical Center, Columbus, Ohio, USA.,Department of Orthopaedics, The Ohio State University, Wexner Medical Center, Columbus, Ohio, USA.,National Centre for Advanced Tribology at Southampton (nCATS), National Biofilm Innovation Centre (NBIC), Department of Mechanical Engineering, University of Southampton, Southampton, UK
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27
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Schwarz EM, McLaren AC, Sculco TP, Brause B, Bostrom M, Kates SL, Parvizi J, Alt V, Arnold WV, Carli A, Chen AF, Choe H, Coraça‐Huber DC, Cross M, Ghert M, Hickok N, Jennings JA, Joshi M, Metsemakers W, Ninomiya M, Nishitani K, Oh I, Padgett D, Ricciardi B, Saeed K, Sendi P, Springer B, Stoodley P, Wenke JC, Hospital for Special Surgery 2019 Biofilm Symposium Workgroup. Adjuvant antibiotic-loaded bone cement: Concerns with current use and research to make it work. J Orthop Res 2021; 39:227-239. [PMID: 31997412 PMCID: PMC7390691 DOI: 10.1002/jor.24616] [Citation(s) in RCA: 72] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Revised: 01/07/2020] [Accepted: 01/13/2020] [Indexed: 02/04/2023]
Abstract
Antibiotic-loaded bone cement (ALBC) is broadly used to treat orthopaedic infections based on the rationale that high-dose local delivery is essential to eradicate biofilm-associated bacteria. However, ALBC formulations are empirically based on drug susceptibility from routine laboratory testing, which is known to have limited clinical relevance for biofilms. There are also dosing concerns with nonstandardized, surgeon-directed, hand-mixed formulations, which have unknown release kinetics. On the basis of our knowledge of in vivo biofilms, pathogen virulence, safety issues with nonstandardized ALBC formulations, and questions about the cost-effectiveness of ALBC, there is a need to evaluate the evidence for this clinical practice. To this end, thought leaders in the field of musculoskeletal infection (MSKI) met on 1 August 2019 to review and debate published and anecdotal information, which highlighted four major concerns about current ALBC use: (a) substantial lack of level 1 evidence to demonstrate efficacy; (b) ALBC formulations become subtherapeutic following early release, which risks induction of antibiotic resistance, and exacerbated infection from microbial colonization of the carrier; (c) the absence of standardized formulation protocols, and Food and Drug Administration-approved high-dose ALBC products to use following resection in MSKI treatment; and (d) absence of a validated assay to determine the minimum biofilm eradication concentration to predict ALBC efficacy against patient specific micro-organisms. Here, we describe these concerns in detail, and propose areas in need of research.
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Affiliation(s)
- Edward M. Schwarz
- Department of Orthopaedics, Center for Musculoskeletal Research University of Rochester Rochester New York
| | - Alex C. McLaren
- Department of Orthopaedic Surgery, College of Medicine‐Phoenix University of Arizona Phoenix Arizona
| | - Thomas P. Sculco
- Department of Orthopaedic Surgery, Weill Cornell Medicine Hospital for Special Surgery New York New York
| | - Barry Brause
- Department of Infectious Diseases, Weill Cornell Medicine Hospital for Special Surgery New York New York
| | - Mathias Bostrom
- Department of Orthopaedic Surgery, Weill Cornell Medicine Hospital for Special Surgery New York New York
| | - Stephen L. Kates
- Department of Orthopaedic Surgery Virginia Commonwealth University Richmond Virginia
| | - Javad Parvizi
- Department of Orthopaedics Rothman Institute at Thomas Jefferson University Hospital Philadelphia Pennsylvania
| | - Volker Alt
- Department of Trauma Surgery University Medical Centre Regensburg Regensburg Germany
| | - William V. Arnold
- Department of Orthopaedics Rothman Institute at Thomas Jefferson University Hospital Philadelphia Pennsylvania
| | - Alberto Carli
- Department of Orthopaedic Surgery, Weill Cornell Medicine Hospital for Special Surgery New York New York
| | - Antonia F. Chen
- Department of Orthopaedics, Brigham and Women's Hospital Harvard Medical School Boston Massachusetts
| | - Hyonmin Choe
- Department of Orthopaedic Yokohama City University Yokohama Japan
| | - Débora C. Coraça‐Huber
- Department of Orthopaedic Surgery, Experimental Orthopedics, Research Laboratory for Biofilms and Implant Associated Infections Medical University of Innsbruck Innsbruck Austria
| | - Michael Cross
- Department of Orthopaedic Surgery, Weill Cornell Medicine Hospital for Special Surgery New York New York
| | - Michelle Ghert
- Division of Orthopaedic Surgery, Department of Surgery McMaster University Hamilton Ontario Canada
| | - Noreen Hickok
- Department of Orthopaedic Surgery, Department of Biochemistry & Molecular Biology Thomas Jefferson University Philadelphia Pennsylvania
| | | | - Manjari Joshi
- Division of Infectious Diseases, R Adams Cowley Shock Trauma Center University of Maryland Baltimore Maryland
| | | | - Mark Ninomiya
- Department of Orthopaedics, Center for Musculoskeletal Research University of Rochester Rochester New York
| | - Kohei Nishitani
- Department of Orthopaedic Surgery Graduate School of Medicine, Kyoto University Sakyo Kyoto Japan
| | - Irvin Oh
- Department of Orthopaedics, Center for Musculoskeletal Research University of Rochester Rochester New York
| | - Douglas Padgett
- Department of Orthopaedic Surgery, Weill Cornell Medicine Hospital for Special Surgery New York New York
| | - Benjamin Ricciardi
- Department of Orthopaedics, Center for Musculoskeletal Research University of Rochester Rochester New York
| | - Kordo Saeed
- Southampton University Hospitals NHS Foundation Trust, Department of Microbiology, Microbiology and Innovation Research Unit (MIRU) and University of Southampton, School of Medicine Southampton UK
| | - Parham Sendi
- Institute for Infectious Diseases University of Bern, Bern and Department of Infectious Diseases, Hospital Epidemiology and Department of Orthopaedics and Traumatology, University of Basel Basel Switzerland
- Department of Orthopaedics and Traumatology University Hospital Basel Basel Switzerland
| | - Bryan Springer
- Department of Orthopaedic Surgery, OrthoCarolina Hip and Knee Center Atrium Musculoskeletal Institute Charlotte North Carolina
| | - Paul Stoodley
- Department of Microbial Infection and Immunity and Orthopaedics The Ohio State University Columbus Ohio
| | - Joseph C. Wenke
- Orthopaedic Trauma Department U.S. Army Institute of Surgical Research Fort Sam Houston Texas
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Leta TH, Gjertsen JE, Dale H, Hallan G, Lygre SHL, Fenstad AM, Dyrhovden GS, Westberg M, Wik TS, Jakobsen RB, Aamodt A, Röhrl SM, Gøthesen ØJ, Lindalen E, Heir S, Ludvigsen J, Bruun T, Hansen AK, Aune KEM, Warholm M, Skjetne JP, Badawy M, Høvding P, Husby OS, Karlsen ØE, Furnes O. Antibiotic-Loaded Bone Cement in Prevention of Periprosthetic Joint Infections in Primary Total Knee Arthroplasty: A Register-based Multicentre Randomised Controlled Non-inferiority Trial (ALBA trial). BMJ Open 2021; 11:e041096. [PMID: 33509845 PMCID: PMC7845702 DOI: 10.1136/bmjopen-2020-041096] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
INTRODUCTION The current evidence on the efficacy of antibiotic-loaded bone cement (ALBC) in reducing the risk of periprosthetic joint infections (PJI) after primary joint reconstruction is insufficient. In several European countries, the use of ALBC is routine practice unlike in the USA where ALBC use is not approved in low-risk patients. Therefore, we designed a double-blinded pragmatic multicentre register-based randomised controlled non-inferiority trial to investigate the effects of ALBC compared with plain bone cement in primary total knee arthroplasty (TKA). METHODS AND ANALYSIS A minimum of 9,172 patients undergoing full-cemented primary TKA will be recruited and equally randomised into the ALBC group and the plain bone cement group. This trial will be conducted in Norwegian hospitals that routinely perform cemented primary TKA. The primary outcome will be risk of revision surgery due to PJI at 1-year of follow-up. Secondary outcomes will be: risk of revision due to any reason including aseptic loosening at 1, 6, 10 and 20 years of follow-up; patient-related outcome measures like function, pain, satisfaction and health-related quality of life at 1, 6 and 10 years of follow-up; risk of changes in the microbial pattern and resistance profiles of organisms cultured in subsequent revisions at 1, 6, 10 and 20 years of follow-up; cost-effectiveness of routine ALBC versus plain bone cement use in primary TKA. We will use 1:1 randomisation with random permuted blocks and stratify by participating hospitals to randomise patients to receive ALBC or plain bone cement. Inclusion, randomisation and follow-up will be through the Norwegian Arthroplasty Register. ETHICS AND DISSEMINATION The trial was approved by the Western Norway Regional Committees on Medical and Health Research Ethics (reference number: 2019/751/REK vest) on 21 June 2019. The findings of this trial will be disseminated through peer-reviewed publications and conference presentations. TRIAL REGISTRATION NUMBER NCT04135170.
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Affiliation(s)
- Tesfaye H Leta
- Faculty of Health Science, VID Specialized University, Bergen, Norway
- The Norwegian Arthroplasty Register, Department of Orthopedic Surgery, Haukeland University Hospital, Bergen, Norway
| | - Jan-Erik Gjertsen
- The Norwegian Arthroplasty Register, Department of Orthopedic Surgery, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, Faculty of Medicine, University of Bergen, Bergen, Norway
| | - Håvard Dale
- The Norwegian Arthroplasty Register, Department of Orthopedic Surgery, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, Faculty of Medicine, University of Bergen, Bergen, Norway
| | - Geir Hallan
- The Norwegian Arthroplasty Register, Department of Orthopedic Surgery, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, Faculty of Medicine, University of Bergen, Bergen, Norway
| | - Stein Håkon Låstad Lygre
- The Norwegian Arthroplasty Register, Department of Orthopedic Surgery, Haukeland University Hospital, Bergen, Norway
- Department of Occupational Medicine, Haukeland University Hospital, Bergen, Norway
| | - Anne Marie Fenstad
- The Norwegian Arthroplasty Register, Department of Orthopedic Surgery, Haukeland University Hospital, Bergen, Norway
| | - Gro Sævik Dyrhovden
- Department of Clinical Medicine, Faculty of Medicine, University of Bergen, Bergen, Norway
| | - Marianne Westberg
- Division of Orthopedic Surgery, Oslo University Hospital, Oslo, Norway
| | - Tina Stromdal Wik
- Department of Orthopedic Surgery, St. Olavs Hospital, Trondheim, Norway
- Department of Neuromedicine and Movement Science, Faculty of Medicine and Health Science, The Norwegian University of Science and Technology, Bergen, Norway
| | - Rune Bruhn Jakobsen
- Department of Health Management and Health Economics, University of Oslo, Oslo, Norway
- Department of Orthopedic Surgery, Akershus Universitetssykehus HF, Oslo, Norway
| | - Arild Aamodt
- Department of Orthopaedic Surgery, Lovisenberg Diakonal Hospital, Oslo, Norway
| | | | - Øystein Johannes Gøthesen
- Department of Clinical Medicine, Faculty of Medicine, University of Bergen, Bergen, Norway
- Department of Orthopaedic, Haugesund Hospital for Rheumatic Diseases, Haugesund, Norway
| | - Einar Lindalen
- Department of Orthopaedic Surgery, Lovisenberg Diakonal Hospital, Oslo, Norway
| | - Stig Heir
- Department of Orthopedic Surgery, Martina Hansens Hospital, Sandvika, Norway
| | - Jarle Ludvigsen
- Department of Orthopedic Surgery, Stavanger University Hospital, Stavanger, Norway
| | - Trond Bruun
- Department of Medicine, Haukeland University Hospital, Bergen, Norway
| | - Ann Kristin Hansen
- Department of Orthopedic Surgery, University Hospital of North Norway, Tromsø, Norway
- Department of Clinical Medicine, UiT-The Arctic University of Norway, Tromsø, Norway
| | | | - Marianne Warholm
- Department of Information and Communication Technology, Western Norway Regional Health Authority, Bergen, Norway
| | - John Petter Skjetne
- Department of Information and Technology, Central Norway Regional Health Authority, Trondheim, Norway
| | - Mona Badawy
- Coastal Hospital in Hagavik, Department of Orthopaedic Surgery, Haukeland University Hospital, Bergen, Norway
| | - Pål Høvding
- The Norwegian Arthroplasty Register, Department of Orthopedic Surgery, Haukeland University Hospital, Bergen, Norway
| | | | | | - Ove Furnes
- The Norwegian Arthroplasty Register, Department of Orthopedic Surgery, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, Faculty of Medicine, University of Bergen, Bergen, Norway
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Moriarty P, Kayani B, Wallace C, Chang J, Plastow R, Haddad FS. Gentamicin pre-soaking of hamstring autografts decreases infection rates in anterior cruciate ligament reconstruction. Bone Jt Open 2021; 2:66-71. [PMID: 33537678 PMCID: PMC7842165 DOI: 10.1302/2633-1462.21.bjo-2020-0181.r1] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Aims Graft infection following anterior cruciate ligament reconstruction (ACLR) may lead to septic arthritis requiring multiple irrigation and debridement procedures, staged revision operations, and prolonged courses of antibiotics. To our knowledge, there are no previous studies reporting on how gentamicin pre-soaking of hamstring grafts influences infection rates following ACLR. We set out to examine this in our study accordingly. Methods This retrospective study included 2,000 patients (1,156 males and 844 females) who underwent primary ACLR with hamstring autografts between 2007 to 2017. This included 1,063 patients who received pre-soaked saline hamstring grafts for ACLR followed by 937 patients who received pre-soaked gentamicin hamstring grafts for ACLR. All operative procedures were completed by a single surgeon using a standardized surgical technique. Medical notes were reviewed and data relating to the following outcomes recorded: postoperative infection, clinical progress, causative organisms, management received, and outcomes. Results Superficial wound infection developed in 14 patients (1.31 %) receiving pre-saline soaked hamstring grafts compared to 13 patients (1.38 %) receiving pre-gentamicin soaked hamstring grafts, and this finding was not statistically significant (p = 0.692). All superficial wound infections were treated with oral antibiotics with no further complications. There were no recorded cases of septic arthritis in patients receiving pre-gentamicin soaked grafts compared to nine patients (0.85%) receiving pre-saline soaked grafts, which was statistically significant (p = 0.004). Conclusion Pre-soaking hamstring autographs in gentamicin does not affect superficial infection rates but does reduce deep intra-articular infection rates compared to pre-soaking hamstring grafts in saline alone. These findings suggest that pre-soaking hamstring autografts in gentamicin provides an effective surgical technique for reducing intra-articular infection rates following ACLR. Cite this article: Bone Jt Open 2021;2(1):66–71.
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Affiliation(s)
| | | | | | | | | | - Fares S Haddad
- University College Hospital, London, UK.,Institute of Sports, London, UK
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Bendich I, Zhang N, Barry JJ, Ward DT, Whooley MA, Kuo AC. Antibiotic-Laden Bone Cement Use and Revision Risk After Primary Total Knee Arthroplasty in U.S. Veterans. J Bone Joint Surg Am 2020; 102:1939-1947. [PMID: 32890041 DOI: 10.2106/jbjs.20.00102] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND It is controversial whether the use of antibiotic-laden bone cement (ALBC) in primary total knee arthroplasty (TKA) affects periprosthetic joint infection (PJI) or revision rates. The impact of ALBC on outcomes of primary TKA have not been previously investigated in U.S. veterans, to our knowledge. The purposes of this study were to quantify utilization of ALBC among U.S. veterans undergoing primary TKA and to determine if ALBC usage is associated with differences in revision TKA rates. METHODS Patients who had TKA with cement from 2007 to 2015 at U.S. Veterans Health Administration (VHA) hospitals with at least 2 years of follow-up were retrospectively identified. Patients who received high-viscosity Palacos bone cement with or without gentamicin were selected as the final study cohort. Patient demographic and comorbidity data were collected. Revision TKA was the primary outcome. All-cause revisions and revisions for PJI were identified from both VHA and non-VHA hospitals. Unadjusted and adjusted regression analyses were performed to identify variables that were associated with increased revision rates. RESULTS The study included 15,972 patients who had primary TKA with Palacos bone cement at VHA hospitals from 2007 to 2015. Plain bone cement was used for 4,741 patients and ALBC was used for 11,231 patients. Utilization of ALBC increased from 50.6% in 2007 to 69.4% in 2015. At a mean follow-up of 5 years, TKAs with ALBC had a lower all-cause revision rate than those with plain bone cement (5.3% versus 6.7%; p = 0.0009) and a lower rate of revision for PJI (1.9% versus 2.6%; p = 0.005). On multivariable regression, ALBC use was associated with a lower risk of all-cause revision compared with plain bone cement (hazard ratio [HR]: 0.79, 95% confidence interval [CI]: 0.68 to 0.92; p = 0.0019). Seventy-one primary TKAs needed to be implanted with ALBC to avoid 1 revision TKA. CONCLUSIONS The utilization of ALBC for primary TKAs performed at VHA hospitals has increased over time and was associated with a lower all-cause revision rate and a lower rate of revision for PJI. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Ilya Bendich
- Departments of Orthopaedic Surgery (I.B., J.J.B., D.T.W., and A.C.K.), Medicine (N.Z. and M.A.W.), and Epidemiology and Biostatistics (M.A.W.), University of California, San Francisco, San Francisco, California
| | - Ning Zhang
- Departments of Orthopaedic Surgery (I.B., J.J.B., D.T.W., and A.C.K.), Medicine (N.Z. and M.A.W.), and Epidemiology and Biostatistics (M.A.W.), University of California, San Francisco, San Francisco, California.,Veterans Affairs Quality Enhancement Research Initiative, San Francisco, California
| | - Jeffrey J Barry
- Departments of Orthopaedic Surgery (I.B., J.J.B., D.T.W., and A.C.K.), Medicine (N.Z. and M.A.W.), and Epidemiology and Biostatistics (M.A.W.), University of California, San Francisco, San Francisco, California.,Orthopedic Surgery Section, San Francisco Veterans Affairs Health Care System, San Francisco, California
| | - Derek T Ward
- Departments of Orthopaedic Surgery (I.B., J.J.B., D.T.W., and A.C.K.), Medicine (N.Z. and M.A.W.), and Epidemiology and Biostatistics (M.A.W.), University of California, San Francisco, San Francisco, California.,Orthopedic Surgery Section, San Francisco Veterans Affairs Health Care System, San Francisco, California
| | - Mary A Whooley
- Departments of Orthopaedic Surgery (I.B., J.J.B., D.T.W., and A.C.K.), Medicine (N.Z. and M.A.W.), and Epidemiology and Biostatistics (M.A.W.), University of California, San Francisco, San Francisco, California.,Veterans Affairs Quality Enhancement Research Initiative, San Francisco, California
| | - Alfred C Kuo
- Departments of Orthopaedic Surgery (I.B., J.J.B., D.T.W., and A.C.K.), Medicine (N.Z. and M.A.W.), and Epidemiology and Biostatistics (M.A.W.), University of California, San Francisco, San Francisco, California.,Orthopedic Surgery Section, San Francisco Veterans Affairs Health Care System, San Francisco, California
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31
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Rodriguez-Merchan EC. Antibiotic-loaded bone cement in primary total knee arthroplasty: does it reduce the risk of periprosthetic joint infection? Hosp Pract (1995) 2020; 48:188-195. [PMID: 32459547 DOI: 10.1080/21548331.2020.1769417] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Accepted: 05/12/2020] [Indexed: 12/31/2022]
Abstract
BACKGROUND Total knee arthroplasty (TKA) is a widely used technique, the purpose of which is to improve or eliminate knee pain produced by osteoarthritis. One of the most severe complications of primary TKA is periprosthetic joint infection (PJI). To reduce the risk of PJI, some surgeons use antibiotic-loaded bone cement (ALBC) in primary TKA, but others do not. In other words, the routine use of ALBC in primary TKA is controversial. OBJECTIVE The purpose of this article is to perform a narrative review of recent literature with the aim of answering the following question: Does ALBC reduce the risk of PJI in primary TKA? METHODS A Cochrane Library and PubMed (MEDLINE) search related to the role ALBC in primary TKA was analyzed. The only language searched was English. Scientific meeting abstracts and other sources of evidence were not considered. The main criteria for selection were articles that were focused on the role of ALBC in primary TKA. RESULTS One meta-analysis concluded that the prophylactic application of ALBC is not effective in preventing PJI in primary TKA. Two systematic reviews stated that the ALBC does not reduce the prevalence of PJI in primary TKA, so they consider it an unnecessary expense for health systems. One of these systematic reviews concluded that hospital systems that perform 1000 primary TKA operations per year can save between $155,000 and $310,000 per year if they always use plain cement. A prospective study suggested that in patients with diabetes mellitus who are treated with primary TKA, cement impregnated with cefuroxime is effective in preventing PJI. CONCLUSIONS It is logical to recommend the cautious use of ALBC, perhaps only in patients at high risk of infection (immunocompromised, morbid obesity, diabetics, and patients with a history of fracture or infection around the knee).
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Leong JW, Cook MJ, O'Neill TW, Board TN. Is the use of antibiotic-loaded bone cement associated with a lower risk of revision after primary total hip arthroplasty? Bone Joint J 2020; 102-B:997-1002. [PMID: 32731820 DOI: 10.1302/0301-620x.102b8.bjj-2020-0120.r1] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
AIMS The aim of this study was to investigate whether the use of antibiotic-loaded bone cement influenced the risk of revision surgery after primary total hip arthroplasty (THA) for osteoarthritis. METHODS The study involved data collected by the National Joint Registry (NJR) for England and Wales, Northern Ireland and the Isle of Man between 1 September 2005 and 31 August 2017. Cox proportional hazards were used to investigate the association between use of antibiotic-loaded bone cement and the risk of revision due to prosthetic joint infection (PJI), with adjustments made for the year of the initial procedure, age at the time of surgery, sex, American Society of Anesthesiologists (ASA) grade, head size, and body mass index (BMI). We looked also at the association between use of antibiotic-loaded bone cement and the risk of revision due to aseptic loosening or osteolysis. RESULTS The cohort included 418,857 THAs of whom 397,896 had received antibiotic-loaded bone cement and 20,961 plain cement. After adjusting for putative confounding factors, the risk of revision for PJI was lower in those in whom antibiotic-loaded bone cement was used (hazard ration (HR) 0.79; 95% confidence interval (CI) 0.64 to 0.98). There was also a protective effect on the risk of revision due to aseptic loosening or osteolysis, in the period of > 4.1 years after primary THA, HR 0.57, 95% CI 0.45, 0.72. CONCLUSION Within the limits of registry analysis, this study showed an association between the use of antibiotic-loaded bone cement and lower rates of revision due to PJI. The findings support the continued use of antibiotic-loaded bone cement in cemented THA. Cite this article: Bone Joint J 2020;102-B(8):997-1002.
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Affiliation(s)
- Justin W Leong
- Department of Trauma and Orthopaedic Surgery, Wrightington Hospital, Wigan, UK
| | - Michael J Cook
- Versus Arthritis Centre for Epidemiology, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, The University of Manchester, Manchester, UK
| | - Terence W O'Neill
- Versus Arthritis Centre for Epidemiology, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, The University of Manchester, Manchester, UK.,NIHR Manchester Biomedical Research Centre, Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK.,Department of Rheumatology, Salford Royal NHS Foundation Trust, Salford, UK
| | - Timothy N Board
- Department of Trauma and Orthopaedic Surgery, Wrightington Hospital, Wigan, UK
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Lawrie CM, Jo S, Barrack T, Roper S, Wright RW, Nunley RM, Barrack RL. Local delivery of tobramycin and vancomycin in primary total knee arthroplasty achieves minimum inhibitory concentrations for common bacteria causing acute prosthetic joint infection. Bone Joint J 2020; 102-B:163-169. [PMID: 32475280 DOI: 10.1302/0301-620x.102b6.bjj-2019-1639.r1] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
AIMS The aim of this study was to determine if the local delivery of vancomycin and tobramycin in primary total knee arthroplasty (TKA) can achieve intra-articular concentrations exceeding the minimum inhibitory concentration thresholds for bacteria causing acute prosthetic joint infection (PJI). METHODS Using a retrospective single-institution database of all primary TKAs performed between January 1 2014 and May 7 2019, we identified patients with acute PJI that were managed surgically within 90 days of the initial procedure. The organisms from positive cultures obtained at the time of revision were tested for susceptibility to gentamicin, tobramycin, and vancomycin. A prospective study was then performed to determine the intra-articular antibiotic concentration on postoperative day one after primary TKA using one of five local antibiotic delivery strategies with tobramycin and/or vancomycin mixed into the polymethylmethacrylate (PMMA) or vancomycin powder. RESULTS A total of 19 patients with acute PJI after TKA were identified and 29 unique bacterial isolates were recovered. The mean time to revision was 37 days (6 to 84). Nine isolates (31%) were resistant to gentamicin, ten (34%) were resistant to tobramycin, and seven (24%) were resistant to vancomycin. Excluding one Fusobacterium nucleatum, which was resistant to all three antibiotics, all isolates resistant to tobramycin or gentamicin were susceptible to vancomycin and vice versa. Overall, 2.4 g of tobramycin hand-mixed into 80 g of PMMA and 1 g of intra-articular vancomycin powder consistently achieved concentrations above the minimum inhibitory concentrations of susceptible organisms. CONCLUSION One-third of bacteria causing acute PJI after primary TKA were resistant to the aminoglycosides commonly mixed into PMMA, and one-quarter were resistant to vancomycin. With one exception, all bacteria resistant to tobramycin were susceptible to vancomycin and vice versa. Based on these results, the optimal cover for organisms causing most cases of acute PJI after TKA can be achieved with a combination of tobramycin mixed in antibiotic cement, and vancomycin powder. Cite this article: Bone Joint J 2020;102-B(6 Supple A):163-169.
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Affiliation(s)
- Charles M Lawrie
- Department of Orthopedic Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Sally Jo
- Department of Orthopedic Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Toby Barrack
- Department of Orthopedic Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Stephen Roper
- Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Rick W Wright
- Department of Orthopaedics and Rehabilitation, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Ryan M Nunley
- Department of Orthopedic Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Robert L Barrack
- Department of Orthopedic Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
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Auñón Á, Esteban J, Doadrio AL, Boiza-Sánchez M, Mediero A, Eguibar-Blázquez D, Cordero-Ampuero J, Conde A, Arenas MÁ, de-Damborenea JJ, Aguilera-Correa JJ. Staphylococcus aureus Prosthetic Joint Infection Is Prevented by a Fluorine- and Phosphorus-Doped Nanostructured Ti-6Al-4V Alloy Loaded With Gentamicin and Vancomycin. J Orthop Res 2020; 38:588-597. [PMID: 31608498 DOI: 10.1002/jor.24496] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Accepted: 10/04/2019] [Indexed: 02/04/2023]
Abstract
Prosthetic joint infection (PJI) is one of the most devastating complications in orthopedic surgery. One approach used to prevent PJI is local antibiotic therapy. This study evaluates the antibiotic release, in vitro cytocompatibility and in vivo effectiveness in preventing PJI caused by Staphylococcus aureus (S. aureus) of the fluorine- and phosphorus-doped, bottle-shaped, nanostructured (bNT) Ti-6Al-4V alloy loaded with a mixture of gentamicin and vancomycin (GV). We evaluated bNT Ti-6Al-4V loading with a mixture of GV, measuring the release of these antibiotics using high-performance liquid chromatography. Further, we describe bNT Ti-6Al-4V GV cytocompatibility and its efficacy against S. aureus using an in vivo rabbit model. GV was released from bNT Ti-6Al-4V following a Boltzmann non-linear model and maximum release values were obtained at 240 min for both antibiotics. The cell proliferation of MCT3T3-E1 osteoblastic cells significantly increased at 48 (28%) and 168 h (68%), as did the matrix mineralization (52%) of these cells and the gene expression of three of the most important markers related to bone differentiation (more than threefold for VEGF and BGLAP, and 65% for RunX) on bNT Ti-6Al-4V GV compared with control. In vivo study results show that bNT Ti-6Al-4V GV can prevent S. aureus PJI according to histopathological and microbiological results. According to our results, bNT Ti-6Al-4V loaded with a mixture of GV using the soaking method is a promising biomaterial with favorable cytocompatibility and osteointegration, demonstrating local bactericidal properties against S. aureus. © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 38:588-597, 2020.
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Affiliation(s)
- Álvaro Auñón
- Department of Orthopedic Surgery, Fundación Jiménez Díaz University Hospital, Av. Reyes Católicos, 2, 28040, Madrid, Spain
| | - Jaime Esteban
- Department of Clinical Microbiology, IIS-Fundación Jiménez Díaz, UAM, Av. Reyes Católicos, 2, 28040, Madrid, Spain
| | - Antonio L Doadrio
- Department of Inorganic and Bioinorganic Chemistry, Health Research Institute, Complutense University of Madrid, 12 de Octubre i+12, 28040, Madrid, Spain
| | - Macarena Boiza-Sánchez
- Department of Pathology, Fundación Jiménez Díaz University Hospital, Av. Reyes Católicos, 2, 28040, Madrid, Spain
| | - Aranzazu Mediero
- Joint and Bone Research Unit, IIS-Fundación Jimenez Diaz, UAM, Av. Reyes Católicos, 2, 28040, Madrid, Spain
| | - Diego Eguibar-Blázquez
- Department of Experimental Surgery and Animal Research, IIS-Fundación Jimenez Diaz, UAM, Av. Reyes Católicos, 2, 28040, Madrid, Spain
| | - José Cordero-Ampuero
- Department of Orthopaedic Surgery, University Hospital La Princesa, c/Océano Antártico 41, 28760, Tres Cantos, Spain
| | - Ana Conde
- Corrosion and Material Protection Group, Surface Engineering, Corrosion and Durability Department National Center for Metallurgical Research, (CENIM-CSIC) Av. Gregorio del Amo, 8, Madrid, 28040, Spain
| | - María-Ángeles Arenas
- Corrosion and Material Protection Group, Surface Engineering, Corrosion and Durability Department National Center for Metallurgical Research, (CENIM-CSIC) Av. Gregorio del Amo, 8, Madrid, 28040, Spain
| | - Juan-José de-Damborenea
- Corrosion and Material Protection Group, Surface Engineering, Corrosion and Durability Department National Center for Metallurgical Research, (CENIM-CSIC) Av. Gregorio del Amo, 8, Madrid, 28040, Spain
| | - John J Aguilera-Correa
- Department of Clinical Microbiology, IIS-Fundación Jiménez Díaz, UAM, Av. Reyes Católicos, 2, 28040, Madrid, Spain
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Zhang Q, Nettleship I, Schmelzer E, Gerlach J, Zhang X, Wang J, Liu C. Tissue Engineering and Regenerative Medicine Therapies for Cell Senescence in Bone and Cartilage. TISSUE ENGINEERING PART B-REVIEWS 2020; 26:64-78. [DOI: 10.1089/ten.teb.2019.0215] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- Qinghao Zhang
- Department of Materials Science and Engineering, East China University of Science and Technology, Shanghai, P.R. China
- Department of Mechanical Engineering and Materials Science, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Ian Nettleship
- Department of Mechanical Engineering and Materials Science, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Eva Schmelzer
- Department of Surgery, McGowan Institute for Regenerative Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Jorg Gerlach
- Department of Surgery, McGowan Institute for Regenerative Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Xuewei Zhang
- Department of Materials Science and Engineering, East China University of Science and Technology, Shanghai, P.R. China
| | - Jing Wang
- Department of Materials Science and Engineering, East China University of Science and Technology, Shanghai, P.R. China
| | - Changsheng Liu
- Department of Materials Science and Engineering, East China University of Science and Technology, Shanghai, P.R. China
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Jameson SS, Asaad A, Diament M, Kasim A, Bigirumurame T, Baker P, Mason J, Partington P, Reed M. Antibiotic-loaded bone cement is associated with a lower risk of revision following primary cemented total knee arthroplasty: an analysis of 731,214 cases using National Joint Registry data. Bone Joint J 2019; 101-B:1331-1347. [PMID: 31674244 DOI: 10.1302/0301-620x.101b11.bjj-2019-0196.r1] [Citation(s) in RCA: 58] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
AIMS Antibiotic-loaded bone cements (ALBCs) may offer early protection against the formation of bacterial biofilm after joint arthroplasty. Use in hip arthroplasty is widely accepted, but there is a lack of evidence in total knee arthroplasty (TKA). The objective of this study was to evaluate the use of ALBC in a large population of TKA patients. MATERIALS AND METHODS Data from the National Joint Registry (NJR) of England and Wales were obtained for all primary cemented TKAs between March 2003 and July 2016. Patient, implant, and surgical variables were analyzed. Cox proportional hazards models were used to assess the influence of ALBC on risk of revision. Body mass index (BMI) data were available in a subset of patients. RESULTS Of 731 214 TKAs, 15 295 (2.1%) were implanted with plain cement and 715 919 (97.9%) with ALBC. There were 13 391 revisions; 2391 were performed for infection. After adjusting for other variables, ALBC had a significantly lower risk of revision for any cause (hazard ratio (HR) 0.85, 95% confidence interval (CI) 0.77 to 0.93; p < 0.001). ALBC was associated with a lower risk of revision for all aseptic causes (HR 0.85, 95% CI 0.77 to 0.95; p < 0.001) and revisions for infection (HR 0.84, 95% CI 0.67 to 1.01; p = 0.06). The results were similar when BMI was added into the model, and in a subanalysis where surgeons using only ALBC over the entire study period were excluded. Prosthesis survival at ten years for TKAs implanted with ALBC was 96.3% (95% CI 96.3 to 96.4) compared with 95.5% (95% CI 95.0 to 95.9) in those implanted with plain cement. On a population level, where 100 000 TKAs are performed annually, this difference represents 870 fewer revisions at ten years in the ALBC group. CONCLUSION After adjusting for a range of variables, ALBC was associated with a significantly lower risk of revision in this registry-based study of an entire nation of primary cemented knee arthroplasties. Using ALBC does not appear to increase midterm implant failure rates. Cite this article: Bone Joint J 2019;101-B:1331-1347.
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Affiliation(s)
- Simon S Jameson
- South Tees Hospitals NHS Foundation Trust, Middlesbrough, UK
| | - Asaad Asaad
- Trauma & Orthopaedics, Northern Deanery, Newcastle upon Tyne, UK
| | - Marina Diament
- Trauma & Orthopaedics, Northern Deanery, Newcastle upon Tyne, UK
| | | | | | - Paul Baker
- South Tees Hospitals NHS Foundation Trust, Middlesbrough, UK
| | | | - Paul Partington
- Northumbria Healthcare NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Mike Reed
- Northumbria Healthcare NHS Foundation Trust, Newcastle upon Tyne, UK.,University of York, York, UK
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Berberich C, Sanz-Ruiz P. Risk assessment of antibiotic resistance development by antibiotic-loaded bone cements: is it a clinical concern? EFORT Open Rev 2019; 4:576-584. [PMID: 31754463 PMCID: PMC6836079 DOI: 10.1302/2058-5241.4.180104] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
Because of the risk of bacterial biofilm infections, prophylactic use of antibiotics in orthopaedic procedures involving the implantation of large prosthesis systems is considered mandatory. A strategy based on the rationale that local antibiotics released from bone cement or other carriers establish a second antibacterial frontline in and around the prosthesis is considered complementary to the administration of systemic antibiotics. Although less common as a consequence of the initially very high drug concentrations of local antibiotics in the tissues, a selection process of previous high resistance bacteria may occur, leading to antibiotic resistance. The use of antibiotic combinations in bone cement is generally accepted to improve antibiotic efficacy and minimizes the treatment failure risk due to antibiotic resistance. This is important in septic revisions and/or in patients at particularly high risk of infection. On an individual basis, the benefit of a lower infection probability with combined systemic and local antibiotic application should outweigh the risk of the selection of more resistant bacteria. Each prevented infection means that a complex and extended antibiotic therapy with risk of resistance development over time has been avoided. On an epidemiological level there is no clinical evidence that the routine use of bone cement impregnated with appropriate bactericidal antibiotics promotes the widespread development of antibiotic resistance and thereby puts the successful treatment of a prosthetic joint infection at higher risk. Cite this article: EFORT Open Rev 2019;4:576-584. DOI: 10.1302/2058-5241.4.180104
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Affiliation(s)
- Christof Berberich
- Department of Medical Training and Education, Heraeus Medical GmbH, Wehrheim, Germany
| | - Pablo Sanz-Ruiz
- Department of Traumatology and Orthopaedic Surgery, General University Hospital Gregorio Marañón, Madrid, Spain
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Huang W, Wang Y, McMullen LM, McDermott MT, Deng H, Du Y, Chen L, Zhang L. Stretchable, tough, self-recoverable, and cytocompatible chitosan/cellulose nanocrystals/polyacrylamide hybrid hydrogels. Carbohydr Polym 2019; 222:114977. [DOI: 10.1016/j.carbpol.2019.114977] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Revised: 06/05/2019] [Accepted: 06/06/2019] [Indexed: 11/17/2022]
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Anis HK, Sodhi N, Faour M, Klika AK, Mont MA, Barsoum WK, Higuera CA, Molloy RM. Effect of Antibiotic-Impregnated Bone Cement in Primary Total Knee Arthroplasty. J Arthroplasty 2019; 34:2091-2095.e1. [PMID: 31109755 DOI: 10.1016/j.arth.2019.04.033] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Revised: 04/01/2019] [Accepted: 04/17/2019] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND The purpose of this study is to evaluate the effect of commercially available antibiotic-impregnated bone cement (AIBC) on (1) prosthetic joint infections (PJIs) and (2) surgical site infections (SSIs) after primary total knee arthroplasty (TKA). METHODS A review of primary TKAs between 2014 and 2017 from an institutional database was conducted. This identified 12,541 cases which were separated into AIBC (n = 4337) and non-AIBC (8,164) cohorts. Medical records were reviewed for PJIs and SSIs (mean 2-year postoperative period). Infection rates between the cohorts were compared with univariate analyses followed by subanalysis of high risk patients (defined as having 2 or more of the following characteristics: >65 years, body mass index >40, or Charlson Comorbidity Index score >3). To control for confounders, multivariate analyses were performed with regression models adjusted for age, gender, body mass index, comorbidities, year, operative times, and lengths of stay. RESULTS On univariate analysis, PJI rates were higher in the AIBC cohort (1.0%) compared to the non-AIBC cohort (0.5%, P < .001). Subanalysis of the high risk patients also showed that PJI rates were higher in the AIBC cohort (1.9% vs 0.6%, P < .01). After adjusting for potential confounders, no significant associations between PJIs and AIBC use were found (odds ratio 1.4, 95% confidence interval 0.9-2.3, P = .133). Similarly, no significant differences in SSI rates were observed between the AIBC (2.9%) and non-AIBC cohorts (2.4%, P = .060) and no significant associations between SSIs and AIBC were found with multivariate analysis (odds ratio 1.0, 95% confidence interval CI 0.8-1.3, P = .948). CONCLUSION This study found that there was no clinically or statistically significant decrease in infection rates with AIBC in primary TKAs.
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Affiliation(s)
- Hiba K Anis
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, OH
| | - Nipun Sodhi
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, OH
| | - Mhamad Faour
- Department of Orthopaedic Surgery, Cleveland Clinic Florida, Weston, FL
| | - Alison K Klika
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, OH
| | - Michael A Mont
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, OH
| | - Wael K Barsoum
- Department of Orthopaedic Surgery, Cleveland Clinic Florida, Weston, FL
| | - Carlos A Higuera
- Department of Orthopaedic Surgery, Cleveland Clinic Florida, Weston, FL
| | - Robert M Molloy
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, OH
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van Vugt TAG, Arts JJ, Geurts JAP. Antibiotic-Loaded Polymethylmethacrylate Beads and Spacers in Treatment of Orthopedic Infections and the Role of Biofilm Formation. Front Microbiol 2019; 10:1626. [PMID: 31402901 PMCID: PMC6671866 DOI: 10.3389/fmicb.2019.01626] [Citation(s) in RCA: 121] [Impact Index Per Article: 20.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Accepted: 07/02/2019] [Indexed: 02/06/2023] Open
Abstract
Polymethylmethacrylate (PMMA) also referred as (acrylic) bone cement is a non-degradable biomaterial that has been used in clinical orthopedic practice for several decades. PMMA can be used in a plain formulation, but is often used in an antibiotic-loaded formulation in (primary and revision) arthroplasty and in treatment of orthopedic infections as prosthetic joint infections (PJI) and chronic osteomyelitis. In treatment of PJIs antibiotic-loaded PMMA is often used as a carrier material for local antibiotic delivery in addition to treatment with systemic antibiotics. In this case, the antibiotic-loaded PMMA is often used as a spacer or as a bead chain. Since the introduction of PMMA as an antibiotic carrier there is a tremendous amount of scientific and clinical papers published, which studied numerous different aspects of antibiotic-loaded PMMA. This paper will review the research regarding basic principles of antibiotic-loaded PMMA as mechanism of action, antibiotic-release capacities, choice of antibiotics and influences on mechanical properties of PMMA. Subsequently, concerns regarding the application of antibiotic-loaded PMMA, biofilm formation, antibiotic resistance and local or systemic toxicity will be discussed. In addition to these subjects, the role of antibiotic loaded PMMA in clinical treatment of PJIs and chronic osteomyelitis is discussed in the final part of this paper.
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Perni S, Caserta S, Pasquino R, Jones SA, Prokopovich P. Prolonged Antimicrobial Activity of PMMA Bone Cement with Embedded Gentamicin-Releasing Silica Nanocarriers. ACS APPLIED BIO MATERIALS 2019; 2:1850-1861. [DOI: 10.1021/acsabm.8b00752] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Affiliation(s)
- Stefano Perni
- School of Pharmacy and Pharmaceutical Sciences, Cardiff University, Cardiff CF10 3NB, United Kingdom
| | - Sergio Caserta
- Department of Chemical, Materials and Industrial Production Engineering, University of Naples Federico II, Napoli 80125, Italy
| | - Rossana Pasquino
- Department of Chemical, Materials and Industrial Production Engineering, University of Naples Federico II, Napoli 80125, Italy
| | - Steve A. Jones
- University Hospital Llandough, Cardiff & Vale University Health Board, Penlan Road, Penarth, Vale of Glamorgan, Wales CF64 2XX, United Kingdom
| | - Polina Prokopovich
- School of Pharmacy and Pharmaceutical Sciences, Cardiff University, Cardiff CF10 3NB, United Kingdom
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Turhan S. Does the Use of Antibiotic-Loaded Bone Cement Have an Effect on Deep Infection in Primary Total Knee Arthroplasty Practice? Surg Infect (Larchmt) 2019; 20:244-246. [PMID: 30707653 DOI: 10.1089/sur.2018.123] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Total knee arthroplasty (TKA) is performed to improve the quality of life by reducing knee arthralgia. One of the most destructive and expensive complications of TKA is deep infection. The primary purpose of this study was to evaluate the effect of using antibiotic-loaded bone cement (ALBC) on the incidence of deep infection after primary TKA. PATIENTS AND METHODS A total of 506 patients who underwent primary knee arthroplasty at the Antalya Training and Research Hospital between February 2009 and January 2016 were investigated retrospectively. RESULTS The ALBC was used for 85 patients (16.7%), who constituted group 1. Plain bone cement was used for 421 patients (83.2%), who constituted group 2. Deep infection was observed in one patient (1.1%) in group 1 and in six patients (1.4%) in group 2, a difference that is not statistically significant. On average, the deep infection occurred six months after the surgery at the earliest and 19 months at the latest. CONCLUSION Use of ALBC did not decrease the incidence of deep infection in TKA. Therefore, we prefer bone cement without any antibiotic.
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Affiliation(s)
- Sadullah Turhan
- Antalya Training and Research Hospital, Department of Orthopaedics and Traumatology, Antalya, Turkey
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Sultan AA, Samuel LT, Umpierrez E, Swiergosz A, Rabin J, Mahmood B, Mont MA. Routine use of commercial antibiotic-loaded bone cement in primary total joint arthroplasty: a critical analysis of the current evidence. ANNALS OF TRANSLATIONAL MEDICINE 2019; 7:73. [PMID: 30963068 DOI: 10.21037/atm.2018.11.50] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Antibiotic-loaded cement (ABLC) has been widely utilized as an adjuvant treatment for patients with periprosthetic joint infection (PJI) but has also evolved to play a prophylactic role against infection in primary total joint arthroplasties (TJA). Nevertheless, there is currently a paucity of studies that systematically investigated this concept. This review aimed at answering the following questions: (I) Can routine use of ABLC help reduce the current infection rates in primary TJA? (II) What are the risks associated with this approach? And (III) can routine use be justified in primary TJA from an economic standpoint? Multiple databases were queried including PubMed, EMBASE, EBSCO Host, and SCOPUS. Studies published between January 1, 1990 and March 31, 2018 were reviewed. Inclusion criteria were studies reporting: (I) clinical outcomes of routine use of ABLC in primary hip and knee arthroplasty with 2-year minimum follow-up, (II) complications related to the use of ABLC, (III) cost of using ABLC. The final analysis included 24 studies. Data from multiple studies demonstrate contradictory results for infection rates when ABLC is used in all primary procedures with a majority of studies showing similar infection rates between ABLC and plain cement. The main concerns associated with routine use of ABLC are negative effects on the mechanical stability of cement, possible systemic and local toxicity of the absorbed antibiotic, and development of resistant bacterial strains. However, current literature has not clinically validated these concerns. Lastly, with an estimated increase in 117 million dollars with the routine use of ABLC in only 50% of TJAs performed each year, it is difficult to justify the use of ABLC without clear superiority in reducing infection. The use of ABLC has undeniably changed the way orthopaedic surgeons deal with PJI today. However, the large-scale, prophylactic use of ABLC in primary TJAs requires further research and justification.
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Affiliation(s)
- Assem A Sultan
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Linsen T Samuel
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Erica Umpierrez
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Andrew Swiergosz
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Jacob Rabin
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Bilal Mahmood
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Michael A Mont
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, OH, USA.,Department of Orthopaedic Surgery, Lenox Hill Hospital, New York, NY, USA
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Holleyman RJ, Deehan DJ, Walker L, Charlett A, Samuel J, Shirley MDF, Baker PN. Staphylococcal resistance profiles in deep infection following primary hip and knee arthroplasty: a study using the NJR dataset. Arch Orthop Trauma Surg 2019; 139:1209-1215. [PMID: 30877427 PMCID: PMC6687688 DOI: 10.1007/s00402-019-03155-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Indexed: 11/29/2022]
Abstract
INTRODUCTION This study aimed to (1) report the rates of resistance against a variety of antibiotics for pure Staphylococcal infections, and (2) examine the impact of ALBC use at primary surgery has on resistance patterns for patients undergoing first-time revision of primary hip and knee arthroplasty for indication of infection. MATERIALS AND METHODS Data from the National Joint Registry database for England and Wales were linked to microbiology data held by Public Health England to identify a consecutive series of 258 primary hip and knee arthroplasties performed between April 2003 and January 2014 that went on to have a revision for Staphylococcal deep periprosthetic infection. Multivariate binary logistic regression was used to study predictors of microorganism resistance to a range of antimicrobials. RESULTS After adjusting for patient and surgical factors, multivariate analysis showed the use of gentamicin-loaded bone cement at the primary surgery was associated with a significant increase in the risk of Staphylococcal gentamicin resistance (odds ratio 8.341, 95% CI 2.297-30.292, p = 0.001) and methicillin resistance (odds ratio 3.870, 95% CI 1.319-11.359, p = 0.014) at revision for infection. CONCLUSIONS Clinicians must anticipate the possibility of antibiotic resistance to ALBC utilised at primary surgery.
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Affiliation(s)
- Richard J. Holleyman
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, NE2 4HH UK ,Health Education North East, Newcastle upon Tyne, NE15 8NY UK
| | - David J. Deehan
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, NE2 4HH UK ,Newcastle upon Tyne NHS Foundation Trust, Newcastle upon Tyne, NE7 7DN UK
| | - Lucy Walker
- Health Education North East, Newcastle upon Tyne, NE15 8NY UK
| | - Andre Charlett
- Centre for Infectious Disease Surveillance and Control, Public Health England, London, NW9 5EQ UK
| | - Julie Samuel
- Newcastle upon Tyne NHS Foundation Trust, Newcastle upon Tyne, NE7 7DN UK
| | - Mark D. F. Shirley
- Biological, Clinical, and Environmental Systems Modelling Group, School of Biology, Newcastle University, Newcastle upon Tyne, NE1 7RU UK
| | - Paul N. Baker
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, NE2 4HH UK ,Department of Trauma and Orthopaedics, James Cook University Hospital, Middlebrough, TS4 3BW UK
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Badha V, Moore R, Heffernan J, Castaneda P, McLaren A, Overstreet D. Determination of Tobramycin and Vancomycin Exposure Required to Eradicate Biofilms on Muscle and Bone Tissue In Vitro. J Bone Jt Infect 2019; 4:1-9. [PMID: 30755841 PMCID: PMC6367195 DOI: 10.7150/jbji.29711] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Accepted: 11/10/2018] [Indexed: 01/09/2023] Open
Abstract
Background: Bacterial biofilms cause chronic orthopaedic infections. Surgical debridement to remove biofilm can be ineffective without adjuvant local antimicrobials because undetected biofilm fragments may remain in the wound and reestablish the infection if untreated. However, the concentrations and duration of antimicrobial exposure necessary to eradicate bacteria from clinical biofilms remain largely undefined. In this study, we determined the minimum biofilm eradication concentration (MBEC) of tobramycin and vancomycin for bacterial biofilms grown on bone and muscle in vitro. Methods: Biofilms of pathogens found in musculoskeletal infections (S. aureus, S. epidermidis, E. faecalis, P. aeruginosa, and E. coli) were established for 72 hr on rabbit muscle and bone specimens in vitro and characterized by SEM imaging and CFU counts. Biofilm-covered tissue specimens were exposed to serial log2 dilutions (4000-31.25 µg/mL) of tobramycin, vancomycin, or a 1:1 combination of both drugs for 6, 24, or 72 hr. Tissues were subcultured following antimicrobial exposure to determine bacterial survival. The breakpoint concentration with no surviving bacteria was defined as the MBEC for each pathogen-antimicrobial-exposure time combination. Results: All tested pathogens formed biofilm on tissue. Tobramycin/vancomycin (1:1) was the most effective antimicrobial regimen with MBEC on muscle (10/10 pathogens) or bone (7/10 pathogens) generally in the range of 100-750 µg/mL with 24 or 72 hr exposure. MBEC decreased with exposure time for 53.3% of biofilms between 6 and 24 hr, 53.3% of biofilms between 24 and 72 hr, and for 76.7% of biofilms between 6 and 72 hr. MBECs on bone were significantly higher than corresponding MBECs on muscle tissue (p < 0.05). In most cases, tissue MBECs were lower compared to previously published MBECs for the same pathogens on polystyrene tissue-culture plates. Conclusions: The majority of MBECs for orthopaedic infections on bone and muscle are on the order of 100-750 µg/mL of vancomycin+tobramycin when sustained for at least 24 hr, which may be clinically achievable using high-dose antimicrobial-loaded bone cement (ALBC).
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Affiliation(s)
- Vajra Badha
- School of Biological & Health Systems Engineering, Arizona State University, Tempe, AZ, USA
- Sonoran Biosciences, Chandler, AZ, USA
| | - Rex Moore
- School of Biological & Health Systems Engineering, Arizona State University, Tempe, AZ, USA
- Sonoran Biosciences, Chandler, AZ, USA
| | | | | | - Alex McLaren
- School of Biological & Health Systems Engineering, Arizona State University, Tempe, AZ, USA
- Sonoran Biosciences, Chandler, AZ, USA
- University of Arizona College of Medicine, Phoenix, AZ, USA
| | - Derek Overstreet
- School of Biological & Health Systems Engineering, Arizona State University, Tempe, AZ, USA
- Sonoran Biosciences, Chandler, AZ, USA
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Abstract
Antibiotic-laden bone cement (ALBC) has a number of different uses in primary and revision total joint arthroplasty. However, considerable controversy remains regarding how and when it is best used. The prophylactic use of low-dose ALBC in primary cemented total hip arthroplasty is well supported by the literature, conferring both clinical and economic benefits. In contrast, conclusive evidence on the clinical efficacy or economic benefit of the routine use of ALBC in primary total knee arthroplasty remains elusive. Given the currently available evidence, we cannot determine definitively whether the routine use of ALBC in primary total knee arthroplasty is justified, although selective use in patients with a high risk of infection seems warranted. The routine use of ALBC in revision total joint arthroplasty is well accepted, with good supporting evidence in studies of both aseptic and first-stage revision procedures. Although limited clinical evidence exists on the use of ALBC at the time of definitive component reimplantation after septic revision, the rationale for its use is strong.
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Knecht CS, Moley JP, McGrath MS, Granger JF, Stoodley P, Dusane DH. Antibiotic loaded calcium sulfate bead and pulse lavage eradicates biofilms on metal implant materials in vitro. J Orthop Res 2018; 36:2349-2354. [PMID: 29603341 DOI: 10.1002/jor.23903] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2018] [Accepted: 03/27/2018] [Indexed: 02/04/2023]
Abstract
Pulse lavage (PL) debridement and antibiotic loaded calcium sulfate beads (CS-B) are both used for the treatment of biofilm related periprosthetic joint infection (PJI). However, the efficacy of these alone and in combination for eradicating biofilm from orthopaedic metal implant surfaces is unclear. The purpose of the study was to understand the efficacy of PL and antibiotic loaded CS-B in eradicating bacterial biofilms on 316L stainless steel (SS) alone and in combination in vitro. Biofilms of bioluminescent strains of Pseudomonas aeruginosa Xen41 and a USA300 MRSA Staphylococcus aureus SAP231 were grown on SS coupons for 3 days. The coupons were either, (i) debrided for 3 s with PL, (ii) exposed to tobramycin (TOB) and vancomycin (VAN) loaded CS-B for 24 h, or (iii) exposed to both. An untreated biofilm served as a control. The amount of biofilm was measured by bioluminescence, viable plate count and confocal microscopy using live/dead staining. PL alone reduced the CFU count of both strains of biofilms by approximately 2 orders of magnitude, from an initial cell count on metal surface of approximately 109 CFU/cm2 . The antibiotic loaded CS-B caused an approximate six log reduction and the combination completely eradicated viable biofilm bacteria. Bioluminescence and confocal imaging corroborated the CFU data. While PL and antibiotic loaded CS-B both significantly reduced biofilm, the combination of two was more effective than alone in removing biofilms from SS implant surfaces. © 2018 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 36:2349-2354, 2018.
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Affiliation(s)
- Cory S Knecht
- Department of Orthopaedics, Cleveland Clinic, Akron General, Akron, Ohio
| | - James P Moley
- Department of Microbial Infection and Immunity, The Ohio State University, 716 Biomedical Research Tower (BRT), 460 W 12th Ave, Columbus, Ohio 43210
| | - Mary S McGrath
- Department of Microbial Infection and Immunity, The Ohio State University, 716 Biomedical Research Tower (BRT), 460 W 12th Ave, Columbus, Ohio 43210
| | - Jeffrey F Granger
- Department of Orthopaedics, The Ohio State University, Columbus, Ohio 43210
| | - Paul Stoodley
- Department of Microbial Infection and Immunity, The Ohio State University, 716 Biomedical Research Tower (BRT), 460 W 12th Ave, Columbus, Ohio 43210.,Department of Orthopaedics, The Ohio State University, Columbus, Ohio 43210.,National Centre for Advanced Tribology at Southampton (nCATS), University of Southampton, Southampton SO17 1BJ, United Kingdom
| | - Devendra H Dusane
- Department of Microbial Infection and Immunity, The Ohio State University, 716 Biomedical Research Tower (BRT), 460 W 12th Ave, Columbus, Ohio 43210
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Tyas B, Marsh M, Oswald T, Refaie R, Molyneux C, Reed M. Antibiotic resistance profiles of deep surgical site infections in hip hemiarthroplasty; comparing low dose single antibiotic versus high dose dual antibiotic impregnated cement. J Bone Jt Infect 2018; 3:123-129. [PMID: 30013893 PMCID: PMC6043471 DOI: 10.7150/jbji.22192] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2017] [Accepted: 02/04/2018] [Indexed: 12/27/2022] Open
Abstract
Objectives: The incidence of fractured neck of femur (FNOF) is increasing yearly. Many of these patients undergo hip hemiarthroplasty. High dose dual-antibiotic cement (HDDAC) has been shown to reduce rates of deep surgical site infection (SSI) when compared to the current standard low dose single-antibiotic cement (LDSAC) in a quasi-randomised controlled trial. Some concerns exist regarding the use of HDDAC and the development of antibiotic resistance. We reviewed cases of infection in LDSAC and HDDAC bone cement with regard to causative organism and resistance profile. Methods: A retrospective analysis was undertaken of all hemiarthroplasties within our trust from April 2008 to December 2014. We identified all patients in this time period who acquired a deep SSI. The infecting organisms and susceptibility patterns were collated for each cement. Results: We identified 1941 hemiarthroplasties. There were 38 deep surgical site infections representing an infection rate of 3.4% in LDSAC patients and 1.2% in HDDAC patients. The majority of infections were polymicrobial. Staphylococcus epidermidis was the most commonly isolated organism. It accounted for a larger proportion of HDDAC than LDSAC infections (p<0.05). Infection with Corynebacterium species and S. aureus, including MRSA, was eradicated completely with the use of HDDAC. There was no significant change in the proportion of Gram negative and Gram positive infections between the two cements. In Gram positive organisms, there was no significant change in resistance to most antibiotics. Although fewer resistant infections overall, there were significant increases in the proportion of resistance to ciprofloxacin and clindamycin with HDDAC. We observed no resistance to daptomycin or linezolid in either cement and levels of resistance remained low to rifampicin and teicoplanin. In Gram negative organisms, no significant change in resistance was observed. Conclusions: We observed a significantly lower infection rate with the use of HDDAC compared to LDSAC. Such was this reduced infection rate that there was a trend to a lower rate of resistance with the use of HDDAC. However, there were increases in the proportion of resistant cases, most notably to clindamycin and ciprofloxacin in Gram positive organisms, possibly reflecting the higher number of S. epidermidis in the HDDAC group. Whilst the differences in our study were not found to be statistically significant, it is reassuring for teams using HDDAC to prevent SSI in hip hemiarthroplasty.
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Affiliation(s)
- Ben Tyas
- Foundation Doctor, University Hospital North Durham, North Road, Durham, DH1 5TW, United Kingdom
| | - Martin Marsh
- Clinical Research Fellow, Northumbria Specialist Emergency Healthcare Centre, Northumbrian Road, Cramlington, NE23 6NZ, United Kingdom
| | - Tamsin Oswald
- Consultant Microbiologist, Northumbria Specialist Emergency Healthcare Centre, Northumbrian Road, Cramlington, NE23 6NZ, United Kingdom
| | - Ramsay Refaie
- Clinical Research Fellow, Northumbria Specialist Emergency Healthcare Centre, Northumbrian Road, Cramlington, NE23 6NZ, United Kingdom
| | - Catherine Molyneux
- Consultant Microbiologist, Royal Victoria Infirmary, Queen Victoria Road, NE1 4LP, United Kingdom
| | - Mike Reed
- Consultant Trauma and Orthopaedic Surgeon, Northumbria Specialist Emergency Healthcare Centre, Northumbrian Road, Cramlington, NE23 6NZ, United Kingdom
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Winkler C, Dennison J, Wooldridge A, Larumbe E, Caroom C, Jenkins M, Brindley G. Do local antibiotics reduce periprosthetic joint infections? A retrospective review of 744 cases. J Clin Orthop Trauma 2018; 9:S34-S39. [PMID: 29628696 PMCID: PMC5883907 DOI: 10.1016/j.jcot.2017.08.007] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Revised: 08/07/2017] [Accepted: 08/17/2017] [Indexed: 11/17/2022] Open
Abstract
Periprosthetic joint infections (PJI) are uncommon but not rare and have significant morbidity and financial implications. Local antibiotics have been used successfully in other areas of orthopedics to reduce postoperative infections, but this method has not been proven in total joint arthroplasty (TJA). Beginning January 1, 2014, our primary investigators began using surgical site lavage with providone-iodine solution and administering 2 g of vancomcyin powder in the surgical wound prior to capsule closure for all primary and revision total hip and knee arthroplasties. We performed a retrospective chart review of patients two years prior to this date and two years after to compare occurrence of PJI. The groups were broken down into patients who received local antibiotics versus those who did not. The groups were further broken down by type of surgery performed; primary or revision total hip or knee arthroplasty. Administration of local antibiotics was preventative for PJI only in the primary total knee arthroplasty group (aOR = 0.28, 0.09-0.89). Administration of local antibiotics trended towards a preventative effect for PJI in the other groups but was not statistically significant. Patients receiving local antibiotics had similar blood urea nitrogen and creatinine levels postoperatively compared to the no antibiotics group indicating minimal systemic effects of local vancomycin powder. While the use of local antibiotics may prevent PJI, more data is required especially in the revision arthroplasty groups.
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50
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Siljander MP, Sobh AH, Baker KC, Baker EA, Kaplan LM. Multidrug-Resistant Organisms in the Setting of Periprosthetic Joint Infection-Diagnosis, Prevention, and Treatment. J Arthroplasty 2018; 33:185-194. [PMID: 28869114 DOI: 10.1016/j.arth.2017.07.045] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2017] [Revised: 07/22/2017] [Accepted: 07/25/2017] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Periprosthetic joint infection (PJI) is a rare yet challenging problem in total hip and knee arthroplasties. The management of PJI remains difficult primarily due to the evolution of resistance by the infecting organisms. METHODS This review profiles acquired mechanisms of bacterial resistance and summarizes established and emerging techniques in PJI diagnosis, prevention, and treatment. RESULTS New techniques in PJI diagnosis and prevention continue to be explored. Antibiotics combined with 1 or 2-stage revision are associated with the higher success rates and remain the mainstay of treatment. CONCLUSION With higher prevalence of antibiotic-resistant organisms, novel antibiotic implant and wound care materials, improved methods for organism identification, and well-defined organism-specific treatment algorithms are needed to optimize outcomes of PJI.
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Affiliation(s)
- Matthew P Siljander
- Department of Orthopaedic Surgery, Beaumont Health System, Royal Oak, Michigan
| | - Ali H Sobh
- Department of Orthopaedic Surgery, Beaumont Health System, Royal Oak, Michigan
| | - Kevin C Baker
- Department of Orthopaedic Research, Beaumont Health System, Royal Oak, Michigan
| | - Erin A Baker
- Department of Orthopaedic Research, Beaumont Health System, Royal Oak, Michigan
| | - Lige M Kaplan
- Department of Orthopaedic Surgery, Beaumont Health System, Royal Oak, Michigan
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