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McPherson EJ, Chowdhry M, Dipane MV, Marahrens B, Pena DD, Stavrakis AI. Antibiotic-Loaded Calcium Sulphate Beads for Treatment of Acute Periprosthetic Joint Infection in Total Knee Arthroplasty: Results Based on Risk Stratification. J Clin Med 2025; 14:1531. [PMID: 40095454 PMCID: PMC11899950 DOI: 10.3390/jcm14051531] [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: 01/10/2025] [Revised: 02/10/2025] [Accepted: 02/12/2025] [Indexed: 03/19/2025] Open
Abstract
Background: A post-operative or late acute periprosthetic joint infection (PJI) after Total Knee Arthroplasty (TKA) requires a protocol of aggressive joint Debridement, modular implant Exchange, Component Retention, and post-operative Antimicrobial therapy (DECRA). Recently, the novel addition of intra-articular Antimicrobial Loaded Calcium Sulphate (AL-CaSO4) beads during DECRA has been utilized to improve microbial eradication. This study reviews a consecutive series of DECRA TKA procedures with AL-CaSO4 beads with a standardized antimicrobial regimen. We hypothesize AL-CaSO4 beads will not improve infection-free implant survival in compromised hosts and limbs. Methods: This consecutive series included DECRA procedures for acute post-operative or late hematogenous PJI-TKA (primary and revision) detected within 4 weeks. One gram of vancomycin powder and 240 mg of liquid tobramycin were added to 10 cc of CaSO4 powder to create 3.0 and 4.8 mm beads delivered into the joint at closure. All patients were risk stratified according to McPherson Staging and followed for a minimum of 1 year. Results: Forty-two patients were studied. The infection-free success rate of DECRA with AL-CaSO4 was 62% (26/42) at 1 year. Average bead volume per case was 18.6 cc (range = 10-40 cc). McPherson Host stage and Limb Score were found to be significantly correlated with the success of the DECRA (p < 0.05). The success rate was highest in A-hosts (87.5%), declining to 50% in B-hosts, and 25% in C-hosts. Similarly, the success rate was highest for patients with Limb score 1 (100%), declining to 58.6% with Limb score 2, and 20% with Limb score 3. Importantly, a previous episode of infection in the affected joint was associated with significantly increased failure (p = 0.000025). Conclusions: This study reports an overall higher infection-free success rate of DECRA using AL-CaSO4 beads compared to the current literature. Antibiotic beads provide an advantage in selected groups that include A or B hosts and Limb scores of 1 or 2. In C-hosts, where the immune system is weak, or Limb score 3, where the wound is compromised and leaks, antibiotic beads do not improve success. Importantly, DECRAs should not be considered curative with a prior history of joint infection. In these difficult circumstances, one should consider an exchange protocol.
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Affiliation(s)
- Edward J. McPherson
- Department of Orthopaedic Surgery, David Geffen School of Medicine, University of California (UCLA), Los Angeles, CA 90404, USA; (E.J.M.); (M.V.D.); (D.D.P.); (A.I.S.)
| | - Madhav Chowdhry
- Department of Continuing Education, University of Oxford, Oxford OX1 2JA, UK
| | - Matthew V. Dipane
- Department of Orthopaedic Surgery, David Geffen School of Medicine, University of California (UCLA), Los Angeles, CA 90404, USA; (E.J.M.); (M.V.D.); (D.D.P.); (A.I.S.)
| | - Benedikt Marahrens
- Department of Internal Medicine, Brandenburg Medical School, Neuruppin, 14770 Brandenburg, Germany;
| | - Diego Dela Pena
- Department of Orthopaedic Surgery, David Geffen School of Medicine, University of California (UCLA), Los Angeles, CA 90404, USA; (E.J.M.); (M.V.D.); (D.D.P.); (A.I.S.)
| | - Alexandra I. Stavrakis
- Department of Orthopaedic Surgery, David Geffen School of Medicine, University of California (UCLA), Los Angeles, CA 90404, USA; (E.J.M.); (M.V.D.); (D.D.P.); (A.I.S.)
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Adolf J, David Luo T, Gehrke T, Citak M. The top ten benefits of one-stage septic exchange in the management of periprosthetic joint infections. Arch Orthop Trauma Surg 2024; 144:5089-5092. [PMID: 38393443 DOI: 10.1007/s00402-024-05217-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2023] [Accepted: 01/29/2024] [Indexed: 02/25/2024]
Affiliation(s)
- Jakob Adolf
- Helios ENDO-Klinik, Holstenstraße 2, 22767, Hamburg, Germany
| | - T David Luo
- Helios ENDO-Klinik, Holstenstraße 2, 22767, Hamburg, Germany
- Orthopaedics Northeast, 5050 N Clinton St, Fort Wayne, IN, 46825, USA
| | - Thorsten Gehrke
- Helios ENDO-Klinik, Holstenstraße 2, 22767, Hamburg, Germany
| | - Mustafa Citak
- Helios ENDO-Klinik, Holstenstraße 2, 22767, Hamburg, Germany.
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Sangaletti R, Andriollo L, Montagna A, Franzoni S, Colombini P, Perticarini L, Benazzo F, Rossi SMP. Diagnosis and Treatment of Acute Periprosthetic Infections with the BioFire ® System within a Time-Dependent and Bacterium-Dependent Protocol: Review and Prosthesis-Saving Protocol. Biomedicines 2024; 12:2082. [PMID: 39335595 PMCID: PMC11428812 DOI: 10.3390/biomedicines12092082] [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: 07/03/2024] [Revised: 08/10/2024] [Accepted: 09/10/2024] [Indexed: 09/30/2024] Open
Abstract
Despite ongoing efforts to enhance diagnostic and treatment processes, the success rate for eradicating infections, particularly prosthetic joint infections (PJIs), currently stands at around 50%. For acute infections occurring shortly after arthroplasty, guidelines recommend a treatment known as DAIR (debridement, antibiotics, and implant retention). This approach is suggested for infections within 30 days post-arthroplasty or with less than 3 weeks of symptoms, provided that there is a stable implant and adequate soft-tissue mass. Several authors have suggested extending the use of DAIR beyond the initial 3-week period in specific cases. This extension practice seems increasingly feasible due to the rapid diagnostic capabilities offered by BioFire®. This technology allows for quick pathogen identification, aiding in the exclusion of cases that do not fit the criteria for the DAIR/DAPRI (debridement, antibiotic pearls and retention of the implant) protocol based on pathogen identification. The aim of this review is to re-examine the current literature on acute infections and present our proposed "prosthesis-saving" protocol, which integrates the BioFire® molecular diagnostic system. Continued research and assessment of the efficacy and safety of these protocols, especially regarding extended treatment timelines, are crucial for advancing the management of acute infections and enhancing outcomes for PJI patients.
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Affiliation(s)
- Rudy Sangaletti
- Sezione di Chirurgia Protesica ad Indirizzo Robotico—Unità di Traumatologia dello Sport, Ortopedia e Traumatologia, Fondazione Poliambulanza, 25124 Brescia, Italy
| | - Luca Andriollo
- Sezione di Chirurgia Protesica ad Indirizzo Robotico—Unità di Traumatologia dello Sport, Ortopedia e Traumatologia, Fondazione Poliambulanza, 25124 Brescia, Italy
- Ortopedia e Traumatologia, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Alice Montagna
- Sezione di Chirurgia Protesica ad Indirizzo Robotico—Unità di Traumatologia dello Sport, Ortopedia e Traumatologia, Fondazione Poliambulanza, 25124 Brescia, Italy
- Ortopedia e Traumatologia, Università degli Studi di Pavia, 27100 Pavia, Italy
| | - Simone Franzoni
- Sezione di Chirurgia Protesica ad Indirizzo Robotico—Unità di Traumatologia dello Sport, Ortopedia e Traumatologia, Fondazione Poliambulanza, 25124 Brescia, Italy
| | - Paolo Colombini
- Sezione di Chirurgia Protesica ad Indirizzo Robotico—Unità di Traumatologia dello Sport, Ortopedia e Traumatologia, Fondazione Poliambulanza, 25124 Brescia, Italy
| | - Loris Perticarini
- Sezione di Chirurgia Protesica ad Indirizzo Robotico—Unità di Traumatologia dello Sport, Ortopedia e Traumatologia, Fondazione Poliambulanza, 25124 Brescia, Italy
| | - Francesco Benazzo
- Sezione di Chirurgia Protesica ad Indirizzo Robotico—Unità di Traumatologia dello Sport, Ortopedia e Traumatologia, Fondazione Poliambulanza, 25124 Brescia, Italy
- Biomedical Sciences Area, IUSS Istituto Universitario di Studi Superiori, 27100 Pavia, Italy
| | - Stefano Marco Paolo Rossi
- Sezione di Chirurgia Protesica ad Indirizzo Robotico—Unità di Traumatologia dello Sport, Ortopedia e Traumatologia, Fondazione Poliambulanza, 25124 Brescia, Italy
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Dombrowsky A, Jolissaint J, Otero J. Pasteurella multocida From a Cat Scratch as a Cause of Recurrent Prosthetic Joint Infection After Previously Successful Single-Stage Exchange Arthroplasty. Arthroplast Today 2024; 27:101351. [PMID: 38690092 PMCID: PMC11058723 DOI: 10.1016/j.artd.2024.101351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2023] [Revised: 02/04/2024] [Accepted: 02/10/2024] [Indexed: 05/02/2024] Open
Abstract
We report a case of a 74-year-old female with a history of a prosthetic joint infection that was successfully treated with a single-stage exchange arthroplasty, off antibiotics, and without symptoms for 20 months. She presented 1 week after a cat scratch with acute knee pain, and aspiration grew Pasteurella multocida. She was successfully treated with surgical debridement and a prolonged course of antibiotics. Debate remains in the literature regarding whether recurrent infections represent a previously undetected organism or a new infection. Our report provides convincing evidence that, at least in some circumstances, the infection is new. Furthermore, this is the first case described of P. multocida resulting in a recurrent prosthetic joint infection after a previously successful exchange arthroplasty due to a different causative organism.
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Affiliation(s)
| | | | - Jesse Otero
- Atrium Health – Musculoskeletal Institute, Charlotte, NC, USA
- OrthoCarolina – Hip and Knee Center, Charlotte, NC, USA
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Pradhan TN, Viswanathan VK, Badge R, Pradhan N. Single-stage revision in the management of prosthetic joint infections after total knee arthroplasty - A review of current concepts. J Clin Orthop Trauma 2024; 52:102431. [PMID: 38854773 PMCID: PMC11153906 DOI: 10.1016/j.jcot.2024.102431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2024] [Revised: 05/08/2024] [Accepted: 05/24/2024] [Indexed: 06/11/2024] Open
Abstract
Introduction Prosthetic joint infection (PJI) is a devastating complication following total knee arthroplasty (TKA); and the gold standard surgical approach involves a two-staged, revision TKA (TSR). Owing to the newer, emerging evidence on this subject, there has been gradual shift towards a single-stage revision approach (SSR), with the purported benefits of mitigated patient morbidity, decreased complications and reduced costs. However, there is still substantial lacuna in the evidence regarding the safety and outcome of the two approaches in chronic PJI. This study aimed to comprehensively review of the literature on SSR; and evaluate its role within Revision TKA post PJI. Methods The narrative review involved a comprehensive search of the databases (Embase, Medline and Pubmed), conducted on 20th of January 2024 using specific key words. All the manuscripts discussing the use of SSR for the management of PJI after TKA were considered for the review. Among the screened manuscripts, opinion articles, letters to the editor and non-English manuscripts were excluded. Results The literature search yielded a total 232 studies. Following a detailed scrutiny of these manuscripts, 26 articles were finally selected. The overall success rate following SSR is reported to range from 73 % to 100 % (and is comparable to TSR). SSR is performed in PJI patients with bacteriologically-proven infection, adequate soft tissue cover, immuno-competent host and excellent tolerance to antibiotics. The main difference between SSR and TSR is that the interval between the 2 stages is only a few minutes instead of 6 weeks. Appropriate topical, intraoperative antibiotic therapy, followed by adequate postoperative systemic antibiotic cover are necessary to ascertain good outcome. Some of the major benefits of SSR over TSR include reduced morbidity, decreased complications (such as arthrofibrosis or anesthesia-associated adverse events), meliorated extremity function, earlier return to activities, mitigated mechanical (prosthesis-associated) complications and enhanced patient satisfaction. Conclusion SSR is a reliable approach for the management of chronic PJI. Based on our comprehensive review of the literature, it may be concluded that the right selection of patients, extensive debridement, sophisticated reconstruction strategy, identification of the pathogenic organism, initiation of appropriate antibiotic therapy and ensuring adequate follow-up are the key determinants of successful outcome. To achieve this will undoubtedly require an MDT approach to be taken on a case-by-case basis.
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Affiliation(s)
- Tej Nikhil Pradhan
- University College London, London, UK
- Imperial College London, London, UK
| | | | - Ravi Badge
- Warrington and Halton Hospitals NHS Foundation Trust, Warrington, UK
- Edge Hill University, Ormskirk, UK
- Liverpool University, Liverpool, UK
- Diploma in Sports Medicine (International Olympic Committee), UK
| | - Nikhil Pradhan
- Warrington and Halton Hospitals NHS Foundation Trust, Warrington, UK
- Edge Hill University, Ormskirk, UK
- University of Chester, Chester, UK
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Parvizi J, Cha Y, Chisari E, Kim K, Koo KH. Comprehensive Guidance for the Prevention of Periprosthetic Joint Infection After Total Joint Arthroplasty and Pitfalls in the Prevention. J Korean Med Sci 2024; 39:e147. [PMID: 38651227 PMCID: PMC11035713 DOI: 10.3346/jkms.2024.39.e147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Accepted: 03/18/2024] [Indexed: 04/25/2024] Open
Abstract
Total joint arthroplasty (TJA) is a surgical procedure, in which parts of damaged joints are removed and replaced with a prosthesis. The main indication of TJA is osteoarthritis, and the volume of TJA is rising annually along with the increase of aged population. Hip and knee are the most common joints, in which TJAs are performed. The TJA prosthesis is composed of metal, plastic, or ceramic device. Even though TJA is the most successful treatment for end-stage osteoarthritis, it is associated with various complications, and periprosthetic joint infection (PJI) is the most serious complication after TJA. With the increasing volume of TJAs, there is a simultaneous rise in the incidence of PJI. Contamination of the surgical wound and the adherence of bacteria to the surface of prosthetic component represent the initial step in the pathogenesis of PJI. The main sources of the contamination are 1) patient's own flora, 2) droplets in the operation room air, and 3) surgical gloves and instruments. Even though modern techniques have markedly reduced the degree of contamination, TJAs cannot be done in completely germ-free conditions and some degree of contamination is inevitable in all surgical procedures. However, not all contamination leads to PJI. It develops when the burden of contamination exceeds the immune threshold or the colony forming units (CFUs) and various factors contribute to a decrease in the CFU level. Surgeons should be aware of the germ burden/CFU concept and should monitor sources of contamination to maintain the germ burden below the CFU to prevent PJI.
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Affiliation(s)
- Javad Parvizi
- International Joint Center, Acibadem University Hospital, Istanbul, Turkey
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA, USA
| | - Yonghan Cha
- Department of Orthopedic Surgery, Daejeon Eulji Medical Center, Eulji University School of Medicine, Daejeon, Korea
| | - Emanuele Chisari
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA, USA
| | - Kangbaek Kim
- Kay Joint Center at Cheil Orthopaedic Hospital, Seoul, Korea
| | - Kyung-Hoi Koo
- Kay Joint Center at Cheil Orthopaedic Hospital, Seoul, Korea
- Seoul National University Bundang Hospital, Seongnam, Korea.
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Ward SA, Habibi AA, Ashkenazi I, Arshi A, Meftah M, Schwarzkopf R. Innovations in the Isolation and Treatment of Biofilms in Periprosthetic Joint Infection: A Comprehensive Review of Current and Emerging Therapies in Bone and Joint Infection Management. Orthop Clin North Am 2024; 55:171-180. [PMID: 38403364 DOI: 10.1016/j.ocl.2023.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/27/2024]
Abstract
Periprosthetic joint infections (PJIs) are a devastating complication of joint arthroplasty surgeries that are often complicated by biofilm formation. The development of biofilms makes PJI treatment challenging as they create a barrier against antibiotics and host immune responses. This review article provides an overview of the current understanding of biofilm formation, factors that contribute to their production, and the most common organisms involved in this process. This article focuses on the identification of biofilms, as well as current methodologies and emerging therapies in the management of biofilms in PJI.
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Affiliation(s)
- Spencer A Ward
- NYU Langone Orthopedic Hospital, NYU Langone Health, 301 East 17th Street, Room 1402, New York, NY 10003, USA
| | - Akram A Habibi
- NYU Langone Orthopedic Hospital, NYU Langone Health, 301 East 17th Street, Room 1402, New York, NY 10003, USA
| | - Itay Ashkenazi
- NYU Langone Orthopedic Hospital, NYU Langone Health, 301 East 17th Street, Room 1402, New York, NY 10003, USA
| | - Armin Arshi
- NYU Langone Orthopedic Hospital, NYU Langone Health, 301 East 17th Street, Room 1402, New York, NY 10003, USA
| | - Morteza Meftah
- NYU Langone Orthopedic Hospital, NYU Langone Health, 301 East 17th Street, Room 1402, New York, NY 10003, USA
| | - Ran Schwarzkopf
- NYU Langone Orthopedic Hospital, NYU Langone Health, 301 East 17th Street, Room 1402, New York, NY 10003, USA.
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Longo UG, De Salvatore S, Bandini B, Lalli A, Barillà B, Budhiparama NC, Lustig S. Debridement, antibiotics, and implant retention (DAIR) for the early prosthetic joint infection of total knee and hip arthroplasties: a systematic review. J ISAKOS 2024; 9:62-70. [PMID: 37714518 DOI: 10.1016/j.jisako.2023.09.003] [Citation(s) in RCA: 23] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2023] [Revised: 08/21/2023] [Accepted: 09/07/2023] [Indexed: 09/17/2023]
Abstract
PURPOSE Early periprosthetic joint infection (PJI) represents one of the most fearsome complications of joint replacement. No international consensus has been reached regarding the best approach for early prosthetic knee and hip infections. The aim of this updated systematic review is to assess whether debridement, antibiotics, and implant retention (DAIR) is an effective choice of treatment in early postoperative and acute hematogenous PJI. METHODS This systematic review was performed using the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. The diagnostic criteria defining a PJI, the most present pathogen, and the days between the index procedure and the onset of the PJI were extracted from the selected articles. Additionally, the mean follow-up, antibiotic regimen, and success rate of the treatment were also reported. RESULTS The articles included provided a cohort of 970 patients. Ten studies specified the joint of their cohort in PJIs regarding either hip prostheses or knee prostheses, resulting in 454 total knees and 460 total hips. The age of the patients ranged from 18 to 92 years old. Success rates for the DAIR treatments in the following cohort ranged from 55.5% up to a maximum of 90% (mean value of 71%). CONCLUSION Even though the DAIR procedure is quite limited, it is still considered an effective option for patients developing an early post-operative or acute hematogenous PJI. However, there is a lack of studies, in particular randomized control trials (RCTs), comparing DAIR with one-stage and two-stage revision protocols in the setting of early PJIs, reflecting the necessity to conduct further high-quality studies to face the burden of early PJI.
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Affiliation(s)
- Umile Giuseppe Longo
- Research Unit of Orthopaedic and Trauma Surgery, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, 00128 Roma, Italy; Research Unit of Orthopaedic and Trauma Surgery, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo, 21, 00128 Roma, Italy.
| | - Sergio De Salvatore
- Research Unit of Orthopaedic and Trauma Surgery, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, 00128 Roma, Italy; Research Unit of Orthopaedic and Trauma Surgery, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo, 21, 00128 Roma, Italy.
| | - Benedetta Bandini
- Research Unit of Orthopaedic and Trauma Surgery, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, 00128 Roma, Italy; Research Unit of Orthopaedic and Trauma Surgery, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo, 21, 00128 Roma, Italy.
| | - Alberto Lalli
- Research Unit of Orthopaedic and Trauma Surgery, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, 00128 Roma, Italy; Research Unit of Orthopaedic and Trauma Surgery, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo, 21, 00128 Roma, Italy.
| | - Bruno Barillà
- Research Unit of Orthopaedic and Trauma Surgery, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, 00128 Roma, Italy; Research Unit of Orthopaedic and Trauma Surgery, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo, 21, 00128 Roma, Italy.
| | | | - Sebastien Lustig
- Orthopaedic Department, Lyon North University Hospital, Hôpital de La Croix Rousse, Hospices Civils de Lyon, 103 Grande Rue de la Croix Rousse, 69004 Lyon, France.
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Eriksson HK, Lazarinis S, Järhult JD, Hailer NP. Early Staphylococcal Periprosthetic Joint Infection (PJI) Treated with Debridement, Antibiotics, and Implant Retention (DAIR): Inferior Outcomes in Patients with Staphylococci Resistant to Rifampicin. Antibiotics (Basel) 2023; 12:1589. [PMID: 37998791 PMCID: PMC10668653 DOI: 10.3390/antibiotics12111589] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Revised: 10/30/2023] [Accepted: 11/01/2023] [Indexed: 11/25/2023] Open
Abstract
It is unknown how rifampicin resistance in staphylococci causing a periprosthetic joint infection (PJI) affects outcomes after debridement, antibiotics, and implant retention (DAIR). We thus aimed to compare the risk of relapse in DAIR-treated early PJI caused by staphylococci with or without rifampicin resistance. In total, 81 patients affected by early PJI were included, and all patients were treated surgically with DAIR. This was repeated if needed. The endpoint of relapse-free survival was estimated using the Kaplan-Meier method, and Cox regression models were fitted to assess the risk of infection relapse for patients infected with rifampicin-resistant bacteria, adjusted for age, sex, type of joint, and type of index surgery. In patients with rifampicin-resistant staphylococci, relapse was seen in 80% after one DAIR procedure and in 70% after two DAIR procedures. In patients with rifampicin-sensitive bacteria, 51% had an infection relapse after one DAIR procedure and 33% had an infection relapse after two DAIR procedures. Patients with rifampicin-resistant staphylococcal PJI thus had an increased adjusted risk of infection relapse of 1.9 (95% CI: 1.1-3.6, p = 0.04) after one DAIR procedure compared to patients with rifampicin-sensitive bacteria and a 4.1-fold (95% CI: 1.2-14.1, p = 0.03) increase in risk of infection relapse after two DAIR procedures. Staphylococcal resistance to rifampicin is associated with inferior outcomes after DAIR. These findings suggest that DAIR may not be a useful strategy in early PJI caused by rifampicin-resistant staphylococci.
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Affiliation(s)
- Hannah K. Eriksson
- Department of Surgical Sciences, Section of Orthopaedics, Uppsala University, 751 83 Uppsala, Sweden; (S.L.); (N.P.H.)
| | - Stergios Lazarinis
- Department of Surgical Sciences, Section of Orthopaedics, Uppsala University, 751 83 Uppsala, Sweden; (S.L.); (N.P.H.)
| | - Josef D. Järhult
- Zoonosis Science Center, Department of Medical Sciences, Uppsala University, 751 83 Uppsala, Sweden;
| | - Nils P. Hailer
- Department of Surgical Sciences, Section of Orthopaedics, Uppsala University, 751 83 Uppsala, Sweden; (S.L.); (N.P.H.)
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Moran M, Patel SH, Kahlon G. Clostridium Bifermentans Infection of a Prosthetic Knee Joint in a Patient With Human Immunodeficiency Virus: A Case Report. Cureus 2023; 15:e47370. [PMID: 38021966 PMCID: PMC10657489 DOI: 10.7759/cureus.47370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Accepted: 10/19/2023] [Indexed: 12/01/2023] Open
Abstract
We reported a case of Clostridium bifermentans (C. bifermentans) infection in the prosthetic knee joint of a human immunodeficiency virus (HIV) patient, who presented with swelling, discomfort, pain, and redness in the right lower extremity. An uncommon yet potentially lethal human illness triggered by C. bifermentans. Foreign material is especially susceptible to local infection because of the local immunodeficiency close to the implant. Intravenous (IV) cefepime and IV ampicillin/sulbactam were administered to the patient. The idea of performing surgery to eradicate the infection was under consideration, but its necessity remained uncertain, and the decision to proceed with surgery had not been finalized.
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Affiliation(s)
- Matthew Moran
- Internal Medicine, Einstein Medical Center Philadelphia, Philadelphia, USA
| | - Saloni H Patel
- Internal Medicine, Global Remote Research Scholars Program, Philadelphia, Ahmedabad, IND
| | - Gunjan Kahlon
- Internal Medicine, Einstein Medical Center Philadelphia, Philadelphia, USA
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11
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Chong YY, Chan PK, Chan VWK, Cheung A, Luk MH, Cheung MH, Fu H, Chiu KY. Application of machine learning in the prevention of periprosthetic joint infection following total knee arthroplasty: a systematic review. ARTHROPLASTY 2023; 5:38. [PMID: 37316877 PMCID: PMC10265805 DOI: 10.1186/s42836-023-00195-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Accepted: 05/11/2023] [Indexed: 06/16/2023] Open
Abstract
BACKGROUND Machine learning is a promising and powerful technology with increasing use in orthopedics. Periprosthetic joint infection following total knee arthroplasty results in increased morbidity and mortality. This systematic review investigated the use of machine learning in preventing periprosthetic joint infection. METHODS A systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. PubMed was searched in November 2022. All studies that investigated the clinical applications of machine learning in the prevention of periprosthetic joint infection following total knee arthroplasty were included. Non-English studies, studies with no full text available, studies focusing on non-clinical applications of machine learning, reviews and meta-analyses were excluded. For each included study, its characteristics, machine learning applications, algorithms, statistical performances, strengths and limitations were summarized. Limitations of the current machine learning applications and the studies, including their 'black box' nature, overfitting, the requirement of a large dataset, the lack of external validation, and their retrospective nature were identified. RESULTS Eleven studies were included in the final analysis. Machine learning applications in the prevention of periprosthetic joint infection were divided into four categories: prediction, diagnosis, antibiotic application and prognosis. CONCLUSION Machine learning may be a favorable alternative to manual methods in the prevention of periprosthetic joint infection following total knee arthroplasty. It aids in preoperative health optimization, preoperative surgical planning, the early diagnosis of infection, the early application of suitable antibiotics, and the prediction of clinical outcomes. Future research is warranted to resolve the current limitations and bring machine learning into clinical settings.
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Affiliation(s)
- Yuk Yee Chong
- Department of Orthopaedics and Traumatology, School of Clinical Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Ping Keung Chan
- Department of Orthopaedics and Traumatology, School of Clinical Medicine, The University of Hong Kong, Hong Kong SAR, China.
| | - Vincent Wai Kwan Chan
- Department of Orthopaedics and Traumatology, Queen Mary Hospital, Hong Kong SAR, China
| | - Amy Cheung
- Department of Orthopaedics and Traumatology, Queen Mary Hospital, Hong Kong SAR, China
| | - Michelle Hilda Luk
- Department of Orthopaedics and Traumatology, Queen Mary Hospital, Hong Kong SAR, China
| | - Man Hong Cheung
- Department of Orthopaedics and Traumatology, School of Clinical Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Henry Fu
- Department of Orthopaedics and Traumatology, School of Clinical Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Kwong Yuen Chiu
- Department of Orthopaedics and Traumatology, School of Clinical Medicine, The University of Hong Kong, Hong Kong SAR, China
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Okafor CE, Nghiem S, Byrnes J. Is 2-Stage Septic Revision Worth the Money? A Cost-Utility Analysis of a 1-Stage Versus 2-Stage Septic Revision of Total Knee Arthroplasty. J Arthroplasty 2023; 38:347-354. [PMID: 36154866 DOI: 10.1016/j.arth.2022.09.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Revised: 08/23/2022] [Accepted: 09/05/2022] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Two-stage exchange arthroplasty remains the gold standard for the management of prosthetic joint infection (PJI) of the knee, but several studies have demonstrated that 1-stage exchange is as effective as 2-stage exchange. This study aimed to support decision-making via an economic evaluation of 1-stage compared to 2-stage exchange for total knee arthroplasty septic revision in patients who did not have compelling indication PJI (ie, Methicillin-resistant Staphylococcus aureus, multiorganism, systemic sepsis, comorbidities, culture negative, resistant organism, and immunocompromised) to undergo a 2-stage exchange. METHODS A cost-utility analysis was performed using a Markov cohort model from the health care provider perspective using Australia data. One-stage septic knee revisions were compared with 2-stage exchange procedures for chronic PJI using a patient-lifetime horizon. Health outcomes were expressed as quality-adjusted life-years (QALY), whereas costs were presented in 2020 Australian dollars. Sensitivity analyses, population expected values of perfect information, and the perfect information for parameters (EVPPI) were assessed to estimate the opportunity costs surrounding the decision made at a willingness-to-pay threshold of $50,000 per QALY. RESULTS The incremental cost-effectiveness ratio of 2-stage exchange compared with 1-stage exchange was $231,000 per QALY, with 98.5% of the probabilistic sensitivity simulations above the willingness-to-pay threshold. The population expected value of perfect information was $882,000, whereas the expected value of perfect information for parameters for the "cost parameters" was $207,000. CONCLUSION The adoption of 1-stage septic knee revision is the optimal choice for patients who have a PJI and who do not have a compelling need for a 2-stage exchange arthroplasty. One-stage exchange for PJI should be advocated in patients who meet the eligibility criteria.
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Affiliation(s)
- Charles E Okafor
- Centre for Applied Health Economics, School of Medicine and Dentistry, Griffith University, Queensland, Australia; Menzies Health Institute, Griffith University, Queensland, Australia
| | - Son Nghiem
- Department of Health Services, Research and Policy, Australian National University, Canberra, Australia
| | - Joshua Byrnes
- Centre for Applied Health Economics, School of Medicine and Dentistry, Griffith University, Queensland, Australia; Menzies Health Institute, Griffith University, Queensland, Australia
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13
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Vasso M, Capasso L, Corona K, Pola E, Toro G, Schiavone Panni A. Periprosthetic knee infection: treatment options. Orthop Rev (Pavia) 2022; 14:37537. [PMID: 36349351 PMCID: PMC9635989 DOI: 10.52965/001c.37537] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/26/2024] Open
Abstract
Infection is one of the most catastrophic complication following total knee arthroplasty (TKA) and represents the second most common cause of TKA failure. Treatment of a patient with periprosthetic joint infection (PJI) could require often costly and prolonged hospital stays, weeks or months of antibiotic therapy, and multiple surgical procedures. The best management is still highly debating, whereas many treatment options are available. These include suppressive antibiotics, arthroscopic irrigation and debridement, open debridement with insert exchange, single-stage reimplantation and two-stage reimplantation. The choice of the treatment depends on many variables, including integrity of implant, timing of the infection, host factors (age, health, immunologic status), virulence of the infecting organism and wishes of the patient. The aim of this review is to provide a comprehensive understaning of the different options for knee PJIs.
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Affiliation(s)
- Michele Vasso
- Multidisciplinary Department of Medicine for Surgery and Orthodontics, University of Campania "Luigi Vanvitelli" - Naples (Italy)
| | - Luigi Capasso
- San Giovanni Calibita "Fatebenefratelli - Isola Tiberina" Hospital - Rome (Italy)
| | - Katia Corona
- Department of Medicine and Health Sciences "Vincenzo Tiberio", University of Molise, Campobasso (Italy)
| | - Enrico Pola
- Multidisciplinary Department of Medicine for Surgery and Orthodontics, University of Campania "Luigi Vanvitelli" - Naples (Italy)
| | - Giuseppe Toro
- Multidisciplinary Department of Medicine for Surgery and Orthodontics, University of Campania "Luigi Vanvitelli" - Naples (Italy)
| | - Alfredo Schiavone Panni
- Multidisciplinary Department of Medicine for Surgery and Orthodontics, University of Campania "Luigi Vanvitelli" - Naples (Italy)
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14
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Barbera JP, Xiao RC, Williams CS, Poeran J, Moucha CS, Chen DD, Hayden BL. Treatment patterns and failure rates associated with prosthetic joint infection in unicompartmental knee arthroplasty: A systematic review. J Orthop 2022; 34:288-294. [PMID: 36158037 PMCID: PMC9493286 DOI: 10.1016/j.jor.2022.09.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2022] [Accepted: 09/10/2022] [Indexed: 10/31/2022] Open
Abstract
Background Prosthetic joint infection (PJI) following unicompartmental knee arthroplasty (UKA) is a rare but challenging complication. A paucity of literature exists regarding the management of PJI in UKA. This systematic review aims to assess current treatment patterns in UKA PJI and analyze the failure rates associated with treatment. Methods PubMed, Scopus, and EMBASE were systematically searched for studies that presented cases of PJI following UKA. Data regarding study design, country of publication, index procedure type, diagnosis of PJI, number and incidence of PJI, timing of PJI (acute versus chronic), treatment, and outcomes were recorded. Failure rates in acute and chronic PJI as well as total failure rates were analyzed. Results Sixteen articles were identified that met inclusion criteria. These included 97 PJI cases (37 acute, 58 chronic, 2 unknown timing); incidence across all studies of 0.80%. The most common treatment for all PJI cases was debridement, antibiotics, and implant retention (DAIR) (40.2%), followed by two-stage conversion to total knee arthroplasty (TKA) (33.0%), one-stage conversion to TKA (23.7%), and one-stage exchange UKA (3.1%). There were no significant differences in failure rates across procedures for acute, chronic or overall PJI management (p > 0.05 for all). Conclusion This systematic review found relatively few studies reporting on PJI after UKA compared to the available TKA evidence. Further research is warranted to better elucidate the most appropriate treatment of PJI after UKA in both the acute and chronic setting along with risk factors for failure.
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Affiliation(s)
- Joseph P. Barbera
- Department of Orthopaedic Surgery, Mount Sinai Health System, New York, NY, USA
| | - Ryan C. Xiao
- Department of Orthopaedic Surgery, Mount Sinai Health System, New York, NY, USA
| | | | - Jashvant Poeran
- Department of Orthopaedic Surgery, Mount Sinai Health System, New York, NY, USA
| | - Calin S. Moucha
- Department of Orthopaedic Surgery, Mount Sinai Health System, New York, NY, USA
| | - Darwin D. Chen
- Department of Orthopaedic Surgery, Mount Sinai Health System, New York, NY, USA
| | - Brett L. Hayden
- Department of Orthopaedic Surgery, Mount Sinai Health System, New York, NY, USA
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15
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Mian HM, Lyons JG, Perrin J, Froehle AW, Krishnamurthy AB. A review of current practices in periprosthetic joint infection debridement and revision arthroplasty. ARTHROPLASTY 2022; 4:31. [PMID: 36045436 PMCID: PMC9434893 DOI: 10.1186/s42836-022-00136-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Accepted: 06/09/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Periprosthetic joint infection remains a significant challenge for arthroplasty surgeons globally. Over the last few decades, there has been much advancement in terms of treatment and diagnosis, however, the fight rages on. As management of periprosthetic joint infections continues to evolve, it is critical to reflect back on current debridement practices to establish common ground as well as identify areas for future research and improvement. BODY: In order to understand the debridement techniques of periprosthetic joint infections, one must also understand how to diagnose a periprosthetic joint infection. Multiple definitions have been elucidated over the years with no single consensus established but rather sets of criteria. Once a diagnosis has been established the decision of debridement method becomes whether to proceed with single vs two-stage revision based on the probability of infection as well as individual patient factors. After much study, two-stage revision has emerged as the gold standard in the management of periprosthetic infections but single-stage remains prominent with further and further research. CONCLUSION Despite decades of data, there is no single treatment algorithm for periprosthetic joint infections and subsequent debridement technique. Our review touches on the goals of debridement while providing a perspective as to diagnosis and the particulars of how intraoperative factors such as intraarticular irrigation can play pivotal roles in infection eradication. By providing a perspective on current debridement practices, we hope to encourage future study and debate on how to address periprosthetic joint infections best.
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Affiliation(s)
- Humza M Mian
- Department of Orthopaedic Surgery, Wright State University Boonshoft School of Medicine, 30 E. Apple St. Suite #2200, Dayton, OH, 45409, USA.
| | - Joseph G Lyons
- Department of Orthopaedic Surgery, Wright State University Boonshoft School of Medicine, 30 E. Apple St. Suite #2200, Dayton, OH, 45409, USA
| | - Joshua Perrin
- Wright State University Boonshoft School of Medicine, Wright State Physicians Bldg, 725 University Blvd., Dayton, OH, 45435, USA
| | - Andrew W Froehle
- Department of Orthopaedic Surgery, Wright State University Boonshoft School of Medicine, 30 E. Apple St. Suite #2200, Dayton, OH, 45409, USA
- School of Nursing, Kinesiology and Health, Wright State University, 3640 Colonel Glenn Hwy., Dayton, OH, 45435, USA
| | - Anil B Krishnamurthy
- Department of Orthopaedic Surgery, Wright State University Boonshoft School of Medicine, 30 E. Apple St. Suite #2200, Dayton, OH, 45409, USA
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16
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Visperas A, Santana D, Klika AK, Higuera‐Rueda CA, Piuzzi NS. Current treatments for biofilm-associated periprosthetic joint infection and new potential strategies. J Orthop Res 2022; 40:1477-1491. [PMID: 35437846 PMCID: PMC9322555 DOI: 10.1002/jor.25345] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Revised: 04/11/2022] [Accepted: 04/16/2022] [Indexed: 02/04/2023]
Abstract
Periprosthetic joint infection (PJI) remains a devastating complication after total joint arthroplasty. Bacteria involved in these infections are notorious for adhering to foreign implanted surfaces and generating a biofilm matrix. These biofilms protect the bacteria from antibiotic treatment and the immune system making eradication difficult. Current treatment strategies including debridement, antibiotics, and implant retention, and one- and two-stage revisions still present a relatively high overall failure rate. One of the main shortcomings that has been associated with this high failure rate is the lack of a robust approach to treating bacterial biofilm. Therefore, in this review, we will highlight new strategies that have the potential to combat PJI by targeting biofilm integrity, therefore giving antibiotics and the immune system access to the internal network of the biofilm structure. This combination antibiofilm/antibiotic therapy may be a new strategy for PJI treatment while promoting implant retention.
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Affiliation(s)
- Anabelle Visperas
- Department of Orthopaedic SurgeryCleveland Clinic FoundationClevelandOhioUSA
| | - Daniel Santana
- Department of Orthopaedic SurgeryCleveland Clinic FoundationClevelandOhioUSA
- Cleveland Clinic Lerner College of MedicineCase Western Reserve UniversityClevelandOhioUSA
| | - Alison K. Klika
- Department of Orthopaedic SurgeryCleveland Clinic FoundationClevelandOhioUSA
| | | | - Nicolas S. Piuzzi
- Department of Orthopaedic SurgeryCleveland Clinic FoundationClevelandOhioUSA
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17
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Smith EL, Dugdale EM, McAlpine K, Habibi AA, Niu R, Baratz MD, Freccero DM. Bias Does Not Exist in Treating Knee Periprosthetic Joint Infection Among Patients With Substance Use Disorder. Orthopedics 2021; 44:e385-e389. [PMID: 34039201 DOI: 10.3928/01477447-20210414-10] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Debridement, antibiotics with implant retention (DAIR), and 2-stage revision are standard surgical interventions for treating knee periprosthetic joint infection (PJI). Patients with substance use disorder (SUD), especially addictive drug use disorder (DUD), have been shown to receive inferior medical care in many specialties compared with nonusers. The authors identified patients with a diagnosis of PJI after knee arthroplasty who received either DAIR or 2-stage revision with the Nationwide Inpatient Sample (NIS) database from 2010 to 2014. Patients were stratified into 2 groups, patients with DUD and nonusers, based on Diagnostic and Statistical Manual of Mental Disorders, 5th Edition, criteria. Descriptive analysis was conducted to show the national trend for knee PJI treatment among the 2 patient groups. Multivariate logistic regression was used to compare the prevalence of DAIR and 2-stage revision between these 2 groups, adjusted for likely confounders, including age, sex, income, race, and comorbidities. Among the 11,331 patients with knee infection, 139 (1.23%) had DUD. Compared with nonusers, patients with DUD were significantly younger (P<.001), had more chronic conditions (P<.001), and were predominantly in lower income quartiles (P=.046). The 2 groups did not differ in sex and race (P=.072 and P=.091, respectively). The authors found that 30.22% of patients with DUD and 36.36% of nonusers received DAIR. The difference in these proportions was not statistically significant (P=.135). The results did not change after adjustment for confounding factors (P=.509). The findings suggested that bias does not exist among orthopedic surgeons who choose DAIR or 2-stage revision for knee PJI among patients with DUD. [Orthopedics. 2021;44(3):e385-e389.].
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18
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Chaiyakit P, Meknavin S, Hongku N, Onklin I. Debridement, antibiotics, and implant retention combined with direct intra-articular antibiotic infusion in patients with acute hematogenous periprosthetic joint infection of the knee. BMC Musculoskelet Disord 2021; 22:557. [PMID: 34144684 PMCID: PMC8214261 DOI: 10.1186/s12891-021-04451-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Accepted: 06/04/2021] [Indexed: 12/03/2022] Open
Abstract
Background Debridement, antibiotics, and implant retention (DAIR) is the recommended treatment for acute hematogenous periprosthetic joint infection (PJI) after total knee arthroplasty (TKA). However, DAIR is associated with a high percentage of unsuccessful outcomes. Since 2007, direct intra-articular antibiotic infusion, which can provide a high concentration of intra-articular antibiotic, has been used in combination with DAIR to improve treatment outcomes among patients in our institution. This study aimed to assess the outcomes of DAIR combined with direct intra-articular antibiotic infusion in patients who presented with acute hematogenous PJI after TKA. Methods We reviewed the data of all patients diagnosed with acute hematogenous PJI after primary TKA (from 2008 to 2015) who received DAIR combined with direct intra-articular antibiotic infusion. Results In total, 15 knees in 12 patients were semi-urgently treated with this method. The mean follow-up time was 93.3 (minimum: 56) months, and the longest follow-up time was 11 years. Two patients (n = 3 knees) had a well-functioning, non-infected prosthesis 6 and 10 years after the procedure. Two patients (n = 2 knees) had re-infection 2 and 5 years after surgery, and they required two-stage revision. None of the patients were lost to follow-up. Finally, 13 (86.6%) of 15 infected knees were successfully treated with this method. Conclusions DAIR combined with direct intra-articular antibiotic infusion is an effective treatment for acute hematogenous PJI after TKA.
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Affiliation(s)
- Pruk Chaiyakit
- Department of Orthopedics, Faculty of Medicine, Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand.
| | - Surapoj Meknavin
- Department of Orthopedics, Faculty of Medicine, Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand
| | - Natthapong Hongku
- Department of Orthopedics, Faculty of Medicine, Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand
| | - Ittiwat Onklin
- Department of Orthopedics, Faculty of Medicine, Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand
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Does Early Debridement, Antibiotic Therapy and Implant Retention (DAIR) have a Role in Managing Periprosthetic Joint Infection of the Knee in Indian Scenario: A Retrospective Analysis of Outcomes. Indian J Orthop 2021; 55:961-966. [PMID: 34194654 PMCID: PMC8192604 DOI: 10.1007/s43465-020-00308-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Accepted: 11/02/2020] [Indexed: 02/04/2023]
Abstract
PURPOSE To report outcomes of Debridement, Antibiotic therapy and Implant Retention (DAIR) for periprosthetic knee joint infections (PJI) in the Indian population and to study factors influencing outcomes. METHODS This was a Retrospective study of 80 cases of acute PJI after total knee arthroplasty who were treated by DAIR, within 2 weeks of onset of infection. A standardised institutional management protocol was applied to all cases. Patients were followed up for a minimum 1 year. Outcomes of DAIR were classified as successful or unsuccessful based on resolution or persistence of infection, and subsequent requirement of revision surgery. Influence of factors, like comorbidities, culture status and microbiological characteristics of causative organism, on outcomes was assessed. RESULTS Overall 55 patients (68.75%) had successful eradication of infection after DAIR. 27 (33.7%) patients were culture negative and 53 (66.2%) patients grew organisms on culture. There was no statistically significant difference in outcomes (p = 0.082) between culture-positive cases (69.8% success rate) and (66.7% success rate) in culture negative cases. Furthermore, no difference in outcomes was observed in culture-positive patients between those who grew Gram-positive organisms versus Gram-negative organisms (p = 0.398) Similarly, patient comorbidities did not significantly alter the outcomes after DAIR (p = 0.732). CONCLUSION Our study demonstrates that early DAIR within 2 weeks of onset of infection using a standard protocol during surgery and postoperatively can result in good outcomes. Patient comorbidities, culture status (positive versus negative), Gram staining characteristics of organisms and the identity of pathogenic bacteria did not influence outcomes of DAIR for acute PJI.
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20
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Davis B, Ford A, Holzmeister AM, Rees HW, Belich PD. Management of Periprosthetic Hip and Knee Joint Infections With a Known Sinus Tract-A Single-Center Experience. Arthroplast Today 2021; 8:124-127. [PMID: 33748371 PMCID: PMC7966922 DOI: 10.1016/j.artd.2021.02.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2020] [Revised: 01/31/2021] [Accepted: 02/14/2021] [Indexed: 12/20/2022] Open
Abstract
Background Prosthetic joint infection (PJI) is a serious complication after total joint arthroplasty (TJA). A sinus tract communicating with a prosthetic joint is a major criterion defining PJI. Despite this fact, many patients presenting with a draining sinus tract undergo invasive procedures before initiation of two-stage revision arthroplasty. We hypothesized that many patients undergo nondefinitive procedures to treat the sinus tract, rather than undergoing definitive treatment of infection with two-stage revision. Methods A retrospective review of all cases of two-stage revision arthroplasty at Loyola University Medical Center between January 2004 and May 2018 was performed. Patients with infected TJA and periprosthetic sinus tract were included. Records were queried for laboratory values and prior procedures. Results We identified 160 patients who underwent two-stage revision for infection over the 14-year period. Of the 160 patients, 25 had a documented periprosthetic sinus tract before initiation of definitive revision arthroplasty and were included. Eleven (44.0%) had one or more procedures including interventional radiology drain placement, local wound care, or formal irrigation and debridement before definitive treatment. Forty-five percent of patients that underwent nondefinitive procedures before definitive surgery had either an erythrocyte sedimentation rate or C-reactive protein at normal or near-normal levels. Conclusion Many arthroplasty patients presenting with periprosthetic sinus tracts undergo nondefinitive procedures before definitive treatment. Inherent surgical risks of these procedures can increase the overall morbidity and mortality of these patients. Further effort is needed to educate surgeons regarding management of sinus tracts after TJA.
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Affiliation(s)
| | | | | | - Harold W. Rees
- Corresponding author. 2160 South First Avenue, Maywood, IL 60153. Tel.: 1-708-216-1274.
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21
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Klemt C, Tirumala V, Oganesyan R, Xiong L, van den Kieboom J, Kwon YM. Single-Stage Revision of the Infected Total Knee Arthroplasty Is Associated With Improved Functional Outcomes: A Propensity Score-Matched Cohort Study. J Arthroplasty 2021; 36:298-304. [PMID: 32778418 DOI: 10.1016/j.arth.2020.07.012] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Revised: 06/30/2020] [Accepted: 07/06/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Single-stage revision is an alternative to the standard 2-stage revision, potentially minimizing morbidities and improving functional outcomes. This study aimed at comparing single-stage and 2-stage revision total knee arthroplasty (TKA) for chronic periprosthetic joint infection (PJI) with regard to patient-reported outcome measures (PROMs) and complication rates. METHODS A total of 185 consecutive revision TKA patients for chronic PJI with complete preoperative and postoperative PROMs were investigated. A total of 44 patients with single-stage revision TKA were matched to 88 patients following 2-stage revision TKA using propensity score matching, yielding a total of 132 propensity score-matched patients for analysis. Patient demographics and clinical information including reinfection and readmission rates were evaluated. RESULTS There was no significant difference in preoperative PROMs between propensity score-matched single-stage and 2-stage revision TKA cohorts. Postoperatively, significantly higher PROMs for single-stage revision TKA were observed for Knee disability and Osteoarthritis Outcome Score physical function (62.2 vs 51.9, P < .01), physical function short form 10A (42.8 vs 38.1, P < .01), PROMIS SF Physical (44.8 vs 41.0, P = .01), and PROMIS SF Mental (50.5 vs 47.1, P = .02). There was no difference between propensity score-matched single-stage and 2-stage revision TKA cohorts for clinical outcomes including reinfection rates (25.0% vs 27.2%, P = .78) and 90-day readmission rates (22.7% vs 25.0%, P = .77). CONCLUSION This study illustrated that single-stage revision TKA for chronic PJI may be associated with superior patient-reported outcomes compared to 2-stage revision for the infected TKA using a variety of PROMs. Improved PROMs were not accompanied by differences in complication rates between both cohorts, suggesting that single-stage revision TKA may provide an effective alternative to 2-stage revision in patients with chronic TKA PJI.
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Affiliation(s)
- Christian Klemt
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School
| | | | - Ruben Oganesyan
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School
| | - Liang Xiong
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School
| | - Janna van den Kieboom
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School
| | - Young-Min Kwon
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School
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Lazic I, Scheele C, Pohlig F, von Eisenhart-Rothe R, Suren C. Treatment options in PJI - is two-stage still gold standard? J Orthop 2021; 23:180-184. [PMID: 33551610 PMCID: PMC7848725 DOI: 10.1016/j.jor.2020.12.021] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2020] [Accepted: 12/08/2020] [Indexed: 02/07/2023] Open
Abstract
Total knee arthroplasty (TKA) is a successful treatment for osteoarthritis with good clinical outcomes 1,2. Periprosthetic joint infection (PJI) in TKA has a low incidence between 0.5 and 3% but it is nevertheless one of the most dreadful complications 3-6. Two-staged revisions are considered to be the gold standard for revision in chronic PJI with infection eradication rates of over 90% 7. Recently, similar infection eradication rates after one-staged revision arthroplasty have been reported 8-10, raising the question whether the two-staged approach can still be considered the gold standard. We therefore performed a literature review to analyse the correlation of one-staged and two-staged TKA revisions with recurrent infection rates and functional outcomes. Studies concerning PJI treated by one- or two-staged revision published between 2000 and 2020 were retrieved by searching the databases PubMed/Medline and the Cochrane Database of Systematic Reviews. 29 studies were included in this qualitative synthesis. Mean follow-up was at 4.9 ± 2.6 years. The mean infection eradication rate after one-staged revision vs. two-staged revision in TKA was 87 ± 8.8% vs. 83 ± 11.7%. The functional outcome measured by the mean Knee Society Score (KSS) of one-staged revision vs. two-staged revision in TKA was 80 ± 5.9 vs. 80 ± 3.9 points. One-staged revision arthroplasty in TKA appears to have similar infection eradication rates and functional outcomes compared to two-staged revision arthroplasty. However, these results should be interpreted with caution, since selection bias may have played a significant role. Several criteria to guide the surgeon in selecting the appropriate procedure have been described, but the current recommendations are based on poor evidence as randomized controlled trials are lacking 11,12. Two-staged revision remains a successful treatment option which is rightly the gold standard. However, there is a variety of cases in which one-staged revision is a viable alternative, where similar success rates and functional outcome can be expected 7,13.
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Affiliation(s)
- Igor Lazic
- Department of Orthopedics and Sports Orthopedics, Klinikum Rechts der Isar; Technical University of Munich (TUM), Ismaningerstr. 22, 81675, Munich, Germany
| | - Christian Scheele
- Department of Orthopedics and Sports Orthopedics, Klinikum Rechts der Isar; Technical University of Munich (TUM), Ismaningerstr. 22, 81675, Munich, Germany
| | - Florian Pohlig
- Department of Orthopedics and Sports Orthopedics, Klinikum Rechts der Isar; Technical University of Munich (TUM), Ismaningerstr. 22, 81675, Munich, Germany
| | - Rüdiger von Eisenhart-Rothe
- Department of Orthopedics and Sports Orthopedics, Klinikum Rechts der Isar; Technical University of Munich (TUM), Ismaningerstr. 22, 81675, Munich, Germany
| | - Christian Suren
- Department of Orthopedics and Sports Orthopedics, Klinikum Rechts der Isar; Technical University of Munich (TUM), Ismaningerstr. 22, 81675, Munich, Germany
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McQuivey KS, Bingham J, Chung A, Clarke H, Schwartz A, Pollock JR, Beauchamp C, Spangehl MJ. The Double DAIR: A 2-Stage Debridement with Prosthesis-Retention Protocol for Acute Periprosthetic Joint Infections. JBJS Essent Surg Tech 2021; 11:e19.00071-e19.00071. [PMID: 34123550 PMCID: PMC8189597 DOI: 10.2106/jbjs.st.19.00071] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Debridement and implant retention (DAIR) has variable success as a treatment for acute periprosthetic joint infection (PJI), with generally poor outcomes reported in the literature1. Because of the unacceptably high failure rate of DAIR, we implemented a 2-stage debridement protocol that includes the use of high-dose antibiotic beads between stages for the treatment of acute PJI. In 2 previous studies, with an average follow-up of 3.5 years in each study, we reported overall infection-control rates of 87% and 90%2,3. DESCRIPTION Following exposure of the joint, cultures are obtained, and all modular components are removed, scrubbed, and soaked in an antiseptic solution. A thorough irrigation and debridement with complete synovectomy is performed, followed by temporary reinsertion of the original modular parts. High-dose antibiotic cement beads are inserted into the joint, and the joint is closed. Approximately 5 to 6 days later, a second debridement is performed, the beads are removed, and the new modular, sterile components are implanted. The patient is placed on a course of intravenous and, later, oral antibiotics, in addition to a standard postoperative rehabilitation protocol. ALTERNATIVES Long-term suppressive antibiotic therapy.One-stage DAIR.One-stage exchange arthroplasty.Two-stage exchange arthroplasty.Resection arthroplasty.Amputation. RATIONALE The treatment of acute PJI has historically consisted of a single irrigation and debridement, with exchange of modular parts and retention of the components, followed by intravenous antibiotic therapy. Despite having lower rates of patient morbidity compared with a 2-stage exchange arthroplasty, this more traditional procedure also has a higher rate of failure, with reported rates as high as 60% to 84%4-12. The utility of component retention continues to be a topic of debate13. Alternatives to component retention include both 1- and 2-stage exchange procedures. Although these modalities offer potentially higher rates of infection control, they are associated with substantial patient morbidity, particularly in patients with well-fixed implants14-16. Furthermore, exchange procedures may result in substantial iatrogenic bone loss, which can be problematic in revision total joint arthroplasty procedures, in which bone stock may already be limited. The double-DAIR protocol offers infection-control rates that are comparable with those of component-exchange procedures, but with the lower patient morbidity associated with component-retention procedures. Furthermore, the double-DAIR procedure provides the added benefit of retaining important bone stock. EXPECTED OUTCOMES The success rate for the double-DAIR procedure has been reproducible, with infection-control rates of 87% and 90% reported in 2 studies from a single cohort at our institution2,3. These rates represent a substantial improvement compared with a single irrigation and debridement1, and are on par with those reported for 2-stage exchange arthroplasty procedures17-21. The infection-control rates of the double-DAIR procedure did not significantly vary depending on whether infection occurred following a total knee or total hip arthroplasty. However, not surprisingly, patients who underwent debridement following a revision procedure had a lower rate of success (77.1% successful infection control) compared with patients debrided following a primary procedure (93.8% successful infection control). We could not demonstrate an association with organism and success or failure of treatment.Although not significant, there was a trend toward an association between the time from symptom onset to initial treatment and infection control (p = 0.07)2. Patients with successful infection control underwent the initial debridement an average of 6.2 days after symptom onset, compared with 10.7 days in patients in whom treatment had failed. Several other studies have demonstrated that successful infection control is associated with earlier initial irrigation and debridement22-27. We strongly support that, in the setting of confirmed acute PJI, prompt initiation of treatment optimizes the chances for successful infection control. IMPORTANT TIPS Thorough debridement is key to successful infection control of infection.Antibiotic-loaded bone cement has repeatedly been demonstrated to be safe, and we recommend its use28-31.Extended oral antibiotics following debridement with component retention can increase infection-free survivorship32.
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Affiliation(s)
- Kade S. McQuivey
- Department of Orthopaedic Surgery, Mayo Clinic, Phoenix, Arizona
| | - Joshua Bingham
- Department of Orthopaedic Surgery, Mayo Clinic, Phoenix, Arizona
| | - Andrew Chung
- Department of Orthopaedic Surgery, Mayo Clinic, Phoenix, Arizona
| | - Henry Clarke
- Department of Orthopaedic Surgery, Mayo Clinic, Phoenix, Arizona
| | - Adam Schwartz
- Department of Orthopaedic Surgery, Mayo Clinic, Phoenix, Arizona
| | | | | | - Mark J. Spangehl
- Department of Orthopaedic Surgery, Mayo Clinic, Phoenix, Arizona
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24
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Lum ZC, Holland CT, Meehan JP. Systematic review of single stage revision for prosthetic joint infection. World J Orthop 2020; 11:559-572. [PMID: 33362992 PMCID: PMC7745489 DOI: 10.5312/wjo.v11.i12.559] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2020] [Revised: 10/20/2020] [Accepted: 11/29/2020] [Indexed: 02/06/2023] Open
Abstract
While advanced technology, increased medical knowledge and improved surgical technique has improved patient outcomes in total joint arthroplasty, prosthetic joint infection still remains one of the leading causes of increased healthcare costs, medical resources and societal burdens in orthopaedic care. Two stage arthroplasty revision remains the gold standard for treatment of prosthetic joint infection. Proponents of single stage revision arthroplasty for infection argue that it results in lower healthcare costs while improving patient reported functional outcomes and with equivalent success rates. Here we review the history of single stage revision arthroplasty, discuss the key principles, highlight the indications and contraindications, and review the reported outcomes with a focus on future developments of single stage revision arthroplasty for hip and knee periprosthetic joint infections.
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Affiliation(s)
- Zachary C Lum
- Department of Orthopaedic Surgery, Davis Medical Center, University of California, Sacramento, CA 95817, United States
| | - Christopher Thomas Holland
- Department of Orthopaedics, University of California, Davis Medical Center, Sacramento, CA 95817, United States
| | - John P Meehan
- Department of Orthopaedics, University of California, Davis Medical Center, Sacramento, CA 95817, United States
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25
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Open Debridement is Superior to Arthroscopic Debridement for the Infected Total Knee Arthroplasty. J Arthroplasty 2020; 35:3716-3723. [PMID: 32713724 DOI: 10.1016/j.arth.2020.06.039] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Revised: 06/08/2020] [Accepted: 06/15/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Acutely infected total knee arthroplasty (TKA) is commonly treated with debridement, antibiotics, and implant retention (DAIR). There are no direct comparative studies to determine whether debridement should be performed open or arthroscopically for infected TKA. The aim of this study is to compare the outcomes of open vs arthroscopic debridement of infected TKAs. METHODS All patients at a university teaching hospital with an infected TKA treated with DAIR between 2002 and 2017 were analyzed. The primary outcome was successful treatment defined using international consensus criteria. Secondary outcomes included antibiotic suppression, prosthesis retention, mortality, postoperative range of motion, and length of stay. Clinical, laboratory, surgical, and antibiotic treatment data were collected. Propensity score matching was performed to control for selection bias. RESULTS DAIR was used in 141 patients. The initial DAIR procedure was open for 96 patients and arthroscopic for 45 patients. The success rate was 29% greater for open DAIR (45% open vs 16% arthroscopic; P < .001). After propensity score matching, this benefit was estimated to be 36% (95% confidence interval, 22%-50%; P < .0001). When those on antibiotic suppression were also considered successfully treated, open DAIR was still superior by 34% (95% confidence interval, 18%-51%; P < .0001). CONCLUSION For infected TKA, open DAIR is a more successful index procedure compared with arthroscopic DAIR. Open DAIR remained more successful even when antibiotic suppression is considered successful treatment.
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26
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A tri-component knee plug for the 3rd generation of autologous chondrocyte implantation. Sci Rep 2020; 10:17048. [PMID: 33046760 PMCID: PMC7550599 DOI: 10.1038/s41598-020-73863-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2020] [Accepted: 09/10/2020] [Indexed: 02/01/2023] Open
Abstract
Here, we report a newly designed knee plug to be used in the 3rd generation of Autologous Chondrocyte Implantation (ACI) in order to heal the damaged knee cartilage. It is composed of three components: The first component (Bone Portion) is a 3D printed hard scaffold with large pores (~ 850 µm), made by hydroxyapatite and β-tricalcium phosphate to accommodate the bony parts underneath the knee cartilage. It is a cylinder with a diameter of 20 mm and height of 7.5 mm, with a slight dome shape on top. The plug also comprises a Cartilage Portion (component 2) which is a 3D printed gelatin/elastin/sodium-hyaluronate soft thick porous membrane with large pores to accommodate chondrocytes. Cartilage Portion is secured on top of the Bone Portion using mechanical interlocking by designing specific knobs in the 3D printed construct of the Cartilage Portion. The third component of the plug (Film) is a stitchable permeable membrane consisting of polycaprolactone (PCL) on top of the Cartilage Portion to facilitate sliding of the knee joint and to hold the entire plug in place while allowing nutrients delivery to the Cartilage Portion. The PCL Film is prepared using a combination of film casting and sacrificial material leaching with a pore size of 10 µm. It is surface modified to have specific affinity with the Cartilage Portion. The detailed design criteria and production process of this plug is presented in this report. Full in vitro analyses have been performed, which indicate the compatibility of the different components of the plug relative to their expected functions.
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27
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Abstract
Essential treatment methods for infected knee arthroplasty involve DAIR (debridement, antibiotics, and implant retention), and one and two-stage exchange arthroplasty.Aggressive debridement with the removal of all avascular tissues and foreign materials that contain biofilm is mandatory for all surgical treatment modalities.DAIR is a viable option with an acceptable success rate and can be used as a first surgical procedure for patients who have a well-fixed, functioning prosthesis without a sinus tract for acute-early or late-hematogenous acute infections with no more than four weeks (most favourable being < seven days) of symptoms. Surgeons must focus on the isolation of the causative organism with sensitivities to bactericidal treatment as using one-stage exchange.One-stage exchange is indicated when the patients have:minimal bone loss/soft tissue defect allowing primary wound closure,easy to treat micro-organisms,absence of systemic sepsis andabsence of extensive comorbidities.There are no validated serum or synovial biomarkers to determine optimal timing of re-implantation for two-stage exchange.Antibiotic-free waiting intervals and joint aspiration before the second stage are no longer recommended. The decision to perform aspiration should be made based on the index of suspicion for persistent infection.Re-implantation can be performed when the treating medical team feels that the clinical signs of infection are under control and serological tests are trending downwards. Cite this article: EFORT Open Rev 2020;5:672-683. DOI: 10.1302/2058-5241.5.190069.
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Affiliation(s)
- Ismail Remzi Tözün
- Department of Orthopaedic Surgery and Traumatology, Acibadem Mehmet Ali Aydınlar University, School of Medicine, Acibadem Maslak Hospital, Sarıyer/Istanbul, Turkey
| | - Vahit Emre Ozden
- Department of Orthopaedic Surgery and Traumatology, Acibadem Mehmet Ali Aydınlar University, School of Medicine, Acibadem Maslak Hospital, Sarıyer/Istanbul, Turkey
| | - Goksel Dikmen
- Department of Orthopaedic Surgery and Traumatology, Acibadem Mehmet Ali Aydınlar University, School of Medicine, Acibadem Maslak Hospital, Sarıyer/Istanbul, Turkey
| | - Kayahan Karaytuğ
- Department of Orthopaedic Surgery and Traumatology, Acibadem Mehmet Ali Aydınlar University, School of Medicine, Acibadem Maslak Hospital, Sarıyer/Istanbul, Turkey
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28
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Calanna F, Chen F, Risitano S, Vorhies JS, Franceschini M, Giori NJ, Indelli PF. Debridement, antibiotic pearls, and retention of the implant (DAPRI): A modified technique for implant retention in total knee arthroplasty PJI treatment. J Orthop Surg (Hong Kong) 2020; 27:2309499019874413. [PMID: 31554470 DOI: 10.1177/2309499019874413] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
We describe a modified surgical technique developed to enhance the classical irrigation and debridement procedure to improve the possibilities of retaining an infected total knee arthroplasty. This technique, debridement antibiotic pearls and retention of the implant (DAPRI), aims to remove the intra-articular biofilm allowing a higher and prolonged local antibiotic concentration using calcium sulfate beads. The combination of three different surgical techniques (methylene blue staining, argon beam electrical stimulation, and chlorhexidine gluconate brushing) might enhance the identification, disruption, and finally removal of the bacterial biofilm, which is the main responsible of antibiotics and antibodies resistance. The DAPRI technique might represent a safe and more conservative treatment for acute and early hematogenous periprosthetic joint infection.
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Affiliation(s)
- Filippo Calanna
- Istituto Ortopedico Gaetano Pini, Division of Orthopaedic Surgery, Milan, Italy
| | - Foster Chen
- Department of Orthopaedic Surgery, Stanford University, Stanford, CA, USA
| | - Salvatore Risitano
- Department of Orthopaedic Surgery, Stanford University, Stanford, CA, USA
| | - John S Vorhies
- Department of Orthopaedic Surgery, Stanford University, Stanford, CA, USA
| | | | - Nicholas J Giori
- Department of Orthopaedic Surgery, Stanford University, Stanford, CA, USA
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29
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Kildow BJ, Della-Valle CJ, Springer BD. Single vs 2-Stage Revision for the Treatment of Periprosthetic Joint Infection. J Arthroplasty 2020; 35:S24-S30. [PMID: 32046827 DOI: 10.1016/j.arth.2019.10.051] [Citation(s) in RCA: 71] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Revised: 10/27/2019] [Accepted: 10/27/2019] [Indexed: 02/01/2023] Open
Abstract
Periprosthetic joint infection (PJI) is one of the most devastating complications following total joint arthroplasty, accounting for a projected 10,000 revision surgeries per year by 2030. Chronic PJI is complicated by the presence of bacterial biofilm, requiring removal of components, thorough debridement, and administration of antibiotics for effective eradication. Chronic PJI is currently managed with single-stage or 2-stage revision surgery. To date, there are no randomized, prospective studies available evaluating eradication rates and functional outcomes between the 2 techniques. In this review, both treatment options are described with the most current literature to guide effective surgical decision-making that is cost-effective while decreasing patient morbidity.
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Affiliation(s)
- Beau J Kildow
- OrthoCarolina Hip and Knee Center, Charlotte, North Carolina
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30
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Tran HA, Tran PA. Immobilization-Enhanced Eradication of Bacterial Biofilms and in situ Antimicrobial Coating of Implant Material Surface - an in vitro Study. Int J Nanomedicine 2019; 14:9351-9360. [PMID: 31819436 PMCID: PMC6890190 DOI: 10.2147/ijn.s219487] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Accepted: 11/13/2019] [Indexed: 01/20/2023] Open
Abstract
PURPOSE The aim of this study was to investigate a new method of in situ biofilm treatment for infected prostheses that remove bacterial biofilm and prevent reinfection through the use of an immobilizing agent in combination with the actions of biofilm-lysing enzymes and bactericidal antimicrobials. METHODS We investigated the combination of self-immobilization chemistry of dopamine with a biofilm-lysing enzyme, α-amylase (Am), and an antimicrobial agent, silver nitrate (Ag), to treat model Staphylococcus aureus (S. aureus) biofilms formed on titanium. The efficacy of biofilm removal and bacterial treatment was analyzed by crystal violet, colony-forming unit assays, confocal laser scanning microscopy, and scanning electron microscopy (SEM). To confirm the in situ coating of the titanium surface with antimicrobial Ag as a strategy to prevent bacterial recolonization, SEM in secondary electron mode (SE), backscatter electron mode, (BSE) and energy-dispersive spectroscopy (EDX) were used. The antimicrobial activity of the coated surface was evaluated by optical density measurement and colony-forming unit assays. RESULTS Polydopamine (PDA)-assisted treatment showed approximately a 2 log reduction in recoverable CFU and a 15% increase in biofilm removal efficacy compared to treatments that had only Am or Ag. More importantly, PDA-assisted treatment was found to immobilize Ag on the surface after the treatment, rendering them resistant to bacterial recolonization. CONCLUSION Our in vitro findings suggested that this PDA-assisted treatment and the surface immobilization-enhanced treatment concept could be promising in the development of advanced treatment for implant retention surgery for an infected prosthesis.
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Affiliation(s)
- Hien A Tran
- School of Chemistry, Physics and Mechanical Engineering, Faculty of Science and Engineering, Queensland University of Technology (QUT), Brisbane, Queensland, Australia
- Interface Science and Materials Engineering (ISME) Group, QUT, Brisbane, Queensland, Australia
- Centre in Regenerative Medicine, QUT, Brisbane, Queensland, Australia
- Institute of Health and Biomedical Innovation, Kelvin Grove, Queensland, Australia
| | - Phong A Tran
- School of Chemistry, Physics and Mechanical Engineering, Faculty of Science and Engineering, Queensland University of Technology (QUT), Brisbane, Queensland, Australia
- Interface Science and Materials Engineering (ISME) Group, QUT, Brisbane, Queensland, Australia
- Centre in Regenerative Medicine, QUT, Brisbane, Queensland, Australia
- Institute of Health and Biomedical Innovation, Kelvin Grove, Queensland, Australia
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31
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Yan CH, Arciola CR, Soriano A, Levin LS, Bauer TW, Parvizi J. Team Approach: The Management of Infection After Total Knee Replacement. JBJS Rev 2019; 6:e9. [PMID: 29664872 DOI: 10.2106/jbjs.rvw.17.00058] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
- Chun Hoi Yan
- Department of Orthopaedics & Traumatology, The University of Hong Kong, Hong Kong SAR, People's Republic of China
| | - Carla Renata Arciola
- Research Unit on Implant Infections, Rizzoli Orthopaedic Institute, Bologna, Italy.,Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Bologna, Italy
| | - Alex Soriano
- Department of Infectious Diseases, Hospital Clinic of Barcelona, IDIBAPS, University of Barcelona, Spain
| | - L Scott Levin
- Department of Orthopaedic Surgery, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - Thomas W Bauer
- Department of Pathology and Laboratory Medicine, Hospital for Special Surgery, New York, NY
| | - Javad Parvizi
- Department of Orthopaedic Surgery, Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
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32
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Diaz-Dilernia F, Costantini J, Nicolino TI, Sanchez MDL, Carbo L. Unusual Listeria monocytogenes hematogenous infection in total knee replacement treated with one-stage revision surgery. Arthroplast Today 2019; 5:296-300. [PMID: 31516969 PMCID: PMC6728532 DOI: 10.1016/j.artd.2019.06.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Revised: 06/17/2019] [Accepted: 06/17/2019] [Indexed: 12/17/2022] Open
Abstract
Septic arthritis due to Listeria monocytogenes (LM) is extremely rare and most infections due to this organism are seen in immunocompromised patients. We describe a patient without immunological compromise, with a late total knee arthroplasty infection caused by LM treated with one-stage revision surgery. She had an elevated erythrocyte sedimentation rate (79 mm/h) and C-reactive protein (13 mg/dL). Aspiration of the knee joint yielded purulent fluid; cultures showed LM. The patient was given 6 weeks of intravenous ampicillin, followed by trimethoprim/sulfamethoxazole, and finally amoxicillin orally for 7 months. Two years after revision surgery, radiographs showed no evidence of implant loosening. This is a single case and although one-stage approach seemed to have worked, it should not be recommended on the basis of a single report.
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Affiliation(s)
- Fernando Diaz-Dilernia
- Institute of Orthopaedics "Carlos E. Ottolenghi", Italian Hospital of Buenos Aires, Buenos Aires, Argentina
| | - Julian Costantini
- Institute of Orthopaedics "Carlos E. Ottolenghi", Italian Hospital of Buenos Aires, Buenos Aires, Argentina
| | - Tomas I Nicolino
- Institute of Orthopaedics "Carlos E. Ottolenghi", Italian Hospital of Buenos Aires, Buenos Aires, Argentina
| | - Marisa Del Lujan Sanchez
- Institute of Orthopaedics "Carlos E. Ottolenghi", Italian Hospital of Buenos Aires, Buenos Aires, Argentina
| | - Lisandro Carbo
- Institute of Orthopaedics "Carlos E. Ottolenghi", Italian Hospital of Buenos Aires, Buenos Aires, Argentina
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33
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Iza K, Foruria X, Moreta J, Uriarte I, Loroño A, Aguirre U, de Los Mozos JLM. DAIR (Debridement, Antibiotics and Implant Retention) less effective in hematogenous total knee arthroplasty infections. J Orthop Surg Res 2019; 14:278. [PMID: 31462250 PMCID: PMC6712600 DOI: 10.1186/s13018-019-1324-5] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2019] [Accepted: 08/18/2019] [Indexed: 12/12/2022] Open
Abstract
Background Debridement and irrigation with prosthetic retention followed by antibiotic therapy (DAIR) is one of the treatments of choice in acute infections after a total knee arthroplasty. However, the success rate varies widely in the literature, depending on several factors such as comorbidities of the patient, duration of infection, and microorganisms involved. The goal of this study was to assess the outcomes of this therapeutic option and to identify possible predictors of the result. Methods We retrospectively reviewed cases of acute postoperative (≤ 3 months from index procedure) and acute hematogenous periprosthetic knee infections treated with DAIR at our hospital between 2004 and 2016. Overall, 26 knees were included, with a mean age of 73.4 years. Several variables related to patient characteristics, infection type, and surgery were examined to evaluate their influence on outcome, and functional and radiographic outcome were assessed. The mean follow-up was 41 months. A descriptive analysis was carried out on the collected data, and a univariate analysis was performed with the objective of searching for influential factors in the resolution of the infection using the chi-square nonparametric test in the case of the categorical variables and the Wilcoxon test for the continuous ones. Moreover, univariate cox regression analysis was performed. Results The overall success rate was 77% at the last follow-up, recording a significantly greater cure in acute infections (93% acute vs 58% acute hematogenous, p = 0.03). The infections in which the Staphylococcus aureus was isolated had a significantly lower cure rate, with only 33% of success, compared to 82% of the non-aureus microorganisms (p < 0.05). Conclusions The present study shows a considerable cure rate in the treatment of acute knee infections through DAIR, although patient comorbidities, type of infection, and causative microorganism should be considered for decision-making.
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Affiliation(s)
- Kattalin Iza
- Department of Orthopaedic Surgery and Traumatology, Hospital Galdakao-Usansolo, Barrio Labeaga s/n, 48960, Galdakao, Bizkaia, Spain.
| | - Xabier Foruria
- Department of Orthopaedic Surgery and Traumatology, Hospital Galdakao-Usansolo, Barrio Labeaga s/n, 48960, Galdakao, Bizkaia, Spain
| | - Jesús Moreta
- Department of Orthopaedic Surgery and Traumatology, Hospital Galdakao-Usansolo, Barrio Labeaga s/n, 48960, Galdakao, Bizkaia, Spain
| | - Iker Uriarte
- Department of Orthopaedic Surgery and Traumatology, Hospital Galdakao-Usansolo, Barrio Labeaga s/n, 48960, Galdakao, Bizkaia, Spain
| | - Ane Loroño
- Research Unit, Hospital Galdakao-Usansolo, Galdakao, Bizkaia, Spain
| | - Urko Aguirre
- Research Unit, Hospital Galdakao-Usansolo, Galdakao, Bizkaia, Spain
| | - José Luis Martínez de Los Mozos
- Department of Orthopaedic Surgery and Traumatology, Hospital Galdakao-Usansolo, Barrio Labeaga s/n, 48960, Galdakao, Bizkaia, Spain
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Hariharan TD, Chandy VJ, George J, Mathew AJ, Premnath J, Pragasam AK, Prakash JJ, Oomen AT, Poonnoose PM. Microbiological profile and outcomes of two-stage revision hip arthroplasty. Indian J Med Microbiol 2019; 37:67-71. [PMID: 31424013 DOI: 10.4103/ijmm.ijmm_19_25] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Background Prosthetic joint infection (PJI) is one of the most challenging cases that confront modern orthopaedics. Two-stage revision, which is the standard of care for PJI, is the preferred mode of treatment for these infections. Aims and Objectives To study the microbiological profile of prosthetic joint infections (PJI) in the hip and to assess the efficacy of a two stage revision surgery for PJI. We also aimed to study the sensitivity and specificity of ESR and CRP in the diagnosis of PJI. Materials and Methods The microbiological profile, clinical and radiological outcomes of 22 patients who had a two-stage revision for PJI of the hip between 2013 and 2017 were retrospectively analysed. PJI was defined using the criteria provided by the International Consensus Statement on PJI 2013. Results Staphylococcus aureus was found to be the most common organism in PJI. Debridement was successful in removing the organism in 74% of PJI. At the time of re-implantation (second stage), six joints grew organisms that were different from that isolated at the index debridement - coagulase-negative staphylococci (3cases) and enterococci (3cases). Other infection parameters for these patients were negative. None of the patients who had two-stage revision surgery had clinical evidence of reinfection or radiological evidence of loosening at a mean of 2-year follow-up. An ESR cut off of >30mm/hr had a sensitivity of 75% and specificity of 88% in predicting PJI. A CRP >10mg/L had a sensitivity of 75% and specificity of 69%. The sensitivity and specificity of using both ESR and CRP cut-offs in the diagnosis of infection were 57% and 94%, respectively. The positive predictive value was 94% and negative predictive value was 56%. Conclusion The outcomes of the study justify a two-stage revision arthroplasty for PJI of the hip. The use of ESR and CRP as screening tests for the success of debridement has value - but should be interpreted with caution.
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Affiliation(s)
- T D Hariharan
- Department of Orthopaedic Surgery, Christian Medical College, Vellore, Tamil Nadu, India
| | - V J Chandy
- Department of Orthopaedic Surgery, Christian Medical College, Vellore, Tamil Nadu, India
| | - Jerry George
- Department of Orthopaedic Surgery, Christian Medical College, Vellore, Tamil Nadu, India
| | - Ajit Joseph Mathew
- Department of Orthopaedic Surgery, Christian Medical College, Vellore, Tamil Nadu, India
| | - John Premnath
- Department of Orthopaedic Surgery, Christian Medical College, Vellore, Tamil Nadu, India
| | - Agila Kumari Pragasam
- Department of Clinical Microbiology, Christian Medical College, Vellore, Tamil Nadu, India
| | - John Jude Prakash
- Department of Clinical Microbiology, Christian Medical College, Vellore, Tamil Nadu, India
| | - Anil Thomas Oomen
- Department of Orthopaedic Surgery, Christian Medical College, Vellore, Tamil Nadu, India
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Eriksson HK, Ahadpour D, Hailer NP, Lazarinis S, Järhult JD. Linezolid in the treatment of periprosthetic joint infection caused by coagulase-negative staphylococci. Infect Dis (Lond) 2019; 51:683-690. [PMID: 31389725 DOI: 10.1080/23744235.2019.1642510] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Background: Periprosthetic joint infection (PJI) caused by coagulase-negative staphylococci (CoNS) is increasingly common and is sometimes treated with off-label use of linezolid. Methods: We conducted a retrospective study of patients with PJI caused by CoNS treated with surgical intervention and orally administrated linezolid during the period 1995-2014 (n = 28). Clinical outcomes and adverse events related to linezolid administration were evaluated. Mean time to follow-up was 4.3 years (range: 0.2-12). Results: Twenty-two of 28 patients were infection-free at follow-up. No CoNS strain was resistant to vancomycin, but 16 of 28 were resistant to rifampicin, 23 of 28 to clindamycin and 20 of 27 to quinolones. The mean duration of linezolid treatment was 4.2 weeks (range: 1-12). Eleven of 28 patients had an adverse event related to the antimicrobial treatment, and four had to discontinue linezolid, but all adverse events were reversible within 2 months after discontinuation. Conclusions: Oral linezolid administration combined with adequate surgical treatment may be useful for the treatment of PJIs caused by CoNS.
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Affiliation(s)
- Hannah K Eriksson
- a Department of Surgical Sciences/Section of Orthopaedics, Uppsala University , Uppsala , Sweden
| | - David Ahadpour
- a Department of Surgical Sciences/Section of Orthopaedics, Uppsala University , Uppsala , Sweden
| | - Nils P Hailer
- a Department of Surgical Sciences/Section of Orthopaedics, Uppsala University , Uppsala , Sweden
| | - Stergios Lazarinis
- a Department of Surgical Sciences/Section of Orthopaedics, Uppsala University , Uppsala , Sweden
| | - Josef D Järhult
- b Department of Medical Sciences, Zoonosis Science Center, Uppsala University , Uppsala , Sweden
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Pangaud C, Ollivier M, Argenson JN. Outcome of single-stage versus two-stage exchange for revision knee arthroplasty for chronic periprosthetic infection. EFORT Open Rev 2019; 4:495-502. [PMID: 31537999 PMCID: PMC6719605 DOI: 10.1302/2058-5241.4.190003] [Citation(s) in RCA: 116] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
The gold standard for treating chronic periprosthetic joint infection is still considered to be double-stage exchange revision. The purpose of this review is to analyse the difference in terms of eradication rates and functional outcome after single- and double-stage prosthetic exchange for chronic periprosthetic joint infection around the knee. We reviewed full text articles written in English from 1992 to 2018 reporting the success rates and functional outcomes of either single-stage exchange or double-stage exchange for knee arthroplasty revision performed for chronic infection. In the case of double-stage exchange, particular attention was paid to the type of spacer: articulating or static. In all, 32 articles were analysed: 14 articles for single-stage including 687 patients and 18 articles for double-stage including 1086 patients. The average eradication rate was 87.1% for the one-stage procedure and 84.8% for the two-stage procedure. The functional outcomes were similar in both groups: the average Knee Society Knee Score was 80.0 in the single-stage exchange group and 77.8 in the double-stage exchange. The average range of motion was 91.4° in the single-stage exchange group and 97.8° in the double-stage exchange group. Single-stage exchange appears to be a viable alternative to two -stage exchange in cases of chronic periprosthetic joint infection around the knee, provided there are no contra-indications, producing similar results in terms of eradication rates and functional outcomes, and offering the advantage of a unique surgical procedure, lower morbidity and reduced costs. Cite this article: EFORT Open Rev 2019;4:495-502. DOI: 10.1302/2058-5241.4.190003
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Affiliation(s)
- Corentin Pangaud
- Hôpital Sainte Marguerite, Aix Marseille Université, Marseille, France
| | - Matthieu Ollivier
- Hôpital Sainte Marguerite, Aix Marseille Université, Marseille, France
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Citak M, Friedenstab J, Abdelaziz H, Suero EM, Zahar A, Salber J, Gehrke T. Risk Factors for Failure After 1-Stage Exchange Total Knee Arthroplasty in the Management of Periprosthetic Joint Infection. J Bone Joint Surg Am 2019; 101:1061-1069. [PMID: 31220022 DOI: 10.2106/jbjs.18.00947] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND One-stage exchange arthroplasty in the management of periprosthetic joint infection was introduced at our institution. The purpose of this study was to analyze the risk factors of failure after periprosthetic joint infection following total knee arthroplasty treated with 1-stage exchange. METHODS Ninety-one patients who underwent failed treatment following 1-stage exchange total knee arthroplasty due to periprosthetic joint infection from January 2008 to December 2017 were included. From the same period, we randomly selected a 1:1 matched control group without a subsequent revision surgical procedure. Bivariate analyses, including preoperative, intraoperative, and postoperative factors, as well as logistic regression, were performed to identify risk factors for failure. RESULTS Bivariate analysis yielded 10 predictors (variables with significance at p < 0.05) for failure involving re-revision for any reason and 11 predictors for failure involving re-revision for reinfection. The binary logistic regression model revealed the following risk factors for re-revision for any reason: history of a 1-stage exchange for infection (odds ratio [OR], 26.706 [95% confidence interval (CI), 5.770 to 123.606]; p < 0.001), history of a 2-stage exchange (OR, 3.948 [95% CI, 1.869 to 8.339]; p < 0.001), and isolation of enterococci (OR, 16.925 [95% CI, 2.033 to 140.872]; p = 0.009). The risk factors for reinfection in the binary logistic regression analysis were history of 1-stage or 2-stage exchange arthroplasty, isolation of enterococci, and isolation of streptococci (OR, 6.025 [95% CI, 1.470 to 24.701]; p = 0.013). CONCLUSIONS We identified several risk factors of failure after 1-stage exchange arthroplasty for periprosthetic joint infection, most of which were not related to the patient comorbidities. Among them, previous exchange due to periprosthetic joint infection and the isolation of Enterococcus or Streptococcus species were associated with a higher risk of failure. Besides a multidisciplinary approach, being aware of the identified risk factors when evaluating patients with periprosthetic joint infection could lead to better outcomes. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Mustafa Citak
- Department of Orthopaedic Surgery, Helios ENDO-Klinik Hamburg, Hamburg, Germany
| | - Jasmin Friedenstab
- Department of Orthopaedic Surgery, Helios ENDO-Klinik Hamburg, Hamburg, Germany.,Department of Surgery, Ruhr-University Hospital, Bochum, Germany
| | - Hussein Abdelaziz
- Department of Orthopaedic Surgery, Helios ENDO-Klinik Hamburg, Hamburg, Germany
| | - Eduardo M Suero
- Department of General, Trauma and Reconstructive Surgery, Ludwig-Maximilians-University München, München, Germany
| | - Akos Zahar
- Department of Orthopaedic Surgery, Helios ENDO-Klinik Hamburg, Hamburg, Germany
| | - Jochen Salber
- Department of Surgery, Ruhr-University Hospital, Bochum, Germany
| | - Thorsten Gehrke
- Department of Orthopaedic Surgery, Helios ENDO-Klinik Hamburg, Hamburg, Germany
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Chung AS, Niesen MC, Graber TJ, Schwartz AJ, Beauchamp CP, Clarke HD, Spangehl MJ. Two-Stage Debridement With Prosthesis Retention for Acute Periprosthetic Joint Infections. J Arthroplasty 2019; 34:1207-1213. [PMID: 30872035 DOI: 10.1016/j.arth.2019.02.013] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Revised: 01/31/2019] [Accepted: 02/11/2019] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Historically, infection control rates with debridement and component retention have been poor in the management of acute prosthetic joint infections. We previously described a 2-stage debridement with prosthesis retention protocol for acute periprosthetic joint infection and reported a 90% success rate in a sample of 20 patients. METHODS A retrospective review of 83 patients who underwent a 2-stage debridement with implant retention with a minimum 1-year follow-up was performed. Patient data were primarily analyzed to determine infection control rates. Infections were considered controlled when patients had not undergone a reoperation for infection, and demonstrated lack of any clinical signs or symptoms of infection (a well healed wound, diminishing swelling and warmth, absence of erythema, improvement in baseline pain symptoms) A secondary goal of this study was to examine the effects of symptom duration on infection control rate. RESULTS Average patient follow-up was 41.8 months (range 12-171) for all patients. The overall protocol success rate was 86.7% (72/83): 82.9% in hips and 89.6% in knees. Additionally, protocol success was observed in 45 of 48 primary joints (93.8%) and 27 of 35 (77.1%) revision joints (P = .046). Average time from onset of symptoms to surgery was 6.2 days for successfully treated patients (range 0-27 days) compared to 10.7 days for those who failed treatment (range 1-28 days, P = .070). CONCLUSION This 2-stage retention protocol resulted in a higher likelihood of infection control compared to prior reports of single stage debridement and modular part exchange.
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Affiliation(s)
- Andrew S Chung
- Department of Orthopaedic Surgery, Mayo Clinic, Phoenix, AZ
| | | | | | | | | | - Henry D Clarke
- Department of Orthopaedic Surgery, Mayo Clinic, Phoenix, AZ
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Bialecki J, Bucsi L, Fernando N, Foguet P, Guo S, Haddad F, Hansen E, Janvari K, Jones S, Keogh P, McHale S, Molloy R, Mont MA, Morgan-Jones R, Ohlmeier M, Saldaña A, Sodhi N, Toms A, Walker R, Zahar A. Hip and Knee Section, Treatment, One Stage Exchange: Proceedings of International Consensus on Orthopedic Infections. J Arthroplasty 2019; 34:S421-S426. [PMID: 30348563 DOI: 10.1016/j.arth.2018.09.026] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
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Ottesen CS, Troelsen A, Sandholdt H, Jacobsen S, Husted H, Gromov K. Acceptable Success Rate in Patients With Periprosthetic Knee Joint Infection Treated With Debridement, Antibiotics, and Implant Retention. J Arthroplasty 2019; 34:365-368. [PMID: 30401558 DOI: 10.1016/j.arth.2018.09.088] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2018] [Revised: 09/25/2018] [Accepted: 09/26/2018] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Acute periprosthetic joint infection (PJI) following primary total knee arthroplasty (TKA) surgery can be treated with debridement, antibiotics, and implant retention (DAIR). However, varying results have been reported in the literature and optimal timing of the procedure is still debated. In this retrospective cohort study, we investigate (a) success rate of DAIR for treating PJI following primary TKA surgery and (b) whether time after primary surgery until DAIR and (c) type of isolated microorganism influence outcome. METHODS Sixty-seven patients with PJI following primary TKA surgery treated with DAIR were identified. Patients with insufficient data and patients who did not fulfill Musculoskeletal Infection Society PJI criteria were excluded, leaving 58 patients for analysis. Minimum follow-up was 2 years. A DAIR was considered a success if the patient was infection free after 2 years. RESULTS The overall success rate of PJI treated with DAIR was 84%. Median time until DAIR was 21 days (7-1092). Thirty-four patients (59%) were revised within 28 days, 42 patients (72%) within 42 days, while 10 patients (17%) were revised more than 90 days after primary TKA surgery. The success rates were 85%, 88%, and 60%, respectively. In the patients revised within 90 days, our success rate was 90% (43/48) regardless of the involved microorganism. CONCLUSION We find DAIR to be a viable and safe treatment option for PJI following primary TKA surgery, when performed early after primary surgery and with the addition of a relevant postrevision antibiotic regime.
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Affiliation(s)
- Casper S Ottesen
- Department of Orthopedic Surgery, Copenhagen University Hospital, Copenhagen, Denmark
| | - Anders Troelsen
- Department of Orthopedic Surgery, Copenhagen University Hospital, Copenhagen, Denmark
| | - Håkon Sandholdt
- Department of Orthopedic Surgery, Copenhagen University Hospital, Copenhagen, Denmark
| | - Steffen Jacobsen
- Department of Orthopedic Surgery, Copenhagen University Hospital, Copenhagen, Denmark
| | - Henrik Husted
- Department of Orthopedic Surgery, Copenhagen University Hospital, Copenhagen, Denmark
| | - Kirill Gromov
- Department of Orthopedic Surgery, Copenhagen University Hospital, Copenhagen, Denmark
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Karczewski D, Winkler T, Renz N, Trampuz A, Lieb E, Perka C, Müller M. A standardized interdisciplinary algorithm for the treatment of prosthetic joint infections. Bone Joint J 2019; 101-B:132-139. [PMID: 30700114 DOI: 10.1302/0301-620x.101b2.bjj-2018-1056.r1] [Citation(s) in RCA: 69] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
AIMS In 2013, we introduced a specialized, centralized, and interdisciplinary team in our institution that applied a standardized diagnostic and treatment algorithm for the management of prosthetic joint infections (PJIs). The hypothesis for this study was that the outcome of treatment would be improved using this approach. PATIENTS AND METHODS In a retrospective analysis with a standard postoperative follow-up, 95 patients with a PJI of the hip and knee who were treated with a two-stage exchange between 2013 and 2017 formed the study group. A historical cohort of 86 patients treated between 2009 and 2011 not according to the standardized protocol served as a control group. The success of treatment was defined according to the Delphi criteria in a two-year follow-up. RESULTS Patients in the study group had a significantly higher Charlson Comorbidity Index (3.9 vs 3.1; p = 0.009) and rate of previous revisions for infection (52.6% vs 36%; p = 0.025), and tended to be older (69.0 vs 66.2 years; p = 0.075) with a broader polymicrobial spectrum (47.3% vs 33.7%; p = 0.062). The rate of recurrent infection (3.1% vs 10.4%; p = 0.048) and the mean time interval between the two stages of the procedure (66.6 vs 80.7 days; p < 0.001) were reduced significantly in the study group compared with the control group. CONCLUSION We were able to show that the outcome following the treatment of PJIs of the hip and knee is better when managed in a separate department with an interdisciplinary team using a standard algorithm.
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Affiliation(s)
- D Karczewski
- Center for Musculoskeletal Surgery, Department of Orthopaedic Surgery, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - T Winkler
- Center for Musculoskeletal Surgery, Department of Orthopaedic Surgery, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - N Renz
- Center for Musculoskeletal Surgery, Department of Orthopaedic Surgery, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - A Trampuz
- Center for Musculoskeletal Surgery, Department of Orthopaedic Surgery, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - E Lieb
- Center for Musculoskeletal Surgery, Department of Orthopaedic Surgery, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - C Perka
- Center for Musculoskeletal Surgery, Department of Orthopaedic Surgery, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - M Müller
- Center for Musculoskeletal Surgery, Department of Orthopaedic Surgery, Charité - Universitätsmedizin Berlin, Berlin, Germany
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Pellegrini A, Legnani C, Meani E. A new perspective on current prosthetic joint infection classifications: introducing topography as a key factor affecting treatment strategy. Arch Orthop Trauma Surg 2019; 139:317-322. [PMID: 30374532 PMCID: PMC6394468 DOI: 10.1007/s00402-018-3058-y] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Indexed: 02/06/2023]
Abstract
Periprosthetic joint infection (PJI) is a relatively frequent and devastating complication following prosthetic joint implantation. Several classification systems have been presented by various authors and are routinely used in clinical practice to help in early diagnosis and treatment. The most widely accepted classifications of periprosthetic infections rely on the timing of clinical presentation. Unfortunately, these schemes possess important shortcomings which limit their usefulness in clinical practice, as data reported in literature are contrasting, with success rate ranging from 60 to 80%, irrespectively of prosthetic infection timing. An attempt is made by us to update the current knowledge on PJIs by looking them from a different perspective, introducing a topographic principle in their classification. Our approach is based on the theory that identifying the exact location of the bacterial colonization may allow to decide whether to conservatively treat the patient or to perform a more radical intervention. The aim is to improve the understanding of the aetiology of this serious complication, lead to the appropriate treatment strategy according to the stage of the disease thus enhancing the outcomes of surgical management. Such a strategy, if widely accepted, could guide research studies on the management of PJIs. The availability of investigations like scintigraphy could aid in identifying pathogenetic processes and their exact location, which may be missed on conventional radiographs, and could enable orthopaedic surgeons to have a better understanding of PJI patterns.
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Affiliation(s)
- Antonio Pellegrini
- IRCCS Istituto Ortopedico Galeazzi, Centre for Reconstructive Surgery and Osteoarticular Infections, Milan, Italy
| | - Claudio Legnani
- IRCCS Istituto Ortopedico Galeazzi, Sport Traumatology and Minimally Invasive Surgery Center, Milan, Italy
| | - Enzo Meani
- IRCCS Istituto Ortopedico Galeazzi, Centre for Reconstructive Surgery and Osteoarticular Infections, Milan, Italy
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Weston JT, Watts CD, Mabry TM, Hanssen AD, Berry DJ, Abdel MP. Irrigation and debridement with chronic antibiotic suppression for the management of infected total knee arthroplasty. Bone Joint J 2018; 100-B:1471-1476. [DOI: 10.1302/0301-620x.100b11.bjj-2018-0515.r1] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Aims The results of irrigation and debridement with component retention (IDCR) in the treatment of acutely infected total knee arthroplasties (TKAs) have been variable. The aim of this study was to assess the outcome after IDCR when combined with chronic antibiotic suppression. We also evaluated survivorship free from subsequent infection, removal of the components, and death, as well as the risk factors for failure. Patients and Methods This was a single-centre retrospective review of 134 infected primary TKAs that were treated with IDCR. Infections within four weeks of the procedure were defined as acute postoperative infections, and those occurring more than four weeks after the procedure with symptoms for less than three weeks were defined as acute haematogenous infections. Patients were treated with intravenous antibiotics for four to six weeks, followed by chronic oral antibiotic suppression. Estimates of survival were made using a competing risk analysis. The mean follow-up was five years (2.1 to 13). Results The infection was an acute postoperative infection in 23 TKAs and an acute haematogenous infection in 111 TKAs. The incidence of subsequent infection was 36% in those with an acute postoperative infection and 33% in those with a haematogenous infection, five years postoperatively (p = 0.40). Age < 60 years increased the risk of subsequent infection (hazard ratio (HR) 2.4; p = 0.009) and removal of the components (HR 2.8; p = 0.007). Infection with a staphylococcal species increased the risk of subsequent infection (HR 3.6; p < 0.001), and removal of the components (HR 3.2; p = 0.002). Musculoskeletal Infection Society host type and local extremity grade, body mass index (BMI), the duration of symptoms, gender, and the presence of a monoblock tibial component had no significant effect on the outcome. Conclusion In a rigorously defined group of acute periprosthetic infections after TKA treated with IDCR and chronic antibiotic suppression, the infection-free survival at five years was 66%. The greatest risk factor for failure was an infection with a staphylococcal species, followed by age of < 60 years. Cite this article: Bone Joint J 2018;100-B:1471–76.
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Affiliation(s)
- J. T. Weston
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | | | - T. M. Mabry
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - A. D. Hanssen
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - D. J. Berry
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - M. P. Abdel
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
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Kunutsor SK, Beswick AD, Whitehouse MR, Wylde V, Blom AW. Debridement, antibiotics and implant retention for periprosthetic joint infections: A systematic review and meta-analysis of treatment outcomes. J Infect 2018; 77:479-488. [PMID: 30205122 DOI: 10.1016/j.jinf.2018.08.017] [Citation(s) in RCA: 95] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2017] [Revised: 05/10/2018] [Accepted: 08/14/2018] [Indexed: 01/19/2023]
Abstract
OBJECTIVES We aimed to assess infection control rates after DAIR in patients with periprosthetic joint infection (PJI) following joint arthroplasty and evaluate factors associated with infection control using a systematic review and meta-analysis. METHODS We searched MEDLINE, EMBASE, Web of Science, Cochrane databases and reference lists of relevant studies up to May 2017. Longitudinal studies conducted in patients with PJI treated exclusively by DAIR were eligible. Infection control rates were meta-analysed using random-effect models after arcsine transformation. RESULTS We included 93 articles based on 99 unique observational studies with data on 4897 PJIs treated by DAIR. The infection control rate for DAIR ranged from 11.1% to 100% with an overall pooled estimate of 61.4% (95% CI, 57.3-65.4) and a 95% prediction interval of 25.5% to 91.8%. Infection control rates remained generally similar for several relevant characteristics, except for evidence of variation by age, geographical location, type of infection and joint affected, duration of parenteral antibiotic therapy after the DAIR procedure, and period (year) of DAIR procedure. CONCLUSIONS The DAIR approach remains an option for the treatment of PJI as it is associated with acceptable infection control rates, particularly in acute postoperative infections and infections of the hip and shoulder joints.
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Affiliation(s)
- Setor K Kunutsor
- National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol NHS Foundation Trust and University of Bristol, Learning & Research Building (Level 1), Southmead Hospital, Bristol BS10 5NB, UK; Translational Health Sciences, Bristol Medical School, Musculoskeletal Research Unit, University of Bristol, Learning & Research Building (Level 1), Southmead Hospital, Bristol BS10 5NB, UK.
| | - Andrew D Beswick
- Translational Health Sciences, Bristol Medical School, Musculoskeletal Research Unit, University of Bristol, Learning & Research Building (Level 1), Southmead Hospital, Bristol BS10 5NB, UK
| | - Michael R Whitehouse
- National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol NHS Foundation Trust and University of Bristol, Learning & Research Building (Level 1), Southmead Hospital, Bristol BS10 5NB, UK; Translational Health Sciences, Bristol Medical School, Musculoskeletal Research Unit, University of Bristol, Learning & Research Building (Level 1), Southmead Hospital, Bristol BS10 5NB, UK
| | - Vikki Wylde
- National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol NHS Foundation Trust and University of Bristol, Learning & Research Building (Level 1), Southmead Hospital, Bristol BS10 5NB, UK; Translational Health Sciences, Bristol Medical School, Musculoskeletal Research Unit, University of Bristol, Learning & Research Building (Level 1), Southmead Hospital, Bristol BS10 5NB, UK
| | - Ashley W Blom
- National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol NHS Foundation Trust and University of Bristol, Learning & Research Building (Level 1), Southmead Hospital, Bristol BS10 5NB, UK; Translational Health Sciences, Bristol Medical School, Musculoskeletal Research Unit, University of Bristol, Learning & Research Building (Level 1), Southmead Hospital, Bristol BS10 5NB, UK
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Zaruta DA, Qiu B, Liu AY, Ricciardi BF. Indications and Guidelines for Debridement and Implant Retention for Periprosthetic Hip and Knee Infection. Curr Rev Musculoskelet Med 2018; 11:347-356. [PMID: 29869769 PMCID: PMC6105472 DOI: 10.1007/s12178-018-9497-9] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
PURPOSE OF REVIEW Prosthetic joint infection is one the most common causes of revision surgery after hip or knee replacement. Debridement and implant retention (DAIR) is one method of treating these infections; however, significant controversy exists. The purpose of our review was to describe current knowledge about indications, intraoperative/postoperative patient management, and outcomes of DAIR. RECENT FINDINGS Patient selection affects the success of DAIR. Medical comorbidities, duration of symptoms, and nature of infectious organism all influence outcomes. Intraoperative techniques such as open arthrotomy, extensive debridement, copious irrigation, and exchange of modular parts remain current standards for DAIR. Postoperative administration of antibiotics tailored to operative cultures remains critical. Antibiotic suppression may increase the success of DAIR. DAIR provides reasonable infection eradication between 50 and 80% with improved outcomes in appropriately selected patients. More research is needed on the use of adjuvant therapies intraoperatively and the role of postoperative antibiotic suppression.
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Affiliation(s)
- Douglas A Zaruta
- Department of Orthopedic Surgery, University of Rochester School of Medicine, Highland Hospital, 1000 South Avenue, Rochester, NY, 14620, USA
| | - Bowen Qiu
- Department of Orthopedic Surgery, University of Rochester School of Medicine, Highland Hospital, 1000 South Avenue, Rochester, NY, 14620, USA
| | - Andrew Y Liu
- Department of Orthopedic Surgery, University of Rochester School of Medicine, Highland Hospital, 1000 South Avenue, Rochester, NY, 14620, USA
| | - Benjamin F Ricciardi
- Department of Orthopedic Surgery, University of Rochester School of Medicine, Highland Hospital, 1000 South Avenue, Rochester, NY, 14620, USA.
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Rowan FE, Donaldson MJ, Pietrzak JR, Haddad FS. The Role of One-Stage Exchange for Prosthetic Joint Infection. Curr Rev Musculoskelet Med 2018; 11:370-379. [PMID: 29987643 PMCID: PMC6105475 DOI: 10.1007/s12178-018-9499-7] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
PURPOSE OF REVIEW In an era of increasing numbers of hip and knee replacements, strategies to manage prosthetic joint infection (PJI) that are effective at infection control with good patient-reported outcomes and cost containment for health systems are needed. Interest in single-stage exchange for PJI is rising and we assess evidence from the last 5 years related to this treatment strategy. RECENT FINDINGS Only five series for total knee replacement and ten series for total hip replacement have been reported in the last five years. More review articles and opinion pieces have been written. Reinfection rates in these recent studies range from 0 to 65%, but a meta-analysis and systematic review of all studies showed a reinfection rate of 7.6% (95% CI 3.4-13.1) and 8.8% (95% CI 7.2-10.6) for single-stage and two-stage revisions respectively. There is emerging evidence to support single-stage revision in the setting of significant bony deficiency and atypical PJIs such as fungal infections. Prospective randomised studies are recruiting and are necessary to guide the direction of single-stage revision selection criteria. The onus of surgical excellence in mechanical removal of implants, necrotic tissue, and biofilms lies with the arthroplasty surgeon and must remain the cornerstone of treatment. Single-stage revision may be considered the first-line treatment for all PJIs unless the organism is unknown, the patient is systemically septic, or there is a poor tissue envelope.
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Affiliation(s)
- Fiachra E Rowan
- Department of Orthopaedic Surgery, University College London Hospital, 250 Euston Road, London, NW1 2PG, UK.
- The Princess Grace Hospital, 42-52 Nottingham Place, Marylebone, London, W1U 5NY, UK.
| | - Matthew J Donaldson
- Department of Orthopaedic Surgery, University College London Hospital, 250 Euston Road, London, NW1 2PG, UK
- The Princess Grace Hospital, 42-52 Nottingham Place, Marylebone, London, W1U 5NY, UK
| | - Jurek R Pietrzak
- Department of Orthopaedic Surgery, University College London Hospital, 250 Euston Road, London, NW1 2PG, UK
- The Princess Grace Hospital, 42-52 Nottingham Place, Marylebone, London, W1U 5NY, UK
| | - Fares S Haddad
- Department of Orthopaedic Surgery, University College London Hospital, 250 Euston Road, London, NW1 2PG, UK
- The Princess Grace Hospital, 42-52 Nottingham Place, Marylebone, London, W1U 5NY, UK
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Dx Duffy S, Ahearn N, Darley ES, Porteous AJ, Murray JR, Howells NR. Analysis Of The KLIC-score; An Outcome Predictor Tool For Prosthetic Joint Infections Treated With Debridement, Antibiotics And Implant Retention. J Bone Jt Infect 2018; 3:150-155. [PMID: 30128265 PMCID: PMC6098819 DOI: 10.7150/jbji.21846] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2017] [Accepted: 12/09/2017] [Indexed: 12/15/2022] Open
Abstract
Background: Debridement, antibiotics and implant retention (DAIR) forms the primary treatment modality for early prosthetic joint infection (PJI). The KLIC score has been proposed as a risk stratification tool for use in predicting outcome of prosthetic knee infections. Our aim was to determine the accuracy of this scoring system at an independent tertiary PJI centre in a typical DAIR population. Methods: Between 2008 and 2015, patients with infected knee prostheses treated with DAIR were identified. The patient notes and blood tests were reviewed retrospectively and the 'KLIC-score' was calculated and correlated with outcome. The end point for early failure was defined as: 1) the need for unscheduled surgery, 2) infection-related death ≤12 months from debridement or 3) the need for suppressive antibiotic treatment. Results: 59 patients received DAIR procedures for knee PJI. Treatment was successful in 41 patients (69%) with early failure in 18 patients (31%). Patients deemed high-risk (KLIC-score ≥7) had notably higher failure rates (60%) than those scoring <7 (28%). No relationship can be drawn between KLIC-scores of <7 and failure rates. Conclusions: The KLIC-score applied retrospectively was able to predict patients with the highest risk of early failure but provides little information in patients with scores of <7.
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Affiliation(s)
- Sean Dx Duffy
- Avon Orthopaedic Centre, Southmead Hospital, Bristol
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48
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[Revision surgery in acute periprosthetic knee joint infections]. OPERATIVE ORTHOPADIE UND TRAUMATOLOGIE 2018; 30:309-320. [PMID: 30054644 DOI: 10.1007/s00064-018-0558-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Accepted: 04/02/2018] [Indexed: 10/28/2022]
Abstract
OBJECTIVE Reduction of pathogens in the knee joint by removal of infected periprosthetic soft tissue, irrigation and modular implant exchange of the total knee arthroplasty (TKA) to eliminate the infection and long-term preservation of the TKA. INDICATIONS Early infection of TKA (<4 weeks postoperatively); acute hematogenous TKA infection (symptom duration <3 weeks). CONTRAINDICATIONS Delayed (>4 weeks postoperatively) or chronic TKA infection; TKA loosening; difficult-to-treat pathogens; critical soft tissue with draining sinus tract. SURGICAL TECHNIQUE Excision of the wound or old surgical scar (= primary approach to the knee joint). Preparation of subcutaneous tissue. Opening the joint capsule. Removal of the old suture in tissue layers. Five tissue samples taken for microbiological and 1 tissue sample for histopathological examination using an unused instrument from the knee joint. Debridement of the upper recesses with complete synovectomy. Partial resection of Hoffa's fat body. Eversion of the patella. Resection of peripatellar soft tissue and infection membranes from the medial and lateral part of the capsule. Removal of the polyethylene inlay. Débridement of the posterior joint capsule with protection of vessels and nerve. Systematic removal of avital and infected periprosthetic tissue. Checking for correct fit of the femoral and tibial part of TKA. Antiseptic rinsing of the joint cavity with mechanical cleaning of the TKA. Extensive irrigation of the joint cavity by jet lavage (3-5 l saline solution). Glove change of the surgical team and new operation coverage. Inserting new polyethylene. Layerwise wound closure. POSTOPERATIVE MANAGEMENT Removal of redon drain on postoperative day 2. Physiotherapy and CPM. Removal of cutaneous suture about 2 weeks postoperatively. Antibiotic treatment for 12 weeks postoperatively (2 weeks intravenous, 10 weeks per oral). Checking of inflammatory markers. RESULTS Using correct indications and therapy, up to 90% of patients with acute periprosthetic TKA infection can be successfully treated with infection elimination and TKA preservation.
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Klare CM, Fortney TA, Kahng PW, Cox AP, Keeney BJ, Moschetti WE. Prognostic Factors for Success After Irrigation and Debridement With Modular Component Exchange for Infected Total Knee Arthroplasty. J Arthroplasty 2018; 33:2240-2245. [PMID: 29572037 PMCID: PMC5997491 DOI: 10.1016/j.arth.2018.02.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2017] [Revised: 01/25/2018] [Accepted: 02/05/2018] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Irrigation and debridement with modular component exchange (IDMCE) can treat prosthetic joint infection (PJI) after total knee arthroplasty (TKA). Compared to 2-stage revision, IDMCE is associated with lower morbidity but may carry higher infection recurrence rates. We aimed to identify prognostic factors associated with successful IDMCE in patients with PJI. METHODS We identified 99 consecutive patients who underwent IDMCE following TKA PJI at a tertiary academic medical center from November 2009 through January 2016. Examined variables included age, gender, symptom duration, body mass index, Charlson comorbidity index, total protein, albumin, hemoglobin A1c, erythrocyte sedimentation rate (ESR), C-reactive protein, white blood cell count, gram stain results, final cultures, and use of long-term antibiotic suppression. Success was defined as no further operation on the ipsilateral knee. We used t tests and chi-square analyses to determine whether each preoperative factor was associated with IDMCE reoperation. RESULTS At mean follow-up of 2.6 years, 64 patients who underwent IDMCE were defined as successful. Thirty-five patients required one or more additional procedures for recurrent infection; of these, 20 patients underwent 2-stage revision. Patients with symptom duration of less than 2 days avoided additional surgery in 88% of cases. Elevated ESR >47 mm/h was the only variable associated with reoperation (P = .005). There were no associations among the other examined variables. CONCLUSION Using IDMCE for PJI after TKA required reoperation in 35% of cases. Elevated preoperative ESR laboratory values and duration of symptoms >2 days were associated with reoperation.
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Affiliation(s)
- Christian M. Klare
- Department of Orthopaedics, Dartmouth-Hitchcock Medical Center, 1 Medical Center Drive, Lebanon, New Hampshire, 03756-001, USA
| | - Thomas A. Fortney
- Department of Orthopaedics, Dartmouth-Hitchcock Medical Center, 1 Medical Center Drive, Lebanon, New Hampshire, 03756-001, USA
| | - Peter W. Kahng
- Geisel School of Medicine, Dartmouth College, 1 Medical Center Drive, Lebanon, New Hampshire, 03756-001, USA
| | - Andrew P. Cox
- Geisel School of Medicine, Dartmouth College, 1 Medical Center Drive, Lebanon, New Hampshire, 03756-001, USA
| | - Benjamin J. Keeney
- Department of Orthopaedics, Dartmouth-Hitchcock Medical Center, 1 Medical Center Drive, Lebanon, New Hampshire, 03756-001, USA,Geisel School of Medicine, Dartmouth College, 1 Medical Center Drive, Lebanon, New Hampshire, 03756-001, USA,Berkley Medical Management Solutions, 10851 Mastin St., Overland Park, Kansas, 66210, USA,Corresponding Author: , 41 Hough St., Lebanon, New Hampshire, 03766 Phone: 510-227-9208
| | - Wayne E. Moschetti
- Department of Orthopaedics, Dartmouth-Hitchcock Medical Center, 1 Medical Center Drive, Lebanon, New Hampshire, 03756-001, USA,Geisel School of Medicine, Dartmouth College, 1 Medical Center Drive, Lebanon, New Hampshire, 03756-001, USA
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50
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Narayanan R, Anoushiravani AA, Elbuluk AM, Chen KK, Adler EM, Schwarzkopf R. Irrigation and Debridement for Early Periprosthetic Knee Infection: Is It Effective? J Arthroplasty 2018; 33:1872-1878. [PMID: 29428466 DOI: 10.1016/j.arth.2017.12.039] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2017] [Revised: 12/19/2017] [Accepted: 12/27/2017] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Irrigation and debridement (I&D) is performed for early management of periprosthetic joint infection (PJI) following total knee arthroplasty (TKA). Symptom reporting is a subjective measure and may miss direct management of PJI. Utilizing an objective time interval from index procedure to I&D may better inform treatment decisions. METHODS From 2009 to 2017, retrospective review was performed of 55 knee PJI cases at our institution. All patients underwent polyethylene liner exchange and I&D for PJI. Patients were stratified by time from index procedure to I&D (≤2 weeks, >2 weeks). Success was defined as eradication of infection and resolution of presenting symptoms. Failed cases required subsequent procedures due to infection. RESULTS Average follow-up time after index TKA was 2.5 years. Among patients with I&D within 2 weeks of index TXA, 14 patients (82%) were successfully treated while 3 (18%) had infection recurrence. These outcomes were significantly improved compared to patients with I&D after 2 weeks: 19 (50%) successes and 19 (50%) failures (P = .024). Staphylococcal species were the most frequent pathogen in patients treated before and after 2 weeks of index TKA (39% and 50%, respectively). Outcomes were pathogen-independent in PJIs treated before or after 2 weeks of index TKA (P = .206 and .594, respectively). CONCLUSION Our results demonstrate that patients with early PJI managed with I&D and liner exchange within 2 weeks of index TKA had higher rates of treatment success when compared to those with I&D beyond 2 weeks. These findings suggest that time from index TKA to I&D is an objective and reliable indicator of treatment success when considering I&D in acute onset knee PJI.
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Affiliation(s)
- Rajkishen Narayanan
- Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, New York, New York
| | | | - Ameer M Elbuluk
- Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, New York, New York
| | - Kevin K Chen
- Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, New York, New York
| | - Edward M Adler
- Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, New York, New York
| | - Ran Schwarzkopf
- Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, New York, New York
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