|
1
|
Wahl P, Drennan P, Schläppi M, Achermann Y, Leunig M, Gautier E, Benninger E. Systemic antibiotic prophylaxis in arthroplasty - a narrative review of how many doses are optimal. EFORT Open Rev 2024; 9:1106-1119. [PMID: 39620563 PMCID: PMC11619733 DOI: 10.1530/eor-24-0022] [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] [Indexed: 12/08/2024] Open
Abstract
Systemic antibiotic prophylaxis (SAP) is well-established in arthroplasty to prevent periprosthetic joint infection. However, the optimal duration and dosing of SAP remain a matter of debate, as evidenced by ongoing discordance between recommendations and clinical practice, reflected in the heterogeneity and imprecision of national and societal guidelines. The evidence currently available regarding the duration of SAP is summarised and discussed, specifically the postoperative repeated administration of antimicrobials within the first 24 h. The evidence available suffers from limitations, specifically deficiencies in outcome assessments in the available randomised controlled trials. Observational studies suggest that a short postoperative prolongation (<24 h) of SAP in arthroplasty may result in superior long-term outcomes compared to a single dose, and that an optimal dosing strategy, which warrants further prospective evaluation, may involve 'stacked dosing' in the early postoperative period, with re-administration every two half-lives when using commonly recommended beta-lactam antibiotics, instead of repetition at usual dosing intervals over 24 h. A stacked approach would also cover recognised indications for repetition, such as major blood loss and increased duration of operation, potentially simplifying prescribing protocols. Pharmacokinetic simulations are provided to illustrate the distinct concentration-time profiles associated with different prophylaxis regimens. Prolonging SAP beyond 24 h is not recommended. This review concludes by providing recommendations for further research, particularly a call to document SAP regimens with sufficient detail (choice of drug, dose regimen, and duration of administration) into established national arthroplasty registries, which should rapidly enable a significantly more nuanced understanding of these critical issues than permitted by the current literature.
Collapse
Affiliation(s)
- Peter Wahl
- Division of Orthopaedics and Traumatology, Cantonal Hospital Winterthur, Winterthur, Switzerland
- Faculty of Medicine, University of Bern, Bern, Switzerland
| | - Philip Drennan
- Kennedy Institute, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Michel Schläppi
- Division of Orthopaedics and Traumatology, Cantonal Hospital Winterthur, Winterthur, Switzerland
| | - Yvonne Achermann
- Department of Internal Medicine, Hospital Zollikerberg, Zurich, Switzerland
- Department of Dermatology, University Hospital Zurich, Zurich, Switzerland
- Faculty of Medicine, University of Zurich, Zurich, Switzerland
| | - Michael Leunig
- Department of Orthopedics, Schulthess Clinic, Zurich, Switzerland
| | - Emanuel Gautier
- Department of Orthopaedics, HFR Fribourg – Cantonal Hospital, Fribourg, Switzerland
| | - Emanuel Benninger
- Division of Orthopaedics and Traumatology, Cantonal Hospital Winterthur, Winterthur, Switzerland
- Faculty of Medicine, University of Zurich, Zurich, Switzerland
| |
Collapse
|
|
2
|
Leta TH, Chang RN, Fenstad AM, Lie SA, Lygre SHL, Lindberg-Larsen M, Pedersen AB, Lutro O, Willis J, Frampton C, Wyatt M, Dragosloveanu S, Vorovenci AE, Dragomirescu D, Dale H, Hallan G, Gjertsen JE, Prentice HA, Furnes O, Sedrakyan A, Paxton EW. Number of Doses of Systemic Antibiotic Prophylaxis May Be Reduced in Cemented Primary Knee Arthroplasty Irrespective of Use of Antibiotic in the Cement: A Multiregistry-Based Meta-Analysis. JB JS Open Access 2024; 9:e24.00140. [PMID: 39664766 PMCID: PMC11623873 DOI: 10.2106/jbjs.oa.24.00140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2024] Open
Abstract
Background The use of systemic antibiotic prophylaxis (SAP) and antibiotic-loaded bone cement (ALBC) is the accepted practice to reduce the risk of periprosthetic joint infection (PJI) in primary total knee arthroplasty (pTKA). However, practice varies internationally. This study's primary aim was to compare the risk of PJI revision after pTKA with ALBC + SAP vs. plain bone cement (PBC) + SAP, and the secondary aim was to assess whether the risk of PJI revision varies with the number of SAP doses. Methods Cohort of 289,926 pTKAs for osteoarthritis from arthroplasty registries in Denmark, New Zealand, Norway, Romania, and United States registered from 2010 to 2020. One-year revision for PJI following pTKA with ALBC + SAP vs. PBC + SAP, and single vs. multiple SAP doses was compared. We computed cumulative percent revision (1 minus Kaplan-Meier) using distributed analysis method and adjusted hazard rate ratios (HRRs) using Cox regression analyses within each registry. Advanced distributed meta-analysis was performed to summarize HRRs from all countries. Results Among all pTKAs, 64.4% were performed with ALBC + SAP. Each registry reported a 1-year cumulative percent revision for PJI of <1.00% for both pTKAs with ALBC + SAP (0.34%-0.80%) and with PBC + SAP (0.54%-0.69%). The distributed meta-analysis showed HRR = 1.21; (95% confidence interval [CI], 0.79-1.87) for ALBC + SAP compared with PBC + SAP. Similar risk of PJI revision was observed between pTKAs with ALBC + single vs. multiple doses of SAP: 2 doses (0.95; 95% CI, 0.68-1.33), 3 doses (1.09; 95% CI, 0.64-1.87), and 4 doses (1.23; 95% CI, 0.69-2.21). Comparable results were found for the PBC + SAP group except for higher risk of PJI revision with 4 doses of SAP (2.74; 95% CI, 1.11-6.75). Conclusions ALBC and PBC entailed similar risk of PJI revision when patients received SAP in pTKA, regardless of number of SAP doses. ALBC or PBC used in combination with SAP in pTKAs, with one single preoperative dose of SAP may be sufficient without compromising the patient safety. Level of evidence Level III. See Instructions for Authors for a complete description of levels of evidence.
Collapse
Affiliation(s)
- Tesfaye H. Leta
- The Norwegian Arthroplasty Register, Department of Orthopedic Surgery, Haukeland University Hospital, Bergen, Norway
- Faculty of Health Science, VID Specialized University, Bergen, Norway
- Department of Population Health Science, Weill Medical College of Cornell University, New York
- Medical Device Surveillance & Assessment, Kaiser Permanente, San Diego
| | - Richard N. Chang
- Medical Device Surveillance & Assessment, Kaiser Permanente, San Diego
| | - Anne Marie Fenstad
- The Norwegian Arthroplasty Register, Department of Orthopedic Surgery, Haukeland University Hospital, Bergen, Norway
| | - Stein Atle Lie
- The Norwegian Arthroplasty Register, Department of Orthopedic Surgery, Haukeland University Hospital, Bergen, Norway
- Center for Translational Oral Research (TOR), Department of Dentistry, University of Bergen, Bergen, Norway
| | - Stein Håkon L. Lygre
- The Norwegian Arthroplasty Register, Department of Orthopedic Surgery, Haukeland University Hospital, Bergen, Norway
- Department of Occupational Medicine, Haukeland University Hospital, Bergen, Norway
| | - Martin Lindberg-Larsen
- The Danish Knee Arthroplasty Register, Odense, Denmark
- Department of Orthopaedic Surgery and Traumatology, Odense University Hospital, Odense, Denmark
| | - Alma B. Pedersen
- The Danish Knee Arthroplasty Register, Odense, Denmark
- Department of Clinical Epidemiology, Aarhus University Hospital and Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Olav Lutro
- Department of Medicine, Stavanger University Hospital, Stavanger, Norway
| | - Jinny Willis
- The New Zealand Joint Registry, Christchurch, New Zealand
| | - Chris Frampton
- The New Zealand Joint Registry, Christchurch, New Zealand
| | - Michael Wyatt
- The New Zealand Joint Registry, Christchurch, New Zealand
| | - Serban Dragosloveanu
- Romanian Arthroplasty Registry, Bucharest, Romania
- University of Medicine and Pharmacy–Carol Davila–Bucharest–UMFCD Bucharest, Romania
- Foisor Orthopaedic Hospital, Bucharest, Romania
| | - Andreea E. Vorovenci
- Romanian Arthroplasty Registry, Bucharest, Romania
- Economic Cybernetics and Statistics Doctoral School, Bucharest University of Economic Studies, Bucharest, Romania
| | - Dan Dragomirescu
- Romanian Arthroplasty Registry, Bucharest, Romania
- Economic Cybernetics and Statistics Doctoral School, Bucharest University of Economic Studies, Bucharest, Romania
| | - Håvard Dale
- The Norwegian Arthroplasty Register, Department of Orthopedic Surgery, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, Faculty of Medicine, University of Bergen, Bergen, Norway
| | - Geir Hallan
- The Norwegian Arthroplasty Register, Department of Orthopedic Surgery, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, Faculty of Medicine, University of Bergen, Bergen, Norway
| | - Jan-Erik Gjertsen
- The Norwegian Arthroplasty Register, Department of Orthopedic Surgery, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, Faculty of Medicine, University of Bergen, Bergen, Norway
| | | | - Ove Furnes
- The Norwegian Arthroplasty Register, Department of Orthopedic Surgery, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, Faculty of Medicine, University of Bergen, Bergen, Norway
| | - Art Sedrakyan
- Department of Population Health Science, Weill Medical College of Cornell University, New York
| | | |
Collapse
|
|
3
|
Zhao H, Li L, Wang HY, Ding L, Wang Y, Liu X, Tian S, Wang Y. Efficacy analysis of clinical serological indicators in the diagnosis of postoperative periprosthetic joint infection in patients with rheumatoid arthritis or osteoarthritis. INTERNATIONAL ORTHOPAEDICS 2024; 48:1945-1952. [PMID: 38581467 DOI: 10.1007/s00264-024-06171-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Accepted: 04/01/2024] [Indexed: 04/08/2024]
Abstract
PURPOSE To investigate the incidence of periprosthetic joint infection (PJI) in patients with rheumatoid arthritis (RA) or osteoarthritis (OA) after primary joint arthroplasty; to analyze the optimal cut-off values of clinical serum markers C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), and D-dimer for the diagnosis of PJI in RA patients; and to explore their diagnostic efficacy and clinical significance. METHODS Clinical data of 15,702 patients with RA (578) or OA (15,124) who underwent total joint arthroplasty from 2013 to 2021 were retrospectively analyzed. Serum CRP, ESR, and D-dimer were recorded for each patient, and subject characteristic curves were used to determine the optimal threshold values of CRP, ESR, and D-dimer for RA-PJI and OA-PJI and to compare the areas under the curves to assess the diagnostic efficacy of the optimal threshold values of serologic indices for RA-PJI. RESULTS The five year incidence of PJI was 6.92% in RA patients and 0.67% in OA patients. The optimal thresholds of CRP, ESR, and D-dimer for the diagnosis of RA-PJI were respectively 13.85 mg/L, 33.02 mm/h, and 796.50 ng/mL. The sensitivities of the optimal thresholds were respectively 67.6%, 62.2%, and 56.8%, and the specificities were 74.7%, 60.4%, and 74.4%. CONCLUSION RA patients have a higher incidence of PJI than OA patients. The optimal thresholds for CRP, ESR, and d-dimer for the diagnosis of PJI were higher in RA patients than in OA patients, but the sensitivity and specificity of the diagnosis were not as good as in OA patients.
Collapse
Affiliation(s)
- Hengxin Zhao
- Department of Orthopedic Surgery, The Affiliated Hospital of Qingdao University, Jiangsu Road 16, Qingdao, 266071, China
| | - Lianggang Li
- Department of Orthopedic Surgery, The Affiliated Hospital of Qingdao University, Jiangsu Road 16, Qingdao, 266071, China
| | - Hong-Yu Wang
- Department of Orthopedic Surgery, The Affiliated Hospital of Qingdao University, Jiangsu Road 16, Qingdao, 266071, China
| | - Lanfeng Ding
- Department of Orthopedic Surgery, The Affiliated Hospital of Qingdao University, Jiangsu Road 16, Qingdao, 266071, China
| | - Yuanhe Wang
- Department of Orthopedic Surgery, The Affiliated Hospital of Qingdao University, Jiangsu Road 16, Qingdao, 266071, China
| | - Xiaokai Liu
- Department of Orthopedic Surgery, The Affiliated Hospital of Qingdao University, Jiangsu Road 16, Qingdao, 266071, China
| | - Shaoqi Tian
- Department of Orthopedic Surgery, The Affiliated Hospital of Qingdao University, Jiangsu Road 16, Qingdao, 266071, China.
| | - Yan Wang
- Department of Gynecology, The Women and Children's Hospital of Qingdao, Tongfu Road 6, Qingdao, 266034, China.
| |
Collapse
|
|
4
|
Moja L, Zanichelli V, Mertz D, Gandra S, Cappello B, Cooke GS, Chuki P, Harbarth S, Pulcini C, Mendelson M, Tacconelli E, Ombajo LA, Chitatanga R, Zeng M, Imi M, Elias C, Ashorn P, Marata A, Paulin S, Muller A, Aidara-Kane A, Wi TE, Were WM, Tayler E, Figueras A, Da Silva CP, Van Weezenbeek C, Magrini N, Sharland M, Huttner B, Loeb M. WHO's essential medicines and AWaRe: recommendations on first- and second-choice antibiotics for empiric treatment of clinical infections. Clin Microbiol Infect 2024; 30 Suppl 2:S1-S51. [PMID: 38342438 DOI: 10.1016/j.cmi.2024.02.003] [Citation(s) in RCA: 24] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Revised: 01/26/2024] [Accepted: 02/04/2024] [Indexed: 02/13/2024]
Abstract
The WHO Model List of Essential Medicines (EML) prioritizes medicines that have significant global public health value. The EML can also deliver important messages on appropriate medicine use. Since 2017, in response to the growing challenge of antimicrobial resistance, antibiotics on the EML have been reviewed and categorized into three groups: Access, Watch, and Reserve, leading to a new categorization called AWaRe. These categories were developed taking into account the impact of different antibiotics and classes on antimicrobial resistance and the implications for their appropriate use. The 2023 AWaRe classification provides empirical guidance on 41 essential antibiotics for over 30 clinical infections targeting both the primary health care and hospital facility setting. A further 257 antibiotics not included on the EML have been allocated an AWaRe group for stewardship and monitoring purposes. This article describes the development of AWaRe, focussing on the clinical evidence base that guided the selection of Access, Watch, or Reserve antibiotics as first and second choices for each infection. The overarching objective was to offer a tool for optimizing the quality of global antibiotic prescribing and reduce inappropriate use by encouraging the use of Access antibiotics (or no antibiotics) where appropriate. This clinical evidence evaluation and subsequent EML recommendations are the basis for the AWaRe antibiotic book and related smartphone applications. By providing guidance on antibiotic prioritization, AWaRe aims to facilitate the revision of national lists of essential medicines, update national prescribing guidelines, and supervise antibiotic use. Adherence to AWaRe would extend the effectiveness of current antibiotics while helping countries expand access to these life-saving medicines for the benefit of current and future patients, health professionals, and the environment.
Collapse
Affiliation(s)
- Lorenzo Moja
- Health Products Policy and Standards, World Health Organization, Geneva, Switzerland.
| | - Veronica Zanichelli
- Health Products Policy and Standards, World Health Organization, Geneva, Switzerland
| | - Dominik Mertz
- Department of Medicine, McMaster University, Hamilton, Canada; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada; World Health Organization Collaborating Centre for Infectious Diseases, Research Methods and Recommendations, McMaster University, Hamilton, Canada
| | - Sumanth Gandra
- Division of Infectious Diseases, Department of Internal Medicine, Washington University School of Medicine in St. Louis, Missouri, United States
| | - Bernadette Cappello
- Health Products Policy and Standards, World Health Organization, Geneva, Switzerland
| | - Graham S Cooke
- Department of Infectious Diseases, Imperial College London, London, UK
| | - Pem Chuki
- Antimicrobial Stewardship Unit, Jigme Dorji Wangchuck National Referral Hospital, Thimphu, Bhutan
| | - Stephan Harbarth
- Infection Control Programme, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland; World Health Organization Collaborating Centre on Infection Prevention and Control and Antimicrobial Resistance, Geneva, Switzerland
| | - Celine Pulcini
- APEMAC, and Centre régional en antibiothérapie du Grand Est AntibioEst, Université de Lorraine, CHRU-Nancy, Nancy, France
| | - Marc Mendelson
- Division of Infectious Diseases and HIV Medicine, Department of Medicine, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - Evelina Tacconelli
- Infectious Diseases Unit, Department of Diagnostics and Public Health, University of Verona, Verona, Italy
| | - Loice Achieng Ombajo
- Department of Clinical Medicine and Therapeutics, University of Nairobi, Nairobi, Kenya; Center for Epidemiological Modelling and Analysis, University of Nairobi, Nairobi, Kenya
| | - Ronald Chitatanga
- Antimicrobial Resistance National Coordinating Centre, Public Health Institute of Malawi, Blantyre, Malawi
| | - Mei Zeng
- Department of Infectious Diseases, Children's Hospital of Fudan University, Shanghai, China
| | | | - Christelle Elias
- Service Hygiène et Epidémiologie, Hospices Civils de Lyon, Lyon, France; Centre International de Recherche en Infectiologie, Institut National de la Santé et de la Recherche Médicale U1111, Centre National de la Recherche Scientifique Unité Mixte de Recherche 5308, École Nationale Supérieure de Lyon, Université Claude Bernard Lyon 1, Lyon, France
| | - Per Ashorn
- Center for Child, Adolescent and Maternal Health Research, Faculty of Medicine and Health Technology, Tampere University and Tampere University Hospital, Tampere, Finland
| | | | - Sarah Paulin
- Antimicrobial Resistance Division, World Health Organization, Geneva, Switzerland
| | - Arno Muller
- Antimicrobial Resistance Division, World Health Organization, Geneva, Switzerland
| | | | - Teodora Elvira Wi
- Department of Global HIV, Hepatitis and STIs Programme, World Health Organization, Geneva, Switzerland
| | - Wilson Milton Were
- Department of Maternal, Newborn, Child and Adolescent Health and Ageing, World Health Organization, Geneva, Switzerland
| | - Elizabeth Tayler
- WHO Regional Office for the Eastern Mediterranean (EMRO), World Health Organisation, Cairo, Egypt
| | | | - Carmem Pessoa Da Silva
- Antimicrobial Resistance Division, World Health Organization, Geneva, Switzerland; Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | | | - Nicola Magrini
- NHS Clinical Governance, Romagna Health Authority, Ravenna, Italy; World Health Organization Collaborating Centre for Evidence Synthesis and Guideline Development, Bologna, Italy
| | - Mike Sharland
- Centre for Neonatal and Paediatric Infections, Institute for Infection and Immunity, St George's University of London, London, UK
| | - Benedikt Huttner
- Health Products Policy and Standards, World Health Organization, Geneva, Switzerland
| | - Mark Loeb
- Department of Medicine, McMaster University, Hamilton, Canada; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada; World Health Organization Collaborating Centre for Infectious Diseases, Research Methods and Recommendations, McMaster University, Hamilton, Canada
| |
Collapse
|
|
5
|
Yang K, Sambandam S. Total hip arthroplasty in patients with colostomy: impact on inpatient complications, hospital costs, and length of stay. Arch Orthop Trauma Surg 2024; 144:509-516. [PMID: 37755481 DOI: 10.1007/s00402-023-05060-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Accepted: 09/01/2023] [Indexed: 09/28/2023]
Abstract
INTRODUCTION The presence of permanent end-colostomy is traditionally thought of as a risk factor for complications following orthopedic joint replacement; however, literature supporting this association is scarce. This study aims to discern how length of stay, cost of stay, and inpatient complications following total hip arthroplasty (THA) are impacted by presence of colostomy. METHODS Data from the National Inpatient Sample was analyzed by International Classification of Diseases, 10th Revision, Clinical Modification regarding THA in patients with and without end-colostomy. Unmatched and matched analyses comparing length of stay, cost of stay, and post-operative adverse outcomes between the two groups were conducted. In the unmatched analysis, 445 THA patients with colostomy were compared to 367,449 THA patients without colostomy. The colostomy patients were then matched for age, sex, race, diabetes, obesity, and the matched groups consisted of 445 patients with and 425 patients without colostomy, respectively. RESULTS Compared to the THA without colostomy group, the colostomy group was significantly older, had longer hospital stays, and greater cost of stay. When matched for age and comorbidities, length of hospital stay (p < 0.001) and cost of stay (p = 0.002) remained significantly higher. The colostomy group was at significantly increased risk for periprosthetic fracture, dislocation, and infection compared to all THA patients. When matched for age and common comorbidities, the colostomy group had significantly higher risk in only periprosthetic dislocation [p = 0.003, OR 11.8 (1.6-4.6, 95% CI)] and periprosthetic infection [p < 0.05, OR 2.7 (0.97-7.7 95% CI)]. CONCLUSION Patients with colostomy are at risk of longer hospital courses and greater incurred costs following THA compared to patients without colostomy. They are additionally at significantly increased risk of periprosthetic dislocation and periprosthetic infection, warranting treatment as high-risk patients. STUDY DESIGN Retrospective cohort study.
Collapse
Affiliation(s)
- Kristine Yang
- University of Texas Southwestern Medical Center, Dallas, TX, USA.
| | | |
Collapse
|
|
6
|
Soares do Brito J, Esperança Martins M, Goes R, Spranger A, Almeida P, Fernandes I, Portela J. Closed-incision negative-pressure wound therapy (ciNPWT) to minimize wound-related complications in lower limb reconstruction after bone tumor resection: preliminary proof-of-concept study. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2023; 33:2895-2902. [PMID: 36897409 DOI: 10.1007/s00590-023-03501-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Accepted: 02/26/2023] [Indexed: 03/11/2023]
Abstract
AIMS The purpose of this study was to compare the impact of postoperative closed-incision negative-pressure wound therapy (ciNPWT) and conventional dressings in wound-related complications after bone tumor resection and reconstruction. PATIENTS AND METHODS A total of 50 patients with bone tumors and clinical indication for wide resection and reconstruction were included and divided into two groups (A and B). Bone defect reconstructions were achieved with modular endoprosthesis or biologic techniques, mainly involving allografts with free vascularized fibula. Group A received ciNPWT, and Group B conventional dressings. Wound-related complications, including wound dehiscence, persistent wound leakage, surgical site infections (SSIs), and causes for surgical revision, were assessed. RESULTS Nineteen patients were included in Group A and 31 in Group B. No significant differences were found between groups regarding epidemiologic and clinical presentation features, contrarily to reconstructive options, which were significantly different between both (Fisher = 10,100; p = 0.005). Additionally, Group A presented lower wound dehiscence rate (0 vs. 19.4%; χ2(1) = 4.179; p = 0.041), SSI rate (0 vs. 19.4%; χ2(1) = 4.179; p = 0.041), and surgical revision rate (5.3% vs. 32.3%; χ2(1) = 5.003; p = 0.025) compared to Group B. CONCLUSIONS This is the first study reporting the impact of ciNPWT after bone tumor resection and reconstruction, and its results support a potential role for this technique in diminishing postoperative wound complications and SSIs. A multicentric randomized controlled trial may help clarify the role and impact of ciNPWT after bone tumor resection and reconstruction.
Collapse
Affiliation(s)
- Joaquim Soares do Brito
- Department of Orthopedics and Trauma, Centro Hospitalar Universitário Lisboa Norte, 1649-028, Lisbon, Portugal.
| | - Miguel Esperança Martins
- Department of Medical Oncology, Centro Hospitalar Universitário Lisboa Norte, 1649-028, Lisbon, Portugal
- Translational Oncobiology Laboratory, Instituto de Medicina Molecular - João Lobo Antunes, Faculdade de Medicina de Lisboa, 1649-028, Lisbon, Portugal
| | - Rodrigo Goes
- Department of Orthopedics and Trauma, Centro Hospitalar Universitário Lisboa Norte, 1649-028, Lisbon, Portugal
| | - André Spranger
- Department of Orthopedics and Trauma, Centro Hospitalar Universitário Lisboa Norte, 1649-028, Lisbon, Portugal
| | - Paulo Almeida
- Department of Orthopedics and Trauma, Centro Hospitalar Universitário Lisboa Norte, 1649-028, Lisbon, Portugal
| | - Isabel Fernandes
- Department of Medical Oncology, Centro Hospitalar Universitário Lisboa Norte, 1649-028, Lisbon, Portugal
- Translational Oncobiology Laboratory, Instituto de Medicina Molecular - João Lobo Antunes, Faculdade de Medicina de Lisboa, 1649-028, Lisbon, Portugal
| | - José Portela
- Department of Orthopedics and Trauma, Centro Hospitalar Universitário Lisboa Norte, 1649-028, Lisbon, Portugal
| |
Collapse
|
|
7
|
Abedi AA, Varnum C, Pedersen AB, Gromov K, Hallas J, Iversen P, Jakobsen T, Jimenez-Solem E, Kidholm K, Kjerulf A, Lange J, Odgaard A, Rosenvinge FS, Solgaard S, Sperling K, Stegger M, Christensen R, Overgaard S. Effect of single versus multiple prophylactic antibiotic doses on prosthetic joint infections following primary total hip arthroplasty in patients with osteoarthritis at public and private hospitals in Denmark: protocol for a nationwide cross-over, cluster randomised, non-inferiority trial [The Pro-Hip-Quality Trial]. BMJ Open 2023; 13:e071487. [PMID: 37604637 PMCID: PMC10445366 DOI: 10.1136/bmjopen-2022-071487] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Accepted: 06/21/2023] [Indexed: 08/23/2023] Open
Abstract
INTRODUCTION A feared complication after total hip arthroplasty (THA) is prosthetic joint infection (PJI), associated with high morbidity and mortality. Prophylactic antibiotics can reduce the risk of PJI. However, there is no consensus on the dosages and current recommendations are based on a low evidence level. The objective is to compare the effect of a single versus multiple doses of prophylactic antibiotics administered within 24 hours on PJI. METHODS AND ANALYSIS The study is designed as a cross-over, cluster randomised, non-inferiority trial. All clinical centres use both antibiotic practices (1 year of each intervention). All Danish orthopaedic surgery departments will be involved: Based on quality databases, 2-year cohorts of approximately 20 000 primary THAs conducted at 39 public and private hospitals, will be included. INCLUSION CRITERIA age ≥18 years, all indications for THA except patients operated due to acute or sequelae from proximal femoral or pelvic fractures or bone tumour or metastasis. The primary outcome is PJI within 90 days after primary THA. Secondary outcomes include (1) serious adverse events, (2) potential PJI, (3) length of hospitalisation stay, (4) cardiovascular events, (5) hospital-treated infections, (6) community-based antibiotic use, (7) opioid use and (8) use of acetaminophen and non-steroidal anti-inflammatory drugs. All outcome measures will be extracted from national databases. Analyses will be based on the intention-to-treat population. Non-inferiority will be shown if the upper limit of the two-sided 95% CI for the OR is less than 1.32 for the single dose as compared with multiple doses. The results will establish best practice on antibiotic prophylaxis dosages in the future. ETHICS AND DISSEMINATION This study has been approved by Committees on Health Research Ethics for The Capital Region of Denmark (21069108) and The Danish Medicines Agency (2021091723). All results will be presented in peer-reviewed medical journals and international conferences. TRIAL REGISTRATION NUMBER NCT05530551.
Collapse
Affiliation(s)
- Armita Armina Abedi
- Department of Orthopedic Surgery and Traumatology, Copenhagen University Hospital Bispebjerg, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen Faculty of Health and Medical Sciences, Copenhagen, Denmark
| | - Claus Varnum
- Department of Orthopedics, Lillebaelt Hospital - University Hospital Southern Denmark, Vejle, Denmark
- Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | - Alma Becic Pedersen
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | - Kirill Gromov
- Department of Orthopedic Surgery, Copenhagen University Hospital, Hvidovre Hospital, Hvidovre, Denmark
| | - Jesper Hallas
- Department of Public Health, Clinical Pharmacology, Pharmacy, and Environmental Medicine, University of Southern Denmark, Odense, Denmark
| | - Pernille Iversen
- The Danish Clinical Quality Program- National Clinical Registries (RKKP), Copenhagen, Denmark
| | - Thomas Jakobsen
- Department of Orthopedics, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Espen Jimenez-Solem
- Department of Clinical Pharmacology, Bispebjerg Hospital, Copenhagen, Denmark
| | - Kristian Kidholm
- Centre for Innovative Medical Technology, Odense Universitetshospital, Odense, Denmark
| | - Anne Kjerulf
- Infectious Disease Epidemiology & Prevention, Statens Serum Institut, Copenhagen, Denmark
| | - Jeppe Lange
- Department of Orthopedic Surgery, Regional Hospital Horsens, Horsens, Denmark
- Department of Clinical Medicine, Århus Universitet Klinisk Institut, Aarhus, Denmark
| | - Anders Odgaard
- Department of Orthopaedic Surgery, Rigshospitalet, Copenhagen, Denmark
| | | | - Søren Solgaard
- Department of Hip and Knee Surgery, Copenhagen University Hospital, Herlev-Gentofte University Hospital, Hellerup, Denmark
| | - Kim Sperling
- Department of Orthopedic Surgery, Nastved Hospital, Nastved, Denmark
| | - Marc Stegger
- Department of Microbiological Surveillance and Research, Statens Serum Institut, Copenhagen, Denmark
| | - Robin Christensen
- Parker Institute, Frederiksberg and Bispebjerg Hospital, Copenhagen, Denmark
| | - Søren Overgaard
- Department of Orthopedic Surgery and Traumatology, Copenhagen University Hospital Bispebjerg, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen Faculty of Health and Medical Sciences, Copenhagen, Denmark
| |
Collapse
|
|
8
|
Böhle S, Vogel AM, Matziolis G, Strube P, Rohe S, Brodt S, Mastrocola M, Eijer H, Rödel J, Lindemann C. Comparison of two different antiseptics regarding intracutaneous microbial load after preoperative skin cleansing in total knee and hip arthroplasties. Sci Rep 2022; 12:18246. [PMID: 36309598 PMCID: PMC9617848 DOI: 10.1038/s41598-022-23070-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Accepted: 10/25/2022] [Indexed: 12/31/2022] Open
Abstract
Periprosthetic infections (PPIs) are a serious concern in total knee and hip arthroplasty, and they have an increasing incidence. To prevent PPI, preoperative skin disinfection, as a key element of antisepsis, represents an important part of infection prevention. However, no specific antiseptic agent is endorsed by the relevant guidelines. The purpose of this retrospective, not randomized study was to investigate the difference in the residual bacteria load between an approved antiseptic with an alcohol-based solution with additional benzalkonium chloride (BAC) and an alcohol-based solution with additional octenidine dihydrochloride (OCT) at two different time periods. In 200 consecutive patients with total knee or hip arthroplasty, skin samples from the surgical sites were collected after skin disinfection with BAC (100 g solution contain: propan-2-ol 63.0 g, benzalkonium chloride 0.025 g) or OCT (100 g solution contain: octenidine dihydrochloride 0.1 g, propan-1-ol, 30.0 g, propan-2-ol 45.0 g) (100 patients per group). Following the separation of cutis and subcutis and its processing, culture was performed on different agar plates in aerobic and anaerobic environments. In the case of bacteria detection, the microbial identification was determined by matrix-assisted laser desorption ionization-time of flight mass spectrometry (MALDI-TOF MS), and the number of contaminated samples was compared between the groups. Additionally, multiple regression analysis was performed to examine the effect of the type of disinfectant, BMI, age, sex, rheumatoid arthritis, diabetes mellitus, skin disorders, smoking status, and localization of skin samples on positive bacteria detection. A total of 34 samples were positive for bacteria in the BAC group, while only 17 samples were positive in the OCT group (p = 0.005). Disinfectant type was the only significant parameter in the multiple regression analysis (p = 0.006). A significantly higher contamination rate of the subcutis was shown in the BAC group compared to the OCT group (19 vs. 9, p = 0,003). After the change from BAC to OCT in preoperative skin cleansing in the hip and knee areas, the number of positive cultures decreased by 50%, which might have been caused by a higher microbicidal activity of OCT. Therefore, the use of OCT in preoperative cleansing may reduce the risk of PPI in hip and knee surgery. Randomized controlled trials are required to confirm the effect and to evaluate if it reduces the risk of PPI.
Collapse
Affiliation(s)
- Sabrina Böhle
- Orthopaedic Department of the Waldkliniken Eisenberg, Orthopaedic Professorship of the University Hospital Jena, Campus Eisenberg, Klosterlausnitzer Straße 81, 07607 Eisenberg, Germany
| | - Anna-Maria Vogel
- Orthopaedic Department of the Waldkliniken Eisenberg, Orthopaedic Professorship of the University Hospital Jena, Campus Eisenberg, Klosterlausnitzer Straße 81, 07607 Eisenberg, Germany
| | - Georg Matziolis
- Orthopaedic Department of the Waldkliniken Eisenberg, Orthopaedic Professorship of the University Hospital Jena, Campus Eisenberg, Klosterlausnitzer Straße 81, 07607 Eisenberg, Germany
| | - Patrick Strube
- Orthopaedic Department of the Waldkliniken Eisenberg, Orthopaedic Professorship of the University Hospital Jena, Campus Eisenberg, Klosterlausnitzer Straße 81, 07607 Eisenberg, Germany
| | - Sebastian Rohe
- Orthopaedic Department of the Waldkliniken Eisenberg, Orthopaedic Professorship of the University Hospital Jena, Campus Eisenberg, Klosterlausnitzer Straße 81, 07607 Eisenberg, Germany
| | - Steffen Brodt
- Orthopaedic Department of the Waldkliniken Eisenberg, Orthopaedic Professorship of the University Hospital Jena, Campus Eisenberg, Klosterlausnitzer Straße 81, 07607 Eisenberg, Germany
| | - Mario Mastrocola
- Department of Orthopaedic Surgery, Spital Emmental, Oberburgstrasse 54, 3400 Burgdorf, Switzerland
| | - Henk Eijer
- Department of Orthopaedic Surgery, Spital Emmental, Oberburgstrasse 54, 3400 Burgdorf, Switzerland
| | - Jürgen Rödel
- grid.275559.90000 0000 8517 6224Institute of Medical Microbiology, Jena University Hospital, 07747 Jena, Germany
| | - Chris Lindemann
- Orthopaedic Department of the Waldkliniken Eisenberg, Orthopaedic Professorship of the University Hospital Jena, Campus Eisenberg, Klosterlausnitzer Straße 81, 07607 Eisenberg, Germany
| |
Collapse
|
|
9
|
MUKKA S, HAILER NP, MÖLLER M, GORDON M, LAZARINIS S, ROGMARK C, ÖSTLUND O, SKÖLDENBERG O, WOLF O. Study protocol: The DAICY trial-dual versus single-antibiotic impregnated cement in primary hemiarthroplasty for femoral neck fracture-a register-based cluster-randomized crossover-controlled trial. Acta Orthop 2022; 93:794-800. [PMID: 36200646 PMCID: PMC9535850 DOI: 10.2340/17453674.2022.4819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND AND PURPOSE Older patients with a displaced femoral neck fracture (FNF) are often treated with a cemented primary hemiarthroplasty (HA). The DAICY trial investigates whether high-dose dual-impregnated antibioticloaded cement (DIAC) including gentamicin and clindamycin can reduce the risk of periprosthetic joint infection (PJI) in comparison with low-dose single-impregnated gentamicin antibiotic-loaded cement (SIAC), in patients ≥ 60 years treated with a cemented HA for a displaced FNF. STUDY DESIGN The trial is a national, multicenter, register-based, cluster-randomized, crossover trial. Patients ≥ 60 years with a non-pathological, displaced FNF (Type Garden 3-4/AO 31-B2 or B3) suitable for HA according to local guidelines are eligible for inclusion. Participating orthopedic departments will be randomized to start with either SIAC (control group) or DIAC treatment (intervention group) for 2 years. After 2 years, the study departments will then change to the other treatment arm for the remaining 2 years of the study. Approximately 7,000 patients will be included. The study is pragmatic in that the choice of implant brands, surgical approach and peri- and postoperative protocols follow the local routines of each participating department. All outcome variables will be retrieved after linkage of the study cohort to the following Swedish registers: the Fracture Register, the Arthroplasty Register, the National Patient Register and the Prescribed Drug Registry Outcome: The primary outcome will be periprosthetic joint infection of the index joint within 1 year after surgery. Secondary outcomes will be any reoperation on the index joint, mortality within 90 days and 1 year, resistance patterns of causative bacteria in cases of PJI, and health economics. Potential added value: This trial is designed to support or refute the efficacy of DIAC used in patients with a displaced FNF, potentially reducing PJI and resource allocation. Start of the trial and estimated duration - The DAICY trial started recruiting patients in January 2022 and will continue recruiting for approximately 4 years. Complete follow-up expected in 5 years.
Collapse
Affiliation(s)
- Sebastian MUKKA
- Department of Surgical and Perioperative Science (Orthopaedics), Umeå University, Umeå
| | - Nils P HAILER
- Department of Surgical Sciences, Orthopaedics, Uppsala University, Uppsala
| | - Michael MÖLLER
- Institute of Clinical Science, Sahlgrenska Academy, University of Gothenburg, Gothenburg,Swedish Fracture Register, Registercentrum Västra Götaland, Gothenburg
| | - Max GORDON
- Department of Clinical Sciences at Danderyd Hospital, Division of Orthopaedics, Karolinska Institutet, Stockholm
| | - Stergios LAZARINIS
- Department of Surgical Sciences, Orthopaedics, Uppsala University, Uppsala
| | - Cecilia ROGMARK
- Department of Orthopedics, Lund University, Skåne University Hospital, Malmö,Swedish Arthroplasty Register, Registercentrum Västra Götaland, Gothenburg
| | | | - Olof SKÖLDENBERG
- Department of Clinical Sciences at Danderyd Hospital, Division of Orthopaedics, Karolinska Institutet, Stockholm
| | - Olof WOLF
- Department of Surgical Sciences, Orthopaedics, Uppsala University, Uppsala,Swedish Fracture Register, Registercentrum Västra Götaland, Gothenburg
| | | |
Collapse
|
|
10
|
Kajal S, Mishra A, Gupta P, Kumar Kairo A. Duration of Antibiotic Prophylaxis for Cochlear Implantation: A Systematic Review. J Int Adv Otol 2022; 18:269-275. [PMID: 35608498 PMCID: PMC10682799 DOI: 10.5152/iao.2022.21454] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Accepted: 08/26/2021] [Indexed: 11/30/2023] Open
Abstract
Antibiotic prophylaxis is commonly given to all patients undergoing cochlear implant surgery. However, currently, there is no consensus if pro- phylactic usage of antibiotics in cochlear implantation accords any benefit and if the duration of such use varies according to the surgeon's experience or institutional preference. A systematic review was conducted to gather evidence on ideal duration for antibiotic prophylaxis rec- ommended for patients undergoing cochlear implantation. We registered the protocol in the International Prospective Register of Systematic Reviews (CRD42021235079) and reported the systematic review following the Preferred Reporting Items for Systematic Reviews and Meta- Analysis statement. Of the 278 screened articles, 6 full-text original articles satisfied the inclusion criteria and were included. There were a total of 2081 participants in these 6 retrospective studies and all studies except 1 included both adult and pediatric populations. Antibiotic therapy was given as intervention, either as single dose or multiple doses, and compared with other group(s) receiving either no antibiotic prophylaxis or a different duration of prophylaxis. Three studies did not find any significant difference between infection rates when a different duration of antibiotic prophylaxis was given, while 2 studies found a single dose to be more efficacious, and yet another study concluded that a longer dura- tion of antibiotic prophylaxis was more beneficial. Based on the available data, the ideal duration of post-operative antibiotic therapy to be given after cochlear implant surgery could not be defined. However, administrating a single dose of intraoperative antibiotic seems to be the most consistent practice so far.
Collapse
Affiliation(s)
- Smile Kajal
- Department of Otorhinolaryngology & Head-Neck Surgery, All India Institute of Medical Sciences, New Delhi, India
| | - Archana Mishra
- Department of Pharmacology, All India Institute of Medical Sciences, New Delhi, India
| | - Pooja Gupta
- Department of Pharmacology, All India Institute of Medical Sciences, New Delhi, India
| | - Arvind Kumar Kairo
- Department of Otorhinolaryngology & Head-Neck Surgery, All India Institute of Medical Sciences, New Delhi, India
| |
Collapse
|
|
11
|
Ghert M, Schneider P, Guyatt G, Thabane L, Vélez R, O'Shea T, Randall RL, Turcotte R, Wilson D, Wunder JS, Baptista AM, Cheng EY, Doung YC, Ferguson PC, Giglio V, Hayden J, Heels-Ansdell D, Khan SA, Sampath Kumar V, McKay P, Miller B, van de Sande M, Zumárraga JP, Bhandari M. Comparison of Prophylactic Intravenous Antibiotic Regimens After Endoprosthetic Reconstruction for Lower Extremity Bone Tumors: A Randomized Clinical Trial. JAMA Oncol 2022; 8:345-353. [PMID: 34989778 PMCID: PMC8739829 DOI: 10.1001/jamaoncol.2021.6628] [Citation(s) in RCA: 43] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Question Can a 5-day regimen of postoperative, prophylactic, intravenous antibiotics reduce the rate of surgical site infections in patients with a lower extremity bone tumor undergoing complex endoprosthetic reconstruction compared with a 1-day regimen? Findings In this randomized clinical trial including 604 patients in the primary analysis, the 5-day regimen did not reduce the rate of surgical site infection compared with the 1-day regimen, although it resulted in a higher rate of antibiotic-related complications, notably Clostridioides difficile–associated colitis. Meaning The results of this study suggest that prolonging use of postoperative antibiotics beyond 1 day does not reduce the rate of surgical site infection but increases the risk of clinically significant antibiotic-related complications. Importance The use of perioperative, prophylactic, intravenous antibiotics is standard practice to reduce the risk of surgical site infection after oncologic resection and complex endoprosthetic reconstruction for lower extremity bone tumors. However, evidence guiding the duration of prophylactic treatment remains limited. Objective To assess the effect of a 5-day regimen of postoperative, prophylactic, intravenous antibiotics compared with a 1-day regimen on the rate of surgical site infections within 1 year after surgery. Design, Setting, and Participants This randomized clinical superiority trial was performed at 48 clinical sites in 12 countries from January 1, 2013, to October 29, 2019. The trial included patients with a primary bone tumor or a soft tissue sarcoma that had invaded the femur or tibia or oligometastatic bone disease of the femur or tibia with expected survival of at least 1 year who required surgical management by excision and endoprosthetic reconstruction. A total of 611 patients were enrolled, and 7 were excluded for ineligibility. Interventions A 1- or 5-day regimen of postoperative prophylactic intravenous cephalosporin (cefazolin or cefuroxime) that began within 8 hours after skin closure and was administered every 8 hours thereafter. Those randomized to the 1-day regimen received identical saline doses every 8 hours for the remaining 4 days; patients, care providers, and outcomes assessors were blinded to treatment regimen. Main Outcomes and Measures The primary outcome in this superiority trial was a surgical site infection (superficial incisional, deep incisional, or organ space) classified according to the criteria established by the Centers for Disease Control and Prevention within 1 year after surgery. Secondary outcomes included antibiotic-related complications, unplanned additional operations, oncologic and functional outcomes, and mortality. Results Of the 604 patients included in the final analysis (mean [SD] age, 41.2 [21.9] years; 361 [59.8%] male; 114 [18.9%] Asian, 43 [7.1%] Black, 34 [5.6%] Hispanic, 15 [2.5%] Indigenous, 384 [63.8%] White, and 12 [2.0%] other), 293 were randomized to a 5-day regimen and 311 to a 1-day regimen. A surgical site infection occurred in 44 patients (15.0%) allocated to the 5-day regimen and in 52 patients (16.7%) allocated to the 1-day regimen (hazard ratio, 0.93; 95% CI, 0.62-1.40; P = .73). Antibiotic-related complications occurred in 15 patients (5.1%) in the 5-day regimen and in 5 patients (1.6%) allocated to the 1-day regimen (hazard ratio, 3.24; 95% CI, 1.17-8.98; P = .02). Other secondary outcomes did not differ significantly between treatment groups. Conclusions and Relevance This randomized clinical trial did not confirm the superiority of a 5-day regimen of postoperative intravenous antibiotics over a 1-day regimen in preventing surgical site infections after surgery for lower extremity bone tumors that required an endoprosthesis. The 5-day regimen group had significantly more antibiotic-related complications. Trial Registration ClinicalTrials.gov Identifier: NCT01479283
Collapse
Affiliation(s)
| | - Michelle Ghert
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Patricia Schneider
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Gordon Guyatt
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada.,Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Lehana Thabane
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Roberto Vélez
- Hospital Vall d'Hebron, Vall d'Hebron Institut de Recerca, Barcelona, Spain
| | - Timothy O'Shea
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - R Lor Randall
- Department of Orthopaedic Surgery, University of California Davis Health, Sacramento
| | - Robert Turcotte
- Division of Orthopaedic Surgery, Department of Surgery, McGill University, Montreal, Quebec, Canada
| | - David Wilson
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Jay S Wunder
- University of Toronto Musculoskeletal Oncology Unit, Mount Sinai Hospital, Division of Orthopaedic Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - André Mathias Baptista
- Instituto de Ortopedia e Traumatologia do Hospital das Clínicas da Universidade de São Paulo, São Paulo, Brazil
| | - Edward Y Cheng
- Department of Orthopaedic Surgery, University of Minnesota, Minneapolis
| | - Yee-Cheen Doung
- Department of Orthopaedics and Rehabilitation, Oregon Health & Science University, Portland
| | - Peter C Ferguson
- University of Toronto Musculoskeletal Oncology Unit, Mount Sinai Hospital, Division of Orthopaedic Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Victoria Giglio
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - James Hayden
- Department of Orthopaedics and Rehabilitation, Oregon Health & Science University, Portland
| | - Diane Heels-Ansdell
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Shah Alam Khan
- Department of Orthopaedics, All India Institute of Medical Sciences, Delhi, India
| | | | - Paula McKay
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Benjamin Miller
- Department of Orthopaedics and Rehabilitation, University of Iowa, Iowa City
| | - Michiel van de Sande
- Department of Orthopaedic Surgery, Leids Universitair Medisch Centrum, Leiden, the Netherlands
| | - Juan P Zumárraga
- Instituto de Ortopedia e Traumatologia do Hospital das Clínicas da Universidade de São Paulo, São Paulo, Brazil
| | - Mohit Bhandari
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada.,Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| |
Collapse
|
|
12
|
Lei Z, Zhang H, Zhang E, You J, Ma X, Bai X. Antibacterial activities and cell responses of Ti-Ag alloys with a hybrid micro- to nanostructured surface. J Biomater Appl 2021; 34:1368-1380. [PMID: 32264765 DOI: 10.1177/0885328220905103] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Zeming Lei
- Hand Surgery Ward, Central Hospital Attached to Shenyang Medical College, Shenyang, China.,Department of Orthopedics and Sports Medicine and Joint Surgery, The People's Hospital of China Medical University, Shenyang, China
| | - Hangzhou Zhang
- Department of Orthopedics and Sports Medicine and Joint Surgery, The First Affiliated Hospital of China Medical University, Shenyang, China
| | - Erlin Zhang
- Key Laboratory for Anisotropy and Texture of Materials (ATM), Education Ministry of China, School of Material Science and Engineering, Northeastern University, Shenyang, China
| | - Junhua You
- School of Materials Science and Engineering, Shenyang University of Technology, Shenyang, China
| | - Xiaoxue Ma
- Department of Medical Microbiology and Parasitology, College of Basic Medical Sciences, China Medical University, Shenyang, China
| | - Xizhuang Bai
- Department of Orthopedics and Sports Medicine and Joint Surgery, The People's Hospital of China Medical University, Shenyang, China
| |
Collapse
|
|
13
|
|
|
14
|
Christensen DD, Moschetti WE, Brown MG, Lucas AP, Jevsevar DS, Fillingham YA. Perioperative Antibiotic Prophylaxis: Single and 24-Hour Antibiotic Dosages are Equally Effective at Preventing Periprosthetic Joint Infection in Total Joint Arthroplasty. J Arthroplasty 2021; 36:S308-S313. [PMID: 33712358 DOI: 10.1016/j.arth.2021.02.037] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2020] [Revised: 02/08/2021] [Accepted: 02/11/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Perioperative antibiotic prophylaxis is used to prevent surgical site infection and periprosthetic joint infection (PJI) after total joint arthroplasty (TJA). Secondary to a national shortage of cefazolin, patients at our institution began receiving a single preoperative prophylactic antibiotic dose for primary TJA and no 24-hour postoperative antibiotic prophylaxis. The purpose of the study was to compare the efficacy of single-dose antibiotic use versus 24-hour dosing of prophylactic antibiotics in the prevention of acute PJI and short-term complications after primary TJA. METHODS A retrospective review of 3317 patients undergoing primary TJA performed from January 2015 to December 2019 identified 554 patients who received a single dose of preoperative antibiotic prophylaxis during the antibiotic shortage and 2763 patients who received post-TJA 24-hour antibiotic prophylaxis before the shortage. Patient records were evaluated for acute PJI, superficial infection, 90-day reoperation, and 90-day complications. RESULTS There were no significant differences in patient characteristics between single-dose and 24-hour antibiotic groups. Similarly, there were no significant differences in rates of acute PJI (0.7% vs 0.2%; P = .301), superficial infection (2.4% vs 1.4%; P = .221), 90-day reoperation (2.1% vs 1.1%; P = .155), and 90-day complications (9.9% vs 7.9%; P = .169) between single and 24-hour antibiotic dose. Post hoc power analysis demonstrated adequate sample size, beta = 93%. CONCLUSION Single-dose prophylactic antibiotics did not lead to an increased risk of acute PJI or short-term complications after TJA. Our study suggests that administration of a single antibiotic dose may be safely considered in patients undergoing routine primary TJA.
Collapse
Affiliation(s)
- David D Christensen
- Dartmouth Hitchcock Medical Center, Lebanon, NH; Dartmouth College Geisel School of Medicine, Hanover, NH
| | - Wayne E Moschetti
- Dartmouth Hitchcock Medical Center, Lebanon, NH; Dartmouth College Geisel School of Medicine, Hanover, NH
| | - Marcel G Brown
- Dartmouth College Geisel School of Medicine, Hanover, NH
| | | | - David S Jevsevar
- Dartmouth Hitchcock Medical Center, Lebanon, NH; Dartmouth College Geisel School of Medicine, Hanover, NH
| | - Yale A Fillingham
- Dartmouth Hitchcock Medical Center, Lebanon, NH; Dartmouth College Geisel School of Medicine, Hanover, NH
| | | |
Collapse
|
|
15
|
Bourazani M, Asimakopoulou E, Magklari C, Fyrfiris N, Tsirikas I, Diakoumis G, Kelesi M, Fasoi G, Kormas T, Lefaki G. Developing an enhanced recovery after surgery program for oncology patients who undergo hip or knee reconstruction surgery. World J Orthop 2021; 12:346-359. [PMID: 34189073 PMCID: PMC8223725 DOI: 10.5312/wjo.v12.i6.346] [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: 11/30/2020] [Revised: 04/20/2021] [Accepted: 05/07/2021] [Indexed: 02/06/2023] Open
Abstract
Enhanced recovery after surgery (ERAS) protocols are applied in orthopedic surgery and are intended to reduce perioperative stress by implementing combined evidence-based practices with the cooperation of various health professionals as an interdisciplinary team. ERAS pathways include pre-operative patient counselling, regional anesthesia and analgesia techniques, post-operative pain management, early mobilization and early feeding. Studies have shown improvement in the recovery of patients who followed an ERAS program after hip or knee arthroplasty, compared with those who followed a traditional care approach. ERAS protocols reduce post-operative stress, contribute to rapid recovery, shorten length of stay (LOS) without increasing the complications or readmissions, improve patient satisfaction and decrease the hospital costs. We suggest that the ERAS pathway could reduce the LOS in hospital for patients undergoing total hip replacement or total knee replacement. These programs require good organization and handling by the multidisciplinary team. ERAS programs increase patient's satisfaction due to their active participation which they experience as personalized treatment. The aim of the study was to develop an ERAS protocol for oncology patients who undergo bone reconstruction surgeries using massive endoprosthesis, with a view to improving the surgical outcomes.
Collapse
Affiliation(s)
- Maria Bourazani
- Department of Anesthesiology, “Saint-Savvas” Anticancer Hospital of Athens, Athens 11522, Attica, Greece
- Department of Nursing, University of West Attica, Athens 12243, Attica, Greece
| | - Eleni Asimakopoulou
- Department of Anesthesiology, “Saint-Savvas” Anticancer Hospital of Athens, Athens 11522, Attica, Greece
| | - Chrysseida Magklari
- Department of Anesthesiology, “Saint-Savvas” Anticancer Hospital of Athens, Athens 11522, Attica, Greece
| | - Nikolaos Fyrfiris
- Department of Anesthesiology, “Saint-Savvas” Anticancer Hospital of Athens, Athens 11522, Attica, Greece
| | | | - Giakoumis Diakoumis
- Orthopedic Clinic, “Saint-Savvas” Anticancer Hospital of Athens, Athens 11522, Attica, Greece
| | - Martha Kelesi
- Department of Nursing, University of West Attica, Athens 12243, Attica, Greece
| | - Georgia Fasoi
- Department of Nursing, University of West Attica, Athens 12243, Attica, Greece
| | - Theodoros Kormas
- Orthopedic Clinic, “Saint-Savvas” Anticancer Hospital of Athens, Athens 11522, Attica, Greece
| | - Gunhild Lefaki
- Department of Anesthesiology, “Saint-Savvas” Anticancer Hospital of Athens, Athens 11522, Attica, Greece
| |
Collapse
|
|
16
|
Specific detection of Staphylococcus aureus infection and marker for Alzheimer disease by surface enhanced Raman spectroscopy using silver and gold nanoparticle-coated magnetic polystyrene beads. Sci Rep 2021; 11:6240. [PMID: 33737512 PMCID: PMC7973519 DOI: 10.1038/s41598-021-84793-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Accepted: 02/17/2021] [Indexed: 12/12/2022] Open
Abstract
Targeted and effective therapy of diseases demands utilization of rapid methods of identification of the given markers. Surface enhanced Raman spectroscopy (SERS) in conjunction with streptavidin-biotin complex is a promising alternative to culture or PCR based methods used for such purposes. Many biotinylated antibodies are available on the market and so this system offers a powerful tool for many analytical applications. Here, we present a very fast and easy-to-use procedure for preparation of streptavidin coated magnetic polystyrene-Au (or Ag) nanocomposite particles as efficient substrate for surface SERS purposes. As a precursor for the preparation of SERS active and magnetically separable composite, commercially available streptavidin coated polystyrene (PS) microparticles with a magnetic core were utilized. These composites of PS particles with silver or gold nanoparticles were prepared by reducing Au(III) or Ag(I) ions using ascorbic acid or dopamine. The choice of the reducing agent influences the morphology and the size of the prepared Ag or Au particles (15-100 nm). The prepare composites were also characterized by HR-TEM images, mapping of elements and also magnetization measurements. The content of Au and Ag was determined by AAS analysis. The synthesized composites have a significantly lower density against magnetic composites based on iron oxides, which considerably decreases the tendency to sedimentation. The polystyrene shell on a magnetic iron oxide core also pronouncedly reduces the inclination to particle aggregation. Moreover, the preparation and purification of this SERS substrate takes only a few minutes. The PS composite with thorny Au particles with the size of approximately 100 nm prepared was utilized for specific and selective detection of Staphylococcus aureus infection in joint knee fluid (PJI) and tau protein (marker for Alzheimer disease).
Collapse
|
|
17
|
Agni NR, Costa ML, Achten J, O'Connor H, Png ME, Peckham N, Dutton SJ, Wallis S, Milca S, Reed M. A randomized clinical trial of low dose single antibiotic-loaded cement versus high dose dual antibiotic-loaded cement in patients receiving a hip hemiarthroplasty after fracture: A protocol for the WHiTE 8 COPAL study. Bone Jt Open 2021; 2:72-78. [PMID: 33630700 PMCID: PMC7925209 DOI: 10.1302/2633-1462.22.bjo-2020-0174] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
AIMS Patients receiving cemented hemiarthroplasties after hip fracture have a significant risk of deep surgical site infection (SSI). Standard UK practice to minimize the risk of SSI includes the use of antibiotic-loaded bone cement with no consensus regarding type, dose, or antibiotic content of the cement. This is the protocol for a randomized clinical trial to investigate the clinical and cost-effectiveness of high dose dual antibiotic-loaded cement in comparison to low dose single antibiotic-loaded cement in patients 60 years and over receiving a cemented hemiarthroplasty for an intracapsular hip fracture. METHODS The WHiTE 8 Copal Or Palacos Antibiotic Loaded bone cement trial (WHiTE 8 COPAL) is a multicentre, multi-surgeon, parallel, two-arm, randomized clinical trial. The pragmatic study will be embedded in the World Hip Trauma Evaluation (WHiTE) (ISRCTN 63982700). Participants, including those that lack capacity, will be allocated on a 1:1 basis stratified by recruitment centre to either a low dose single antibiotic-loaded bone cement or a high dose dual antibiotic-loaded bone cement. The primary analysis will compare the differences in deep SSI rate as defined by the Centers for Disease Control and Prevention within 90 days of surgery via medical record review and patient self-reported questionnaires. Secondary outcomes include UK Core Outcome Set for hip fractures, complications, rate of antibiotic prescription, resistance patterns of deep SSI, and resource use (more specifically, cost-effectiveness) up to four months post-randomization. A minimum of 4,920 patients will be recruited to obtain 90% power to detect an absolute difference of 1.5% in the rate of deep SSI at 90 days for the expected 3% deep SSI rate in the control group. CONCLUSION The results of this trial will provide evidence regarding clinical and cost-effectiveness between low dose single and high dose dual antibiotic-loaded bone cement, which will inform policy and practice guidelines such as the National Institute for Health and Care Excellence guidance on management of hip fractures. Cite this article: Bone Jt Open 2021;2(2):72-78.
Collapse
Affiliation(s)
- Nickil Ramesh Agni
- Trauma and Orthopaedics, Northumbria Healthcare NHS Foundation Trust, Ashington, UK
| | - Matthew L Costa
- Oxford Trauma and Emergency Care, NDORMS, University of Oxford, Kadoorie Centre, John Radcliffe Hospital, Oxford, UK
| | - Juul Achten
- Oxford Trauma and Emergency Care, NDORMS, University of Oxford, Kadoorie Centre, John Radcliffe Hospital, Oxford, UK
| | - Heather O'Connor
- Oxford Clinical Trial Research Unit, NDORMS, University of Oxford, Oxford, UK
| | - May Ee Png
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Nicholas Peckham
- Oxford Clinical Trial Research Unit, NDORMS, University of Oxford, Oxford, UK
| | - Susan J Dutton
- Oxford Clinical Trial Research Unit, NDORMS, University of Oxford, Oxford, UK
| | - Stephanie Wallis
- Oxford Trauma and Emergency Care, NDORMS, University of Oxford, Kadoorie Centre, John Radcliffe Hospital, Oxford, UK
| | - Svetlana Milca
- Oxford Trauma and Emergency Care, NDORMS, University of Oxford, Kadoorie Centre, John Radcliffe Hospital, Oxford, UK
| | - Mike Reed
- Trauma and Orthopaedics, Northumbria Healthcare NHS Foundation Trust, Ashington, UK
| |
Collapse
|
|
18
|
Zastrow RK, Huang HH, Galatz LM, Saunders-Hao P, Poeran J, Moucha CS. Characteristics of Antibiotic Prophylaxis and Risk of Surgical Site Infections in Primary Total Hip and Knee Arthroplasty. J Arthroplasty 2020; 35:2581-2589. [PMID: 32402578 DOI: 10.1016/j.arth.2020.04.025] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Revised: 04/07/2020] [Accepted: 04/13/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Despite numerous antibiotic prophylaxis options for total hip arthroplasty (THA) and total knee arthroplasty (TKA), an assessment of practice patterns and comparative effectiveness is lacking. We aimed to characterize antibiotic utilization patterns and associations with infection risk and hypothesized differences in infection risk based on regimen. METHODS A retrospective cohort study was performed using data from 436,724 THA and 862,918 TKA (Premier Healthcare Database; 2006-2016). Main exposures were antibiotic type and duration: day of surgery only (day 0) or through postoperative day 1 (day 1). The primary outcome was surgical site infection (SSI) <30 days postoperation. Mixed-effect models measured associations between prophylaxis regimen and SSI as odds ratios (ORs) with 95% confidence intervals (CIs). RESULTS SSI prevalence was 0.21% (n = 914) for THA and 0.22% (n = 1914) for TKA. Among THA procedures, the most commonly used antibiotics were cefazolin (74.1%), vancomycin (8.4%), "other" antibiotic combinations (7.1%), vancomycin + cefazolin (5.1%), and clindamycin (3.3%). Here, 51.8% received prophylaxis on day 0 only, whereas 48.2% received prophylaxis through day 1. Similar patterns existed for TKA. Relative to cefazolin, higher SSI odds were seen with vancomycin (OR = 1.36; CI 1.09-1.71) in THA and with vancomycin (OR = 1.29; CI = 1.10-1.52), vancomycin + cefazolin (OR = 1.35; CI = 1.12-1.64), clindamycin (OR = 1.38; CI = 1.11-1.71), and "other" antibiotic combinations (OR = 1.28; CI = 1.07-1.53) in TKA. Prophylaxis duration did not alter SSI odds. Results were corroborated in sensitivity analyses. CONCLUSION Antibiotic prophylaxis regimens other than cefazolin were associated with increased SSI risk among THA/TKA patients. These findings emphasize a modifiable intervention to mitigate infection risk.
Collapse
Affiliation(s)
- Ryley K Zastrow
- Department of Medical Education, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Hsin-Hui Huang
- Department of Population Health Science and Policy, Institute for Healthcare Delivery Science, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Leesa M Galatz
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY
| | | | - Jashvant Poeran
- Department of Population Health Science and Policy, Institute for Healthcare Delivery Science, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Calin S Moucha
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY
| |
Collapse
|
|
19
|
Emara AK, Nageeb E, George J, Buttaro MA, Higuera C, Piuzzi NS. Hypovitaminosis D in lower extremity Joint Arthroplasty: A systematic review and meta-analysis. J Orthop 2020; 21:109-116. [PMID: 32255990 PMCID: PMC7114851 DOI: 10.1016/j.jor.2020.03.010] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Accepted: 03/23/2020] [Indexed: 12/17/2022] Open
Abstract
The purpose of the current systematic review was to identify the prevalence of hypovitaminosis-D in LE-TJA patients; and outline the association between pre-operative hypovitaminosis and post-operative outcomes. A search of PubMed-Medline and the Cochrane-Library databases was performed for literature published before November 27th, 2019. The eighteen studies analyzed had a pooled prevalence for vitamin D insufficiency (20 - <30 ng/mL) and deficiency (<20 ng/mL) of 53.4% and 39.4%, respectively. Hypovitaminosis-D was associated with higher complication rates (p = 0.043), and a greater prevalence among septic versus aseptic revisions (p = 0.016). Therefore, pre-operative screening for hypovitaminosis-D can be beneficial in patients undergoing LE-TJA. LEVEL OF EVIDENCE Systematic Review (Level III).
Collapse
Affiliation(s)
- Ahmed K. Emara
- Cleveland Clinic, Department of Orthopedic Surgery, 9500 Euclid Ave/A41, Cleveland, OH, 44195, USA
| | - Emmanuel Nageeb
- Cleveland Clinic, Department of Orthopedic Surgery, 9500 Euclid Ave/A41, Cleveland, OH, 44195, USA
| | - Jaiben George
- Cleveland Clinic, Department of Orthopedic Surgery, 9500 Euclid Ave/A41, Cleveland, OH, 44195, USA
| | - Martin A. Buttaro
- Hip Surgery Unit "Sir John Charnley", Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Carlos Higuera
- Cleveland Clinic, Department of Orthopedic Surgery, 9500 Euclid Ave/A41, Cleveland, OH, 44195, USA
| | - Nicolas S. Piuzzi
- Cleveland Clinic, Department of Orthopedic Surgery, 9500 Euclid Ave/A41, Cleveland, OH, 44195, USA
- Instituto Universitario del Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| |
Collapse
|
|
20
|
Savvidou OD, Kaspiris A, Trikoupis I, Kakouratos G, Goumenos S, Melissaridou D, Papagelopoulos PJ. Efficacy of antimicrobial coated orthopaedic implants on the prevention of periprosthetic infections: a systematic review and meta-analysis. J Bone Jt Infect 2020; 5:212-222. [PMID: 32670776 PMCID: PMC7358967 DOI: 10.7150/jbji.44839] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Accepted: 06/05/2020] [Indexed: 02/07/2023] Open
Abstract
Introduction: Implant-associated infections are a major problem in orthopaedic surgery. Local delivery systems of antimicrobial agents on the implant surface have attracted great interest recently. The purpose of this study was to identify antimicrobial coatings currently used in clinical practice, examining their safety and effectiveness in reducing post-operative infection rates. Materials and Methods: A systematic review was conducted in four databases (Medline, Embase, Cochrane, Cinahl) according to the Preferred Reporting Items for Systematic reviews and Meta-analysis (PRISMA) guidelines up to December 2019, using the key words “orthopaedic implant coated”, “coated implant infection”, “silver coating ” and “antibiotic coating”. Results: Seven articles involving 1307 patients (561 with coated implants and 746 controls who were not) comparing the incidence of periprosthetic infections after the application of internal fracture fixation, total arthroplasties and endoprostheses were evaluated. Three different coating technologies were identified: gentamicin coating for tibia nail and total arthroplasties; silver technology and povidone-iodine coating for tumour endoprostheses and titanium implants. Meta-analysis demonstrated that patients who were treated with antimicrobial coated implants presented lower infection rates compared to controls over the seven studies (Q = 6.1232, I2 = 0.00, 95% CI: 1.717 to 4.986, OR: 2.926, Z= 3.949, p<0.001). Subgroup statistical analysis revealed that each coating technique was effective in the prevention of periprosthetic infections (Q = 9.2606, I2 = 78.40%, 95% CI: 1.401 to 4.070, OR: 2.388, Z= 3.200, p<0.001). Conclusion: All technologies were reported to have good biocompatibility and were effective in the reduction of post-operative peri-prosthetic infection rates.
Collapse
Affiliation(s)
- Olga D Savvidou
- 1 st Department of Orthopaedic Surgery, School of Medicine, National and Kapodistrian University of Athens, "ATTIKON" University General Hospital, Athens, Greece
| | - Angelos Kaspiris
- Laboratory of Molecular Pharmacology/Division for Orthopaedic Research, School of Health Sciences, University of Patras, Patras 26504, Greece
| | - Ioannis Trikoupis
- 1 st Department of Orthopaedic Surgery, School of Medicine, National and Kapodistrian University of Athens, "ATTIKON" University General Hospital, Athens, Greece
| | - George Kakouratos
- 1 st Department of Orthopaedic Surgery, School of Medicine, National and Kapodistrian University of Athens, "ATTIKON" University General Hospital, Athens, Greece
| | - Stavros Goumenos
- 1 st Department of Orthopaedic Surgery, School of Medicine, National and Kapodistrian University of Athens, "ATTIKON" University General Hospital, Athens, Greece
| | - Dimitra Melissaridou
- 1 st Department of Orthopaedic Surgery, School of Medicine, National and Kapodistrian University of Athens, "ATTIKON" University General Hospital, Athens, Greece
| | - Panayiotis J Papagelopoulos
- 1 st Department of Orthopaedic Surgery, School of Medicine, National and Kapodistrian University of Athens, "ATTIKON" University General Hospital, Athens, Greece
| |
Collapse
|
|
21
|
Wainwright TW, Gill M, McDonald DA, Middleton RG, Reed M, Sahota O, Yates P, Ljungqvist O. Consensus statement for perioperative care in total hip replacement and total knee replacement surgery: Enhanced Recovery After Surgery (ERAS ®) Society recommendations. Acta Orthop 2020; 91:3-19. [PMID: 31663402 PMCID: PMC7006728 DOI: 10.1080/17453674.2019.1683790] [Citation(s) in RCA: 391] [Impact Index Per Article: 78.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Background and purpose - There is a large volume of heterogeneous studies across all Enhanced Recovery After Surgery (ERAS®) components within total hip and total knee replacement surgery. This multidisciplinary consensus review summarizes the literature, and proposes recommendations for the perioperative care of patients undergoing total hip replacement and total knee replacement with an ERAS program.Methods - Studies were selected with particular attention being paid to meta-analyses, randomized controlled trials, and large prospective cohort studies that evaluated the efficacy of individual items of the perioperative treatment pathway to expedite the achievement of discharge criteria. A consensus recommendation was reached by the group after critical appraisal of the literature.Results - This consensus statement includes 17 topic areas. Best practice includes optimizing preoperative patient education, anesthetic technique, and transfusion strategy, in combination with an opioid-sparing multimodal analgesic approach and early mobilization. There is insufficient evidence to recommend that one surgical technique (type of approach, use of a minimally invasive technique, prosthesis choice, or use of computer-assisted surgery) over another will independently effect achievement of discharge criteria.Interpretation - Based on the evidence available for each element of perioperative care pathways, the ERAS® Society presents a comprehensive consensus review, for the perioperative care of patients undergoing total hip replacement and total knee replacement surgery within an ERAS® program. This unified protocol should now be further evaluated in order to refine the protocol and verify the strength of these recommendations.
Collapse
Affiliation(s)
- Thomas W Wainwright
- Orthopaedic Research Institute, Bournemouth Univesity, Bournemouth, UK
- The Royal Bournemouth and Christchurch Hospitals NHS Foundation Trust, Bournemouth, UK
| | - Mike Gill
- Golden Jubilee National Hospital, Glasgow, Scotland
| | - David A McDonald
- Scottish Government, Glasgow, Scotland
- Nursing, Midwifery and Allied Health Professions Research Unit, Glasgow Caledonian University, Glasgow, Scotland
| | - Robert G Middleton
- Orthopaedic Research Institute, Bournemouth Univesity, Bournemouth, UK
- The Royal Bournemouth and Christchurch Hospitals NHS Foundation Trust, Bournemouth, UK
- Poole Hospital NHS Foundation Trust, Poole, UK
| | - Mike Reed
- Northumbria Healthcare NHS Foundational Trust, Northumbria, UK
- Health Sciences, University of York, York, UK
| | - Opinder Sahota
- Nottingham University Hospital, Nottingham, UK
- Nottingham University, Nottingham, UK
| | - Piers Yates
- University of Western Australia, Perth, Australia
| | | |
Collapse
|
|
22
|
Sadigursky D, Sousa M, de Jesus L, Neto J, Lobão DV, Azi M. Risk of infection following total knee arthroplasty in patients with asymptomatic bacteriuria: A meta-analysis. JOURNAL OF ORTHOPEDICS, TRAUMATOLOGY AND REHABILITATION 2020. [DOI: 10.4103/jotr.jotr_8_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
|
|
23
|
Zhang J, Zhang XY, Jiang FL, Wu YP, Yang BB, Liu ZY, Liu D. Antibiotic-impregnated bone cement for preventing infection in patients receiving primary total hip and knee arthroplasty: A meta-analysis. Medicine (Baltimore) 2019; 98:e18068. [PMID: 31804314 PMCID: PMC6919433 DOI: 10.1097/md.0000000000018068] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Surgical-site infections after primary total joint arthroplasty (TJA) are a significant issue. Antibiotic-impregnated bone cement (AIBC) has been widely used for the treatment of infected joints, but routine use of AIBC in primary TJA remains controversial. In this systematic review, we evaluated the efficacy of AIBC in reducing surgical-site infections after primary TJA. METHODS We systematically searched Pubmed, EMbase, Cochrane Library, CMB, CNKI, and WanFang Data for studies (published until June 1, 2019) evaluating AIBC use in reducing infection rates. Two reviewers independently screened the literature according to inclusion and exclusion criteria, extracted data, and assessed the methodological quality of included studies. Meta-analysis was performed using Review Manager 5.3 software. The registration number is CRD42017078341 in PROSPERO. RESULTS In total, 10 studies were included, resulting in a sample size of 13,909 arthroplasty cases. The overall pooled data demonstrated that, compared with systemic antibiotics, AIBC was more effective in decreasing deep infection rates (odds ratio [OR] = 0.35, 95% confidence interval [CI] = 0.14-0.89, P = .030), although there were higher superficial infection rates with AIBC (OR = 1.53, 95% CI = 1.11-2.11, P = .010). Compared to systemic antibiotics alone, AIBC with systemic antibiotics significantly decreased deep infection rates (OR = 0.55, 95% CI = 0.41-0.75, P = .0001) but there was no difference in superficial infection rates (OR = 1.43, 95% CI = 0.81-2.54, P = .220). In the subgroup analysis, both randomized controlled trials and cohort studies had reduced deep infection rates after primary TJA (OR = 0.61, 95% CI = 0.37-0.99, P = .050 and OR = 0.49, 95% CI = 0.34-0.70, P = .0001, respectively). AIBC decreased deep infection rates in both total hip and knee arthroplasty (OR = 0.25, 95% CI = 0.12-0.52, P = .0002 and OR = 0.62, 95% CI = 0.45-0.87, P = .005, respectively). Deep infection rates were significantly decreased by AIBC with gentamicin (OR = 0.31, 95% CI = 0.20-0.49, P < .00001) but unaffected by AIBC with cefuroxime (OR = 0.35, 95% CI = 0.10-1.20, P = .100). Deep infection rates in the AIBC and control groups were similar when laminar airflow was applied to the operating room (OR = 0.90, 95% CI = 0.60-1.35, P = .620); however, without laminar airflow, the efficacy of AIBC in decreasing deep infection rates was significantly higher than that of control group (OR = 0.21, 95% CI = 0.08-0.59, P = .003). CONCLUSIONS AIBC may significantly decrease deep infection rates after primary total hip and knee arthroplasty, with or without systemic antibiotics.
Collapse
Affiliation(s)
- Jin Zhang
- Clinical Pharmacy Office, Baoji Central Hospital, Baoji
- Xi’an Jiaotong University Health Science Center
| | - Xiao-Yu Zhang
- Clinical Pharmacy Office, Baoji Central Hospital, Baoji
| | - Feng-Li Jiang
- Clinical Pharmacy Office, Baoji Central Hospital, Baoji
| | - Yi-Ping Wu
- Clinical Pharmacy Office, Baoji Central Hospital, Baoji
| | - Bei-Bei Yang
- Clinical Pharmacy Office, Baoji Central Hospital, Baoji
| | - Zi-Yun Liu
- Clinical Pharmacy Office, Baoji Central Hospital, Baoji
| | - Dong Liu
- Clinical Pharmacy Office, Baoji Central Hospital, Baoji
- Department of Pharmacology, Xi’an Jiaotong University Health Science Center, Xi’an, China
| |
Collapse
|
|
24
|
Ghosh A, Chatterji U. An evidence-based review of enhanced recovery after surgery in total knee replacement surgery. J Perioper Pract 2019; 29:281-290. [PMID: 30212288 DOI: 10.1177/1750458918791121] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Rationale: Enhanced recovery after surgery is gaining popularity among orthopaedic surgeons across the globe and hence a strong evidence base had to be reviewed to make an evidence-based sustainable protocol.MethodsThe following databases, PubMed, OVID, Cochrane database and EMBASE were searched. The search was limited to 15 components of enhanced recovery after surgery programme which is divided into preoperative, intraoperative and postoperative phases. Inclusion criteria were restricted to articles published in English within the last 15 years and articles comprising of unicompartmental arthroplasty, revision knee arthroplasty, bilateral simultaneous knee arthroplasty and only hip arthroplasty excluded. The full texts were analysed and controversies and limitations of various studies were summarised.DiscussionEach component of the programme was thoroughly reviewed and strength and weaknesses of the evidence base summarised. The strength of the evidence was assessed by critically appraising the study methodology and justifying the appropriateness of the inclusion in enhanced recovery after surgery protocol.ConclusionEnhanced recovery after surgery has already been used successfully in various surgical specialities. Enhanced recovery after surgery programmes in knee arthroplasty are yet to be established as a universal practice to be adopted globally. This evidence-based review provides an insight into the best evidence linked to each component and their rationale for inclusion in the proposed enhanced recovery after surgery protocol.
Collapse
Affiliation(s)
- Arijit Ghosh
- Trauma and Orthopaedics, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Urjit Chatterji
- Trauma and Orthopaedics, University Hospitals of Leicester NHS Trust, Leicester, UK
| |
Collapse
|
|
25
|
Schwarz EM, Parvizi J, Gehrke T, Aiyer A, Battenberg A, Brown SA, Callaghan JJ, Citak M, Egol K, Garrigues GE, Ghert M, Goswami K, Green A, Hammound S, Kates SL, McLaren AC, Mont MA, Namdari S, Obremskey WT, O'Toole R, Raikin S, Restrepo C, Ricciardi B, Saeed K, Sanchez-Sotelo J, Shohat N, Tan T, Thirukumaran CP, Winters B. 2018 International Consensus Meeting on Musculoskeletal Infection: Research Priorities from the General Assembly Questions. J Orthop Res 2019; 37:997-1006. [PMID: 30977537 DOI: 10.1002/jor.24293] [Citation(s) in RCA: 184] [Impact Index Per Article: 30.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Revised: 02/22/2019] [Accepted: 03/19/2019] [Indexed: 02/04/2023]
Abstract
Musculoskeletal infections (MSKI) remain the bane of orthopedic surgery, and result in grievous illness and inordinate costs that threaten healthcare systems. As prevention, diagnosis, and treatment has remained largely unchanged over the last 50 years, a 2nd International Consensus Meeting on Musculoskeletal Infection (ICM 2018, https://icmphilly.com) was completed. Questions pertaining to all areas of MSKI were extensively researched to prepare recommendations, which were discussed and voted on by the delegates using the Delphi methodology. The questions, including the General Assembly (GA) results, have been published (GA questions). However, as critical outcomes include: (i) incidence and cost data that substantiate the problems, and (ii) establishment of research priorities; an ICM 2018 research workgroup (RW) was assembled to accomplish these tasks. Here, we present the result of the RW consensus on the current and projected incidence of infection, and the costs per patient, for all orthopedic subspecialties, which range from 0.1% to 30%, and $17,000 to $150,000. The RW also identified the most important research questions. The Delphi methodology was utilized to initially derive four objective criteria to define a subset of the 164 GA questions that are high priority for future research. Thirty-eight questions (23% of all GA questions) achieved the requisite > 70% agreement vote, and are highlighted in this Consensus article within six thematic categories: acute versus chronic infection, host immunity, antibiotics, diagnosis, research caveats, and modifiable factors. Finally, the RW emphasizes that without appropriate funding to address these high priority research questions, a 3rd ICM on MSKI to address similar issues at greater cost is inevitable.
Collapse
Affiliation(s)
- Edward M Schwarz
- Department of Orthopaedics, Center for Musculoskeletal Research, University of Rochester, Rochester, New York
| | - Javad Parvizi
- Department of Orthopaedics, Rothman Institute at Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Thorsten Gehrke
- Department of Orthopaedic Surgery, Helios Endo Klinik Hamburg, Hamburg, Germany
| | - Amiethab Aiyer
- Department of Orthopaedic Surgery, University of Miami/Miller School of Medicine, Miami, Florida
| | - Andrew Battenberg
- Department of Orthopaedics, Kaiser Permanente Vacaville Medical Center, Vacaville, California
| | - Scot A Brown
- Department of Orthopaedics, Rothman Institute at Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - John J Callaghan
- Deparment of Orthopedics and Rehabilitation, University of Iowa, Iowa City, Iowa
| | - Mustafa Citak
- Department of Orthopaedic Surgery, Helios Endo Klinik Hamburg, Hamburg, Germany
| | - Kenneth Egol
- Department of Orthopedic Surgery, New York University, New York, New York
| | - Grant E Garrigues
- Midwest Orthopaedics at Rush, Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois
| | - Michelle Ghert
- Department of Orthopaedic Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Karan Goswami
- Department of Orthopaedics, Rothman Institute at Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Andrew Green
- Department of Orthopaedic Surgery, Brown University, Providence, Rhode Island
| | - Sommer Hammound
- Department of Orthopaedics, Rothman Institute at Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Stephen L Kates
- Department of Orthopaedic Surgery, Virginia Commonwealth University, Richmond, Virginia
| | - Alex C McLaren
- Department of Orthopaedic Surgery, College of Medicine-Phoenix, University of Arizona, Phoenix, Arizona
| | - Michael A Mont
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Surena Namdari
- Department of Orthopaedics, Rothman Institute at Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - William T Obremskey
- Department of Orthopedic Surgery, Vanderbilt Medical Center, Nashville, Tennessee
| | - Robert O'Toole
- Department of Orthopaedics, University of Maryland, Baltimore, Maryland
| | - Steven Raikin
- Department of Orthopaedics, Rothman Institute at Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Camilo Restrepo
- Department of Orthopaedics, Rothman Institute at Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Benjamin Ricciardi
- Department of Orthopaedics, Center for Musculoskeletal Research, University of Rochester, Rochester, New York
| | - Kordo Saeed
- Department of Microbiology, Hampshire Hospitals NHS Foundation Trust, Winchester and Basingstoke, United Kingdom
- Department of Microbiology, School of Medicine, University of Southampton, Southampton, United Kingdom
| | | | - Noam Shohat
- Department of Medicine, Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Israel
| | - Timothy Tan
- Department of Orthopaedics, Rothman Institute at Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Caroline P Thirukumaran
- Department of Orthopaedics, Center for Musculoskeletal Research, University of Rochester, Rochester, New York
| | - Brian Winters
- Department of Orthopaedics, Rothman Institute at Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| |
Collapse
|
|
26
|
Sanders FRK, Goslings JC, Mathôt RAA, Schepers T. Target site antibiotic concentrations in orthopedic/trauma extremity surgery: is prophylactic cefazolin adequately dosed? A systematic review and meta-analysis. Acta Orthop 2019; 90:97-104. [PMID: 30739547 PMCID: PMC6461090 DOI: 10.1080/17453674.2019.1577014] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Background and purpose - The incidence of surgical site infections (SSIs) in trauma/orthopedic surgery varies between different body parts. Antibiotic prophylaxis (e.g., with cefazolin) lowers infection rates in closed fracture surgery and in primary arthroplasty. For prophylactic antibiotics to prevent infections, sufficient concentrations at the target site (location of surgery) are required. However, dosage recommendations and the corresponding efficacy are unclear. This review assesses target site cefazolin concentrations and the effect of variation in dose and location of target site during orthopedic extremity surgery. Methods - For this meta-analysis and systematic review, the literature was searched using the following keywords: "cephalosporins," "orthopedic," "extremity," "surgical procedures," and "pharmacokinetics". Trials measuring target site antibiotic concentrations (bone, soft tissue, synovia) during orthopedic surgery after a single dose of cefazolin were included. Results - The search identified 14 studies reporting on concentrations in the shoulder (n = 1), hip (n = 8), knee (n = 8), or foot (n = 1). A large variation was seen between studies, but the pooled results of 4 studies showed higher concentrations in hip than in knee (mean difference: 4 ug/g, 95% CI 0.8-7). Articles comparing different doses of cefazolin reported higher bone concentrations after 2 g than before, but pooling results did not lead to a statistically significant difference. Interpretation - Although not all results could be pooled, this study shows that cefazolin concentrations are higher in the hip than in the knee. These findings suggest that the dose of prophylactic cefazolin might not be sufficient in distal parts of the extremity. Further research should investigate whether a higher dose of cefazolin can lead to higher concentrations and fewer SSIs.
Collapse
Affiliation(s)
- Fay R K Sanders
- Trauma Unit, Department of Surgery, Amsterdam UMC, University of Amsterdam;;
| | | | - Ron A A Mathôt
- Department of Hospital Pharmacy, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Tim Schepers
- Trauma Unit, Department of Surgery, Amsterdam UMC, University of Amsterdam;; ,Correspondence:
| |
Collapse
|
|
27
|
Bondarenko S, Chang CB, Cordero-Ampuero J, Kates S, Kheir M, Klement MR, McPherson E, Morata L, Silibovsky R, Skaliczki G, Soriano A, Suárez R, Szatmári A, Webb J, Young S, Zimmerli W. General Assembly, Prevention, Antimicrobials (Systemic): Proceedings of International Consensus on Orthopedic Infections. J Arthroplasty 2019; 34:S61-S73. [PMID: 30348584 DOI: 10.1016/j.arth.2018.09.055] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
|
|
28
|
Surgical antibiotic prophylaxis – The evidence and understanding its impact on consensus guidelines. Infect Dis Health 2018. [DOI: 10.1016/j.idh.2018.05.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
|
|
29
|
Soffin EM, YaDeau JT. Enhanced recovery after surgery for primary hip and knee arthroplasty: a review of the evidence. Br J Anaesth 2018; 117:iii62-iii72. [PMID: 27940457 DOI: 10.1093/bja/aew362] [Citation(s) in RCA: 184] [Impact Index Per Article: 26.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Enhanced recovery after surgery (ERAS) protocols produce significant clinical and economic benefits in a range of surgical subspecialties. There is a long tradition of applying clinical pathways to the perioperative care of joint arthroplasty patients. Enhanced recovery after surgery represents the next step in the evolution of standardized care. To date, reports of full ERAS pathways for hip or knee arthroplasty are lacking. In this narrative review, we present the evidence base that can be usefully applied to constructing ERAS pathways for hip or knee arthroplasty. The history and rationale for applying ERAS to joint arthroplasty are explained. Evidence demonstrates improved outcomes after joint arthroplasty when a standardized approach to care is implemented. The efficacy of individual ERAS components in hip or knee replacement is considered, including preoperative education, intraoperative anaesthetic techniques, postoperative analgesia, and early mobilization after joint arthroplasty. Interventions lacking high-quality evidence are identified, together with recommendations for future research. Based on currently available evidence, we present a model ERAS pathway that can be applied to perioperative care of patients undergoing hip or knee arthroplasty.
Collapse
Affiliation(s)
- E M Soffin
- Department of Anesthesiology, Hospital for Special Surgery, Weill Cornell Medical College, 535 East 70th Street, New York, NY 10021, USA
| | - J T YaDeau
- Department of Anesthesiology, Hospital for Special Surgery, Weill Cornell Medical College, 535 East 70th Street, New York, NY 10021, USA
| |
Collapse
|
|
30
|
van der Bruggen W, Hirschmann MT, Strobel K, Kampen WU, Kuwert T, Gnanasegaran G, Van den Wyngaert T, Paycha F. SPECT/CT in the Postoperative Painful Knee. Semin Nucl Med 2018; 48:439-453. [PMID: 30193650 DOI: 10.1053/j.semnuclmed.2018.05.003] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
This review summarizes the role of SPECT/CT in patients with a painful postoperative knee and describes typical diagnostic criteria in these patients. Pain after knee surgery is common and is influenced by the underlying pathology, the type of surgery, and the patient. Knee joint-preserving surgery includes osteotomy, ligament reconstruction, meniscus surgery, and cartilage repair procedures, often used in combination. Knee arthroplasty procedures consist of unicondylar, patellofemoral, and primary or revision total knee prosthesis. In patients with pain after knee joint-preserving surgery, MRI remains the reference standard. After ligament reconstruction, CT can evaluate postoperative tunnel positioning, and bone SPECT/CT can contribute by assessing overloading or biodegradation problems. After meniscal or cartilage surgery, SPECT/CT can be particularly helpful to identify compartment overloading or nonhealing chondral or osteochondral lesions as cause of pain. SPECT/CT arthrography can assess cartilage damage at an early stage due to altered biomechanical forces. After corrective osteotomy of the knee, SPECT/CT can reveal complications such as overloading, nonunion, or patellofemoral problems. After arthroplasty, conventional radiographs lack both sensitivity to detect aseptic loosening and specificity in differentiating aseptic from infectious loosening. Secondly, hardware-induced artifacts still hamper CT and MRI, despite improving and increasingly available metal artifact reduction techniques. Bone scintigraphy is a proven useful adjunct to conventional radiography and MRI to reveal the pain generator and is less hampered by artifacts from metallic implants compared with CT and MRI. Nevertheless, the optimal imaging strategy in evaluating complications after knee arthroplasty is still a matter of debate. Although the evidence of the use of BS SPECT/CT is still limited, it is growing steadily. In particular, recent data on specific uptake patterns in tibial and femoral zones after total knee arthroplasty and the impact of integrating biomechanics into the assessment of SPECT/CT appear promising, but more research is needed.
Collapse
Affiliation(s)
- Wouter van der Bruggen
- Department of Radiology and Nuclear Medicine, Slingeland Hospital, Doetinchem, The Netherlands..
| | - Michael T Hirschmann
- Department of Orthopaedic Surgery and Traumatology, Kantonsspital Baselland (Bruderholz, Liestal, Laufen), Bruderholz, Switzerland
| | - Klaus Strobel
- Department of Radiology and Nuclear Medicine, Lucerne Cantonal Hospital, Lucerne, Switzerland
| | | | - Torsten Kuwert
- Clinic of Nuclear Medicine, University Hospital Erlangen, Erlangen, Germany
| | - Gopinath Gnanasegaran
- Department of Nuclear Medicine, Royal Free London NHS Foundation Trust, London, United Kingdom
| | - Tim Van den Wyngaert
- Department of Nuclear Medicine, Antwerp University Hospital, Edegem, Belgium.; Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Belgium
| | - Frédéric Paycha
- Department of Nuclear Medicine, Hôpital Lariboisière, Assistance Publique-Hôpitaux de Paris, Paris, France
| |
Collapse
|
|
31
|
Abstract
BACKGROUND Implant-related infections are associated with impaired bone healing and osseointegration. In vitro antiadhesive and antibacterial properties and in vivo antiinflammatory effects protecting against bone loss of various formulations of vitamin E have been demonstrated in animal models. However, to the best of our knowledge, no in vivo studies have demonstrated the synergistic activity of vitamin E in preventing bacterial adhesion to orthopaedic implants, thus supporting the bone-implant integration. QUESTIONS/PURPOSES The purpose of this study was to test whether a vitamin E phosphate coating on titanium implants may be able to reduce (1) the bacterial colonization of prosthetic implants and (2) bone resorption and osteomyelitis in a rat model of Staphylococcus aureus-induced implant-related infection. METHODS Twelve rats were bilaterally injected in the femurs with S aureus UAMS-1-Xen40 and implanted with uncoated or vitamin E phosphate-coated titanium Kirschner wires without local or systemic antibiotic prophylaxis. Eight rats represented the uninfected control group. A few hours after surgery, two control and three infected animals died as a result of unexpected complications. With the remaining rats, we assessed the presence of bacterial contamination with qualitative bioluminescence imaging and Gram-positive staining and with quantitative bacterial count. Bone changes in terms of resorption and osteomyelitis were quantitatively analyzed through micro-CT (bone mineral density) and semiquantitatively through histologic scoring systems. RESULTS Six weeks after implantation, we found only a mild decrease in bacterial count in coated versus uncoated implants (Ti versus controls: mean difference [MD], -3.705; 95% confidence interval [CI], -4.416 to -2.994; p < 0.001; TiVE versus controls: MD, -3.063; 95% CI, -3.672 to -2.454; p < 0.001), whereas micro-CT analysis showed a higher bone mineral density at the knee and femoral metaphysis in the vitamin E-treated group compared with uncoated implants (knee joint: MD, -11.88; 95% CI, -16.100 to -7.664; p < 0.001 and femoral metaphysis: MD, -19.87; 95% CI, -28.82 to -10.93; p < 0.001). We found decreased osteonecrosis (difference between medians, 1.5; 95% CI, 1-2; p < 0.002) in the infected group receiving the vitamin E-coated nails compared with the uncoated nails. CONCLUSIONS These preliminary findings indicate that vitamin E phosphate implant coatings can exert a protective effect on bone deposition in a highly contaminated animal model of implant-related infection. CLINICAL RELEVANCE The use of vitamin E coatings may open new perspectives for developing coatings that can limit septic loosening of infected implants with bacterial contamination. However, a deeper insight into the mechanism of action and the local release of vitamin E as a coating for orthopaedic implants is required to be used in clinics in the near future. Although this study cannot support the antimicrobial properties of vitamin E, promising results were obtained for bone-implant osseointegration. These preliminary results will require further in vivo investigations to optimize the host response in the presence of antibiotic prophylaxis.
Collapse
|
|
32
|
Robertsson O, Thompson O, W-Dahl A, Sundberg M, Lidgren L, Stefánsdóttir A. Higher risk of revision for infection using systemic clindamycin prophylaxis than with cloxacillin. Acta Orthop 2017; 88:562-567. [PMID: 28492106 PMCID: PMC5560222 DOI: 10.1080/17453674.2017.1324677] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2017] [Accepted: 04/10/2017] [Indexed: 02/08/2023] Open
Abstract
Background and purpose - Clindamycin has not been compared with other antibiotics for prophylaxis in arthroplasty. Since 2009, the Swedish Knee Arthroplasty Register (SKAR) has been collecting information on the prophylactic antibiotic regime used at every individual operation. In Sweden, when there is allergy to penicillin, clindamycin has been the recommended alternative. We examined whether there were differences in the rate of revision due to infection depending on which antibiotic was used as systemic prophylaxis. Patients and methods - Patients who had a total knee arthroplasty (TKA) performed due to osteoarthritis (OA) during the years 2009-2015 were included in the study. Information on which antibiotic was used was available for 80,018 operations (55,530 patients). Survival statistics were used to calculate the rate of revision due to infection until the end of 2015, comparing the group of patients who received cloxacillin with those who received clindamycin as systemic prophylaxis. Results - Cloxacillin was used in 90% of the cases, clindamycin in 7%, and cephalosporins in 2%. The risk of being revised due to infection was higher when clindamycin was used than when cloxacillin was used (RR =1.5, 95% CI: 1.2-2.0; p = 0.001). There was no significant difference in the revision rate for other causes (p = 0.2). Interpretation - We advise that patients reporting allergic reaction to penicillin should have their allergic history explored. In the absence of a clear history of type-I allergic reaction (e.g. urticaria, anaphylaxis, or bronchospasm), we suggest the use of a third-generation cephalosporin instead of clindamycin as perioperative prophylaxis when undergoing a TKR. No recommendation can be given regarding patients with type-1 allergy.
Collapse
Affiliation(s)
- Otto Robertsson
- The Swedish Knee Arthroplasty Register, Lund University, Skåne University Hospital and Department of Clinical Sciences Lund, Orthopedics, Lund, Sweden
| | - Olof Thompson
- Department of Infectious Diseases, Skåne University Hospital, Lund, Sweden
| | - Annette W-Dahl
- The Swedish Knee Arthroplasty Register, Lund University, Skåne University Hospital and Department of Clinical Sciences Lund, Orthopedics, Lund, Sweden
| | - Martin Sundberg
- The Swedish Knee Arthroplasty Register, Lund University, Skåne University Hospital and Department of Clinical Sciences Lund, Orthopedics, Lund, Sweden
| | - Lars Lidgren
- The Swedish Knee Arthroplasty Register, Lund University, Skåne University Hospital and Department of Clinical Sciences Lund, Orthopedics, Lund, Sweden
| | - Anna Stefánsdóttir
- The Swedish Knee Arthroplasty Register, Lund University, Skåne University Hospital and Department of Clinical Sciences Lund, Orthopedics, Lund, Sweden
| |
Collapse
|
|
33
|
Fargašová A, Balzerová A, Prucek R, Sedláková MH, Bogdanová K, Gallo J, Kolář M, Ranc V, Zbořil R. Detection of Prosthetic Joint Infection Based on Magnetically Assisted Surface Enhanced Raman Spectroscopy. Anal Chem 2017; 89:6598-6607. [DOI: 10.1021/acs.analchem.7b00759] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Affiliation(s)
- Ariana Fargašová
- Regional
Centre of Advanced Technologies and Materials, Department of Physical
Chemistry, Faculty of Science, Palacký University Olomouc, Šlechtitelů
27, 783 71 Olomouc, Czech Republic
| | - Anna Balzerová
- Regional
Centre of Advanced Technologies and Materials, Department of Physical
Chemistry, Faculty of Science, Palacký University Olomouc, Šlechtitelů
27, 783 71 Olomouc, Czech Republic
| | - Robert Prucek
- Regional
Centre of Advanced Technologies and Materials, Department of Physical
Chemistry, Faculty of Science, Palacký University Olomouc, Šlechtitelů
27, 783 71 Olomouc, Czech Republic
| | - Miroslava Htoutou Sedláková
- Department
of Microbiology, Faculty of Medicine and Dentistry, Palacký University Olomouc, Hněvotínská 3, 775 15 Olomouc, Czech Republic
| | - Kateřina Bogdanová
- Department
of Microbiology, Faculty of Medicine and Dentistry, Palacký University Olomouc, Hněvotínská 3, 775 15 Olomouc, Czech Republic
| | - Jiří Gallo
- Department
of Orthopaedics, Faculty of Medicine and Dentistry, Palacký University Olomouc, I. P. Pavlova 6, 77520 Olomouc, Czech Republic
| | - Milan Kolář
- Department
of Microbiology, Faculty of Medicine and Dentistry, Palacký University Olomouc, Hněvotínská 3, 775 15 Olomouc, Czech Republic
| | - Václav Ranc
- Regional
Centre of Advanced Technologies and Materials, Department of Physical
Chemistry, Faculty of Science, Palacký University Olomouc, Šlechtitelů
27, 783 71 Olomouc, Czech Republic
| | - Radek Zbořil
- Regional
Centre of Advanced Technologies and Materials, Department of Physical
Chemistry, Faculty of Science, Palacký University Olomouc, Šlechtitelů
27, 783 71 Olomouc, Czech Republic
| |
Collapse
|
|
34
|
Saeed K, Dryden M, Bassetti M, Bonnet E, Bouza E, Chan M, Cortes N, Davis JS, Esposito S, Giordano G, Gould I, Hartwright D, Lye D, Marin M, Morgan-Jones R, Lajara-Marco F, Righi E, Romano CL, Segreti J, Unal S, Williams RL, Yalcin AN. Prosthetic joints: shining lights on challenging blind spots. Int J Antimicrob Agents 2017; 49:153-161. [DOI: 10.1016/j.ijantimicag.2016.10.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2016] [Revised: 09/23/2016] [Accepted: 10/01/2016] [Indexed: 12/12/2022]
|
|
35
|
Voigt J, Mosier M, Darouiche R. Antibiotics and antiseptics for preventing infection in people receiving revision total hip and knee prostheses: a systematic review of randomized controlled trials. BMC Infect Dis 2016; 16:749. [PMID: 27955626 PMCID: PMC5153681 DOI: 10.1186/s12879-016-2063-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2016] [Accepted: 11/08/2016] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Infection rates in revision (second and subsequent) major joint arthroplasty continues to be a significant issue with rates 2-3 times those of primary procedures. The effect of antibiotic and antiseptic prophylaxis on outcomes for this type of surgery has not been adequately reviewed. METHODS A systematic search of the main databases for randomized controlled trials (RCTs) evaluating antibiotics and antiseptics was conducted to evaluate the predetermined endpoints of infection. RESULTS There were five (5) RCTs identified that examined the effects of antibiotic and antiseptic prophylaxis on infections after revision total hip arthroplasty [THA] (total of 304 participants) and total knee arthroplasty [TKA] (total of 206 participants). For TKA, preoperative systemic intravenous (IV) antibiotic prophylaxis plus antibiotic cement may be effective in reducing the incidence of infection in revision TKA at 8+ years. These results however should be interpreted with caution due to the significant biases. For revision THA, there is no RCT evidence that antibiotics/antiseptics have any effect on the infection rate. CONCLUSIONS There is a lack of high quality data demonstrating an effect of antibiotics or antiseptics on infection rates in revision THA/TKA. Considering the rate of infections in revisions is 2-3X that of primary procedures and; there is a consensus recommendation to use similar antibiotic and antiseptic regimens in both primary and revision procedures, there is a need for high quality studies in revision THA/TKA.
Collapse
Affiliation(s)
| | - Michael Mosier
- Washburn University, Morgan Hall, Room 250 J, 1700 SW College Ave, Topeka, KS, 66621, USA
| | - Rabih Darouiche
- Michael E. DeBakey Veterans Affairs Medical Center, 2002 Holcombe Blvd # 128, Houston, TX, 77030, USA
| |
Collapse
|
|
36
|
Gallo J, Panacek A, Prucek R, Kriegova E, Hradilova S, Hobza M, Holinka M. Silver Nanocoating Technology in the Prevention of Prosthetic Joint Infection. MATERIALS (BASEL, SWITZERLAND) 2016; 9:E337. [PMID: 28773461 PMCID: PMC5503077 DOI: 10.3390/ma9050337] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/31/2016] [Revised: 04/26/2016] [Accepted: 04/27/2016] [Indexed: 02/06/2023]
Abstract
Prosthetic joint infection (PJI) is a feared complication of total joint arthroplasty associated with increased morbidity and mortality. There is a growing body of evidence that bacterial colonization and biofilm formation are critical pathogenic events in PJI. Thus, the choice of biomaterials for implanted prostheses and their surface modifications may significantly influence the development of PJI. Currently, silver nanoparticle (AgNP) technology is receiving much interest in the field of orthopaedics for its antimicrobial properties and a strong anti-biofilm potential. The great advantage of AgNP surface modification is a minimal release of active substances into the surrounding tissue and a long period of effectiveness. As a result, a controlled release of AgNPs could ensure antibacterial protection throughout the life of the implant. Moreover, the antibacterial effect of AgNPs may be strengthened in combination with conventional antibiotics and other antimicrobial agents. Here, our main attention is devoted to general guidelines for the design of antibacterial biomaterials protected by AgNPs, its benefits, side effects and future perspectives in PJI prevention.
Collapse
Affiliation(s)
- Jiri Gallo
- Department of Orthopaedics, Faculty of Medicine and Dentistry, Palacký University Olomouc, I. P. Pavlova 6, Olomouc 779 00, Czech Republic.
| | - Ales Panacek
- Regional Centre of Advanced Technologies and Materials, Palacký University Olomouc, Šlechtitelů 27, Olomouc 783 71, Czech Republic.
| | - Robert Prucek
- Regional Centre of Advanced Technologies and Materials, Palacký University Olomouc, Šlechtitelů 27, Olomouc 783 71, Czech Republic.
| | - Eva Kriegova
- Department of Immunology, Faculty of Medicine and Dentistry, Palacký University Olomouc, Hněvotínská 3, Olomouc 779 00, Czech Republic.
| | - Sarka Hradilova
- Regional Centre of Advanced Technologies and Materials, Palacký University Olomouc, Šlechtitelů 27, Olomouc 783 71, Czech Republic.
| | - Martin Hobza
- Department of Orthopaedics, Faculty of Medicine and Dentistry, Palacký University Olomouc, I. P. Pavlova 6, Olomouc 779 00, Czech Republic.
| | - Martin Holinka
- Department of Orthopaedics, Faculty of Medicine and Dentistry, Palacký University Olomouc, I. P. Pavlova 6, Olomouc 779 00, Czech Republic.
| |
Collapse
|
|
37
|
Thornley P, Evaniew N, Riediger M, Winemaker M, Bhandari M, Ghert M. Postoperative antibiotic prophylaxis in total hip and knee arthroplasty: a systematic review and meta-analysis of randomized controlled trials. CMAJ Open 2015; 3:E338-43. [PMID: 26457293 PMCID: PMC4596117 DOI: 10.9778/cmajo.20150012] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Postoperative antibiotic prophylaxis is currently the standard of care for patients undergoing total hip and knee arthroplasty. We evaluated the evidence for this practice in the reduction of surgical-site infections. METHODS We systematically searched MEDLINE, Embase and the Cochrane Library for randomized controlled trials (RCTs) published up to Aug. 15, 2014. We included all RCTs that compared postoperative antibiotic prophylaxis with postoperative placebo or no treatment in patients undergoing primary total hip or knee arthroplasty for osteoarthritis. We combined outcomes for surgical-site infection using a random-effects model and quantified heterogeneity using the χ2 test and the I2 statistic. We assessed the overall quality of the evidence according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. RESULTS We identified 4 RCTs (n = 4036) that met the inclusion criteria. Surgical-site infections occurred in 3.1% (63/2055) of patients in the prophylaxis group and 2.3% (45/1981) in the control group. Postoperative prophylaxis did not reduce the rate of surgical-site infections compared with placebo (risk difference 0.01, 95% confidence interval 0.00 to 0.02; I2 = 26%). This result was robust to sensitivity testing for losses to follow-up. According to the GRADE approach, the overall quality of evidence was very low. INTERPRETATION The available evidence did not show efficacy of postoperative antibiotic prophylaxis for the prevention of surgical-site infections in patients undergoing total hip or knee arthroplasty. Multicentred RCTs are likely to have an important impact on the confidence in the effect estimate and to change the estimate itself.
Collapse
Affiliation(s)
- Patrick Thornley
- Faculty of Health Sciences (Thornley), Michael G. DeGroote School of Medicine; Division of Orthopaedics (Evanview, Riediger, Winemaker, Bhandari, Ghert), Department of Surgery; Department of Clinical Epidemiology and Biostatistics (Bhandari), McMaster University, Hamilton, Ont
| | - Nathan Evaniew
- Faculty of Health Sciences (Thornley), Michael G. DeGroote School of Medicine; Division of Orthopaedics (Evanview, Riediger, Winemaker, Bhandari, Ghert), Department of Surgery; Department of Clinical Epidemiology and Biostatistics (Bhandari), McMaster University, Hamilton, Ont
| | - Michael Riediger
- Faculty of Health Sciences (Thornley), Michael G. DeGroote School of Medicine; Division of Orthopaedics (Evanview, Riediger, Winemaker, Bhandari, Ghert), Department of Surgery; Department of Clinical Epidemiology and Biostatistics (Bhandari), McMaster University, Hamilton, Ont
| | - Mitchell Winemaker
- Faculty of Health Sciences (Thornley), Michael G. DeGroote School of Medicine; Division of Orthopaedics (Evanview, Riediger, Winemaker, Bhandari, Ghert), Department of Surgery; Department of Clinical Epidemiology and Biostatistics (Bhandari), McMaster University, Hamilton, Ont
| | - Mohit Bhandari
- Faculty of Health Sciences (Thornley), Michael G. DeGroote School of Medicine; Division of Orthopaedics (Evanview, Riediger, Winemaker, Bhandari, Ghert), Department of Surgery; Department of Clinical Epidemiology and Biostatistics (Bhandari), McMaster University, Hamilton, Ont
| | - Michelle Ghert
- Faculty of Health Sciences (Thornley), Michael G. DeGroote School of Medicine; Division of Orthopaedics (Evanview, Riediger, Winemaker, Bhandari, Ghert), Department of Surgery; Department of Clinical Epidemiology and Biostatistics (Bhandari), McMaster University, Hamilton, Ont
| |
Collapse
|