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Terry R, Dean S, Hourigan P, Waterson HB, Wylde V, Carpenter N, Whale B, Powell RJ, Tarrant P, Medina-Lara A, Alvand A, Toms AD. MIKROBE: a feasibility study for a randomised controlled trial of one-stage or two-stage surgery for prosthetic knee infection. Pilot Feasibility Stud 2025; 11:49. [PMID: 40241215 PMCID: PMC12001597 DOI: 10.1186/s40814-025-01634-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2024] [Accepted: 04/03/2025] [Indexed: 04/18/2025] Open
Abstract
BACKGROUND Total knee replacement surgery is common, with over 107,000 operations performed in the UK in 2019. After surgery, about 1% of patients develop a deep infection, known as a prosthetic joint infection. Two types of operations, one- or two-stage revision surgery, are routinely performed to treat the infection. Re-infection rates are similar, but there is uncertainty regarding longer-term outcomes for patients. The aim of this study was to establish the feasibility of conducting a future randomised controlled trial that will compare clinical and cost-effectiveness of one-stage versus two-stage revision knee surgery for prosthetic joint infection. METHODS Following eligibility screening, consenting patients took part in an audio-recorded consultation with their surgeon and were then randomised on a 1:1 allocation to one-stage or two-stage revision surgery. Patient-reported outcome measures were administered at baseline and 3 and 6 months postoperatively. Embedded qualitative work with patient participants and nonparticipants and with surgeons to understand the acceptability of trial processes and involvement was undertaken. Patient and public involvement and engagement activities were conducted throughout the study. RESULTS Of 136 patients screened, only 3 were randomised and had surgery as part of the study. Qualitative data were collected from the three participants, as well as from two eligible patients who declined participation and two who withdrew from participation after the initial patient-surgeon consultation. Five surgeons took part in qualitative interviews prior to study end. CONCLUSION This study indicated that a larger randomised controlled trial evaluating one-stage versus two-stage revision knee surgery for prosthetic joint infection is not feasible with the current straightforward randomised controlled trial design. Future research needs to consider the most appropriate study design and methodology to address this important research question. TRIAL REGISTRATION No.: NCT04458961.
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Affiliation(s)
- Rohini Terry
- University of Exeter Medical School, St Luke'S Campus, Heavitree Road, Exeter, EX1 2LU, UK.
| | - Sarah Dean
- University of Exeter Medical School, St Luke'S Campus, Heavitree Road, Exeter, EX1 2LU, UK
| | - Patrick Hourigan
- Exeter Knee Reconstruction Unit, Princess Elizabeth Orthopaedic Centre, Royal Devon University Hospital NHS Trust, Barrack Road, Exeter, EX2 5DW, UK
| | - Hugh Ben Waterson
- Exeter Knee Reconstruction Unit, Princess Elizabeth Orthopaedic Centre, Royal Devon University Hospital NHS Trust, Barrack Road, Exeter, EX2 5DW, UK
| | - Vikki Wylde
- Musculoskeletal Research Unit, NIHR Bristol Biomedical Research Centre, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol Medical School, University of Bristol, Bristol, BS10 5 NB, UK
| | - Natalie Carpenter
- University of Exeter Medical School, St Luke'S Campus, Heavitree Road, Exeter, EX1 2LU, UK
| | - Bethany Whale
- University of Exeter Medical School, St Luke'S Campus, Heavitree Road, Exeter, EX1 2LU, UK
| | - Roy J Powell
- NIHR Research Design Service South West, London, UK
| | - Polly Tarrant
- Exeter Knee Reconstruction Unit, Princess Elizabeth Orthopaedic Centre, Royal Devon University Hospital NHS Trust, Barrack Road, Exeter, EX2 5DW, UK
| | - Antonieta Medina-Lara
- University of Exeter Medical School, St Luke'S Campus, Heavitree Road, Exeter, EX1 2LU, UK
| | - Abtin Alvand
- Nuffield Department of Orthopaedics (NOC), University of Oxford, Oxford, UK
| | - Andrew D Toms
- Exeter Knee Reconstruction Unit, Princess Elizabeth Orthopaedic Centre, Royal Devon University Hospital NHS Trust, Barrack Road, Exeter, EX2 5DW, UK
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Gadd M, Elledge ROC. Dental prophylaxis and alloplastic temporomandibular joint replacement (TMJR): time for a consensus? Br J Oral Maxillofac Surg 2025:S0266-4356(25)00084-1. [PMID: 40335417 DOI: 10.1016/j.bjoms.2025.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2025] [Revised: 03/24/2025] [Accepted: 04/04/2025] [Indexed: 05/09/2025]
Abstract
Searches of the literature and current guidelines have revealed inconsistent recommendations regarding dental optimisation prior to alloplastic temporomandibular joint replacement (TMJR). Furthermore, current literature suggests there is no consensus on antibiotic prophylaxis (AP) for dental procedures following TMJR. A 12-question survey was emailed to Professor Mercuri's TMJ Internetwork Group (144 members) and The European Society of Temporomandibular Joint Surgeons (ESTMJS) (49 members), totalling 177 survey recipients, accounting for those who are members of both groups. Respondents were asked whether routine dental assessments were performed prior to TMJR, if they recommended AP following TMJR, the timeframes and types of procedures for which this was recommended, and the types of antibiotics prescribed. The survey had 50 respondents, as of 15 November 2024, giving an overall response rate of 28.2%, however, the question specific response rate ranged from 29 to 50 respondents. No consensus was reached regarding the types of AP recommended, with 54.2% (n = 26) of respondents offering no prophylaxis for dental treatment following TMJR. The majority of respondents who did provide prophylaxis preferred amoxicillin or co-amoxiclav (n = 25/37), and clindamycin for penicillin allergic patients (n = 13/46). The timeframe for which respondents felt that antibiotics should be offered for dental procedures post-TMJR varied from one month (n = 3/37) to lifelong (n = 6/37), with a modal response of two years (n = 9/35). This survey reflected the lack of consensus seen across available literature and highlights the need for unified guidance to ensure safe and consistent patient care for TMJR patients.
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Affiliation(s)
- Madeleine Gadd
- College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK.
| | - Ross O C Elledge
- Oral and Maxillofacial Surgeon, University Hospitals Birmingham NHS Foundation Trust, UK; University Hospitals Birmingham NHS Foundation Trust, UK.
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3
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Smith TO, Gorick H, Arnold S, Hopgood P. Patient and Health Professional's Perspectives of Periprosthetic Joint Infection: A Systematic Review and Meta-Ethnography. Surg Infect (Larchmt) 2025; 26:195-203. [PMID: 39869034 DOI: 10.1089/sur.2024.253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2025] Open
Abstract
Background: Periprosthetic joint infection (PJI) is a major challenge for surgical teams and patients following an orthopedic surgical procedure. There is limited understanding on patient and health professional's perception of PJI. The aim of this study was to examine the literature to better understand the perspectives of patients, and those who manage PJI. Methods: Published and unpublished literature databases were systematically searched from inception to June 21, 2024. Qualitative studies reporting the perspectives of living with and managing PJI were included. Data were synthesized using a meta-ethnography approach and the GRADE-CERQual tool. Results: Of the 584 citations identified, 10 studies (n = 91 patients; n = 70 health professionals) met the eligibility criteria and were included. Three themes, all moderate-certainty evidence, were identified from the health professional data, including the following: (1) importance of PJI; (2) impact on health professionals; and (3) support for change. From the patient data, six themes on the basis of moderate-certainty evidence were identified: (1) psychological and social impact; (2) physical impacts; (3) relationship with health professionals; (4) relationship with others; (5) uncertainty over the future; and (6) support for change. A novel line of argument was developed offering third-order constructs, on the basis of first- and second-order themes. Conclusion: PJIs are perceived as devastating by both patients and health professionals. They impact on all aspects of a patient's physical, social and psychological health, each interacting on one another over the course of infection and management. Strategies to improve communication, multidisciplinary management, and personalization of care are advocated by both patients and health professionals to promote better outcomes.
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Affiliation(s)
- Toby O Smith
- Warwick Medical School, University of Warwick, Coventry, United Kingdom
- Norfolk and Norwich University Hospital, Norwich, United Kingdom
| | - Hugh Gorick
- Norfolk and Norwich University Hospital, Norwich, United Kingdom
- School of Health Sciences, University of East Anglia, Norwich, United Kingdom
| | - Susanne Arnold
- Warwick Medical School, University of Warwick, Coventry, United Kingdom
| | - Phil Hopgood
- Norfolk and Norwich University Hospital, Norwich, United Kingdom
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Dukes KC, Walhof JF, Hockett Sherlock S, Suh D, Sekar P, Suzuki H, Reisinger HS, Alexander B, Miell KR, Beck B, Pugely A, Schweizer ML. Decisions About Suppressive Antibiotics Among Clinicians at Veterans Affairs Hospitals After Prosthetic Joint Infection. JAMA Netw Open 2025; 8:e251152. [PMID: 40105839 PMCID: PMC11923720 DOI: 10.1001/jamanetworkopen.2025.1152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2024] [Accepted: 01/15/2025] [Indexed: 03/20/2025] Open
Abstract
Importance Indefinite suppressive antibiotic therapy (SAT) is sometimes prescribed after initial antibiotic treatment for prosthetic joint infection (PJI). Limited evidence on outcomes after SAT exists, and using SAT for patients at low risk who may not need it could be associated with antibiotic resistance and adverse events. Objectives To characterize clinical decision-making about SAT after PJI and identify stewardship intervention opportunities to stop or reduce SAT for patients who may not benefit. Design, Setting, and Participants In this qualitative study, interviews were conducted with 41 clinicians involved in decision-making about SAT after PJI at 8 US Veterans Affairs hospitals between November 1, 2019, and July 31, 2021. Analysis was conducted from June 9, 2020, to August 31, 2022. Main Outcomes and Measures Systematic thematic analysis of transcripts of semistructured interviews was conducted to assess the decision-making process for SAT after PJI, including identifying decision-makers, risks and benefits of SAT, and significant time points that occur before or after the SAT prescribing decision. Results A total of 41 clinicians were interviewed. Interviewees reported a complex, usually patient-specific, sometimes collaborative decision-making process. Decisions were emotionally charged because of serious possible repercussions for patients and limited evidence about benefits and risks associated with SAT. Surgeons and infectious diseases physicians were the primary SAT prescribers. Their initial risk-benefit calculation for SAT usually included whether revision surgery could be performed and what type, the organism, patient factors, and clinical signs of infection, as well as their perception of the existing evidence base for SAT after PJI. Interviewees identified significant time points that occured before or after the SAT prescribing decision, including PJI treatment decisions and follow-up appointments. Other potential decision-makers over time included patients, primary care physicians, and pharmacists. Interviewees identified opportunities to discuss SAT-associated benefits and risks with patients as well as other clinicians. Interviewees wanted more evidence about patient outcomes to inform prescribing decisions and emphasized the importance of clinician autonomy and buy-in for practice change. Conclusions and Relevance This qualitative study found that surgeons and infectious diseases physicians often made initial decisions about SAT and identified other potential decision-makers (patients, primary care physicians, pharmacists) and significant time points that occur before or after the SAT prescribing decision, including PJI treatment decisions and follow-up appointments. Stewardship interventions should take into account decision points for patients with PJI across time and the range of decision-makers, including patients, across time.
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Affiliation(s)
- Kimberly C. Dukes
- Center for Access & Delivery Research & Evaluations (CADRE), Iowa City Veterans Affairs Health Care System, Iowa City, Iowa
- Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City
- College of Public Health, University of Iowa, Iowa City
| | - Julia Friberg Walhof
- Center for Access & Delivery Research & Evaluations (CADRE), Iowa City Veterans Affairs Health Care System, Iowa City, Iowa
| | - Stacey Hockett Sherlock
- Center for Access & Delivery Research & Evaluations (CADRE), Iowa City Veterans Affairs Health Care System, Iowa City, Iowa
- Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City
| | - Dan Suh
- Center for Access & Delivery Research & Evaluations (CADRE), Iowa City Veterans Affairs Health Care System, Iowa City, Iowa
| | - Poorani Sekar
- Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City
| | - Hiroyuki Suzuki
- Center for Access & Delivery Research & Evaluations (CADRE), Iowa City Veterans Affairs Health Care System, Iowa City, Iowa
- Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City
| | - Heather Schacht Reisinger
- Center for Access & Delivery Research & Evaluations (CADRE), Iowa City Veterans Affairs Health Care System, Iowa City, Iowa
- Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City
- Institute for Clinical and Translational Science, University of Iowa, Iowa City
| | - Bruce Alexander
- Center for Access & Delivery Research & Evaluations (CADRE), Iowa City Veterans Affairs Health Care System, Iowa City, Iowa
| | - Kelly Richardson Miell
- Center for Access & Delivery Research & Evaluations (CADRE), Iowa City Veterans Affairs Health Care System, Iowa City, Iowa
| | - Brice Beck
- Center for Access & Delivery Research & Evaluations (CADRE), Iowa City Veterans Affairs Health Care System, Iowa City, Iowa
| | - Andrew Pugely
- Department of Surgery, University of Iowa Carver College of Medicine, Iowa City
| | - Marin L. Schweizer
- William S. Middleton Veterans Affairs Hospital, Madison, Wisconsin
- Department of Internal Medicine, School of Medicine and Public Health, University of Wisconsin, Madison
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Careau J, Larmuseau MHD, Drumsta R, Whitley R. "I'm trying to figure out who the hell I am": Examining the psychosocial and mental health experience of individuals learning "Not Parent Expected" news from a direct-to-consumer DNA ancestry test. BMC Psychiatry 2025; 25:9. [PMID: 39757164 PMCID: PMC11702199 DOI: 10.1186/s12888-024-06380-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2024] [Accepted: 12/06/2024] [Indexed: 01/07/2025] Open
Abstract
BACKGROUND According to recent estimates, around 30 million people have taken Direct-to-Consumer DNA ancestry tests, typically marketed as a fun, harmless and exciting process of discovery. These tests estimate a user's ethnic ancestry, also matching users with biological relations on their database. This matching can produce a surprising 'not parent expected' discovery, where a user learns that an assumed parent (typically the father) is not a biological parent. Such news may negatively affect mental health, self-identity and familial relationships, while prompting the utilization of putatively helpful resources by affected individuals. However, there is a lack of research on this topic. Thus, this study aimed to document the psychosocial experience of adults who have learnt that an assumed parent is not a biological parent via a Direct-to-Consumer DNA ancestry test. Specific objectives include investigating and understanding impact on mental health, familial relationships and subsequent resources mobilized. METHODS To meet these objectives, we conducted an inductive qualitative study, allowing for the documentation of common experiences and perspectives. This involved 52 semi-structured interviews with affected individuals, analyzed using thematic analysis. RESULTS This resulted in five overlapping themes, namely (i) participants typically described their experience as an extraordinary shock that had a negative impact on their mental health, with some exceptions; (ii) the experience typically led to a severe and troubling disruption of their self-identity, with some exceptions; (iii) the news often ruptured extant familial relationships, especially with the mother, and any experiences with the new biological family were mixed; (iv) participants sought support from a variety of resources including spouses, siblings, and online peer support groups, which were generally considered helpful, with some exceptions; and (v) many participants consulted mental health professionals, who were sometimes considered supportive, but some participants noted that they were ill-equipped to help. Common across these themes were issues of grief, loss and trauma. CONCLUSIONS This study reveals an expanding, vulnerable, and under-researched population facing unique stressors, that may be at high risk of developing a psychiatric disorder. There is a need for new services and supports for this population including tailored clinical interventions and specific self-care resources.
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Affiliation(s)
- Juliette Careau
- Department of Psychiatry, Douglas Research Centre, McGill University, 6875 LaSalle Blvd, Montreal, QC, Canada
| | - Maarten H D Larmuseau
- Laboratory of Human Genetic Genealogy, Department of Human Genetics, KU Leuven, ON6 Herestraat 49-box 604, Leuven, B-3000, Belgium
| | | | - Rob Whitley
- Department of Psychiatry, Douglas Research Centre, McGill University, 6875 LaSalle Blvd, Montreal, QC, Canada.
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6
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Zink TM, Gonzalez AG, Coden G, Smith EL, Bono JV. Outcomes of Total Knee Arthroplasty Following a Sham Incision Procedure in Patients with Previous Knee Incisions. J Bone Joint Surg Am 2024; 106:1986-1990. [PMID: 39321307 DOI: 10.2106/jbjs.24.00114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/27/2024]
Abstract
BACKGROUND Tenuous blood supply carries a risk of wound-healing problems and subsequent infection following total knee arthroplasty (TKA). This risk may be increased by the presence of previous incisions. Performing a sham incision procedure allows for detection of wound-healing problems prior to performing TKA. The purpose of this retrospective case series is to describe the indications for and technique of a sham incision procedure in patients with previous knee incisions who underwent TKA following this procedure and to report the clinical outcomes observed in these patients following further surgery. METHODS Patients who had prior knee incisions, had undergone a sham incision prior to TKA, and had a minimum follow-up of 2 years were identified, and their cases were retrospectively reviewed. The identified cases typically adhered to the surgeon's standard protocol, which consisted of making a midline incision adventitious to TKA, dissecting down to deep fascia, and closing the wound with suture. Incisions were then observed for at least 4 weeks to determine the viability of the skin flaps before TKA was performed via the same incision. RESULTS A total of 47 knees in 47 patients were included in the study cohort. TKA was performed at an average of 21.1 weeks (range, 4 to 163 weeks) following the sham incision. There were no cases of skin necrosis or periprosthetic joint infection at an average follow-up of 4.6 years (range, 2 to 12 years) after sham incision. A total of 11 patients (23.4%) required manipulation under anesthesia for stiffness. CONCLUSIONS In our series, no patients developed skin necrosis or periprosthetic joint infection following TKA subsequent to a sham incision procedure, suggesting that healed sham incisions are safe to use for TKA and may be considered prior to TKA in cases in which local previous incisions increase the risk of wound-healing problems. LEVEL OF EVIDENCE Prognostic Level IV . See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Thomas M Zink
- Tufts Medical Center, Boston, Massachusetts
- Tufts University School of Medicine, Boston, Massachusetts
- New England Baptist Hospital, Boston, Massachusetts
| | | | - Gloria Coden
- New England Baptist Hospital, Boston, Massachusetts
| | - Eric L Smith
- Tufts University School of Medicine, Boston, Massachusetts
- New England Baptist Hospital, Boston, Massachusetts
| | - James V Bono
- Tufts University School of Medicine, Boston, Massachusetts
- New England Baptist Hospital, Boston, Massachusetts
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7
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Mohiuddin A, Rice J, Ziemba-Davis M, Meneghini RM. Infection Rates After Aseptic Revision Total Hip Arthroplasty With Extended Oral Antibiotic Prophylaxis. J Am Acad Orthop Surg 2024; 32:472-480. [PMID: 38354411 DOI: 10.5435/jaaos-d-23-00750] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Accepted: 12/24/2023] [Indexed: 02/16/2024] Open
Abstract
INTRODUCTION Few US studies have investigated the efficacy of extended oral antibiotic prophylaxis (EOAP) in the prevention of periprosthetic joint infection (PJI) after aseptic revision total hip arthroplasty (R-THA). This study compared PJI rates in aseptic R-THA performed with EOAP with PJI rates in published studies of aseptic R-THA patients not receiving EOAP. METHODS Prospectively documented data on 127 consecutive aseptic R-THAs were retrospectively reviewed. Evidence-based perioperative infection prevention protocols were used, and all patients were discharged on 7-day EOAP. Superficial and deep infections at 30 and 90 days postoperatively and at mean latest follow-up of 27.8 months were statistically compared with all US studies reporting the prevalence of PJI after aseptic R-THA. Complications related to EOAP within 120 days of the index procedure also are reported. RESULTS No superficial or deep infections were observed at 30 and 90 days postoperatively when 7-day postdischarge EOAP was used. Superficial and deep infection rates were 1.57% (two patients) and 3.15% (four patients) at mean latest follow-up, respectively. Comparisons with published 30-day PJI rates of 1.37% ( P = 0.423) and 1.85% ( P = 0.257) were not statistically significant. Two of four comparisons with published 90-day PJI rates of 3.43% ( P = 0.027) and 5.74% ( P = 0.001) were statistically different. The deep PJI rate of 3.15% at mean latest follow-up was significantly lower than two of three published rates at equivalent follow-up including 10.10% ( P = 0.009) and 9.12% ( P = 0.041). No antibiotic-related complications were observed within 120 days of the index procedure. DISCUSSION Study findings possibly support the use of EOAP after aseptic R-THA to prevent catastrophic PJI with revision implants, indicating that the efficacy of EOAP cannot be definitively ruled-in or ruled-out based on available evidence.
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Affiliation(s)
- Amer Mohiuddin
- From the Department of Anesthesia, Indiana University School of Medicine, Indianapolis, IN (Mohiuddin), Department of Family Medicine, Ascension St. Vincent Hospital, Indianapolis, IN (Rice), Indiana University Health Multispecialty Musculoskeletal Center, Carmel, IN (Ziemba-Davis), Department of Orthopaedic Surgery, Indiana University School of Medicine, Indianapolis, IN (Meneghini)
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Sadhwani S, Kamson A, Frear AJ, Sadaka N, Urish KL. Current Concepts on the Clinical and Economic Impact of Periprosthetic Joint Infections. Orthop Clin North Am 2024; 55:151-159. [PMID: 38403362 DOI: 10.1016/j.ocl.2023.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/27/2024]
Abstract
Total joint arthroplasty (TJA) is a common procedure performed throughout the entire world in hopes of alleviating debilitating hip or knee pain. The projected number of TJAs performed in the United States alone is projected to exceed 1.9 million by 2030 and 5 million by 2040. With the significant increase in TJA performed, more periprosthetic joint infections (PJIs) are likely to be encountered. PJIs are a devastating complication of TJA. The economic and clinical burden must be understood and respected to minimize occurrence and allow optimal patient outcomes.
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Affiliation(s)
- Shaan Sadhwani
- Arthritis and Arthroplasty Design Group, Department of Orthopaedic Surgery, School of Medicine, University of Pittsburgh, Pittsburgh, PA 15219, USA; Department of Orthopaedic Surgery, UPMC Central PA, Harrisburg, PA 17109, USA
| | - Anthony Kamson
- Arthritis and Arthroplasty Design Group, Department of Orthopaedic Surgery, School of Medicine, University of Pittsburgh, Pittsburgh, PA 15219, USA; Department of Orthopaedic Surgery, UPMC Central PA, Harrisburg, PA 17109, USA
| | - Andrew J Frear
- Arthritis and Arthroplasty Design Group, Department of Orthopaedic Surgery, School of Medicine, University of Pittsburgh, Pittsburgh, PA 15219, USA
| | - Nadine Sadaka
- Arthritis and Arthroplasty Design Group, Department of Orthopaedic Surgery, School of Medicine, University of Pittsburgh, Pittsburgh, PA 15219, USA
| | - Kenneth L Urish
- Arthritis and Arthroplasty Design Group, Department of Orthopaedic Surgery, School of Medicine, University of Pittsburgh, Pittsburgh, PA 15219, USA; Arthritis and Arthroplasty Design Group, The Bone and Joint Center, Magee Womens Hospital of the University of Pittsburgh Medical Center; Department of Orthopaedic Surgery, Clinical and Translational Science Institute, University of Pittsburgh; Department of Bioengineering, Clinical and Translational Science Institute, University of Pittsburgh.
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Bouji N, Meadows E, Hollander JM, Velayutham M, Stewart E, Herriott J, Dietz MJ. A pilot study of mitochondrial response to an in vivo prosthetic joint Staphylococcus aureus infection model. J Orthop Res 2024; 42:539-546. [PMID: 37794704 PMCID: PMC10959235 DOI: 10.1002/jor.25696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Revised: 03/28/2023] [Accepted: 09/20/2023] [Indexed: 10/06/2023]
Abstract
Prosthetic joint infections (PJI) are associated with orthopaedic morbidity and mortality. Mitochondria, the "cell's powerhouses," are thought to play crucial roles in infection response and in increased risk of sepsis mortality. No current research discusses PJI's effect on mitochondrial function and a lack of understanding of immune-infection interactions potentially hinders patient care. The purpose of this pilot study was to evaluate the impact of simulated PJI on local tissue mitochondrial function. Using an established prosthetic implant-associated in vivo model, tissues were harvested from the surgical limb of a methicillin-sensitive Staphylococcus aureus implant-associated infection group (n = 6) and compared to a noninfected group (n = 6) at postoperative day (POD) 21. Using mitochondrial coupling assays, oxygen consumption rate and extracellular acidification rate were assessed in each group. Electron flow through mitochondrial complexes reflected group activity. Electron Paramagnetic Resonance (EPR) spectrometry measured the oxidizing potential of serum samples from infected versus noninfected groups. On POD21, colony-forming units per gram of tissue showed 5 × 109 in the infected group and 101 in the noninfected group (p < 0.0001). Maximal respiration and oxygen consumption due to adenosine triphosphate synthesis were significantly lower in isolated mitochondria from infected limbs (p = 0.04). Both groups had similar complex I, III, IV, and V activity (p > 0.1). Infected group EPR signal intensity reflecting reactive oxygen species levels was 1.31 ± 0.30 compared to 1.16 ± 0.28 (p = 0.73) in the noninfected group. This study highlights PJI's role in mammalian cell mitochondrial dysfunction and oxidative tissue damage, which can help develop interventions to combat PJI.
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Affiliation(s)
- Nour Bouji
- Department of Orthopaedics, Health Sciences Center-WVU School of Medicine, Morgantown, West Virginia, USA
| | - Ethan Meadows
- Department of Human Performance-Exercise Physiology, Health Sciences Center-WVU School of Medicine, Morgantown, West Virginia, USA
| | - John M Hollander
- Department of Human Performance-Exercise Physiology, Health Sciences Center-WVU School of Medicine, Morgantown, West Virginia, USA
| | - Murugesan Velayutham
- Department of Biochemistry and Molecular Medicine, Health Sciences Center-WVU School of Medicine, Morgantown, West Virginia, USA
| | - Elizabeth Stewart
- Department of Orthopaedics, Health Sciences Center-WVU School of Medicine, Morgantown, West Virginia, USA
| | - Jacob Herriott
- Department of Orthopaedics, Health Sciences Center-WVU School of Medicine, Morgantown, West Virginia, USA
| | - Matthew J Dietz
- Department of Orthopaedics, Health Sciences Center-WVU School of Medicine, Morgantown, West Virginia, USA
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10
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Moore AJ, Wylde V, Whitehouse MR, Beswick AD, Walsh NE, Jameson C, Blom AW. Development of evidence-based guidelines for the treatment and management of periprosthetic hip infection. Bone Jt Open 2023; 4:226-233. [PMID: 37051823 PMCID: PMC10065846 DOI: 10.1302/2633-1462.44.bjo-2022-0155.r1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/03/2023] Open
Abstract
Periprosthetic hip-joint infection is a multifaceted and highly detrimental outcome for patients and clinicians. The incidence of prosthetic joint infection reported within two years of primary hip arthroplasty ranges from 0.8% to 2.1%. Costs of treatment are over five-times greater in people with periprosthetic hip joint infection than in those with no infection. Currently, there are no national evidence-based guidelines for treatment and management of this condition to guide clinical practice or to inform clinical study design. The aim of this study is to develop guidelines based on evidence from the six-year INFection and ORthopaedic Management (INFORM) research programme. We used a consensus process consisting of an evidence review to generate items for the guidelines and online consensus questionnaire and virtual face-to-face consensus meeting to draft the guidelines. The consensus panel comprised 21 clinical experts in orthopaedics, primary care, rehabilitation, and healthcare commissioning. The final output from the consensus process was a 14-item guideline. The guidelines make recommendations regarding increased vigilance and monitoring of those at increased risk of infection; diagnosis including strategies to ensure the early recognition of prosthetic infection and referral to orthopaedic teams; treatment, including early use of DAIR and revision strategies; and postoperative management including appropriate physical and psychological support and antibiotic strategies. We believe the implementation of the INFORM guidelines will inform treatment protocols and clinical pathways to improve the treatment and management of periprosthetic hip infection.
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Affiliation(s)
| | | | | | | | - Nicola E. Walsh
- HAS - Allied Health Professions, University of the West of England, Bristol, UK
| | | | - Ashley W. Blom
- University of Sheffield Faculty of Medicine Dentistry and Health, Sheffield, UK
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de Steiger RN, Pratt NL, Gulyani A, Duszynski KM, Inacio MC, Graves SE, Smith PN, For the Improving Joint Replacement Outcomes in Australia using National Data Linkage Study Working Group. Antibiotic utilisation in primary and revision total hip replacement patients: A registry linkage cohort study of 106 253 patients using the Australian Orthopaedic Association National Joint Replacement Registry. Pharmacoepidemiol Drug Saf 2023; 32:238-247. [PMID: 36070795 PMCID: PMC10946895 DOI: 10.1002/pds.5522] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Revised: 07/29/2022] [Accepted: 08/07/2022] [Indexed: 01/26/2023]
Abstract
PURPOSE Infection is a major complication following joint replacement (JR) surgery. However, little data exist regarding antibiotic utilisation following primary JR and how use changes with subsequent revision surgery. This study aimed to examine variation in antibiotic utilisation rates before and after hip replacement surgery in those revised for infection, revised for other reasons and those without revision. METHODS This retrospective cohort analysis used linked data from the Australian Orthopaedic Association National Joint Replacement Registry and Australian Government Pharmaceutical Benefits Scheme. Patients were included if undergoing total hip replacement (THR) for osteoarthritis in private hospitals between 2002 and 2017. Three groups were examined: primary THR with no subsequent revision (n = 102 577), primary THR with a subsequent revision for reasons other than periprosthetic joint infection (PJI) (n = 3156) and primary THR with a subsequent revision for PJI (n = 520). Monthly antibiotic utilisation rates and prevalence rate ratios (PRRs) with 95% confidence intervals (CIs) were calculated in the 2 years pre- and post-THR. RESULTS Prior to primary THR antibiotic utilisation was 9%-10%. After primary THR, antibiotic utilisation rates were higher among patients revised for PJI (PRR 1.69, 95% CI 1.60-1.79) compared to non-revised patients, while the utilisation rate was lower in patients revised for reasons other than infection (PRR 0.96, 95% CI 0.93-0.98). For those revised for infection, antibiotic utilisation post-revision surgery was two times higher than those revised for other reasons (PRR 2.16, 95% CI 2.08-2.23). Utilisation of injectable antibiotics including, vancomycin, flucloxacillin and cephazolin was higher in those revised for PJI patients 0-2 weeks following surgery but not in those revised for other reasons compared to the non-revised group. CONCLUSIONS Ongoing antibiotic utilisation after primary surgery may be an early signal of problems with the THR and should be a prompt for primary care physicians to refer patients to specialists for further appropriate investigations and management.
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Affiliation(s)
- Richard N. de Steiger
- Department of Surgery, Epworth HealthcareUniversity of MelbourneMelbourneVictoriaAustralia
- Australian Orthopaedic Association National Joint Replacement RegistrySouth Australian Health and Medical Research InstituteAdelaideSouth AustraliaAustralia
| | - Nicole L. Pratt
- Quality Use of Medicines and Pharmacy Research Centre, Clinical and Health ServicesUniversity of South AustraliaAdelaideSouth AustraliaAustralia
| | - Aarti Gulyani
- Quality Use of Medicines and Pharmacy Research Centre, Clinical and Health ServicesUniversity of South AustraliaAdelaideSouth AustraliaAustralia
| | - Katherine M. Duszynski
- Quality Use of Medicines and Pharmacy Research Centre, Clinical and Health ServicesUniversity of South AustraliaAdelaideSouth AustraliaAustralia
| | - Maria C. Inacio
- Registry of Senior AustraliansSouth Australian Health and Medical Research InstituteAdelaideSouth AustraliaAustralia
| | - Stephen E. Graves
- Australian Orthopaedic Association National Joint Replacement RegistrySouth Australian Health and Medical Research InstituteAdelaideSouth AustraliaAustralia
| | - Paul N. Smith
- Australian National University Medical SchoolAustralian National UniversityCanberraAustralian Capital TerritoryAustralia
- Department of Orthopaedic SurgeryCanberra HospitalCanberraAustralian Capital TerritoryAustralia
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Blom AW, Beswick AD, Burston A, Carroll FE, Garfield K, Gooberman-Hill R, Harris S, Kunutsor SK, Lane A, Lenguerrand E, MacGowan A, Mallon C, Moore AJ, Noble S, Palmer CK, Rolfson O, Strange S, Whitehouse MR. Infection after total joint replacement of the hip and knee: research programme including the INFORM RCT. PROGRAMME GRANTS FOR APPLIED RESEARCH 2022. [DOI: 10.3310/hdwl9760] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Background
People with severe osteoarthritis, other joint conditions or injury may have joint replacement to reduce pain and disability. In the UK in 2019, over 200,000 hip and knee replacements were performed. About 1 in 100 replacements becomes infected, and most people with infected replacements require further surgery.
Objectives
To investigate why some patients are predisposed to joint infections and how this affects patients and the NHS, and to evaluate treatments.
Design
Systematic reviews, joint registry analyses, qualitative interviews, a randomised controlled trial, health economic analyses and a discrete choice questionnaire.
Setting
Our studies are relevant to the NHS, to the Swedish health system and internationally.
Participants
People with prosthetic joint infection after hip or knee replacement and surgeons.
Interventions
Revision of hip prosthetic joint infection with a single- or two-stage procedure.
Main outcome measures
Long-term patient-reported outcomes and reinfection. Cost-effectiveness of revision strategies over 18 months from two perspectives: health-care provider and Personal Social Services, and societal.
Data sources
National Joint Registry; literature databases; published cohort studies; interviews with 67 patients and 35 surgeons; a patient discrete choice questionnaire; and the INFORM (INFection ORthopaedic Management) randomised trial.
Review methods
Systematic reviews of studies reporting risk factors, diagnosis, treatment outcomes and cost comparisons. Individual patient data meta-analysis.
Results
In registry analyses, about 0.62% and 0.75% of patients with hip and knee replacement, respectively, had joint infection requiring surgery. Rates were four times greater after aseptic revision. The costs of inpatient and day-case admissions in people with hip prosthetic joint infection were about five times higher than those in people with no infection, an additional cost of > £30,000. People described devastating effects of hip and knee prosthetic joint infection and treatment. In the treatment of hip prosthetic joint infection, a two-stage procedure with or without a cement spacer had a greater negative impact on patient well-being than a single- or two-stage procedure with a custom-made articulating spacer. Surgeons described the significant emotional impact of hip and knee prosthetic joint infection and the importance of a supportive multidisciplinary team. In systematic reviews and registry analyses, the risk factors for hip and knee prosthetic joint infection included male sex, diagnoses other than osteoarthritis, high body mass index, poor physical status, diabetes, dementia and liver disease. Evidence linking health-care setting and surgeon experience with prosthetic joint infection was inconsistent. Uncemented fixation, posterior approach and ceramic bearings were associated with lower infection risk after hip replacement. In our systematic review, synovial fluid alpha-defensin and leucocyte esterase showed high diagnostic accuracy for prosthetic joint infection. Systematic reviews and individual patient data meta-analysis showed similar reinfection outcomes in patients with hip or knee prosthetic joint infection treated with single- and two-stage revision. In registry analysis, there was a higher rate of early rerevision after single-stage revision for hip prosthetic joint infection, but, overall, 40% fewer operations are required as part of a single-stage procedure than as part of a two-stage procedure. The treatment of hip or knee prosthetic joint infection with early debridement and implant retention may be effective in > 60% of cases. In the INFORM randomised controlled trial, 140 patients with hip prosthetic joint infection were randomised to single- or two-stage revision. Eighteen months after randomisation, pain, function and stiffness were similar between the randomised groups (p = 0.98), and there were no differences in reinfection rates. Patient outcomes improved earlier in the single-stage than in the two-stage group. Participants randomised to a single-stage procedure had lower costs (mean difference –£10,055, 95% confidence interval –£19,568 to –£542) and higher quality-adjusted life-years (mean difference 0.06, 95% confidence interval –0.07 to 0.18) than those randomised to a two-stage procedure. Single-stage was the more cost-effective option, with an incremental net monetary benefit at a threshold of £20,000 per quality-adjusted life-year of £11,167 (95% confidence interval £638 to £21,696). In a discrete choice questionnaire completed by 57 patients 18 months after surgery to treat hip prosthetic joint infection, the most valued characteristics in decisions about revision were the ability to engage in valued activities and a quick return to normal activity.
Limitations
Some research was specific to people with hip prosthetic joint infection. Study populations in meta-analyses and registry analyses may have been selected for joint replacement and specific treatments. The INFORM trial was not powered to study reinfection and was limited to 18 months’ follow-up. The qualitative study subgroups were small.
Conclusions
We identified risk factors, diagnostic biomarkers, effective treatments and patient preferences for the treatment of hip and knee prosthetic joint infection. The risk factors include male sex, diagnoses other than osteoarthritis, specific comorbidities and surgical factors. Synovial fluid alpha-defensin and leucocyte esterase showed high diagnostic accuracy. Infection is devastating for patients and surgeons, both of whom describe the need for support during treatment. Debridement and implant retention is effective, particularly if performed early. For infected hip replacements, single- and two-stage revision appear equally efficacious, but single-stage has better early results, is cost-effective at 18-month follow-up and is increasingly used. Patients prefer treatments that allow full functional return within 3–9 months.
Future work
For people with infection, develop information, counselling, peer support and care pathways. Develop supportive care and information for patients and health-care professionals to enable the early recognition of infections. Compare alternative and new treatment strategies in hip and knee prosthetic joint infection. Assess diagnostic methods and establish NHS diagnostic criteria.
Study registration
The INFORM randomised controlled trial is registered as ISRCTN10956306. All systematic reviews were registered in PROSPERO (as CRD42017069526, CRD42015023485, CRD42018106503, CRD42018114592, CRD42015023704, CRD42017057513, CRD42015016559, CRD42015017327 and CRD42015016664).
Funding
This project was funded by the National Institute for Health and Care Research (NIHR) Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 10, No. 10. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Ashley W Blom
- National Institute for Health and Care Research Bristol Biomedical Research Centre, University Hospitals Bristol and Weston NHS Foundation Trust and University of Bristol, Bristol, UK
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Andrew D Beswick
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Amanda Burston
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Fran E Carroll
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Kirsty Garfield
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- Bristol Randomised Trials Collaboration, University of Bristol, Bristol, UK
| | - Rachael Gooberman-Hill
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Shaun Harris
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- Bristol Randomised Trials Collaboration, University of Bristol, Bristol, UK
| | - Setor K Kunutsor
- National Institute for Health and Care Research Bristol Biomedical Research Centre, University Hospitals Bristol and Weston NHS Foundation Trust and University of Bristol, Bristol, UK
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Athene Lane
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- Bristol Randomised Trials Collaboration, University of Bristol, Bristol, UK
| | - Erik Lenguerrand
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | | | - Charlotte Mallon
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Andrew J Moore
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Sian Noble
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Cecily K Palmer
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- National Institute for Health and Care Research Applied Research Collaboration West (NIHR ARC West), University Hospitals Bristol NHS Foundation Trust and University of Bristol, Bristol, UK
| | - Ola Rolfson
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Simon Strange
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Michael R Whitehouse
- National Institute for Health and Care Research Bristol Biomedical Research Centre, University Hospitals Bristol and Weston NHS Foundation Trust and University of Bristol, Bristol, UK
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
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Lenguerrand E, Whitehouse MR, Kunutsor SK, Beswick AD, Baker RP, Rolfson O, Reed MR, Blom AW. Mortality and re-revision following single-stage and two-stage revision surgery for the management of infected primary knee arthroplasty in England and Wales : evidence from the National Joint Registry. Bone Joint Res 2022; 11:690-699. [PMID: 36177603 PMCID: PMC9582862 DOI: 10.1302/2046-3758.1110.bjr-2021-0555.r1] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Aims We compared the risks of re-revision and mortality between two-stage revision surgery and single-stage revision surgery among patients with infected primary knee arthroplasty. Methods Patients with a periprosthetic joint infection (PJI) of their primary knee arthroplasty, initially revised with a single-stage or a two-stage procedure in England and Wales between 2003 and 2014, were identified from the National Joint Registry. We used Poisson regression with restricted cubic splines to compute hazard ratios (HR) at different postoperative periods. The total number of revisions and re-revisions undergone by patients was compared between the two strategies. Results A total of 489 primary knee arthroplasties were revised with single-stage procedure (1,390 person-years) and 2,377 with two-stage procedure (8,349 person-years). The adjusted incidence rates of all-cause re-revision and for infection were comparable between these strategies (HR overall five years, 1.15 (95% confidence interval (CI) 0.87 to 1.52), p = 0.308; HR overall five years, 0.99 (95% CI 0.70 to 1.39), p = 0.949, respectively). Patients initially managed with single-stage revision received fewer revision procedures overall than after two-stage revision (1.2 vs 2.2, p < 0.001). Mortality was lower for single-stage revision between six and 18 months postoperative (HR at six months, 0.51 (95% CI 0.25 to 1.00), p = 0.049 HR at 18 months, 0.33 (95% CI 0.12 to 0.99), p = 0.048) and comparable at other timepoints. Conclusion The risk of re-revision was similar between single- and two-stage revision for infected primary knee arthroplasty. Single-stage group required fewer revisions overall, with lower or comparable mortality at specific postoperative periods. The single-stage revision is a safe and effective strategy to treat infected knee arthroplasties. There is potential for increased use to reduce the burden of knee PJI for patients, and for the healthcare system. Cite this article: Bone Joint Res 2022;11(10):690–699.
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Affiliation(s)
- Erik Lenguerrand
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Michael R Whitehouse
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK.,National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol NHS Foundation Trust and University of Bristol, Bristol, UK
| | - Setor K Kunutsor
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK.,National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol NHS Foundation Trust and University of Bristol, Bristol, UK
| | - Andrew D Beswick
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Richard P Baker
- Avon Orthopaedic Centre, Southmead Hospital, North Bristol NHS Trust, Bristol, UK
| | - Ola Rolfson
- Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Swedish Arthroplasty Register, Gothenburg, Sweden
| | - Michael R Reed
- Northumbria Healthcare NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Ashley W Blom
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK.,National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol NHS Foundation Trust and University of Bristol, Bristol, UK
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14
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Ackerman IN, Busija L, Lorimer M, de Steiger R, Graves SE. Monitoring the lifetime risk of revision knee arthroplasty over a decade : a population-level analysis of Australian national registry data. Bone Joint J 2022; 104-B:613-619. [PMID: 35491580 DOI: 10.1302/0301-620x.104b5.bjj-2021-1219.r1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AIMS This study aimed to describe the use of revision knee arthroplasty in Australia and examine changes in lifetime risk over a decade. METHODS De-identified individual-level data on all revision knee arthroplasties performed in Australia from 2007 to 2017 were obtained from the Australian Orthopaedic Association National Joint Replacement Registry. Population data and life tables were obtained from the Australian Bureau of Statistics. The lifetime risk of revision surgery was calculated for each year using a standardized formula. Separate calculations were undertaken for males and females. RESULTS In total, 43,188 revision knee arthroplasty procedures were performed in Australia during the study period, with a median age at surgery of 69 years (interquartile range (IQR) 62 to 76). In 2017, revision knee arthroplasty rates were highest for males aged 70 to 79 years (102.9 procedures per 100,000 population). Lifetime risk of revision knee arthroplasty for females increased slightly from 1.61% (95% confidence interval (CI) 1.53% to 1.69%) in 2007 to 2.22% (95% CI 2.13% to 2.31%) in 2017. A similar pattern was evident for males, with a lifetime risk of 1.43% (95% CI 1.36% to 1.51%) in 2007 and 2.02% (95% CI 1.93% to 2.11%) in 2017. A decline in procedures performed for loosening/lysis (from 41% in 2007 to 24% in 2017) and pain (from 14% to 9%) was evident, while infection became an increasingly common indication (from 19% in 2007 to 29% in 2017). CONCLUSION Well-validated national registry data can help us understand the epidemiology of revision knee arthroplasty, including changing clinical indications. Despite a small increase over a decade, the lifetime risk of revision knee arthroplasty in Australia is low at one in 45 females and one in 50 males. These methods offer a population-level approach to quantifying revision burden that can be used for ongoing national surveillance and between-country comparisons. Cite this article: Bone Joint J 2022;104-B(5):613-619.
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Affiliation(s)
- Ilana N Ackerman
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Ljoudmila Busija
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Michelle Lorimer
- South Australian Health and Medical Research Institute, Adelaide, Australia
| | - Richard de Steiger
- Department of Surgery, Epworth HealthCare, The University of Melbourne, Melbourne, Australia.,Australian Orthopaedic Association National Joint Replacement Registry, Adelaide, Australia
| | - Stephen E Graves
- Australian Orthopaedic Association National Joint Replacement Registry, Adelaide, Australia
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15
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Demystifying Qualitative Research for Musculoskeletal Practitioners Part 3: Phenomeno-what? Understanding What the Qualitative Researchers Have Done. J Orthop Sports Phys Ther 2022; 52:3-7. [PMID: 34972487 DOI: 10.2519/jospt.2022.10485] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
In part 3 of "Demystifying Qualitative Research for Musculoskeletal Practitioners," we introduce the concept of "methodological approach" to encompass the plan of action that underpins the use of methods and desired outcomes, as well as the use of theory. Understanding the methodological approach in a qualitative study gives the reader a sense of what the qualitative researchers have "done," while theory has varying uses and meanings depending on type of qualitative study. In this installment, we cover some of the common methodological approaches used in the musculoskeletal field and provide a discussion about the different ways in which theory can be considered and used in a qualitative study. J Orthop Sports Phys Ther 2022;52(1):3-7. doi:10.2519/jospt.2022.10485.
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Abdo RCT, Gobbi RG, Leite CBG, Pasoto SG, Leon EP, Lima ALLM, Bonfa E, Pécora JR, Demange MK. Performance of alpha-defensin lateral flow test after synovial fluid centrifugation for diagnosis of periprosthetic knee infection. World J Orthop 2021; 12:565-574. [PMID: 34485103 PMCID: PMC8384616 DOI: 10.5312/wjo.v12.i8.565] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2021] [Revised: 06/14/2021] [Accepted: 07/09/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND The quantitative alpha-defensin enzyme-linked immunosorbent assay (ELISA) demands a prior synovial fluid centrifugation, whereas this processing is not routinely required prior to the alpha-defensin lateral flow test.
AIM To evaluate whether a prior synovial fluid centrifugation could lead the lateral flow performance to achieve comparable results to ELISA during periprosthetic joint infection (PJI) diagnosis.
METHODS Fifty-three cases were included in this study: 22 classified as PJI and 31 classified as aseptic cases, according to Musculoskeletal Infection Society 2013 criteria. Synovial fluid samples were submitted to centrifugation, and the supernatant was evaluated by ELISA and lateral flow tests. The sensitivity (SE), specificity (SP) and accuracy of each method were calculated as well as the agreement between those two methods.
RESULTS In all of the 31 samples from aseptic patients, alpha-defensin ELISA and lateral flow tests showed negative results for infection. Regarding the 22 infected patients, the lateral flow test was positive in 19 cases (86.4%) and the ELISA was positive in 21 (95.5%). Sensibility, SP and accuracy were, respectively, 86.4% (95%CI: 65.1%-97.1%), 100% (95%CI: 88.8%-100%) and 93.2% (95%CI: 82.8%-98.3%) for the lateral flow test and 95.5% (95%CI: 77.2%-99.9%), 100% (95%CI: 88.8%-100%) and 98.1% (95%CI: 89.9%-100%) for ELISA. An agreement of 96.2% between those methods were observed. No statistical difference was found between them (P = 0.48).
CONCLUSION Alpha-defensin lateral flow test showed high SE, SP and accuracy after a prior synovial fluid centrifugation, achieving comparable results to ELISA. Considering the lower complexity of the lateral flow and its equivalent performance obtained in this condition, a prior centrifugation might be added as a valuable step to enhance the PJI diagnosis.
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Affiliation(s)
- Rodrigo Calil Teles Abdo
- Instituto de Ortopedia e Traumatologia, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Sao Paulo 05403-010, Brazil
| | - Riccardo Gomes Gobbi
- Instituto de Ortopedia e Traumatologia, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Sao Paulo 05403-010, Brazil
| | - Chilan Bou Ghosson Leite
- Instituto de Ortopedia e Traumatologia, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Sao Paulo 05403-010, Brazil
| | - Sandra Gofinet Pasoto
- Division of Rheumatology, Faculdade de Medicina da Universidade de São Paulo, Sao Paulo 01246-903, Brazil
| | - Elaine Pires Leon
- Division of Rheumatology, Faculdade de Medicina da Universidade de São Paulo, Sao Paulo 01246-903, Brazil
| | - Ana Lucia Lei Munhoz Lima
- Instituto de Ortopedia e Traumatologia, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Sao Paulo 05403-010, Brazil
| | - Eloisa Bonfa
- Division of Rheumatology, Faculdade de Medicina da Universidade de São Paulo, Sao Paulo 01246-903, Brazil
| | - José Ricardo Pécora
- Instituto de Ortopedia e Traumatologia, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Sao Paulo 05403-010, Brazil
| | - Marco Kawamura Demange
- Instituto de Ortopedia e Traumatologia, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Sao Paulo 05403-010, Brazil
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Walter N, Rupp M, Hinterberger T, Alt V. [Prosthetic infections and the increasing importance of psychological comorbidities : An epidemiological analysis for Germany from 2009 through 2019]. DER ORTHOPADE 2021; 50:859-865. [PMID: 33751197 PMCID: PMC7942820 DOI: 10.1007/s00132-021-04088-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 02/11/2021] [Indexed: 01/28/2023]
Abstract
Hintergrund Die periprothetische Gelenkinfektion (PJI) ist eine gefürchtete Komplikation in der Orthopädie und Unfallchirurgie. Ein potenzieller Anstieg an PJI-Diagnosen, insbesondere in Verbindung mit psychologischen Komorbiditäten, kann zu einer besonderen Herausforderung für Akteure im Gesundheitswesen werden. Bisher ist die Prävalenz für Deutschland unbekannt. Dies erschwert es, den zukünftigen Behandlungsbedarf abzuschätzen und Entwicklungen vorherzusehen, die durch eine Anpassung von Präventions- und Therapiemaßnahmen beeinflusst werden können. Ziel der Arbeit Die vorliegende Arbeit gibt eine detaillierte Übersicht über die Epidemiologie periprothetischer Gelenkinfektionen und psychologischer Komorbiditäten. Material und Methoden Ein Datensatz vom Statistischen Bundesamt (Destatis) aus jährlichen, deutschlandweiten ICD-10-Diagnosekodes von 2009 bis 2019 wurde analysiert. Prävalenzraten des Kodes „T84.5 – Infektion und entzündliche Reaktion durch eine Gelenkendoprothese“ wurden nach Altersgruppe, Geschlecht und in Verbindung mit einer Nebendiagnose des Kapitels F quantifiziert und aufgeschlüsselt. Ergebnisse Seit 2009 steigen die PJI-Diagnosen kontinuierlich an, die Häufigkeit war im Jahr 2018 rückläufig. Im Jahr 2019 wurden 16.174 Fälle entsprechend einer Prävalenz von 23,8/100.000 Einwohner verzeichnet. Eine Entwicklung hinsichtlich mehr Diagnosen bei älteren Patienten wurde evident. Ein Viertel aller Patienten wiesen eine Nebendiagnosen im Bereich psychischer Störungen und Verhaltensstörungen auf, wobei sich die Anzahl an Patienten mit psychologischen Komorbiditäten im letzten Jahrzehnt verdoppelte. Schlussfolgerung Richtlinien zu Präventionsstrategien und psychologische Unterstützungsangebote sollten in der Unfallchirurgie implementiert werden.
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Affiliation(s)
- Nike Walter
- Klinik und Poliklinik für Unfallchirurgie, Universitätsklinikum Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Deutschland.,Abteilung für Psychosomatische Medizin, Universitätsklinikum Regensburg, Franz-Josef-Strauß-Allee 11, Regensburg, 93053, Deutschland
| | - Markus Rupp
- Klinik und Poliklinik für Unfallchirurgie, Universitätsklinikum Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Deutschland
| | - Thilo Hinterberger
- Abteilung für Psychosomatische Medizin, Universitätsklinikum Regensburg, Franz-Josef-Strauß-Allee 11, Regensburg, 93053, Deutschland
| | - Volker Alt
- Klinik und Poliklinik für Unfallchirurgie, Universitätsklinikum Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Deutschland.
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Mottla JL, Murphy JP, Keeling LE, Verstraete R, Zawadsky MW. Role of arthroplasty in the Jehovah's Witness population. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2021; 31:1097-1104. [PMID: 33389053 DOI: 10.1007/s00590-020-02852-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Accepted: 12/14/2020] [Indexed: 01/24/2023]
Abstract
BACKGROUND Total joint arthroplasties aim to improve quality of life from joint-related pain. Jehovah's Witnesses refuse blood products due to their religious beliefs. Surgeons may be reluctant to perform arthroplasty procedures on these patients for fear of uncontrolled bleeding. However, we hypothesize that through preoperative optimization, arthroplasty can be performed safely. METHODS We retrospectively reviewed 184 total joint arthroplasties in Jehovah's Witnesses between 2011 and 2019. Each patient was enrolled in the institutions' Bloodless Medicine program. Hemoglobin levels were recorded through standard laboratory testing while in the hospital. Primary outcomes were changes in preoperative and postoperative hemoglobin measures, short-term outcomes measures, and complications. RESULTS A total of 103 total knee arthroplasties (8 revisions) and 81 total hip arthroplasties (5 revisions) were performed. Hemoglobin drift was 2.5 ± 1.0 for primary TKA and 2.6 ± 1.3 for primary THA (p = 0.570). Hemoglobin drift was 1.9 ± 0.9 for revision TKA and 1.9 ± 0.2 for revision THA (p = 0.990). Only 2.7% of patients met the transfusion requirement of 7 g/dL. The major complication rate for the cohort was 1.6% systemic and 4.9% local, respectively, with no mortalities. The overall readmission rate was 2.7%. CONCLUSION To our knowledge, this is the largest reported sample of Jehovah's Witness patients undergoing total joint arthroplasty. Postoperative hemoglobin values did not prompt additional intervention in the overwhelming majority of patients, and complication rates were acceptable. Our data suggest that primary arthroplasty is safe in the Jehovah's Witness population. Additionally, we show preliminary evidence that revision arthroplasty is safe in Jehovah's Witness patients.
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Affiliation(s)
- Jay L Mottla
- Department of Orthopaedic Surgery, MedStar Georgetown University Hospital, 3800 Reservoir Rd NW, Washington, DC, 20007, USA.
| | - Jordan P Murphy
- Georgetown University School of Medicine, Washington, DC, USA
| | - Laura E Keeling
- Department of Orthopaedic Surgery, MedStar Georgetown University Hospital, 3800 Reservoir Rd NW, Washington, DC, 20007, USA
| | - Richard Verstraete
- Department of Bloodless Medicine, MedStar Georgetown University Hospital, Washington, DC, USA
| | - Mark W Zawadsky
- Department of Orthopaedic Surgery, MedStar Georgetown University Hospital, 3800 Reservoir Rd NW, Washington, DC, 20007, USA
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Embedded sensing package for temporary bone cement spacers in infected total knee arthroplasty. J Mech Behav Biomed Mater 2021; 115:104301. [PMID: 33401065 DOI: 10.1016/j.jmbbm.2020.104301] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 12/16/2020] [Accepted: 12/25/2020] [Indexed: 12/17/2022]
Abstract
The re-infection rate of total knee arthroplasty (TKA) after two stage revision (15%) remains high as it can be challenging to determine whether the infection has been fully cleared between the first and second stage procedures. Temporary embedded sensor systems could be a potential solution to indicate whether the infection has been cleared. In this study a telemetric sensor system to integrate with a bone cement spacer and measure knee joint temperature was designed and evaluated. The sensor package precision, accuracy, hysteresis, and thermal equilibrium were empirically determined. Cadaveric testing was performed with the sensor package implanted inside the femoral notch alongside a pre-formed femoral and tibial bone cement spacer. The limb was tested though 30,000 cycles at 0.5 Hz under a 500 N load. Accuracy and precision of the sensing package were found to be ±0.24 °C and 0.09 °C respectively with negligible hysteresis. Thermal insulation caused by the implant itself was found to produce a thermal time constant of 263 ± 5 s, resulting in a 17 min rise time. Memory capacity enabled data logging every 20 s for a 6 week period before necessitating data transfer. Bluetooth was suitable for data transmission while the package was implanted. Following cyclic loading of the cadaveric specimen, imaging and debridement revealed no issues related to mechanical integrity of the bone cement spacer or encapsulated sensor package. While additional validation is required before use in patients, the concept of temporary embedded sensing technology to aid management of infection treatments is promising.
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Yang J, Parvizi J, Hansen EN, Culvern CN, Segreti JC, Tan T, Hartman CW, Sporer SM, Della Valle CJ. 2020 Mark Coventry Award: Microorganism-directed oral antibiotics reduce the rate of failure due to further infection after two-stage revision hip or knee arthroplasty for chronic infection: a multicentre randomized controlled trial at a minimum of two years. Bone Joint J 2020; 102-B:3-9. [DOI: 10.1302/0301-620x.102b6.bjj-2019-1596.r1] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Aims The aim of this study was to determine if a three-month course of microorganism-directed oral antibiotics reduces the rate of failure due to further infection following two-stage revision for chronic prosthetic joint infection (PJI) of the hip and knee. Methods A total of 185 patients undergoing a two-stage revision in seven different centres were prospectively enrolled. Of these patients, 93 were randomized to receive microorganism-directed oral antibiotics for three months following reimplantation; 88 were randomized to receive no antibiotics, and four were withdrawn before randomization. Of the 181 randomized patients, 28 were lost to follow-up, six died before two years follow-up, and five with culture negative infections were excluded. The remaining 142 patients were followed for a mean of 3.3 years (2.0 to 7.6) with failure due to a further infection as the primary endpoint. Patients who were treated with antibiotics were also assessed for their adherence to the medication regime and for side effects to antibiotics. Results Nine of 72 patients (12.5%) who received antibiotics failed due to further infection compared with 20 of 70 patients (28.6%) who did not receive antibiotics (p = 0.012). Five patients (6.9%) in the treatment group experienced adverse effects related to the administered antibiotics severe enough to warrant discontinuation. Conclusion This multicentre randomized controlled trial showed that a three-month course of microorganism-directed, oral antibiotics significantly reduced the rate of failure due to further infection following a two-stage revision of total hip or knee arthroplasty for chronic PJI. Cite this article: Bone Joint J 2020;102-B(6 Supple A):3–9.
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Affiliation(s)
- JaeWon Yang
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Javad Parvizi
- Department of Orthopaedic Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Erik N. Hansen
- Department of Orthopaedic Surgery, University of California San Francisco Medical Center, San Francisco, California, USA
| | - Chris N. Culvern
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - John C. Segreti
- Department of Internal Medicine, Rush University Medical Center, Chicago, Illinois, USA
| | - Timothy Tan
- Department of Orthopaedic Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Curtis W. Hartman
- Department of Orthopaedic Surgery, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Scott M. Sporer
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Craig J. Della Valle
- Division of Adult Reconstruction, Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, USA
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Ekhtiari S, Wood T, Mundi R, Axelrod D, Khanna V, Adili A, Winemaker M, Bhandari M. Antibiotic Cement in Arthroplasty: A Meta-analysis of Randomized Controlled Trials. Cureus 2020; 12:e7893. [PMID: 32489747 PMCID: PMC7255530 DOI: 10.7759/cureus.7893] [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: 03/24/2020] [Accepted: 04/28/2020] [Indexed: 11/05/2022] Open
Abstract
Introduction Periprosthetic joint infection (PJI) following arthroplasty surgery is a devastating complication. Antibiotic cement has been proposed as a way to reduce PJI rates. The aim of this systematic review and meta-analysis was to review all of the available randomized controlled trial (RCT) evidence on the use of antibiotic cement in arthroplasty. Methods PubMed, MEDLINE, and Embase were searched. All records were screened in triplicate. Eligible RCTs were included. Data regarding study characteristics, patient demographics, and rates of superficial and deep infection were collected. The risk of bias was assessed using the Cochrane Risk of Bias Assessment Tool 2.0. Results Five RCTs were included (n = 4,397). Four studies compared antibiotic cement to plain cement while one study compared high-dose dual-antibiotic (HDDA) cement to low-dose single-antibiotic (LDSA) cement. The mean age of included patients was 76.4 years (range: 68-83). There was no significant difference in superficial infection rates between antibiotic and plain cement (odds ratio (OR): 1.33, 95% Confidence Interval (CI): 0.77-2.30, p = 0.3). There was a large but non-significant reduction in deep infection rates for antibiotic cement (OR: 0.20, 95%CI: 0.03-1.32, p = 0.09). There was a significantly lower rate of infection with HDDA as compared to LDSA (OR: 0.31, 95% CI: 0.09-0.88, p = 0.041). Conclusion The available evidence from RCTs reveals a potential benefit for antibiotic cement in arthroplasty surgery, though this difference is non-significant and highly imprecise. Furthermore, HDDA cement was significantly more effective than LDSA cement. There is a need for large, pragmatic trials on this topic.
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Affiliation(s)
| | - Thomas Wood
- Orthopaedic Surgery, McMaster University, Hamilton, CAN
| | | | | | | | - Anthony Adili
- Orthopaedic Surgery, McMaster University, Hamilton, CAN
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Madarevic T, Buterin A, Jelicic J, Sirola L, Vuckovic D. Functional recovery after two-stage short-interval revision of chronic periprosthetic knee joint infection. INTERNATIONAL ORTHOPAEDICS 2020; 45:985-989. [PMID: 32322941 DOI: 10.1007/s00264-020-04566-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Accepted: 04/02/2020] [Indexed: 10/24/2022]
Abstract
PURPOSE The objective of this study was the functional recovery analysis of patients treated in two-staged short-interval procedure due to knee periprosthetic joint infection (PJI). MATERIALS AND METHODS In the period from January 2015 to December 2018, a two-stage short-interval revision TKA was performed in 35 patients with PJI. Synovial fluid analysis, tissue samples and sonication method were used to diagnose PJI. Active range of motion (AROM) and Hospital for Special Surgery (HSS) score were analysed. RESULTS Functional recovery analysis demonstrated higher AROM and HSS score after the revision TKA. Median pre-operative active flexion motion was 80° with full active extension, and median post-operative active flexion was 105° with full active extension. Median HSS score pre-operatively was 22 and post-operatively was 48. Isolated bacteria in both tissue and sonication fluid were S. epidermidis (27%) and other coagulase-negative staphylococci (25%), followed by S. aureus (10%). CONCLUSION Two-stage short-interval procedure of chronic knee PJI significantly improved functional status of patients in a short period of time. Thirty three out of 35 patients returned to their everyday activities. Adequate surgical technique and implant selection can lead to satisfactory functional outcome.
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Affiliation(s)
- Tomislav Madarevic
- University Hospital for Orthopaedic Surgery Lovran, Lovran, Croatia. .,Medical School University of Rijeka, Rijeka, Croatia.
| | - Antea Buterin
- University Hospital for Orthopaedic Surgery Lovran, Lovran, Croatia.,Special Orthopaedic Hospital Biograd na Moru, Biograd na Moru, Croatia
| | | | - Luka Sirola
- Special Hospital for Orthopaedic Surgery "Dr. Nemec", Matulji, Croatia
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Carpenter CVE, Wylde V, Moore AJ, Sayers A, Blom AW, Whitehouse MR. Perceived occurrence of an adverse event affects patient-reported outcomes after total hip replacement. BMC Musculoskelet Disord 2020; 21:118. [PMID: 32085754 PMCID: PMC7035750 DOI: 10.1186/s12891-020-3127-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Accepted: 02/10/2020] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Dislocation, periprosthetic fracture and infection are serious complications of total hip replacement (THR) and which negatively impact on patients' outcomes including satisfaction, quality of life, mental health and function. The accuracy with which patients report adverse events (AEs) after surgery varies. The impact of patient self-reporting of AEs on patient-reported outcome measures (PROMs) after THR is yet to be investigated. Our aim was to determine the effect of confirmed and perceived AEs on PROMs after primary THR. METHODS A prospective single-centre cohort study of patients undergoing primary THR, with one-year follow-up, was performed. Participants completed forms pre-operatively and 3, 6, 9 and 12 months post-operatively, including Work Productivity and Activity Impairment (WPAI), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), EuroQol-5D-3 L (EQ5D), Self-Administered Patient Satisfaction (SAPS) and AE reporting questionnaires. Results were reported in three groups: No AE, reported but not confirmed AE and confirmed AE. A generalised linear model was used to compare among groups using robust standard errors (SE). RESULTS Forty-one AEs were reported in a cohort of 417 patients (234 females), with 30 AEs reported by 3 months. Eleven (27 reported) infections, two (six reported) periprosthetic fractures and two (eight reported) dislocations were confirmed. Those in the no AE group reported significantly better outcomes that the reported AE group as measured by WOMAC Co-Eff 14.27 (p = 0.01), EQ5D - 0.128 (p = 0.02) and SAPS - 9.926 (p = 0.036) and the combined reported and confirmed AE groups as measured by WOMAC Co-Eff 13.72 (p = 0.002), EQ5D - 0.129 (p = 0.036) and SAPS - 11.512 (p = 0.004). No significant differences were seen in WPAI among groups. CONCLUSIONS Patients who report AEs have worse outcomes than those who do not, regardless of whether the AEs can be confirmed by standard medical record review methods. The observed negative trends suggest that patient perception of AEs may influence patient outcome in a similar way to those with confirmed AEs.
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Affiliation(s)
- Charlotte V E Carpenter
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, 1st Floor Learning & Research Building, Southmead Hospital, Bristol, BS10 5NB, UK.
| | - Vikki Wylde
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, 1st Floor Learning & Research Building, Southmead Hospital, Bristol, BS10 5NB, UK
- National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol NHS Foundation Trust and University of Bristol, Bristol, UK
| | - Andrew J Moore
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, 1st Floor Learning & Research Building, Southmead Hospital, Bristol, BS10 5NB, UK
| | - Adrian Sayers
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, 1st Floor Learning & Research Building, Southmead Hospital, Bristol, BS10 5NB, UK
| | - Ashley W Blom
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, 1st Floor Learning & Research Building, Southmead Hospital, Bristol, BS10 5NB, UK
- National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol NHS Foundation Trust and University of Bristol, Bristol, UK
| | - Michael R Whitehouse
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, 1st Floor Learning & Research Building, Southmead Hospital, Bristol, BS10 5NB, UK
- National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol NHS Foundation Trust and University of Bristol, Bristol, UK
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Influence of Fixation Methods on Prosthetic Joint Infection Following Primary Total Knee Replacement: Meta-Analysis of Observational Cohort and Randomised Intervention Studies. J Clin Med 2019; 8:jcm8060828. [PMID: 31212610 PMCID: PMC6616920 DOI: 10.3390/jcm8060828] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Revised: 05/29/2019] [Accepted: 06/06/2019] [Indexed: 12/15/2022] Open
Abstract
The type of fixation used in primary total knee replacement (TKR) may influence the risk of prosthetic joint infection (PJI). We conducted a systematic review and meta-analysis to assess published evidence linking type of fixation (cemented, uncemented, or hybrid) with the risk of PJI following primary TKR. Randomised controlled trials (RCTs) and observational cohort studies comparing fixation methods and reporting PJI incidence following primary TKR were identified in MEDLINE, Embase, Web of Science, and Cochrane Library up until November 2018. Summary measures were relative risks (RR) with 95% confidence intervals (CIs). We identified 32 eligible articles (24 observational studies and 8 RCTs) involving 1,161,292 TKRs. In pooled analysis of observational studies, uncemented fixation was associated with a decreased overall PJI risk when compared with cemented fixation at 0.76 (0.64–0.89). Comparing antibiotic-loaded cemented fixation with plain cement, there was no significant difference in overall PJI risk at 0.95 (0.69–1.31), but PJI risk was increased in the first 6-month postoperative period to 1.65 (1.12–2.43). Limited data from RCTs showed no differences in PJI risk among the fixation types. Observational evidence suggests uncemented fixation may be associated with lower PJI risk in primary TKR when compared with cemented fixation. In the early postoperative period, antibiotic-loaded cemented fixation may be associated with increased PJI risk when compared with plain cement. This may either reflect appropriate selection of higher risk patients for the development of PJI to cemented and antibiotic-loaded cement or may reflect a lower PJI risk in uncemented TKR due to factors such as shorter operative time.
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25
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Lenguerrand E, Whitehouse MR, Beswick AD, Kunutsor SK, Foguet P, Porter M, Blom AW. Risk factors associated with revision for prosthetic joint infection following knee replacement: an observational cohort study from England and Wales. THE LANCET. INFECTIOUS DISEASES 2019; 19:589-600. [PMID: 31005559 PMCID: PMC6531378 DOI: 10.1016/s1473-3099(18)30755-2] [Citation(s) in RCA: 153] [Impact Index Per Article: 25.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Revised: 11/07/2018] [Accepted: 11/29/2018] [Indexed: 12/15/2022]
Abstract
Background Prosthetic joint infection is a devastating complication of knee replacement. The risk of developing a prosthetic joint infection is affected by patient, surgical, and health-care system factors. Existing evidence is limited by heterogeneity in populations studied, short follow-up, inadequate power, and does not differentiate early prosthetic joint infection, most likely related to the intervention, from late infection, more likely to occur due to haematogenous bacterial spread. We aimed to assess the overall and time-specific associations of these factors with the risk of revision due to prosthetic joint infection following primary knee replacement. Methods In this cohort study, we analysed primary knee replacements done between 2003 and 2013 in England and Wales and the procedures subsequently revised for prosthetic joint infection between 2003 and 2014. Data were obtained from the National Joint Registry linked to the Hospital Episode Statistics data in England and the Patient Episode Database for Wales. Each primary replacement was followed for a minimum of 12 months until the end of the observation period (Dec 31, 2014) or until the date of revision for prosthetic joint infection, revision for another indication, or death (whichever occurred first). We analysed the data using Poisson and piecewise exponential multilevel models to assess the associations between patient, surgical, and health-care system factors and risk of revision for prosthetic joint infection. Findings Of 679 010 primary knee replacements done between 2003 and 2013 in England and Wales, 3659 were subsequently revised for an indication of prosthetic joint infection between 2003 and 2014, after a median follow-up of 4·6 years (IQR 2·6–6·9). Male sex (rate ratio [RR] for male vs female patients 1·8 [95% CI 1·7–2·0]), younger age (RR for age ≥80 years vs <60 years 0·5 [0·4–0·6]), higher American Society of Anaesthesiologists [ASA] grade (RR for ASA grade 3–5 vs 1, 1·8 [1·6–2·1]), elevated body-mass index (BMI; RR for BMI ≥30 kg/m2vs <25 kg/m2 1·5 [1·3–1·6]), chronic pulmonary disease (RR 1·2 [1·1–1·3]), diabetes (RR 1·4 [1·2–1·5]), liver disease (RR 2·2 [1·6–2·9]), connective tissue and rheumatic diseases (RR 1·5 [1·3–1·7]), peripheral vascular disease (RR 1·4 [1·1–1·7]), surgery for trauma (RR 1·9 [1·4–2·6]), previous septic arthritis (RR 4·9 [2·7–7·6]) or inflammatory arthropathy (RR 1·4 [1·2–1·7]), operation under general anaesthesia (RR 1·1 [1·0–1·2]), requirement for tibial bone graft (RR 2·0 [1·3–2·7]), use of posterior stabilised fixed bearing prostheses (RR for posterior stabilised fixed bearing prostheses vs unconstrained fixed bearing prostheses 1·4 [1·3–1·5]) or constrained condylar prostheses (3·5 [2·5–4·7]) were associated with a higher risk of revision for prosthetic joint infection. However, uncemented total, patellofemoral, or unicondylar knee replacement (RR for uncemented vs cemented total knee replacement 0·7 [95% CI 0·6–0·8], RR for patellofemoral vs cemented total knee replacement 0·3 [0·2–0·5], and RR for unicondylar vs cemented total knee replacement 0·5 [0·5–0·6]) were associated with lower risk of revision for prosthetic joint infection. Most of these factors had time-specific effects, depending on the time period post-surgery. Interpretation We have identified several risk factors for revision for prosthetic joint infection following knee replacement. Some of these factors are modifiable, and the use of targeted interventions or strategies could lead to a reduced risk of revision for prosthetic joint infection. Non-modifiable factors and the time-specific nature of the effects we have observed will allow clinicians to appropriately counsel patients preoperatively and tailor follow-up regimens. Funding National Institute for Health Research.
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Affiliation(s)
- Erik Lenguerrand
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Michael R Whitehouse
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK; National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol NHS Foundation Trust and University of Bristol, Bristol, UK
| | - Andrew D Beswick
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Setor K Kunutsor
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK; National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol NHS Foundation Trust and University of Bristol, Bristol, UK
| | - Pedro Foguet
- University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Martyn Porter
- Centre for Hip Surgery, Wrightington Hospital, Wigan, UK
| | - Ashley W Blom
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK; National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol NHS Foundation Trust and University of Bristol, Bristol, UK.
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Provenzano DA, Falowski SM, Xia Y, Doth AH. Spinal Cord Stimulation Infection Rate and Incremental Annual Expenditures: Results From a United States Payer Database. Neuromodulation 2019; 22:302-310. [PMID: 30865341 DOI: 10.1111/ner.12939] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Revised: 12/14/2018] [Accepted: 12/31/2018] [Indexed: 12/16/2022]
Abstract
OBJECTIVES Surgical site infections (SSIs) result in significant negative clinical and economic outcomes. The objective of this study is to estimate annual health expenditures associated with spinal cord stimulation (SCS)-related infections. MATERIALS AND METHODS Data from the Truven MarketScan® databases were used to identify patients with an SCS implant (2009-2014) and a continuous health plan enrollment for at least 12-months before and after implant (index date). Annual expenditures were estimated for patients with a device-related infection vs. those without infection since index date. A generalized linear model estimated annual expenditures attributable to device-related infection. Multivariable expenditure models were conducted separately for patients in initial and replacement groups, controlling for demographics, comorbidities, and clinical characteristics. RESULTS The study included 6615 patients. Multivariable expenditure models revealed that patients with infection have higher annual expenditures than patients without infection. Estimated incremental annual healthcare expenditures for patients with an infection were $59,716 (95% CI: $48,965-$69,480) for initial implanted patients and $64,833 (95% CI: $37,377-$86,519) for replacement patients. Only 26% of patients who were explanted for infection underwent a reimplant. CONCLUSIONS These results show the substantial expenditure burden associated with an SCS-related infection. Management of SCS-related infection is important from both clinical and economic standpoints. The economic and clinical data presented here reinforce the need for additional research and strategies for healthcare providers to minimize SCS infections. Future economic research is needed to further define the specific economic cost drivers associated with the extensive expenditure burden.
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Affiliation(s)
| | | | - Ying Xia
- Medtronic, Health Economics and Outcomes Research, Minneapolis, MN, USA
| | - Alissa H Doth
- Medtronic, Health Economics and Outcomes Research, Minneapolis, MN, USA
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Mallon C, Gooberman-Hill R, Blom A, Whitehouse M, Moore A. Surgeons are deeply affected when patients are diagnosed with prosthetic joint infection. PLoS One 2018; 13:e0207260. [PMID: 30485337 PMCID: PMC6261566 DOI: 10.1371/journal.pone.0207260] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2017] [Accepted: 10/29/2018] [Indexed: 11/18/2022] Open
Abstract
Knee replacement is a common preference sensitive quality-of-life procedure that can reduce pain and improve function for people with advanced knee arthritis. While most patients improve, knee replacement surgery has the potential for serious complications. Prosthetic knee infection is an uncommon but serious complication. This study explored the impact of cases of prosthetic knee infection on surgeons' personal and professional wellbeing. Qualitative telephone interviews were conducted with consultant orthopaedic surgeons who treated patients for prosthetic knee infection in one of six high-volume NHS orthopaedic departments. Data was audio-recorded, transcribed and analysed thematically. Eleven surgeons took part. Analysis identified three overarching themes: (i) At some point infection is inevitable but surgeons still feel accountable; (ii) A profound emotional impact and (iii) Supporting each other. The occurrence of prosthetic joint infection has a significant emotional impact on surgeons who report a collective sense of devastation and personal ownership, even though prosthetic joint infection cannot be fully controlled for. Surgeons stressed the importance of openly discussing the management of prosthetic joint infection with a supportive multidisciplinary team and this has implications for the ways in which orthopaedic surgeons may be best supported to manage this complication. This article also acknowledges that surgeons are not alone in experiencing personal impact when patients have infection.
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Affiliation(s)
- Charlotte Mallon
- Musculoskeletal Research Unit, Department of Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - Rachael Gooberman-Hill
- Musculoskeletal Research Unit, Department of Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, United Kingdom
- National Institute for Health Research Bristol Biomedical Research Centre, Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - Ashley Blom
- Musculoskeletal Research Unit, Department of Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, United Kingdom
- National Institute for Health Research Bristol Biomedical Research Centre, Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - Michael Whitehouse
- Musculoskeletal Research Unit, Department of Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, United Kingdom
- National Institute for Health Research Bristol Biomedical Research Centre, Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - Andrew Moore
- Musculoskeletal Research Unit, Department of Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, United Kingdom
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