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1
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Oe K, Iida H, Otsuki Y, Toyoda T, Kobayashi F, Sogawa S, Nakamura T, Saito T. Validity of a preoperative scoring system for surgical management of periprosthetic hip infection: one-stage vs. two-stage revision. Arch Orthop Trauma Surg 2024; 144:5121-5130. [PMID: 38662000 DOI: 10.1007/s00402-024-05279-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Accepted: 03/10/2024] [Indexed: 04/26/2024]
Abstract
INTRODUCTION There are no widely accepted algorithms for determining optimal treatment for periprosthetic joint infection (PJI). Our study aimed to confirm the validity of a previously published scoring system in a larger number of patients to support a rational surgical treatment strategy for periprosthetic hip infection. MATERIALS AND METHODS Between February 2001 and December 2020, we performed 155 consecutive revision total hip arthroplasties (THAs) for PJI, with mean follow-up of 6 years. One-stage revision THA was performed in 56 hips and two-stage revision THA in 99 hips. Prosthesis survival from recurrent infection was determined by Kaplan-Meier analysis, using implant removal as the endpoint. The pre-operative scoring system (full score of 12 points), including 6 essential elements, was retrospectively evaluated. RESULTS The 10-year survival rates were 98% for one-stage (95% confidence interval [CI], 94-100) and 87% (95% CI, 79-96) for two-stage revision THA. Multivariate Cox regression analysis provided a total preoperative score as an independent risk factor for implant removal (hazard ratio, 0.17; 95% CI, 0.06-0.49; p < 0.001). The sensitivity and specificity at the cut-off of 4 points on the scoring system were 80% and 91%, respectively. The average score for one-stage revision THA in successful and failed cases were 8.9 and 6.0, and for two-stage revision THA were 6.5 and 3.9, respectively. We found significant differences between successful cases in one- and two-stage revision THA (p < 0.05). CONCLUSIONS The preoperative scoring system was useful for managing PJI. One-stage revision THA is recommended in patients scoring ≥ 9 points, and meticulously performed two-stage revision THA is encouraged for patients scoring ≥ 4 points.
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Affiliation(s)
- Kenichi Oe
- Department of Orthopaedic Surgery, Kansai Medical University, 2-5-1 Shinmachi, Hirakata, Osaka, 573-1010, Japan.
| | - Hirokazu Iida
- Department of Orthopaedic Surgery, Kansai Medical University, 2-5-1 Shinmachi, Hirakata, Osaka, 573-1010, Japan
| | - Yosuke Otsuki
- Department of Orthopaedic Surgery, Kansai Medical University, 2-5-1 Shinmachi, Hirakata, Osaka, 573-1010, Japan
| | - Takashi Toyoda
- Department of Orthopaedic Surgery, Kansai Medical University, 2-5-1 Shinmachi, Hirakata, Osaka, 573-1010, Japan
| | - Fumito Kobayashi
- Department of Orthopaedic Surgery, Kansai Medical University, 2-5-1 Shinmachi, Hirakata, Osaka, 573-1010, Japan
| | - Shohei Sogawa
- Department of Orthopaedic Surgery, Kansai Medical University, 2-5-1 Shinmachi, Hirakata, Osaka, 573-1010, Japan
| | - Tomohisa Nakamura
- Department of Orthopaedic Surgery, Kansai Medical University, 2-5-1 Shinmachi, Hirakata, Osaka, 573-1010, Japan
| | - Takanori Saito
- Department of Orthopaedic Surgery, Kansai Medical University, 2-5-1 Shinmachi, Hirakata, Osaka, 573-1010, Japan
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Romanò CL, Bonomo L, Bonomo G, Viale G, Del Sel H, Tezval M. What Is the Role of Local Antimicrobial Protection for One-Stage Revision for Peri-Prosthetic Hip Infection? Antibiotics (Basel) 2024; 13:1060. [PMID: 39596754 PMCID: PMC11590878 DOI: 10.3390/antibiotics13111060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2024] [Revised: 10/27/2024] [Accepted: 11/05/2024] [Indexed: 11/29/2024] Open
Abstract
The aim of this review is to investigate the effective role of local antimicrobial protection for one-stage cemented and cementless hip revision surgery. Twelve studies reporting the results of cemented single-stage procedures with a minimum two-year follow-up were reviewed. When pooling together the data, no infection recurrence was observed on average in 83.3% of the patients (a range of 75.0% to 100%). Only two papers included patients treated without the use of antibiotic-loaded bone cement, with an average infection control of 95.9% in a total of 195 patients. This figure appears to be better than the 80.7% infection control obtained by pooling together all the remaining studies. Concerning cementless one-stage revision, a total of 17 studies, reporting on 521 patients, showed an average of 90.0% (range 56.8% to 100%) no infection recurrence at a minimum two-year follow-up. No comparative study investigated cementless revision with or without local antibacterial protection. The pooled data showed an average infection control of 86.7%, without the application of local antibacterials, compared to 90.1% to 100% with local antimicrobial protection, depending on the technology used. No statistical difference could be found, either considering local antibacterial strategies alone or pooled together. No side effects had been reported by any local antibacterial technique. Local antibacterial protection for one-stage hip revision surgery, although safe and largely performed in the clinical setting, appears to still rely mainly on experts' opinions with no prospective or comparative trial, hence no definitive conclusion can be drawn concerning its effective role in one-stage hip revision surgery.
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Affiliation(s)
| | - Luigi Bonomo
- Universitatea de Medicina si Farmacie Victor Babes din Timisoara, 300041 Timișoara, Romania; (L.B.); (G.B.)
| | - Giulio Bonomo
- Universitatea de Medicina si Farmacie Victor Babes din Timisoara, 300041 Timișoara, Romania; (L.B.); (G.B.)
| | - German Viale
- Department Orthopaedics and Traumatology, British Hospital of Buenos Aires, Buenos Aires 1280, Argentina; (G.V.); (H.D.S.)
| | - Hernán Del Sel
- Department Orthopaedics and Traumatology, British Hospital of Buenos Aires, Buenos Aires 1280, Argentina; (G.V.); (H.D.S.)
| | - Mohammad Tezval
- Klinikum Vest GmbH, Dorstener Str. 151, 45657 Recklinghausen, Germany;
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Lora-Tamayo J, Mancheño-Losa M, Meléndez-Carmona MÁ, Hernández-Jiménez P, Benito N, Murillo O. Appropriate Duration of Antimicrobial Treatment for Prosthetic Joint Infections: A Narrative Review. Antibiotics (Basel) 2024; 13:293. [PMID: 38666969 PMCID: PMC11047716 DOI: 10.3390/antibiotics13040293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Revised: 03/16/2024] [Accepted: 03/19/2024] [Indexed: 04/29/2024] Open
Abstract
Prosthetic joint infections are considered difficult to treat they needing aggressive surgery and long antimicrobial treatments. However, the exact duration of these therapies has been established empirically. In the last years, several studies have explored the possibility of reducing the length of treatment in this setting, with conflicting results. In this narrative review, we critically appraise the published evidence, considering the different surgical approaches (implant retention [DAIR] and one-step and two-step exchange procedures) separately. In patients managed with DAIR, usually treated for at least 12 weeks, a large, randomized trial failed to show that 6 weeks were non-inferior. However, another randomized clinical trial supports the use of 8 weeks, as long as the surgical conditions are favorable and antibiotics with good antibiofilm activity can be administered. In patients managed with a two-step exchange procedure, usually treated during 6 weeks, a randomized clinical trial showed the efficacy of a 4-week course of antimicrobials. Also, the use of local antibiotics may allow the use of even shorter treatments. Finally, in the case of one-step exchange procedures, there is a trend towards reducing the length of therapy, and the largest randomized clinical trial supports the use of 6 weeks of therapy.
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Affiliation(s)
- Jaime Lora-Tamayo
- Department of Internal Medicine, Hospital Universitario 12 de Octubre, Instituto de Investigación Biomédica imas12 Hospital 12 de Octubre, Facultad de Medicina, Universidad Complutense de Madrid, 28041 Madrid, Spain; (M.M.-L.); (P.H.-J.)
- Spanish Group for the Study of Bone and Joint Infections, Spanish Society of Clinical Microbiology and Infectious Diseases (GEIO-SEIMC), 28003 Madrid, Spain; (N.B.); (O.M.)
- CIBERINFEC—CIBER Enfermedades Infecciosas, Instituto de Salud Carlos III, 28029 Madrid, Spain
| | - Mikel Mancheño-Losa
- Department of Internal Medicine, Hospital Universitario 12 de Octubre, Instituto de Investigación Biomédica imas12 Hospital 12 de Octubre, Facultad de Medicina, Universidad Complutense de Madrid, 28041 Madrid, Spain; (M.M.-L.); (P.H.-J.)
- Spanish Group for the Study of Bone and Joint Infections, Spanish Society of Clinical Microbiology and Infectious Diseases (GEIO-SEIMC), 28003 Madrid, Spain; (N.B.); (O.M.)
| | - María Ángeles Meléndez-Carmona
- Department of Microbiology, Hospital Universitario 12 de Octubre, Instituto de Investigación Biomédica imas12 Hospital 12 de Octubre, 28041 Madrid, Spain;
| | - Pilar Hernández-Jiménez
- Department of Internal Medicine, Hospital Universitario 12 de Octubre, Instituto de Investigación Biomédica imas12 Hospital 12 de Octubre, Facultad de Medicina, Universidad Complutense de Madrid, 28041 Madrid, Spain; (M.M.-L.); (P.H.-J.)
| | - Natividad Benito
- Spanish Group for the Study of Bone and Joint Infections, Spanish Society of Clinical Microbiology and Infectious Diseases (GEIO-SEIMC), 28003 Madrid, Spain; (N.B.); (O.M.)
- CIBERINFEC—CIBER Enfermedades Infecciosas, Instituto de Salud Carlos III, 28029 Madrid, Spain
- Infectious Diseases Unit, Hospital de la Santa Creu i Sant Pau, Institut d’Investigació Biomèdica Sant Pau (IIB SANT PAU), Universitat Autònoma de Barcelona, 08193 Barcelona, Spain
- UQ Centre for Clinical Research (UQCCR), The University of Queensland, Brisbane 4072, Australia
| | - Oscar Murillo
- Spanish Group for the Study of Bone and Joint Infections, Spanish Society of Clinical Microbiology and Infectious Diseases (GEIO-SEIMC), 28003 Madrid, Spain; (N.B.); (O.M.)
- CIBERINFEC—CIBER Enfermedades Infecciosas, Instituto de Salud Carlos III, 28029 Madrid, Spain
- Department of Infectious Diseases, Hospital Universitario Bellvitge, IDIBELL (Instituto de Investigación Biomédica de Bellvitge), 08908 L’Hospitalet de Llobregat, Spain
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Alhammad AM, Almangour TA, Almasoudi I, Alalayet W, Almuqbil M, Alsowaida YS, Alotaibi NH. Effectiveness of antibiotic-loaded bone cement in total joint arthroplasty at a tertiary medical center: A retrospective cohort study. Saudi Pharm J 2023; 31:101739. [PMID: 37638217 PMCID: PMC10448162 DOI: 10.1016/j.jsps.2023.101739] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Accepted: 08/03/2023] [Indexed: 08/29/2023] Open
Abstract
Background Data regarding the effectiveness of antibiotic-loaded bone cement (ALBC) in preventing prosthetic joint infections (PJI) after total joint arthroplasty (TJA) is inconsistent. The objective of this study was to evaluate if the routine use of ALBC influenced the risk of revision surgery due to PJI. Methods This is a retrospective cohort study performed between January 2018 and September 2020. Adult patients aged ≥ 18 years who underwent TJA (knee or hip) and received either ALBC or plain cement (PC) were included. The outcome of this study was the rate of revision due to PJI. Multivariate analysis using logistic regression was used to identify factors that may be associated with increased risk of PJI, using STATA 15.1 (StataCorp LP, College Station, Texas, USA). Results A total of 844 patients were screened and 319 patients were included. There were 247 patients in ALBC group and 72 patients in the PC group. Only vancomycin powder was used in all ALBC cases, with a 2 g dose in 50% of the cases (dose ranged between 1 g and 8 g). The status of the prosthetic joint was assessed and recorded up to 2 years of the TJA. Overall, the difference in the rates of PJI between the two groups after primary arthroplasty was not statistically significant (5.6% vs 1.4%; p = 0.173; OR, 4.2; 95% CI, 0.5-33). Conclusion ALBC was not associated with a reduction in PJI rates after primary TJA. More research is needed to further evaluate the effectiveness of ALBC in preventing PJI.
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Affiliation(s)
- Abdullah M. Alhammad
- Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
| | - Thamer A. Almangour
- Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
| | - Imtinan Almasoudi
- Clinical Pharmacy Department, King Saud Medical City, Ministry of Health, Riyadh, Saudi Arabia
| | - Wesal Alalayet
- Pharmaceutical Care Department, King Saud University Medical City, Riyadh, Saudi Arabia
| | - Mansour Almuqbil
- Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
| | - Yazed S. Alsowaida
- Department of Clinical Pharmacy, College of Pharmacy, Hail University, P.O. Box 6166, Hail 81442, Saudi Arabia
| | - Naif H Alotaibi
- Division of Infectious Diseases, Department of Internal Medicine, College of Medicine, King Saud University, PO Box 7805, Riyadh 11472, Saudi Arabia
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Mu W, Ji B, Cao L. Single-stage revision for chronic periprosthetic joint infection after knee and hip arthroplasties: indications and treatments. ARTHROPLASTY 2023; 5:11. [PMID: 36864484 PMCID: PMC9979399 DOI: 10.1186/s42836-023-00168-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Accepted: 01/16/2023] [Indexed: 03/04/2023] Open
Abstract
Single-stage revision for chronic periprosthetic joint infection has been introduced 40 years ago. This option is gaining more and more attention as well as popularity. It is a reliable treatment for the chronic periprosthetic joint infection after knee and hip arthroplasties when implemented by an experienced multi-disciplinary team. However, its indications and corresponding treatments remain controversial. This review focused on the indications and specific treatments related to the option, with an attempt to help surgeons to use this method with more favorable outcomes.
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Affiliation(s)
- Wenbo Mu
- grid.412631.3Department of Orthopedics, the First Affiliated Hospital of Xinjiang Medical University, Urumqi, 830011 Xinjiang China ,grid.13394.3c0000 0004 1799 3993Department of Pharmacognosy, School of Pharmacy, Xinjiang Medical University, Urumqi, 830011 Xinjiang China
| | - Baochao Ji
- grid.412631.3Department of Orthopedics, the First Affiliated Hospital of Xinjiang Medical University, Urumqi, 830011 Xinjiang China
| | - Li Cao
- Department of Orthopedics, the First Affiliated Hospital of Xinjiang Medical University, Urumqi, 830011, Xinjiang, China.
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Li HQ, Li PC, Wei XC, Shi JJ. Effectiveness of antibiotics loaded bone cement in primary total knee arthroplasty: A systematic review and meta-analysis. Orthop Traumatol Surg Res 2022; 108:103295. [PMID: 35552043 DOI: 10.1016/j.otsr.2022.103295] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Revised: 06/10/2021] [Accepted: 06/14/2021] [Indexed: 02/03/2023]
Abstract
INTRODUCTION The application of antibiotics loaded bone cement (ALBC) in the revision of failed total knee arthroplasty (TKA) has been widely accepted to reduce risk of peri-prosthetic infection. However, the prophylactic use of ALBC in primary TKA remains controversial. This study was aimed to identify the prophylactic effect on peri-prosthetic infection and safety of ALBC in primary TKA. HYPOTHESIS The application of ALBC could reduce the risk of peri-prosthetic infection in primary TKA. MATERIALS AND METHODS Electronic platforms including PubMed, EMBASE, and CENTRAL were retrieved to identify studies comparing outcomes of prophylactic ALBC and plain cement in primary TKA. For outcomes reported as dichotomous variable and continuous variable, risk ratio (RR) and weighted mean difference (WMD) as well as their 95% confidence intervals (95% CI) were selected as the effect sizes for pooling. While for those outcomes reported the adjusted effect sizes such as odds ratio (OR, derived from multivariate logistic regression), and hazard ratio (HR, derived from multivariate COX proportional hazard model), the reported effect sizes were selected for pooling. RESULTS A total of 17 studies with 2,074,844 patients (1,093,920 in ALBC group and 980,924 in plain cement group) were eligible for final inclusion. No significant difference was found between ALBC and plain cement groups both for the unadjusted (RR=1.02, 95% CI: 0.86∼1.21, p=0.832) and adjusted (OR=0.94, 95% CI: 0.76∼1.17, p=0.596) peri-prosthetic infection rate. ALBC application was related to significantly increased length of hospital stay (WMD=0.13, 95% CI: 0.10∼0.17, p<0.001). There was no significance on the difference of operation related adverse events between two groups (RR=1.31, 95% CI: 0.68∼2.52, p=0.420). Significantly increased risks of acute renal failure and readmission, and temporarily increased ototoxicity in ALBC group were reported in one of the primary study. DISCUSSION There is no sufficient evidence supporting decreased peri-prosthetic infection rate with ALBC application in primary TKA. What's more, it must be taken into consideration about the safety and added cost of additional impregnated antibiotics. LEVEL OF EVIDENCE III; meta-analysis.
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Affiliation(s)
- Hao-Qian Li
- Department of Orthopaedics, The Second Hospital of Shanxi Medical University, Shanxi Key Laboratory of Bone and Soft Tissue Injury Repair, Taiyuan, 030000 Shanxi, China
| | - Peng-Cui Li
- Department of Orthopaedics, The Second Hospital of Shanxi Medical University, Shanxi Key Laboratory of Bone and Soft Tissue Injury Repair, Taiyuan, 030000 Shanxi, China
| | - Xiao-Chun Wei
- Department of Orthopaedics, The Second Hospital of Shanxi Medical University, Shanxi Key Laboratory of Bone and Soft Tissue Injury Repair, Taiyuan, 030000 Shanxi, China.
| | - Jun-Jun Shi
- Department of Orthopaedics, The Second Hospital of Shanxi Medical University, Shanxi Key Laboratory of Bone and Soft Tissue Injury Repair, Taiyuan, 030000 Shanxi, China
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Samelis PV, Papagrigorakis E, Sameli E, Mavrogenis A, Savvidou O, Koulouvaris P. Current Concepts on the Application, Pharmacokinetics and Complications of Antibiotic-Loaded Cement Spacers in the Treatment of Prosthetic Joint Infections. Cureus 2022; 14:e20968. [PMID: 35154947 PMCID: PMC8815820 DOI: 10.7759/cureus.20968] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/04/2022] [Indexed: 01/15/2023] Open
Abstract
Prosthetic joint infection (PJI) is a devastating complication of total joint replacement surgery. It affects about 2% of primary total joint replacements. Treatment aims at infection eradication and restoration of patient's mobility. Two-stage revision arthroplasty with an interim application of an antibiotic-loaded cement spacer (ALCS) is the widely accepted treatment for PJI. Spacers are powerful local carriers of antibiotics at the site of infection, effective against biofilm-protected microbes. On the other hand, spacers permit some mobility of the patient and facilitate final prosthesis implantation. ALCS's are either commercially available or prepared intraoperatively on prefabricated or improvised molds. Antibiotic elution from the spacer depends on the amount of the antibiotic used for cement impregnation, at the expense of mechanical stiffness of the spacer. The antibiotic should not exceed 4g per 40g of bone cement to preserve the mechanical properties of the cement. Spacers are frequently accompanied by local or systemic complications. The spacer may break, dislocate and compress vessels or nerves of the limb. Systemic complications are the result of excess elution of antibiotic and include nephrotoxicity, hepatotoxicity, ototoxicity, allergic reactions or neutropenia. Elderly patients with comorbidities are at risk to present such complications. Microbial resistance is a potential risk of long-lasting spacer retention. Persisting infection may require multiple spacer replacements.
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Unfried RI, Krause LMF, Cezimbra HM, Pacheco LS, Larangeira JA, Ribeiro TA. A Retrospective Observational Cohort Study of Periprosthetic Hip Infection Treated by one-stage Method Including Cases With Bone Graft Reconstruction. CLINICAL MEDICINE INSIGHTS: ARTHRITIS AND MUSCULOSKELETAL DISORDERS 2022; 15:11795441221090344. [PMID: 35547099 PMCID: PMC9081729 DOI: 10.1177/11795441221090344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/16/2021] [Accepted: 03/03/2022] [Indexed: 11/17/2022]
Abstract
Purpose: Prosthetic joint infection (PJI) is a devastating complication that can affect hip arthroplasty. Its treatment is extremely difficult, and issues regarding the optimal treatment remain unanswered. This study intended to show the effectiveness of the one-stage treatment of PJI. Materials and Methods: A retrospective observational cohort study performed from July 2014- August 2018. All patients with suspected PJI were included. Major and minor criteria developed by the International Consensus on Periprosthetic Joint Infection (ICPJI) was used to define infection. Laboratory tests and image exams were performed, and all patients were followed for at least 2 years. Outcomes: Success rate (2018 ICPJI definition to success) in treatment of PJI using one-stage revision method. Clinical and functional outcomes defined by Harris Hip Score (HHS). Results: Thirty-one patients were screened and 18 analyzed. 69.85 ± 9.76 years was the mean age. Mean follow-up time was 63.84 ± 18.55 months. Ten patients had acetabular defects and required bone graft reconstruction. Sixteen patients were classified as Tier 1, 1 as Tier 3D, and as 1 Tier 3E. Almost 90% of patients submitted to one-stage revision with acetabulum graft reconstruction were free of infection. The overall infection survival rate was 78.31±6.34 months. Candida albicans and sinus tract were statistically significant in univariate Cox’s analysis. The predictor of one-stage revision surgery failure that remained final Cox’s regression model was C. albicans (hazard ratio [HR]: 4.47). Conclusion: Treatment through one-stage revision surgery associated with 6 months of antimicrobial is a viable option with acceptable results even when bone graft reconstruction is necessary. C. albicans was a strong predictor of failure in this cohort.
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Affiliation(s)
- Ricardo Issler Unfried
- Department of and Traumatology, University Hospital of Santa Maria (SOT-HUSM), Federal University of Santa Maria (UFSM), Santa Maria, Brazil
- Master’s Course in Health and Life Sciences, Universidade Franciscana (UFN), Santa Maria, Brazil
| | | | - Helen Minussi Cezimbra
- Department of Infectious Diseases, University Hospital of Santa Maria, Federal University of Santa Maria (UFSM), Santa Maria, Brazil
| | - Liliane Souto Pacheco
- Medicine School, Hospital São Francisco de Assis (HSFA), Universidade Franciscana (UFN), Santa Maria, Brazil
- Department of Infectious Diseases, University Hospital of Santa Maria, Federal University of Santa Maria (UFSM), Santa Maria, Brazil
| | - João Alberto Larangeira
- Department of and Traumatology, University Hospital of Santa Maria (SOT-HUSM), Federal University of Santa Maria (UFSM), Santa Maria, Brazil
| | - Tiango Aguiar Ribeiro
- Department of and Traumatology, University Hospital of Santa Maria (SOT-HUSM), Federal University of Santa Maria (UFSM), Santa Maria, Brazil
- Master’s Course in Health and Life Sciences, Universidade Franciscana (UFN), Santa Maria, Brazil
- Medicine School, Hospital São Francisco de Assis (HSFA), Universidade Franciscana (UFN), Santa Maria, Brazil
- Postgraduate Program of Health Science, Federal University of Santa Maria (UFSM), Santa Maria, Brazil
- Department of Surgery in Orthopaedic, Medicine School, Federal University of Santa Maria (UFSM), Santa Maria, Brazil
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One-Stage Hip Revision Arthroplasty Using Megaprosthesis in Severe Bone Loss of The Proximal Femur Due to Radiological Diffuse Osteomyelitis. Trop Med Infect Dis 2021; 7:tropicalmed7010005. [PMID: 35051121 PMCID: PMC8780561 DOI: 10.3390/tropicalmed7010005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Revised: 12/23/2021] [Accepted: 12/26/2021] [Indexed: 11/17/2022] Open
Abstract
Managing substantial proximal and/or distal femoral bone defects is one of the biggest challenges in chronic hip periprosthetic joint infection. Most authors use two-stage arthroplasty with a temporary antibiotic-loaded cement spacer for the management of these patients. In this study, we show our experience with one-stage exchange arthroplasty in managing severe bone defects due to radiological-extensive proximal femoral osteomyelitis. Two patients were included in the study. They showed radiological-extensive proximal femoral osteomyelitis, and they were treated with one-stage exchange arthroplasty using megaprosthesis. Diffuse osteomyelitis was confirmed in both cases; in one case, the histology was compatible with osteomyelitis, and the other case had a positive culture identified in a bone sample. At a minimum of a four-year follow-up, the patients did not reveal any clinical, radiological or laboratory signs of infection. In conclusion, one-stage exchange arthroplasty and megaprosthesis is an option for the treatment of chronic hip periprosthetic joint infection associated with radiological-diffuse proximal femoral osteomyelitis.
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Lum ZC, Holland CT, Meehan JP. Systematic review of single stage revision for prosthetic joint infection. World J Orthop 2020; 11:559-572. [PMID: 33362992 PMCID: PMC7745489 DOI: 10.5312/wjo.v11.i12.559] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2020] [Revised: 10/20/2020] [Accepted: 11/29/2020] [Indexed: 02/06/2023] Open
Abstract
While advanced technology, increased medical knowledge and improved surgical technique has improved patient outcomes in total joint arthroplasty, prosthetic joint infection still remains one of the leading causes of increased healthcare costs, medical resources and societal burdens in orthopaedic care. Two stage arthroplasty revision remains the gold standard for treatment of prosthetic joint infection. Proponents of single stage revision arthroplasty for infection argue that it results in lower healthcare costs while improving patient reported functional outcomes and with equivalent success rates. Here we review the history of single stage revision arthroplasty, discuss the key principles, highlight the indications and contraindications, and review the reported outcomes with a focus on future developments of single stage revision arthroplasty for hip and knee periprosthetic joint infections.
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Affiliation(s)
- Zachary C Lum
- Department of Orthopaedic Surgery, Davis Medical Center, University of California, Sacramento, CA 95817, United States
| | - Christopher Thomas Holland
- Department of Orthopaedics, University of California, Davis Medical Center, Sacramento, CA 95817, United States
| | - John P Meehan
- Department of Orthopaedics, University of California, Davis Medical Center, Sacramento, CA 95817, United States
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11
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CORR Insights®: A Low Percentage of Patients Satisfy Typical Indications for Single-stage Exchange Arthroplasty for Chronic Periprosthetic Joint Infection. Clin Orthop Relat Res 2020; 478:1787-1789. [PMID: 32541579 PMCID: PMC7371045 DOI: 10.1097/corr.0000000000001349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
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12
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Ahmed SS, Begum F, Kayani B, Haddad FS. Risk factors, diagnosis and management of prosthetic joint infection after total hip arthroplasty. Expert Rev Med Devices 2019; 16:1063-1070. [PMID: 31752561 DOI: 10.1080/17434440.2019.1696673] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Introduction: Although a relatively rare complication, the incidence and prevalence of prosthetic joint infection (PJI) is certainly rising. This is mainly due to the number of arthroplasties performed each year and our ability to capture more cases. There is currently no consensus in the optimal diagnosis and management of the infected total hip arthroplasty. Various management techniques have been described in literature.Areas covered: We discuss and summarize the literature in diagnosing prosthetic joint infection (PJI) including next-generation sequencing. An in-depth critical analysis of the biomarkers and the novel tests available in the market is reviewed including the evolving nature of the diagnostic criteria for PJI. The key issues in managing infected THA are identified.Expert commentary: The senior authors' expert opinion on diagnostic criteria is discussed. We also stress the importance of tissue/fluid analysis of microbiology and histology being key to diagnosis of PJI. The indications of one-stage versus two-stage revision arthroplasty is examined, including techniques for successful one-stage revision.
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Affiliation(s)
- Syed S Ahmed
- Trauma & Orthopaedics, University College Hospital, London, UK.,Trauma & Orthopaedics, Princess Grace Hospital, London, UK
| | - Fahima Begum
- Trauma & Orthopaedics, University College Hospital, London, UK.,Trauma & Orthopaedics, Princess Grace Hospital, London, UK
| | - Babar Kayani
- Trauma & Orthopaedics, University College Hospital, London, UK.,Trauma & Orthopaedics, Princess Grace Hospital, London, UK
| | - Fares S Haddad
- Trauma & Orthopaedics, University College Hospital, London, UK.,Trauma & Orthopaedics, Princess Grace Hospital, London, UK
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Wadehra A, Douthett S, Fallat LM. Single-Stage Tibiotalocalcaneal Arthrodesis With Use of an Antibiotic-Coated Intramedullary Nail for Limb Salvage Following an Open Pilon Fracture Complicated by Osteomyelitis: A Case Report. J Foot Ankle Surg 2019; 58:984-988. [PMID: 31176518 DOI: 10.1053/j.jfas.2018.12.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2018] [Indexed: 02/03/2023]
Abstract
Severe limb deformity can create a major disability, which can ultimately lead to a nonambulatory lifestyle. Limb deformities created by open fractures not only put a patient at risk for a nonfunctional lifestyle but also may lead to gross contamination and osteomyelitis of the osseous structures. At times, these deformities require amputation for better functionality. It is our belief, however, that an attempt at limb salvage should always be considered. When encountering limb deformities with osteomyelitis, most literature refers to a staged technique in which 2 procedures need to be performed: this includes external fixation and/or a temporary antibiotic spacer followed by a permanent intramedullary nail after complete resolution of the infection. Staged procedures prolong the non-weightbearing status of the patient, often decreasing quality of life. The use of a single-stage antibiotic-coated nail has rarely been discussed in the literature. Here we discuss a single-stage technique that may be an option for major deformity limb salvage in the setting of chronic osteomyelitis. This is a case report presenting a 60-year-old female who suffered an open pilon fracture resulting in osteomyelitis and was successfully treated with use of an antibiotic-coated intramedullary nail in a single stage.
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Affiliation(s)
- Ashim Wadehra
- Postgraduate Year 3, Chief Resident, Podiatric Surgical Residency, Department of Podiatric Surgery, Beaumont Hospital Wayne, Wayne, MI.
| | - Steven Douthett
- Fellow, Florida Orthopedic Foot and Ankle Center, Sarasota, FL
| | - Lawrence M Fallat
- Director, Podiatric Surgery Residency, Department of Podiatric Surgery, Beaumont Hospital Wayne, Wayne, MI
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14
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Hip and Knee Section, Prevention, Local Antimicrobials: Proceedings of International Consensus on Orthopedic Infections. J Arthroplasty 2019; 34:S289-S292. [PMID: 30343975 DOI: 10.1016/j.arth.2018.09.013] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
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15
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Rowan FE, Donaldson MJ, Pietrzak JR, Haddad FS. The Role of One-Stage Exchange for Prosthetic Joint Infection. Curr Rev Musculoskelet Med 2018; 11:370-379. [PMID: 29987643 PMCID: PMC6105475 DOI: 10.1007/s12178-018-9499-7] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
PURPOSE OF REVIEW In an era of increasing numbers of hip and knee replacements, strategies to manage prosthetic joint infection (PJI) that are effective at infection control with good patient-reported outcomes and cost containment for health systems are needed. Interest in single-stage exchange for PJI is rising and we assess evidence from the last 5 years related to this treatment strategy. RECENT FINDINGS Only five series for total knee replacement and ten series for total hip replacement have been reported in the last five years. More review articles and opinion pieces have been written. Reinfection rates in these recent studies range from 0 to 65%, but a meta-analysis and systematic review of all studies showed a reinfection rate of 7.6% (95% CI 3.4-13.1) and 8.8% (95% CI 7.2-10.6) for single-stage and two-stage revisions respectively. There is emerging evidence to support single-stage revision in the setting of significant bony deficiency and atypical PJIs such as fungal infections. Prospective randomised studies are recruiting and are necessary to guide the direction of single-stage revision selection criteria. The onus of surgical excellence in mechanical removal of implants, necrotic tissue, and biofilms lies with the arthroplasty surgeon and must remain the cornerstone of treatment. Single-stage revision may be considered the first-line treatment for all PJIs unless the organism is unknown, the patient is systemically septic, or there is a poor tissue envelope.
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Affiliation(s)
- Fiachra E Rowan
- Department of Orthopaedic Surgery, University College London Hospital, 250 Euston Road, London, NW1 2PG, UK.
- The Princess Grace Hospital, 42-52 Nottingham Place, Marylebone, London, W1U 5NY, UK.
| | - Matthew J Donaldson
- Department of Orthopaedic Surgery, University College London Hospital, 250 Euston Road, London, NW1 2PG, UK
- The Princess Grace Hospital, 42-52 Nottingham Place, Marylebone, London, W1U 5NY, UK
| | - Jurek R Pietrzak
- Department of Orthopaedic Surgery, University College London Hospital, 250 Euston Road, London, NW1 2PG, UK
- The Princess Grace Hospital, 42-52 Nottingham Place, Marylebone, London, W1U 5NY, UK
| | - Fares S Haddad
- Department of Orthopaedic Surgery, University College London Hospital, 250 Euston Road, London, NW1 2PG, UK
- The Princess Grace Hospital, 42-52 Nottingham Place, Marylebone, London, W1U 5NY, UK
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16
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Ikebe S, Sonohata M, Kitajima M, Kawano S, Mawatari M. Total hip arthroplasty following Girdlestone arthroplasty. J Orthop Sci 2018; 23:532-537. [PMID: 29459080 DOI: 10.1016/j.jos.2018.01.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2017] [Revised: 01/02/2018] [Accepted: 01/28/2018] [Indexed: 10/18/2022]
Abstract
BACKGROUND Complications associated with re-implantation of total hip arthroplasty (THA) after resection arthroplasty for the treatment of primary septic hip arthritis or infected THA and bipolar hemiarthroplasty (BHA) are not well-documented. Furthermore, no comparison has been made between septic arthritis (SA) and infected THA and BHA. We divided subjects into two groups for evaluation: a SA group and an infected THA or BHA group. METHODS Nineteen hips in 19 patients (12 in the SA group, 7 in the infected THA or BHA group) with an average of 77 months of follow-up from the time of re-implantation THA were retrospectively evaluated. RESULTS The average Japanese Orthopaedic Association hip score improved from 50 points (range, 30 to 73 points) preoperatively to 80 points (range: 64 to 96 points) at the time of the final follow-up (p < 0.01). Intra- and postoperative complications occurred in 11 cases, including intraoperative fracture in 1 hip, deep infection in 6 hips, dislocation in 7 hips, and septic loosening of acetabular component in 2 hips. Following re-implantation, further surgical revision was required in four cases. Two revisions were performed for recurrent infection: one patient had recurrent dislocation of one hip, and one patient had recurrent infection and dislocation. The number of hips with relapsed infection in the infected THA or BHA group (5 hips) was significantly higher than that in the SA group (1 hip) (p < 0.05). CONCLUSIONS Re-implantation after septic hip arthritis or infected THA or BHA was an effective treatment for improving the activity of daily life, especially the gait function. Furthermore, 94.7% of patients were free of infection at the latest follow-up. However, the rate of recurrence of infection was 31.6%, and re-implantation after resection arthroplasty following infected THA or BHA led to a lower rate of infection control than that after primary SA.
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Affiliation(s)
- Satoshi Ikebe
- Department of Orthopaedic Surgery, Faculty of Medicine, Saga University, Nabeshima 5-1-1, Saga, 849-8501, Japan
| | - Motoki Sonohata
- Department of Orthopaedic Surgery, Faculty of Medicine, Saga University, Nabeshima 5-1-1, Saga, 849-8501, Japan.
| | - Masaru Kitajima
- Department of Orthopaedic Surgery, Faculty of Medicine, Saga University, Nabeshima 5-1-1, Saga, 849-8501, Japan
| | - Shunsuke Kawano
- Department of Orthopaedic Surgery, Faculty of Medicine, Saga University, Nabeshima 5-1-1, Saga, 849-8501, Japan
| | - Masaaki Mawatari
- Department of Orthopaedic Surgery, Faculty of Medicine, Saga University, Nabeshima 5-1-1, Saga, 849-8501, Japan
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17
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Hatz D, Anoushiravani AA, Chambers MC, El-Othmani MM, Saleh KJ. Approach to Decrease Infection Following Total Joint Arthroplasty. Orthop Clin North Am 2016; 47:661-71. [PMID: 27637652 DOI: 10.1016/j.ocl.2016.05.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Surgical site infection in total joint arthroplasty is a challenging complication that warrants discussion with regard to prevention and management. Limiting postoperative infection rate is a paramount quest in the orthopedic community. Several preoperative risk factors have been identified in orthopedic literature with regards to likelihood of developing postoperative infection. This article evaluates several factors that predispose total joint arthroplasty patients to infection. Methods of patient surgical preparation designed to decrease postoperative infection, decreasing intraoperative traffic during procedural settings, and elaborate intraoperative prophylactic advancements are assessed. Approaches to decrease postoperative infection by discussing means of lowering rates of postoperative transfusion, wound drainage, and hematoma formation are analyzed.
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Affiliation(s)
- Daniel Hatz
- Division of Orthopaedics and Rehabilitation, Southern Illinois University School of Medicine, 701 North First Street, Springfield, IL 62781, USA
| | - Afshin A Anoushiravani
- Division of Orthopaedics and Rehabilitation, Southern Illinois University School of Medicine, 701 North First Street, Springfield, IL 62781, USA
| | - Monique C Chambers
- Division of Orthopaedics and Rehabilitation, Southern Illinois University School of Medicine, 701 North First Street, Springfield, IL 62781, USA
| | - Mouhanad M El-Othmani
- Division of Orthopaedics and Rehabilitation, Southern Illinois University School of Medicine, 701 North First Street, Springfield, IL 62781, USA
| | - Khaled J Saleh
- Department of Orthopaedic and Sports Medicine, Detroit Medical Center, 311 Mack Avenue, 5th Floor, Detroit, MI 48201, USA.
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Abstract
There is currently no consensus on the optimal management of the infected total hip arthroplasty. Multiple management techniques have been described in contemporary literature.This paper focuses on 2-stage revision for the infected total hip arthroplasty. We discuss the rationale and examine the current evidence for the use of this technique.
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19
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Parry MC, Duncan CP. The challenge of methicillin resistant staphylococcal infection after total hip replacement. Bone Joint J 2014; 96-B:60-5. [PMID: 25381410 DOI: 10.1302/0301-620x.96b11.34333] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Advances in the treatment of periprosthetic joint infections of the hip have once more pushed prosthesis preserving techniques into the limelight. At the same time, the common infecting organisms are evolving to become more resistant to conventional antimicrobial agents. Whilst the epidemiology of resistant staphylococci is changing, a number of recent reports have advocated the use of irrigation and debridement and one-stage revision for the treatment of periprosthetic joint infections due to resistant organisms. This review presents the available evidence for the treatment of periprosthetic joint infections of the hip, concentrating in particular on methicillin resistant staphylococci. Cite this article: Bone Joint J 2014;96-B(11 Suppl A):60–5.
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Affiliation(s)
- M. C. Parry
- University of British Columbia, Department
of Orthopaedics, 3114-910 West 10th Avenue, Vancouver, British
Columbia, Canada
| | - C. P. Duncan
- University of British Columbia, Department
of Orthopaedics, 3114-910 West 10th Avenue, Vancouver, British
Columbia, Canada
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20
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Tsung JD, Rohrsheim JAL, Whitehouse SL, Wilson MJ, Howell JR. Management of periprosthetic joint infection after total hip arthroplasty using a custom made articulating spacer (CUMARS); the Exeter experience. J Arthroplasty 2014; 29:1813-8. [PMID: 24851790 DOI: 10.1016/j.arth.2014.04.013] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2013] [Revised: 04/05/2014] [Accepted: 04/10/2014] [Indexed: 02/01/2023] Open
Abstract
Periprosthetic joint infection (PJI) after THA is a major complication with an incidence of 1%-3%. We report our experiences with a technique using a custom-made articulating spacer (CUMARS) at the first of two-stage treatment for PJI. This technique uses widely available all-polyethylene acetabular components and the Exeter Universal stem, fixed using antibiotic loaded acrylic cement. Seventy-six hips were treated for PJI using this technique. Performed as the first of a two-stage procedure, good functional results were commonly seen, leading to postponing second stage indefinitely with retention of the CUMARS prosthesis in 34 patients. The CUMARS technique presents an alternative to conventional spacers, using readily available components that are well tolerated, allowing weight bearing and mobility, and achieving comparable eradication rates.
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Affiliation(s)
- Jason D Tsung
- Princess Elizabeth Orthopaedic Centre, Royal Devon and Exeter Hospital, Exeter, UK
| | - James A L Rohrsheim
- Princess Elizabeth Orthopaedic Centre, Royal Devon and Exeter Hospital, Exeter, UK
| | - Sarah L Whitehouse
- Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, Australia
| | - Matthew J Wilson
- Princess Elizabeth Orthopaedic Centre, Royal Devon and Exeter Hospital, Exeter, UK
| | - Jonathan R Howell
- Princess Elizabeth Orthopaedic Centre, Royal Devon and Exeter Hospital, Exeter, UK
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21
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Wasko MK, Borens O. Antibiotic cement nail for the treatment of posttraumatic intramedullary infections of the tibia: midterm results in 10 cases. Injury 2013; 44:1057-60. [PMID: 23747122 DOI: 10.1016/j.injury.2013.05.001] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2013] [Revised: 03/24/2013] [Accepted: 05/01/2013] [Indexed: 02/02/2023]
Abstract
INTRODUCTION This is a single, level 1 trauma centre, prospective consecutive patient series with intramedullary infection in the presence of unstable tibial fracture treated using the Kirschner wire-reinforced, antibiotic cement nail. PATIENTS AND METHODS A total of 10 consecutive patients (eight males and two females) with a mean age of 42 years (range, 20-59) suffering from infection after intramedullary nailing for tibial fracture, admitted during a period of 4 years, were included. An antibiotic cement-coated nail, handmade at the time of surgery, was implanted in all patients. This was followed by a standardised 6-week treatment protocol, extraction of the nail and definitive fixation. RESULTS At 6 years of follow-up, infection eradication and bony union were possible in all of the patients. No further infection treatment was necessary; however, all of our patients underwent additional procedures (mean: four additional procedures per patient) for cosmetic or other non-infectious reasons (bone grafting, muscle flaps, etc.). CONCLUSIONS The antibiotic cement-coated nail seems to be an effective treatment for intramedullary infections of the fractured tibia.
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Affiliation(s)
- Marcin Krzysztof Wasko
- Department of Orthopaedics and Inflammatory Disorders of Locomotor System, The Medical Centre of Postgraduate Education, Otwock, Poland.
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Hinarejos P, Guirro P, Leal J, Montserrat F, Pelfort X, Sorli ML, Horcajada JP, Puig L. The use of erythromycin and colistin-loaded cement in total knee arthroplasty does not reduce the incidence of infection: a prospective randomized study in 3000 knees. J Bone Joint Surg Am 2013; 95:769-74. [PMID: 23636182 DOI: 10.2106/jbjs.l.00901] [Citation(s) in RCA: 77] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The use of antibiotic-loaded cement is believed to prevent infection in primary total knee arthroplasty, but there is a lack of randomized studies to support this concept. The aim of this study was to evaluate the use of an antibiotic-loaded cement to reduce the infection rate in primary total knee arthroplasty. METHODS This is a prospective randomized study with 2948 cemented total knee arthroplasties, in which bone cement without antibiotic was used in 1465 knees (the control group) and a bone cement loaded with erythromycin and colistin was used in 1483 knees (the study group). All patients received the same systemic prophylactic antibiotics. The patients were followed for a minimum of twelve months. The rate of infection was analyzed according to the criteria of the Centers for Disease Control and Prevention. RESULTS The rate of deep infection (1.4% in the control group and 1.35% in the study group; p = 0.96) and the rate of superficial infection (1.2% and 1.8%, respectively; p = 0.53) were similar in both groups. The factors related to a higher rate of deep infection in a multivariate analysis were male sex and an operating time of >125 minutes. CONCLUSIONS The use of erythromycin and colistin-loaded bone cement in total knee arthroplasty did not lead to a decrease in the rate of infection when systemic prophylactic antibiotics were used, a finding that suggests that the use of antibiotic-loaded bone cement would not be indicated in the general population. Further research is needed to assess whether its use is recommended for patients with a higher risk of infection.
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Affiliation(s)
- Pedro Hinarejos
- Department of Orthopedic Surgery, Parc de Salut Mar, Universitat Autònoma Barcelona, Hospital de la Esperanza, Sant Josep de la Muntanya, 12, 08024 Barcelona, Spain.
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Preformed antibiotic-loaded cement spacers for two-stage revision of infected total hip arthroplasty. Long-term results. Hip Int 2013; 22 Suppl 8:S46-53. [PMID: 22956370 DOI: 10.5301/hip.2012.9570] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/26/2012] [Indexed: 02/04/2023]
Abstract
Two-stage revision is the most widely accepted and performed intervention for chronically infected hip prosthesis and different interim spacers have been proposed. In recent years, antibiotic-loaded preformed spacers have become available on the market. The aim of this retrospective study was to assess the long-term results of two-stage revision with preformed spacers and uncemented hip prosthesis for the treatment of septic hip prosthesis. From 2000 to 2010, 183 consecutive patients underwent two-stage revision of septic hip prosthesis, with a same protocol, including preformed antibiotic-loaded cement spacer and a cementless modular hip revision prosthesis and four to six weeks antibiotic administration. Clinical and radiologic assessment at a minimum follow-up of two years was performed. At a minimum two years follow-up, 10 patients (5.4%) had had an infection recurrence, four (2.2%) an aseptic loosening and four more required partial revision of the modular components of the prosthesis, because of hip instability/dislocation; 21 patients died or were lost to follow-up. Considering all the reasons for revision, survivorship at eleven years was 93.9%. Harris Hip Score improved from 29.1 ± 14.6 pre-operatively to 41.1 ± 15.9 after spacer implant and 81.7 ± 17.6 after hip revision. The main complications after spacer implant included: spacer dislocation (16.4%), intra-operative femoral fractures (2.7%), and thromboembolism (2.1%). Complications after hip revision were: instability/dislocation (4,3%), intra-operative femoral fractures (1.6%), and thromboembolism (3.3%). Two-stage revision of septic hip prosthesis with preformed antibiotic-loaded spacers and cementless hip prosthesis provides satisfactory long-term results, with reduced complications.
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Value of debridement and irrigation for the treatment of peri-prosthetic infections. A systematic review. Hip Int 2013; 22 Suppl 8:S19-24. [PMID: 22956381 DOI: 10.5301/hip.2012.9566] [Citation(s) in RCA: 77] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/29/2012] [Indexed: 02/04/2023]
Abstract
Debridement and irrigation has been proposed as a salvage procedure for early post-operative and late acute haematogenous periprosthetic hip and knee infections, however the effective ability of this procedure to avoid recurrent infection is still debated. In this systematic review of the literature we reviewed full-text papers published from 1970 through 2011, that reported the success rate of infection eradication after debridement and irrigation with prosthesis retention for the treatment of early septic complications (within six weeks from surgery) or late acute haematogenous infections after hip or knee prosthesis. In all, 14 original articles, reporting the results of 710 patients were retrieved. The average success rate has been, respectively, 45.9% and 52% after a single or repeated debridement and irrigation procedures, at a mean follow-up of 53.3 months. The methodological limitations of this study and the heterogeneous material in the reviewed papers notwithstanding, this systematic review shows that debridement and irrigation procedure is associated with a rather poor outcome, even in a population of patients selected on the basis of symptoms' duration and patients should be adequately informed prior to undergo this salvage procedure.
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25
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Osmon DR, Berbari EF, Berendt AR, Lew D, Zimmerli W, Steckelberg JM, Rao N, Hanssen A, Wilson WR. Diagnosis and management of prosthetic joint infection: clinical practice guidelines by the Infectious Diseases Society of America. Clin Infect Dis 2012; 56:e1-e25. [PMID: 23223583 DOI: 10.1093/cid/cis803] [Citation(s) in RCA: 1388] [Impact Index Per Article: 106.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
These guidelines are intended for use by infectious disease specialists, orthopedists, and other healthcare professionals who care for patients with prosthetic joint infection (PJI). They include evidence-based and opinion-based recommendations for the diagnosis and management of patients with PJI treated with debridement and retention of the prosthesis, resection arthroplasty with or without subsequent staged reimplantation, 1-stage reimplantation, and amputation.
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Affiliation(s)
- Douglas R Osmon
- Division of Infectious Diseases, Mayo Clinic College of Medicine, Rochester, MN 55905, USA.
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26
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Massive septic pelvic osteolysis following revision total hip arthroplasty in a patient with sickle cell anemia: clinical presentation and review of the literature. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2012; 22 Suppl 1:107-11. [PMID: 26662759 DOI: 10.1007/s00590-011-0875-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/06/2011] [Accepted: 09/09/2011] [Indexed: 10/17/2022]
Abstract
Total hip arthroplasty (THA) performed in patients with osteonecrosis, caused by sickle cell disease, carries a higher risk of medical and orthopedic complications, than those observed after THA for osteonecrosis related to other conditions. We report such a case of a male patient, who underwent one-stage revision hip arthroplasty due to septic cup loosening after primary cementless THA and later developed severe septic osteomyelitis of the ipsilateral hemipelvis that had a fatal outcome. The relative literature regarding loosening and infection after THA in patients with sickle cell disease is thoroughly reviewed.
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27
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Zmistowski B, Parvizi J. Identification and treatment of infected total hip arthroplasty. Expert Rev Anti Infect Ther 2012; 10:509-18. [PMID: 22512759 DOI: 10.1586/eri.12.19] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Periprosthetic joint infection (PJI) in the hip following prosthetic joint placement is a devastating outcome of an otherwise often successful surgical treatment (total-hip arthroplasty). Management of PJI is dependent upon accurate diagnosis and successful treatment, both of which are challenging. Recently, great strides have been made in improving the diagnosis of PJI, which has no 'gold standard' diagnostic tool. Proper diagnosis is essential as untreated or undetected PJI can quickly lead to biofilm formation on the implant surface depending upon the infecting organism. Upon complete biofilm formation, successful treatment requires prosthetic resection with immediate or delayed reimplantation. Even with the most aggressive surgical treatment, PJI eradication currently has a success rate of approximately 80%. Unfortunately, technologies to improve the local delivery of antibiotics are not expected to be available in the near future.
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Affiliation(s)
- Benjamin Zmistowski
- The Rothman Institute of Orthopaedics at Thomas Jefferson University Hospital, 925 Chestnut Street, 5th Floor, Philadelphia, PA 19107, USA
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28
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Beswick AD, Elvers KT, Smith AJ, Gooberman-Hill R, Lovering A, Blom AW. What is the evidence base to guide surgical treatment of infected hip prostheses? systematic review of longitudinal studies in unselected patients. BMC Med 2012; 10:18. [PMID: 22340795 PMCID: PMC3364856 DOI: 10.1186/1741-7015-10-18] [Citation(s) in RCA: 87] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2012] [Accepted: 02/16/2012] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Prosthetic joint infection is an uncommon but serious complication of hip replacement. There are two main surgical treatment options, with the choice largely based on the preference of the surgeon. Evidence is required regarding the comparative effectiveness of one-stage and two-stage revision to prevent reinfection after prosthetic joint infection. METHODS We conducted a systematic review to identify randomised controlled trials, systematic reviews and longitudinal studies in unselected patients with infection treated exclusively by one- or two-stage methods or by any method. The Embase, MEDLINE and Cochrane databases were searched up to March 2011. Reference lists were checked, and citations of key articles were identified by using the ISI Web of Science portal. Classification of studies and data extraction were performed independently by two reviewers. The outcome measure studied was reinfection within 2 years. Data were combined to produce pooled random-effects estimates using the Freeman-Tukey arc-sine transformation. RESULTS We identified 62 relevant studies comprising 4,197 patients. Regardless of treatment, the overall rate of reinfection after any treatment was 10.1% (95% CI = 8.2 to 12.0). In 11 studies comprising 1,225 patients with infected hip prostheses who underwent exclusively one-stage revision, the rate of reinfection was 8.6% (95% CI = 4.5 to 13.9). After two-stage revision exclusively in 28 studies comprising 1,188 patients, the rate of reinfection was 10.2% (95% CI = 7.7 to 12.9). CONCLUSION Evidence of the relative effectiveness of one- and two-stage revision in preventing reinfection of hip prostheses is largely based on interpretation of longitudinal studies. There is no suggestion in the published studies that one- or two stage methods have different reinfection outcomes. Randomised trials are needed to establish optimum management strategies.
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Affiliation(s)
- Andrew D Beswick
- School of Clinical Sciences, University of Bristol, Musculoskeletal Research Unit, Southmead Hospital, Southmead Road, Bristol, BS10 5NB, UK.
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Propionibacterium acnes infection as an occult cause of postoperative shoulder pain: a case series. Clin Orthop Relat Res 2011; 469:2824-30. [PMID: 21240577 PMCID: PMC3171528 DOI: 10.1007/s11999-011-1767-4] [Citation(s) in RCA: 102] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2010] [Accepted: 01/03/2011] [Indexed: 01/31/2023]
Abstract
BACKGROUND Infections after shoulder surgery are potentially devastating complications. Propionibacterium acnes is recognized as a causal agent in shoulder infections. The clinical presentation is usually insidious and nonspecific, but a P. acnes infection could be an occult cause of postoperative shoulder pain. QUESTIONS/PURPOSES What are the clinical and microbiologic characteristics of a postsurgical P. acnes shoulder infection and how should it be addressed? PATIENTS AND METHODS Ten patients with an average age of 57 years presented with P. acnes postsurgical shoulder infection. Clinical infection signs and surgical history were assessed and joint aspirates and tissue biopsy specimens were obtained. Diagnosis was confirmed by microbiologic cultures. RESULTS At the time of confirmation of the diagnosis, clinical signs of infection were absent. C-reactive protein and erythrocyte sedimentation rates were inconsistently elevated. Cultures took a mean 7 days to confirm organism growth. The average time from surgery to diagnosis of infection was 1.8 years (range, 0.07-8.0 years). All patients underwent irrigation and débridement and were treated with antibiotics for 6 weeks. CONCLUSIONS P. acnes shoulder infections should be considered as a cause for persistent, unexplained shoulder pain. Shoulder aspirations and tissue samples should be obtained. Surgical débridement and intravenous antibiotics are necessary treatment modalities. LEVEL OF EVIDENCE Level IV, Prognostic study. See the Guidelines for Authors for a complete description of levels of evidence.
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Peel TN, Buising KL, Choong PFM. Prosthetic joint infection: challenges of diagnosis and treatment. ANZ J Surg 2010; 81:32-9. [DOI: 10.1111/j.1445-2197.2010.05541.x] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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Willis-Owen CA, Konyves A, Martin DK. Factors affecting the incidence of infection in hip and knee replacement: an analysis of 5277 cases. ACTA ACUST UNITED AC 2010; 92:1128-33. [PMID: 20675759 DOI: 10.1302/0301-620x.92b8.24333] [Citation(s) in RCA: 145] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Infection remains a significant and common complication after joint replacement and there is debate about which contributing factors are important. Few studies have investigated the effect of the operating time on infection. We collected data prospectively from 5277 hip and knee replacements which included the type of procedure, the operating time, the use of drains, the operating theatre, surgeon, age and gender. In a subgroup of 3449 knee replacements further analysis was carried out using the tourniquet time in place of the operating time. These variables were assessed by the use of generalised linear modelling against superficial, deep or joint-space post-operative infection as defined by the Australian Surgical-Site Infection criteria. The overall infection rate was 0.98%. In the replacement data set both male gender (z = 3.097, p = 0.00195) and prolonged operating time (z = 4.325, p < 0.001) were predictive of infection. In the knee subgroup male gender (z = 2.250, p = 0.02447), a longer tourniquet time (z = 2.867, p = 0.00414) and total knee replacement (versus unicompartmental knee replacement) (z = -2.052, p = 0.0420) were predictive of infection. These findings support the view that a prolonged operating time and male gender are associated with an increased incidence of infection. Steps to minimise intra-operative delay should be instigated, and care should be exercised when introducing measures which prolong the duration of joint replacement.
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Affiliation(s)
- C A Willis-Owen
- Sportsmed SA, 32 Payneham Road, Stepney, South Australia 5069, Australia.
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Romanò CL, Romanò D, Logoluso N, Meani E. Long-stem versus short-stem preformed antibiotic-loaded cement spacers for two-stage revision of infected total hip arthroplasty. Hip Int 2010; 20:26-33. [PMID: 20235080 DOI: 10.1177/112070001002000104] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/22/2009] [Indexed: 02/04/2023]
Abstract
Two-stage revision is the most widely accepted and performed intervention for chronically infected hip prostheses. In recent years short and long stem antibiotic-loaded preformed spacers have become available on the market. The aim of this prospective, comparative study was to assess the safety and efficacy of long stem versus short stem preformed spacers. From year 2000 to 2007 102 consecutive patients underwent two-stage revision of septic hip replacement with a preformed antibiotic-loaded cement spacer and a cementless modular hip revision prosthesis. Patients were divided in two groups: Group L (long stem spacer) (N=60) and Group S (short stem) (N=42) and compared. No systemic toxicity due to local antibiotic release and no spacer breakage were observed in either group. At spacer removal, no statistically significant difference was observed in infection recurrence. After revision, at a mean 4 years follow-up, 2 patients in Group L and 2 in Group S showed infection recurrence. The Harris Hip Score improved in both groups, compared to post spacer implant values: 79.6 + or - 15.4 versus 38.4 + or - 14.5 in Group L (p < 0.0001) and 82.3 + or - 14.4 versus 44.8 + or - 16.6 in Group S (p < 0.0001); the difference between groups was not statistically significant. Short and long stem spacers provide comparable low infection recurrence rate and clinical outcome, with negligible risk of breakage and toxicity.
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Affiliation(s)
- Carlo L Romanò
- Department of Reconstructive Surgery and Bone and Joint Infections, Galeazzi Orthopedic Institute, Milan, Italy.
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Abstract
Modern penile implants, introduced to the market almost four decades ago, have provided a predictable and reliable treatment of erectile dysfunction (ED) despite the development of less-invasive therapies. Infection associated with the placement of these devices does occur, and with prophylactic measures and protocols the incidence has decreased fortunately. In the presence of an infection the implant and all foreign material should be removed. A salvage procedure, during which the wound is thoroughly washed with antiseptic solutions after device removal and placement of a new implant during the same procedure, has a high success rate and is becoming a popular approach. The alternative, device removal with return at a later date for placing a new implant, entails a more difficult corporal dilation, and the resulting erection is noticeably shorter. Patient and partner satisfaction with a penile implant is the highest among all of the treatments for ED.
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Esposito S, Leone S, Bassetti M, Borrè S, Leoncini F, Meani E, Venditti M, Mazzotta F. Italian Guidelines for the Diagnosis and Infectious Disease Management of Osteomyelitis and Prosthetic Joint Infections in Adults. Infection 2009; 37:478-96. [DOI: 10.1007/s15010-009-8269-2] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2008] [Accepted: 03/19/2009] [Indexed: 12/21/2022]
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Antibiotics-impregnated cement spacers in the first step of two-stage revision for infected totally replaced hip joints: report of ten trial cases. J Orthop Sci 2009; 14:704-10. [PMID: 19997816 DOI: 10.1007/s00776-009-1406-z] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2008] [Accepted: 08/19/2009] [Indexed: 02/09/2023]
Abstract
BACKGROUND Periprosthetic infection is one of the serious complications after total hip arthroplasty (THA). This study analyzed the perioperative and postoperative status of patients who underwent antibiotics-impregnated cement spacer technique in the first step of the two-stage revision. METHODS Ten joints of the nine patients (mean age, 65 years; seven women, two men) received two-stage revision as a result of infection that appeared after primary THAs in seven joints, aseptic revision in one, and recurrent type in two. An antibiotics-impregnated cement spacer made by a mold system was applied in the femoral side of all joints. An acetabular spacer was made by hand using a cup gauge in eight joints with extensive tissue loss. RESULTS The change of leg length after the first stage was -2.2 mm, and range of hip flexion was 72 degrees on average, respectively. Patients could walk with crutches after the first stage, except one patient with simultaneous infections of both hips and one with fracture of the cement spacer. One fracture of femoral cement spacer, and one dislocation of femoral spacer accompanied by fracture of acetabular cement spacer and curable recurrent infection, were found. In all cases of the second-stage procedure, the acetabular side was reconstructed with allogeneic bone graft with cross plate and that of the femur was by impaction bone grafting method. In the latest follow-up, reconstructed implants were stable. Seven patients could walk without any supportive devices and two could walk with the support of a T-cane. CONCLUSIONS An antibiotics-impregnated cement spacer in the first step of the two-stage revision was effective not only to compensate tissue loss after removal of the implants and to minimize discrepancy of leg length, but also to contribute to improvement of perioperative and postoperative daily activities of the patient's life as well as treatment of the infection.
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36
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37
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Two-stage revision of infected hip arthroplasty using a shortened post-operative course of antibiotics. Arch Orthop Trauma Surg 2009; 129:489-94. [PMID: 18677498 DOI: 10.1007/s00402-008-0683-x] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2008] [Indexed: 10/21/2022]
Abstract
INTRODUCTION We present a series of 30 consecutive patients with 31 infected total hip arthroplasties treated by a single surgeon over a 4-year period in whom a shortened post-operative course of antimicrobial chemotherapy was used. METHODS The treatment protocol consisted of a two-stage exchange with removal of infected components, insertion of an interim antibiotic eluting cement spacer and re-implantation of an extensively coated uncemented prosthesis on the femoral side. Systemic antibiotic treatment following each stage consisted of an abridged course of 5 days post-operative intra-venous administration followed by complete cessation of anti-microbial therapy. RESULTS At a mean follow-up of 35 months (minimum 24 months), there were no cases of recurrent prosthetic infection and no patient had required revision for aseptic loosening or mechanical instability on the femoral side. The combination of effective-staged surgical joint debridement, a shortened post-operative course of systemic antibiotic treatment and an adequate latent period before re-implantation has led to encourage early results in this series of revised chronic hip joint prosthetic infections.
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39
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Abstract
Penile implants remain a mainstay in treating erectile dysfunction (ED). Despite competing therapies, the number of devices implanted has increased each year. Implant infection continues to be a problem, but recent advances in antibiotic-coated devices and copious use of antiseptic irrigation have reduced the incidence. When confronted with an implant infection, a salvage procedure has gained acceptance that involves immediate replacement of the infected implant after antiseptic washing of the implant cavities. This procedure minimizes shortening of the implant erection and facilitates placement of cylinders in corporal bodies. Among patients and health care providers, satisfaction with penile implant remains the highest for all ED treatments.
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Affiliation(s)
- John J Mulcahy
- Department of Urology, University of Arizona, Paradise Valley, AZ 85253, USA.
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40
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Rudelli S, Uip D, Honda E, Lima ALLM. One-stage revision of infected total hip arthroplasty with bone graft. J Arthroplasty 2008; 23:1165-77. [PMID: 18534510 DOI: 10.1016/j.arth.2007.08.010] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2006] [Accepted: 08/08/2007] [Indexed: 02/01/2023] Open
Abstract
There are many different opinions in the literature regarding the best procedure for revision of infected hip arthroplasty and hence in achieving long-term stabilization of a new implant. Thirty-two patients with 32 loose and infected total hip arthroplasties underwent revision with a bone graft in a 1-stage procedure. The bone graft was used in the acetabulum and femur in 25 patients, in the acetabulum alone in 4 patients and in the femur alone in 3 patients. A metal mesh was necessary in 15 patients to contain the morselized bone graft. At the time of surgical revision, 9 patients had a draining sinus, 6 had a closed sinus, and 17 had never had sinuses in the surgical wound. Antibiotic therapy was administered intravenously and orally for 6 months. Mean follow-up was 103 months (range, 63-183 months), and infection recurred in 2 (6.2%) cases. Further studies are necessary, and continuation of this method is justified.
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Affiliation(s)
- Sergio Rudelli
- Department of Orthopaedic Surgery, Santa Casa Medical School, São Paulo, Brazil
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Long-term results of craniofacial implantation: a return to methyl methacrylate. EUROPEAN JOURNAL OF PLASTIC SURGERY 2008. [DOI: 10.1007/s00238-008-0262-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Silva AGPD, Silva FBDAE, Santos ALGD, Luzo CAM, Sakaki MH, Zumiotti AV. Infecção pós-estabilização intramedular das fraturas diafisárias dos membros inferiores: protocolo de tratamento. ACTA ORTOPEDICA BRASILEIRA 2008. [DOI: 10.1590/s1413-78522008000500002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
O tratamento das infecções pós-estabilização intramedular das fraturas dos membros inferiores apresenta uma grande variedade de opções, desde a limpeza cirúrgica com manutenção da haste até a retirada da haste e colocação de fixador externo. O espaçador diafisário ainda é uma técnica pouco utilizada para o tratamento desse tipo de infecção, existindo poucos relatos na literatura sobre sua aplicação. No IOT HCFMUSP, esta técnica vem sendo empregada de maneira crescente e, no presente trabalho, temos o objetivo de descrever o protocolo de tratamento utilizado em nossa instituição, bem como a apresentação de nossa casuística inicial. O protocolo consiste na antibioticoterapia endovenosa, retirada da haste intra-medular, desbridamento cirúrgico do canal medular e colocação do espaçador diafisário. Revisamos retrospectivamente o prontuário de 11 pacientes com 13 fraturas, sendo cinco femorais e oito tibiais, submetidos à técnica apresentada. O tempo de seguimento variou de 6 a 36 meses, média de 14,27 meses, com resultados satisfatórios ocorridos em dez das treze fraturas estudadas, representando uma taxa de eficácia de 76,93%. Concluímos que o método representa uma boa alternativa para o tratamento destes casos, necessitando ainda novos trabalhos comparativos para a avaliação de suas vantagens e para difundir o uso do método.
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Prolonged implantation of an antibiotic cement spacer for management of shoulder sepsis in compromised patients. J Shoulder Elbow Surg 2007; 16:701-5. [PMID: 17931905 DOI: 10.1016/j.jse.2007.02.118] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2006] [Accepted: 02/12/2007] [Indexed: 02/01/2023]
Abstract
The purpose of this report is to present the preliminary results after treatment of shoulder sepsis with prolonged implantation of an antibiotic-loaded cement spacer in a selected group of compromised patients. The current study included 11 patients (9 men and 2 women) with a mean age of 64 years (range, 36-79 years). All patients were treated with radical débridement, implantation of an antibiotic-impregnated polymethylmethacrylate spacer, and 6 weeks of antibiotic therapy. The subjective complaints, range of motion of the shoulder, functional outcome (mini-Quick Disability of the Arm, Shoulder, and Hand score), and radiographic findings were evaluated. At a mean follow-up of 22 months (range, 15-26 months), 9 patients were free of infection, with pain relief and adequate shoulder function for activities of daily living. Radiographic evaluation revealed no loosening or fracture of the spacer and no progressive degenerative changes involving the glenoid. Prolonged implantation of the spacer may be a useful alternative in selected patients with poor general condition.
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44
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Zeller V, Ghorbani A, Strady C, Leonard P, Mamoudy P, Desplaces N. Propionibacterium acnes: An agent of prosthetic joint infection and colonization. J Infect 2007; 55:119-24. [PMID: 17418419 DOI: 10.1016/j.jinf.2007.02.006] [Citation(s) in RCA: 182] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2006] [Revised: 02/12/2007] [Accepted: 02/19/2007] [Indexed: 11/30/2022]
Abstract
BACKGROUND Prosthetic joint infection (PJI) can present a diagnostic challenge, especially with slow-growing and poorly virulent bacteria. OBJECTIVE To describe the epidemiological, clinical and biological characteristics of Propionibacterium acnes PJI, their treatments and outcomes and compare 2 clinical pictures (according to the time PJI symptoms appeared after the index operation: < or = 2 years, > 2 years). METHODS We conducted a cohort study on P. acnes PJI. Diagnosis was based on > or = 2 positive cultures of intraoperative specimens taken during revision arthroplasties for infection or presumed aseptic loosening. RESULTS Fifty patients with prosthetic hip (34), knee (10) or shoulder (6) infections were included and analyzed according to their symptom-free interval: < or = 2 years for 35 and > 2 years for 15 (mean interval: 11+/-6 years). The numbers of previous prostheses (p=0.04) were higher for the shorter-interval group, which had more frequent signs of infection (p=0.004). These findings suggest infection in most of the patients whose PJI symptoms appeared: < or = 2 years after the index operation, and colonization in the majority of those whose symptoms appeared > 2 years after index surgery. Treatment combining exchange arthroplasty with prolonged intravenous antibiotics was successful for 92% of the patients. CONCLUSION P. acnes can cause different types of PJI: late chronic infections, colonization of loosened prostheses and, exceptionally, acute postoperative infections.
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Affiliation(s)
- Valérie Zeller
- Service d'Orthopédie et de Traumatologie, Groupe Hospitalier Diaconesses-Croix Saint-Simon, 125, rue d'Avron, 75020 Paris, France.
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45
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Cabrita HB, Croci AT, Camargo OPD, Lima ALLMD. Prospective study of the treatment of infected hip arthroplasties with or without the use of an antibiotic-loaded cement spacer. Clinics (Sao Paulo) 2007; 62:99-108. [PMID: 17505692 DOI: 10.1590/s1807-59322007000200002] [Citation(s) in RCA: 74] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2007] [Accepted: 02/26/2007] [Indexed: 11/22/2022] Open
Abstract
PURPOSE Our purpose was to compare 2 methods of treatment of chronic infection in hip arthroplasties--with or without an antibiotic-loaded cement spacer. METHODS In a prospective study, we treated 68 infected hip arthroplasties with discharging sinuses and bone loss, comparing 30 patients treated in 2 stages without the use of a spacer (control group) and 38 patients treated with a vancomycin-loaded spacer (study group). The average follow-up was 4 years (2-8.5 years). One patient died of unrelated causes 4 months after first-stage surgery and was excluded from the study. RESULTS The 2-stage surgery without spacer controlled the infection in 66.7% of patients, and the 2-stage surgery using the spacer controlled it in 89.1% (P < 0.05). At last follow-up, the average Harris Hip Score increased from 19.3 to 69.0 in the control group versus 19.7 to 75.2 in the study group (P > 0.05). The average leg length discrepancy was 2.6 cm in the control group and 1.5 cm in the study group (P < 0.05). The patients treated with a spacer had better clinical results (81.5% of patients with good results against 60.0% for the control group). CONCLUSION The use of an antibiotic-loaded spacer in the 2-stage treatment of infected hip arthroplasties provides better infection control with good functional results and is superior to treatment in 2 stages without a spacer. LEVEL OF EVIDENCE Therapeutic study, Level I-1.
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46
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Teller M, Gopp U, Neumann HG, Kühn KD. Release of gentamicin from bone regenerative materials: Anin vitro study. J Biomed Mater Res B Appl Biomater 2007; 81:23-9. [PMID: 16924618 DOI: 10.1002/jbm.b.30631] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Antibiotic loading of bone regenerative materials is a promising way to protect augmentation procedures from infection during the resorption phase of bone substitutes. Especially in the early stage of implantation, it should protect the grafted site against microbiological pathogens. The present study reports the release kinetics of gentamicin after loading from two synthetic bone filling materials. The first, BONITmatrix, is a biphasic calcium phosphate silica composite obtained by the sol-gel route consisting of 13% silicon dioxide (w/w) and calcium phosphates (hydroxyapatite/beta-tricalcium phosphate 60/40 w/w). The second, Synthacer, is a sintered hydroxyapatite ceramic. Gentamicin was loaded by dipping and by vacuum coating. Release kinetics of the loaded Gentamicin was investigated by fluorescence polarization immunoassay and by staphylococcus aureus assay. By dipping, loading failed for Synthacer, and it was 12.7 mg gentamicin per gram bone substitute for BONITmatrix. By vacuum coating, loading was 11.3 mg gentamicin per gram bone substitute for Synthacer and 7.4 mg gentamicin per gram bone substitute for BONITmatrix. Distinct release kinetics were measured. For Synthacer, a high initial release was followed by a lower protracted release level up to 28 days. For BONITmatrix release was continuous over the investigated 70-day period. The present data suggest that the porosity properties at the nano- and microscopic levels, or the composition are responsible for antibiotic loading and subsequent release.
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Affiliation(s)
- M Teller
- DOT GmbH, Charles-Darwin-Ring 1a, D-18059 Rostock, Germany.
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47
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Abstract
Infection is the second most common cause of prosthetic joint failure. Signs and symptoms associated with prosthetic joint infection may develop weeks or even years following arthroplasty. While some patients with prosthetic joint infection present with findings consistent with acute septic arthritis, many present with pain alone. Morbidity and cost associated with repeat surgery, prolonged medical treatment and joint immobilization render importance to the accurate and timely diagnosis, and appropriate treatment of prosthetic joint infection. No consensus exists, however, in terms of the most cost-effective diagnostic methods or the ideal medical and/or surgical interventions. This review describes diagnostic tests and available treatment for prosthetic joint infection and gives a practical approach to this challenging clinical entity.
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Affiliation(s)
- Paloma Anguita-Alonso
- Infectious Diseases Research Laboratory, Mayo Clinic College of Medicine, Rochester, MN 55905, USA.
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48
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Abstract
Success in the treatment of infected orthopedic prosthesis requires the best surgical approach in combination with prolonged optimum targeted antimicrobial therapy. In choosing the surgical option, one must consider the type of infection, condition of the bone stock and soft tissue, the virulence and antimicrobial susceptibility of the pathogen, the general health and projected longevity of the patient, and the experience of the surgeon. If surgery is not possible, an alternative is long-term oral antimicrobial suppression to maintain a functioning prosthesis. Treatment must be individualized for a specific infection in a specific patient.
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Affiliation(s)
- Irene G Sia
- Division of Infectious Diseases, Mayo Clinic College of Medicine, Rochester, MN 55905, USA.
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49
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Toms AD, Davidson D, Masri BA, Duncan CP. The management of peri-prosthetic infection in total joint arthroplasty. ACTA ACUST UNITED AC 2006; 88:149-55. [PMID: 16434514 DOI: 10.1302/0301-620x.88b2.17058] [Citation(s) in RCA: 147] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- A D Toms
- Princess Elizabeth Orthopaedic Centre, Exeter, Devon EX2 5DW, UK.
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50
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Abstract
Surgeons continually struggle to reduce orthopaedic infections, but no current treatment offers minimum side effects with maximum effectiveness. Antibiotics mixed in plaster of paris have been successful in treating large bony defects in patients with chronic osteomyelitis, and have the advantage of being well tolerated and absorbed by the body. Antibiotics impregnated in polymethylmethacrylate (PMMA) have offered local antibiotic delivery with some success. However, the effect of the antibiotic on the bone cement, the inconsistent elution of the antibiotic, and the need to remove the PMMA implant drives the need for a better system of antibiotic delivery. Polymers or copolymers of antibiotic-impregnated polylactic acid, polyglycolic acid or polyparadioxanone may provide an absorbable system for localized antibiotic delivery. Similar biodegradable systems used to treat small bone fractures have been successful with minimal side effects. In vitro studies have shown promising results of antibiotic elution from bioabsorbable microspheres and beads. Animal in vivo tests have shown that antibiotic impregnated polymers can successfully treat induced osteomyelitis in rabbits and dogs. These studies have provided consistent reproducible results, and now it is time to plan human trials to assess the efficacy of antibiotic microspheres implanted in infected bone and to plan in vivo and in vitro animal testing to investigate the feasibility of antibiotic-polymer-coated components.
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Affiliation(s)
- Kevin Garvin
- University of Nebraska Medical Center, Omaha, 68198, USA.
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