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Fraval A, Gould D, Yilmaz MK, Soriano A, Parvizi J. Antibiotic Holiday in 2-Stage Exchange for Periprosthetic Joint Infection: A Scoping Review. J Bone Joint Surg Am 2025:00004623-990000000-01456. [PMID: 40418706 DOI: 10.2106/jbjs.24.01275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/28/2025]
Abstract
BACKGROUND The use of a 2-stage exchange remains a common management strategy for periprosthetic joint infection (PJI). The use of an "antibiotic holiday" before the second stage to confirm the clearance of infection is often employed, but there is little evidence to guide this practice. The aim of this review was to systematically map the literature reporting on the use of an antibiotic holiday as part of a 2-stage revision for chronic PJI and to answer the question: is there a role for an antibiotic holiday in patients undergoing 2-stage exchange arthroplasty for PJI? METHODS Given the heterogeneity of the literature on this topic, a Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)-compliant scoping review was conducted. Two reviewers developed and refined the search strategy and study eligibility criteria and pilot-tested the data charting form prior to data extraction. Data were analyzed descriptively. RESULTS Three databases were screened, with 504 full-text articles retrieved for review after screening 2,579 titles and abstracts. Of these, 243 were included for data charting. Most studies (238 of 243; 97.9%) were case series, and the remaining 5 (2.1%) were cohort studies that incorporated a direct comparison between continuous therapy and an antibiotic holiday. Most case series (202 of 238; 84.9%) utilized an antibiotic holiday. The proportion of patients who experienced treatment failure in the continuous therapy group (271 of 2,074 patients; 13.1%) was lower than that in the antibiotic holiday group (2,843 of 17,329 patients; 16.4%; p < 0.001). There was a greater proportion of studies with a between-stage interval of <3 months among case series utilizing continuous antibiotic therapy (66.7%) compared with those utilizing an antibiotic holiday (27.2%; p < 0.001). CONCLUSIONS There is no proven superiority of an antibiotic holiday during a 2-stage exchange to treat chronic PJI. Due to the need to extend the duration of the interval between the first and second stages in order to accommodate an antibiotic holiday, patients may be subjected to unnecessary prolongation of their treatment duration without an improvement in outcome. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Andrew Fraval
- Department of Orthopaedics, St Vincent's Hospital Melbourne, Melbourne, Australia
| | - Daniel Gould
- Department of Paediatrics, Royal Children's Hospital, University of Melbourne, Melbourne, Australia
| | | | - Alex Soriano
- Department of Infectious Diseases, Hospital Clínic of Barcelona, University of Barcelona, Barcelona, Spain
- August Pi Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain
- Centro de Investigación Biomédica en Red Enfermedades Infecciosas (CIBER INFEC), Carlos III Health Institute (ISCIII), Madrid, Spain
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Liu X, Gao Y, Leng Y, Zhou J, Qi X. Clinical and Radiographic Outcomes of a Long Cementless Monobloc Stem for Revision Total Hip Arthroplasty Due to Chronic Periprosthetic Infection. J Arthroplasty 2025; 40:1335-1339. [PMID: 39528166 DOI: 10.1016/j.arth.2024.11.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2024] [Revised: 11/03/2024] [Accepted: 11/05/2024] [Indexed: 11/16/2024] Open
Abstract
BACKGROUND A long cementless monobloc stem is widely used for aseptic loosening, with satisfactory 5- to-10-year outcomes reported. Nonetheless, related studies on chronic periprosthetic joint infection (PJI) are scant. This study evaluated the clinical and radiographic outcomes of the stem in 2-stage revisions due to PJI. METHODS This prospective multicenter cohort study consisted of patients from three medical centers who were enrolled in a single arm from January 2017 to May 2022. All patients were diagnosed with chronic PJI based on the International Consensus Meeting criteria and underwent 2-stage revisions using a long monobloc cementless revision stem. Among 44 patients, 37 (12 women and 25 men) completed an average follow-up of 35.6 months (range, 14 to 75). The primary outcome was the stability of the stem; secondary outcomes included infection eradication, Harris Hip Score, leg length discrepancy, major complications, and isolated pathogens at intraoperative cultures. RESULTS At 1 year after revision, the infection-free prosthesis survival rate was 97.3% (95% confidence interval: 96.4 to 98.2). At the last follow-up, the mean subsidence was 2.9 ± 2.1 mm (range, 0.8 to 4.8). Postoperative leg length discrepancy averaged -4.6 ± 4.9 mm (range, -16 to 0). The Engh score averaged 14.1 ± 6.9 (range, zero to 22). The Harris Hip Score improved from a preoperative average of 35.7 ± 8.5 (range, 12 to 50) to 80.4 ± 9.3 (range, 58 to 92) at the 1-year postoperative follow-up (P < 0.01). CONCLUSIONS The long cementless monobloc stem used in the current study presents a feasible option for 2-stage revision in cases of chronic PJI. The bone ingrowth and stability could be observed within the short follow-up time. LEVEL OF EVIDENCE Level IV, prospective cohort study.
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Affiliation(s)
- Xing Liu
- Department of Orthopaedic Surgery, Orthopaedic Center, The First Hospital of Jilin University, Changchun, Jilin, China
| | - Yuhang Gao
- Department of Orthopaedic Surgery, Orthopaedic Center, The First Hospital of Jilin University, Changchun, Jilin, China
| | - Yi Leng
- Department of Orthopaedic Surgery, Orthopaedic Center, The First Hospital of Jilin University, Changchun, Jilin, China
| | - Jiarui Zhou
- Department of Orthopaedic Surgery, Orthopaedic Center, The First Hospital of Jilin University, Changchun, Jilin, China
| | - Xin Qi
- Department of Orthopaedic Surgery, Orthopaedic Center, The First Hospital of Jilin University, Changchun, Jilin, China
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Ji B, Yang C, Li G, Zhang X, Xu B, Mu W, Li Y, Cao L. One-Stage Revision Using Cementless Reconstruction for Chronically Infected Total Hip Arthroplasty: An Average of 11 Years of Follow-Up. J Arthroplasty 2025:S0883-5403(25)00374-2. [PMID: 40273957 DOI: 10.1016/j.arth.2025.04.038] [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: 11/24/2024] [Revised: 04/12/2025] [Accepted: 04/13/2025] [Indexed: 04/26/2025] Open
Abstract
BACKGROUND Although interest in one-stage revision has increased in recent years, long-term follow-up reports remain notably scarce. This study aimed to present the 11-year outcomes of cementless one-stage revision for chronically infected total hip arthroplasty (THA), including infection-free survivorship, radiographic and clinical outcomes, and complications. METHODS A retrospective analysis conducted between 2010 and 2016 included 126 patients who had chronically infected THA and underwent one-stage revision using cementless reconstruction. Kaplan-Meier survival analysis was used to assess postoperative survival, while Cox regression analysis identified risk factors for reinfection. Updated postoperative imaging, Harris Hip Scores, and complications were recorded. Successful infection treatment was defined as the absence of clinical symptoms of infection during follow-up. RESULTS During a mean follow-up period of 11 years (range, eight to 14), 16 patients experienced infection recurrence, resulting in a 10-year infection-free survival rate of 85.4%. Cox regression analysis identified age ≥ 65 years (HR [hazard ratio] 3.0, 95% CI [confidence interval] 1.2 to 8.6; P = 0.02) and American Society of Anesthesiologists grade III (HR 3.1, 95% CI 1.1 to 8.1; P = 0.03) as significant risk factors for reinfection. The presence of a sinus tract, prolonged operative time, culture-negative periprosthetic joint infection, methicillin-resistant pathogen infection, and prior surgery for infection were not associated with recurrence. Among the patients, two experienced recurrent dislocations and one had aseptic loosening, leading to a 10-year aseptic rerevision-free survival rate of 97.0%. The mean postoperative Harris Hip Scores at the latest follow-up was 77.9 points (range, 68.5 to 86.7; P < 0.001). Complications occurred in 26 patients (23.4%), and the 10-year reoperation-free survival rate was 78.7%. CONCLUSIONS A one-stage revision using cementless reconstruction for infected THA demonstrated a favorable infection control rate and sustained satisfactory clinical outcomes. However, further studies with higher-level evidence are needed to validate these findings.
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Affiliation(s)
- Baochao Ji
- Department of Orthopaedics, First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang, China
| | - Chenchen Yang
- Department of Orthopaedics, First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang, China
| | - Guoqing Li
- Department of Orthopaedics, First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang, China
| | - Xiaogang Zhang
- Department of Orthopaedics, First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang, China
| | - Boyong Xu
- Department of Orthopaedics, First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang, China
| | - Wenbo Mu
- Department of Orthopaedics, First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang, China
| | - Yicheng Li
- Department of Orthopaedics, First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang, China
| | - Li Cao
- Department of Orthopaedics, First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang, China; Key Laboratory of High Incidence Disease Research in Xingjiang (Xinjiang Medical University), Ministry of Education, Urumqi, Xinjiang, China; Department of Orthopaedics, Xinjiang Clinical Research Center for Orthopedics, Urumqi, Xinjiang, China
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Tarabichi S, Verhey JT, Lizcano JD, Abe EA, Cancio-Bello A, Tummala SV, Deckey DG, Jennings JM, Parvizi J, Courtney PM, Spangehl MJ, Bingham JS. Diagnostic Thresholds of Synovial Markers for Acute Periprosthetic Joint Infection: One Size Does Not Fit All. J Arthroplasty 2025:S0883-5403(25)00192-5. [PMID: 40023460 DOI: 10.1016/j.arth.2025.02.064] [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: 10/07/2024] [Revised: 02/19/2025] [Accepted: 02/20/2025] [Indexed: 03/04/2025] Open
Abstract
BACKGROUND The diagnosis of periprosthetic joint infection (PJI), particularly during the early postoperative period, remains challenging. The purpose of this multicenter study was to assess the utility of synovial white blood cell (WBC) count and polymorphonuclear leukocyte percentage (PMN%) in the diagnosis of acute PJI at different time intervals after primary total joint arthroplasty (TJA). METHODS This retrospective study identified 225 patients who underwent a joint aspiration within 90 days of their primary TJA at three institutions. A PJI was defined as revision TJA for infection within 7 days of joint aspiration with two positive cultures isolating the same organism. Patients were considered aseptic if they had no reoperation for up to 1 year after arthrocentesis. Receiver operator characteristic curves were used to assess the utility of WBC count and PMN% in the diagnosis of acute PJI at zero to 15, 15 to 45, and 45 to 90 days. Youden's index was used to identify the optimal cutoffs at each time interval. A pairwise comparison was performed to compare the area under the curve (AUC) of the two markers. There were 214 patients included. Of these, 81 (37.9%) were infected and 133 (62.1%) were aseptic. RESULTS The optimal cutoff at zero to 15 days was 21,003 cells/μL for WBC count (AUC 0.937, sensitivity 88.0%, specificity 100%) and 92.0% for PMN% (AUC 0.638, sensitivity 56.0%, specificity 68.4%). Although the diagnostic threshold for WBC count decreased to 5,111 cells/μL at 15 to 45 days and to 2,503 cells/μL at 45 to 90 days, the cutoffs for PMN% did not downtrend in the same fashion (80% at 15 to 45 days; 86% at 45 to 90 days). Using pairwise comparison, the AUC for WBC count was higher than that of PMN% at 0 to 15 days (P = 0.002); however, there was no difference in AUCs at either 15 to 45 days (P = 0.438) or 45 to 90 days (P = 0.826). CONCLUSIONS Based on our findings, it appears that there may be a role for diagnostic thresholds for the identification of acute PJI that are specific to the timing of joint aspiration after primary TJA.
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Affiliation(s)
- Saad Tarabichi
- Department of Orthopaedic Surgery, Mayo Clinic Arizona, Phoenix, Arizona
| | - Jens T Verhey
- Department of Orthopaedic Surgery, Mayo Clinic Arizona, Phoenix, Arizona
| | - Juan D Lizcano
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Elizabeth A Abe
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | | | - Sailesh V Tummala
- Department of Orthopaedic Surgery, Mayo Clinic Arizona, Phoenix, Arizona
| | - David G Deckey
- Department of Orthopaedic Surgery, Mayo Clinic Arizona, Phoenix, Arizona
| | | | - Javad Parvizi
- International Joint Center, Acibadem University Hospital, Istanbul, Turkey
| | - P Maxwell Courtney
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Mark J Spangehl
- Department of Orthopaedic Surgery, Mayo Clinic Arizona, Phoenix, Arizona
| | - Joshua S Bingham
- Department of Orthopaedic Surgery, Mayo Clinic Arizona, Phoenix, Arizona
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Presti ML, Vasco C, Neri MP, Solito L, Pellicanò D, Minerba M, Goracci G, Zaffagnini S. Leukocyte scintigraphy has high specificity but low sensitivity in diagnosing persistent periprosthetic joint infection before reimplantation in two-stage revision. Arch Orthop Trauma Surg 2025; 145:141. [PMID: 39849093 DOI: 10.1007/s00402-024-05657-z] [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: 04/30/2024] [Accepted: 10/21/2024] [Indexed: 01/25/2025]
Abstract
INTRODUCTION Two-stage revision is considered the gold standard treatment in chronic periprosthetic joint infection (PJI) but no specific criteria or examination exist to determine infection eradication before reimplantation. This study aimed to assess the diagnostic performance of leukocyte scintigraphy after the first-stage procedure in two-stage revision for chronic PJI. MATERIAL AND METHODS Patients studied with leukocyte scintigraphy after cement spacer insertion for knee PJI from January 2012 to December 2021 were retrospectively included. Infection was diagnosed using the criteria of the 2018 International Consensus Meeting. When 1 or more minor criteria were positive but the score was < 6, patients were considered not infected if there was no recurrence of infection at least 24 months after the second-stage procedure. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy were found. RESULTS The final cohort included 67 cases in 61 patients (M: F = 32:35; mean age 74 years). There were 43 true negatives, 8 true positives, 12 false negatives, and 4 false positives. The sensitivity and specificity of leukocyte scintigraphy in diagnosing PJI were respectively 40.0% and 91.5%, PPV was 66.7%, NPV was 78.2%, and accuracy was 76.1%. Staphylococcus Epidermidis was the most frequently isolated microorganism (50%). CONCLUSION Due to the high costs and the difficulty in its execution, LLS should not be used routinely but it could represent an additional criterion in doubtful cases. In any case, a thorough evaluation of other pre- and intra-operative tests is essential to determine whether reimplantation or spacer renewal is the best course of action. Special consideration should be given to positive LLS, as its results are highly specific and have a low rate of false positives. Conversely, in over half of infected patients, LLS could give false negatives, making negative LLS results less relevant.
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Affiliation(s)
- Mirco Lo Presti
- IIa Clinica Ortopedica e Traumatologica, IRCCS Istituto Ortopedico Rizzoli, Via Pupilli 1/10, 40136, Bologna, Italy
| | - Cosimo Vasco
- Ospedale Santa Maria della Scaletta, Via Montericco 4, 40026, Imola, Italy.
| | - Maria Pia Neri
- IIa Clinica Ortopedica e Traumatologica, IRCCS Istituto Ortopedico Rizzoli, Via Pupilli 1/10, 40136, Bologna, Italy
| | - Ludovica Solito
- IIa Clinica Ortopedica e Traumatologica, IRCCS Istituto Ortopedico Rizzoli, Via Pupilli 1/10, 40136, Bologna, Italy
| | - Davide Pellicanò
- IIa Clinica Ortopedica e Traumatologica, IRCCS Istituto Ortopedico Rizzoli, Via Pupilli 1/10, 40136, Bologna, Italy
| | - Marco Minerba
- IIa Clinica Ortopedica e Traumatologica, IRCCS Istituto Ortopedico Rizzoli, Via Pupilli 1/10, 40136, Bologna, Italy
| | - Gabrio Goracci
- IIa Clinica Ortopedica e Traumatologica, IRCCS Istituto Ortopedico Rizzoli, Via Pupilli 1/10, 40136, Bologna, Italy
| | - Stefano Zaffagnini
- IIa Clinica Ortopedica e Traumatologica, IRCCS Istituto Ortopedico Rizzoli, Via Pupilli 1/10, 40136, Bologna, Italy
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Tischler EH, Lizcano JD, Shohat N, Tarabichi M, Restrepo C, Parvizi J. The Association of Glycemic Control Medication Regimens and Preoperative Fructosamine Among Total Joint Artrhoplasty Patients. J Am Acad Orthop Surg 2024:00124635-990000000-01127. [PMID: 39467277 DOI: 10.5435/jaaos-d-23-01189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Accepted: 09/04/2024] [Indexed: 10/30/2024] Open
Abstract
BACKGROUND Although glycated hemoglobin A1C (HbA1c) has classically been used for glycemic control screening before surgery, fructosamine, a short-term glucose variability indicator, has been reported to be a more accurate predictor of postoperative periprosthetic joint infection among patients with diabetes mellitus (DM). Given the variability of diabetic medication management, this study aims to identify the associated effect of glycemic control medication regimen (GCMR) on the incidence rate and associated odds of abnormal preoperative fructosamine levels among diabetic primary total knee arthroplasty or total hip arthroplasty patients. METHODS Between 2017 and 2018, consecutive series of total hip arthroplasty and total knee arthroplasty patients were identified, and the final cohort included only diabetic patients. All patients reported preoperative HbA1c and fructosamine levels. GCMR categories included insulin, metformin, and other. Independent risk of GCMR and abnormal fructosamine levels (>293 µmol/L) were identified using multivariable logistic regression, while controlling for preoperative baseline factors including HbA1C. RESULTS Among 420 patients, 15.7% (66/420) were diabetic, of whom 22.7% (15/66) reported an abnormal fructosamine level. Among patients requiring GCMR, 24.0% (18/75), 56.0% (42/75), and 77.7% (58/75) reported using insulin, other, and metformin, respectively. Multivariable logistic regressions demonstrated that insulin-dependent patients with DM reported a 1.71 (95% confidence interval [CI], 0.096 to 30.213, P = 0.716) increased odds of abnormal fructosamine levels compared with nonactive GCMR patients, whereas patients managed with metformin and other glycemic control medications reported a protective 0.48 (95% CI, 0.418 to 5.407, P = 0.549) and 0.32 (95% CI, 0.216 to 4.508, P = 0.393) decreased odds of abnormal fructosamine levels, respectively. CONCLUSION In this study, insulin and other GCMR medications exhibited a trend for increased and decreased odds of having abnormal preoperative fructosamine levels while controlling for baseline HbA1c level compared with patients with DM without active GCMR. This association may be explained by multifactorial short-term glucose variability in insulin users, indicating the continued need and optimization of short-term glycemic variations instead of HbA1c.
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Affiliation(s)
- Eric H Tischler
- Rothman Orthopaedic Institute, Thomas Jefferson University Hospital, Philadelphia, PA (Tischler, Lizcano, Shohat, Tarabichi, and Restrepo), and International Joint Center, Acibadem University Hospital, Istanbul, Turkey (Parvizi)
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Suliman J, Warda H, Samaan M. Review of recent advances in the diagnosis and management of periprosthetic joint infection after total knee arthroplasty part 2: single-stage or two-stage surgical technique? J Orthop Surg Res 2024; 19:643. [PMID: 39395987 PMCID: PMC11470652 DOI: 10.1186/s13018-024-05152-6] [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: 06/17/2024] [Accepted: 10/05/2024] [Indexed: 10/14/2024] Open
Abstract
Periprosthetic joint infection (PJI) after total knee arthroplasty is a complication that affects approximately 2-3% of patients. The management of this issue is complicated and expensive for both the patients and the healthcare system. Multiple management options are available including antibiotic suppressive therapy, surgical management, and salvage procedures. Surgical management is considered a popular option for treating PJI, with multiple available surgical techniques, including single-stage revision arthroplasty and two-stage revision arthroplasty among others. Two-stage revision has been considered the gold standard for treating PJI. This method consists of two surgical procedures with a time interval in between, the first procedure aims to eradicate the infection along with implanting either a static or a mobile spacer, while the second intervention aims to remove the spacer and implant a new prothesis. During the interval period the patient is closely monitored through a handful of laboratory tests and clinical signs that help in assessing the optimal time of undertaking the second stage. However, in recent years, the single-stage method has gained much attention for its comparable outcomes and fewer complications. Contrary to the two-stage method, the single-stage approach consists only of one procedure in which the old infected prosthesis is removed and a new one is implanted. Many articles have compared the two methods over the years but have not agreed on a particular approach to be more potent in eliminating infection and providing better outcomes. Plenty of questions are yet to be answered regarding the two methods, including the superior type of spacer, interim period duration, and single-stage revision inclusion criteria. We herein, aim to address these issues, highlighting recent advances in managing this morbid complication and discussing controversial topics in the staged procedures.
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Affiliation(s)
- Jameel Suliman
- Faculty of Medicine, Tishreen University, Latakia, Syria.
| | - Hamza Warda
- Faculty of Medicine, Al-Baath University, Homs, Syria
| | - Michel Samaan
- Professor of orthopedic surgery at the Faculty of Medicine, Al-Baath University, Homs, Syria
- President of the Syrian association of arthroscopy, Homs, Syria
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Li F, Zhou H, Yang Y, Yang J, Wang H, Hu N. Diagnostic and Predictive Efficacy of Synovial Fluid Versus Serum C-Reactive Protein Levels for Periprosthetic Joint Infection and Reimplantation Success. J Arthroplasty 2024; 39:1932-1938. [PMID: 38670172 DOI: 10.1016/j.arth.2024.04.054] [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: 01/05/2024] [Revised: 04/16/2024] [Accepted: 04/18/2024] [Indexed: 04/28/2024] Open
Abstract
BACKGROUND A 2-stage exchange revision for periprosthetic joint infection (PJI) is associated with major risks for reinfection. Although serum markers are frequently used for diagnosis, their effectiveness remains debatable. Synovial fluid markers may offer a more accurate diagnosis of PJI; however, the importance of these biomarkers, notably synovial fluid C-reactive protein (syCRP), remains controversial, particularly in the context of reimplantation. The present study aimed to clarify these diagnostic uncertainties by evaluating the diagnostic efficacy of syCRP versus serum CRP (seCRP) levels in the context of PJI and recurring or persisting infections before reimplantation. METHODS A total of 186 patients were enrolled and divided into 2 groups: aseptic revision (n = 112) and PJI revision (n = 74). Of the PJI group, 65 were categorized as success and 9 as failure, based on the presence of recurrent or persistent infection before reimplantation. The syCRP and seCRP levels and their changes were assessed preoperatively and in the first-stage and second-stage revisions. Additionally, receiver operating characteristic (ROC) curves and area under the ROC curves (AUCs) were analyzed. RESULTS Both seCRP and syCRP levels were significantly elevated in the PJI group compared with the aseptic group (P < .001). The ROC curve analysis highlighted the enhanced diagnostic accuracy of syCRP for PJI, with an AUC of 0.93 versus 0.80 for seCRP. Furthermore, syCRP proved to be more reliable in predicting reimplantation success, exhibiting an AUC of 0.86 versus 0.63 for seCRP. In evaluating trends in CRP levels to determine reimplantation timing, changes in syCRP levels demonstrated superior diagnostic utility, exhibiting an AUC of 0.79 versus 0.63 for changes in seCRP levels. CONCLUSIONS In assessing PJI and infections before reimplantation, syCRP may offer enhanced accuracy compared with seCRP. Nevertheless, variations in both syCRP and seCRP levels did not consistently predict the outcome of reimplantation.
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Affiliation(s)
- Feilong Li
- Department of Orthopaedics, The Affiliated Dazu Hospital of Chongqing Medical University, Chongqing, China; Department of Orthopaedics, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Haotian Zhou
- Department of Orthopaedics, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Yaji Yang
- Department of Orthopaedics, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Jianye Yang
- Department of Orthopaedics, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Hai Wang
- Department of Orthopaedics, Chongqing University Fuling Hospital, Chongqing, China
| | - Ning Hu
- Department of Orthopaedics, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
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Altsitzioglou P, Avgerinos K, Karampikas V, Gavriil P, Vlachos A, Soucacou F, Zafiris I, Kontogeorgakos V, Papagelopoulos PJ, Mavrogenis AF. Point of care testing for the diagnosis of periprosthetic joint infections: a review. SICOT J 2024; 10:24. [PMID: 38847648 PMCID: PMC11160401 DOI: 10.1051/sicotj/2024019] [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: 04/27/2024] [Accepted: 05/04/2024] [Indexed: 06/09/2024] Open
Abstract
BACKGROUND Periprosthetic joint infection (PJI) remains a major complication following total joint arthroplasties (TJA), significantly affecting patient outcomes and healthcare costs. Despite advances in diagnostic techniques, challenges persist in accurately diagnosing PJI, underscoring the need for effective point-of-care testing (POCT). METHODS This review examines the current literature and latest developments in POCT for diagnosing PJI, focusing on biomarkers such as alpha-defensin, leukocyte esterase, calprotectin, and C-reactive protein (CRP). Criteria from various societies like the Musculoskeletal Infection Society, Infectious Diseases Society of America, and the International Consensus Meeting were compared to evaluate the effectiveness of these biomarkers in a point-of-care setting. RESULTS POCT provides rapid results essential for the timely management of PJI, with alpha-defensin and leukocyte esterase showing high specificity and sensitivity. Recent advancements have introduced novel biomarkers like calprotectin, which demonstrate high diagnostic accuracy. However, challenges such as the variability in test performance and the need for validation under different clinical scenarios remain. DISCUSSION While POCT for PJI shows promising results, their integration into clinical practice requires standardized protocols and further validation. The evolution of these diagnostic tools offers a potential shift toward more personalized and immediate care, potentially improving outcomes for patients undergoing TJA.
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Affiliation(s)
- Pavlos Altsitzioglou
- From the First Department of Orthopaedics, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Konstantinos Avgerinos
- From the First Department of Orthopaedics, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Vasileios Karampikas
- From the First Department of Orthopaedics, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Panayiotis Gavriil
- From the First Department of Orthopaedics, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Apostolos Vlachos
- From the First Department of Orthopaedics, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Fotini Soucacou
- From the First Department of Orthopaedics, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Ioannis Zafiris
- From the First Department of Orthopaedics, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Vasileios Kontogeorgakos
- From the First Department of Orthopaedics, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Panayiotis J Papagelopoulos
- From the First Department of Orthopaedics, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Andreas F Mavrogenis
- From the First Department of Orthopaedics, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
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Ascione T, Balato G, Pagliano P. Upcoming evidence in clinical practice of two-stage revision arthroplasty for prosthetic joint infection. J Orthop Traumatol 2024; 25:26. [PMID: 38761247 PMCID: PMC11102413 DOI: 10.1186/s10195-024-00767-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2024] [Accepted: 04/23/2024] [Indexed: 05/20/2024] Open
Abstract
Total joint arthroplasty is the recommended treatment for patients with end-stage osteoarthritis, as it reduces disability and pain and restores joint function. However, prosthetic joint infection is a serious complication of this procedure, with the two-stage exchange being the most common treatment method. While there is consensus on diagnosing prosthetic joint infection, there is a lack of agreement on the parameters that can guide the surgeon in performing definitive reimplantation in a two-stage procedure. One approach that has been suggested to improve the accuracy of microbiologic investigations before definitive reimplantation is to observe a holiday period from antibiotic therapy to improve the accuracy of cultures from periprosthetic tissues, but these cultures report some degree of aspecificity. Therefore, several pieces of evidence highlight that performing reimplantation using continuous antibiotic therapy should be considered a safe and effective approach, leading to higher cure rates and a shorter period of disability. Dosage of C-reactive protein (CRP), erythrocyte sedimentation rate (ERS) and D-dimer are helpful in diagnosing prosthetic joint infection, but only D-dimer has shown sufficient accuracy in predicting the risk of infection recurrence after a two-stage procedure. Synovial fluid analysis before reimplantation has been shown to be the most accurate in predicting recurrence, and new cutoff values for leukocyte count and neutrophil percentage have shown a useful predictive rule to identify patients at risk of unfavourable outcome. A new scoring system based on a numerical score calculated from the beta coefficient derived through multivariate analysis of D-dimer levels, synovial fluid leukocytes and relative neutrophils percentage has demonstrated high accuracy when it comes to guiding the second step of two-stage procedure. In conclusion, reimplantation may be a suitable option for patients who are on continuous therapy without local symptoms, and with CRP and ERS within the normal range, with low synovial fluid leukocytes (< 952/mL) and a low relative neutrophil percentage (< 52%) and D-dimer below 1100 µg/mL. A numerical score derived from analysing these three parameters can serve as a valuable tool in determining the feasibility of reimplantation in these patients.
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Affiliation(s)
- Tiziana Ascione
- Service of Infectious Diseases, Cardarelli Hospital, Via A. Cardarelli 9, 80131, Naples, Italy.
| | - Giovanni Balato
- Department of Public Health, Orthopedic Unit, "Federico II" University, Naples, Italy
| | - Pasquale Pagliano
- Unit of Infectious Diseases, Department of Medicine, Surgery and Dentistry, "Scuola Medica Salernitana", University of Salerno, Baronissi, Italy
- Clinica Malattie Infettive, AOU San Giovanni di Dio e Ruggi d'Aragona, Salerno, Italy
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11
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Sax FH, Hoyka M, Blersch BP, Fink B. Diagnostics in Late Periprosthetic Infections-Challenges and Solutions. Antibiotics (Basel) 2024; 13:351. [PMID: 38667027 PMCID: PMC11047502 DOI: 10.3390/antibiotics13040351] [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: 01/31/2024] [Revised: 04/02/2024] [Accepted: 04/02/2024] [Indexed: 04/29/2024] Open
Abstract
The rising number of arthroplasties is combined with a rising number of periprosthetic joint infections, which leads to life-concerning consequences for the patients, including extended antibiotic treatment, further surgery and increased mortality. The heterogeneity of the symptoms and inflammatory response of the patients due to, e.g., age and comorbidities and the absence of a single diagnostic test with 100% accuracy make it very challenging to choose the right parameters to confirm or deny a periprosthetic joint infection and to establish a standardized definition. In recent years, additional diagnostic possibilities have emerged primarily through the increasing availability of new diagnostic methods, such as genetic techniques. The aim of the review is to provide an overview of the current state of knowledge about the various tests, including the latest developments. The combination of different tests increases the accuracy of the diagnosis. Each physician or clinical department must select the tests from the available methods that can be best implemented for them in organizational and technical terms. Serological parameters and the cultivation of the samples from aspiration or biopsy should be combined with additional synovial tests to create an accurate figure for the failure of the prosthesis, while imaging procedures are used to obtain additional information for the planned therapeutic procedure.
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Affiliation(s)
- Florian Hubert Sax
- Department of Joint Replacement, General and Rheumatic Orthopaedics, Orthopaedic Clinic Markgröningen gGmbH, Kurt-Lindemann-Weg 10, 71706 Markgröningen, Germany; (F.H.S.); (M.H.); (B.P.B.)
| | - Marius Hoyka
- Department of Joint Replacement, General and Rheumatic Orthopaedics, Orthopaedic Clinic Markgröningen gGmbH, Kurt-Lindemann-Weg 10, 71706 Markgröningen, Germany; (F.H.S.); (M.H.); (B.P.B.)
| | - Benedikt Paul Blersch
- Department of Joint Replacement, General and Rheumatic Orthopaedics, Orthopaedic Clinic Markgröningen gGmbH, Kurt-Lindemann-Weg 10, 71706 Markgröningen, Germany; (F.H.S.); (M.H.); (B.P.B.)
| | - Bernd Fink
- Department of Joint Replacement, General and Rheumatic Orthopaedics, Orthopaedic Clinic Markgröningen gGmbH, Kurt-Lindemann-Weg 10, 71706 Markgröningen, Germany; (F.H.S.); (M.H.); (B.P.B.)
- Orthopaedic Department, University Hospital Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany
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12
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Straub J, Staats K, Vertesich K, Kowalscheck L, Windhager R, Böhler C. Two-stage revision for periprosthetic joint infection after hip and knee arthroplasty. Bone Joint J 2024; 106-B:372-379. [PMID: 38555938 DOI: 10.1302/0301-620x.1064.bjj-2023-0638.r2] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/02/2024]
Abstract
Aims Histology is widely used for diagnosis of persistent infection during reimplantation in two-stage revision hip and knee arthroplasty, although data on its utility remain scarce. Therefore, this study aims to assess the predictive value of permanent sections at reimplantation in relation to reinfection risk, and to compare results of permanent and frozen sections. Methods We retrospectively collected data from 226 patients (90 hips, 136 knees) with periprosthetic joint infection who underwent two-stage revision between August 2011 and September 2021, with a minimum follow-up of one year. Histology was assessed via the SLIM classification. First, we analyzed whether patients with positive permanent sections at reimplantation had higher reinfection rates than patients with negative histology. Further, we compared permanent and frozen section results, and assessed the influence of anatomical regions (knee versus hip), low- versus high-grade infections, as well as first revision versus multiple prior revisions on the histological result at reimplantation. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), chi-squared tests, and Kaplan-Meier estimates were calculated. Results Overall, the reinfection rate was 18%. A total of 14 out of 82 patients (17%) with positive permanent sections at reimplantation experienced reinfection, compared to 26 of 144 patients (18%) with negative results (p = 0.996). Neither permanent sections nor fresh frozen sections were significantly associated with reinfection, with a sensitivity of 0.35, specificity of 0.63, PPV of 0.17, NPV of 0.81, and accuracy of 58%. Histology was not significantly associated with reinfection or survival time for any of the analyzed sub-groups. Permanent and frozen section results were in agreement for 91% of cases. Conclusion Permanent and fresh frozen sections at reimplantation in two-stage revision do not serve as a reliable predictor for reinfection.
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Affiliation(s)
- Jennifer Straub
- Department of Orthopaedics and Trauma Surgery, Medical University of Vienna, Vienna, Austria
| | - Kevin Staats
- Department of Orthopaedics and Trauma Surgery, Medical University of Vienna, Vienna, Austria
| | - Klemens Vertesich
- Department of Orthopaedics and Trauma Surgery, Medical University of Vienna, Vienna, Austria
| | - Lars Kowalscheck
- Department of Pathology, Medical University of Vienna, Vienna, Austria
| | - Reinhard Windhager
- Department of Orthopaedics and Trauma Surgery, Medical University of Vienna, Vienna, Austria
| | - Christoph Böhler
- Department of Orthopaedics and Trauma Surgery, Medical University of Vienna, Vienna, Austria
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13
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Mitterer JA, Frank BJH, Sebastian S, Guger M, Schoefberger L, Hofstaetter JG. The Value of Preoperative Ultrasound-Determined Fluid Film and Joint Aspiration in Revision Hip Arthroplasty. J Arthroplasty 2024; 39:1069-1074. [PMID: 37866461 DOI: 10.1016/j.arth.2023.10.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Revised: 10/12/2023] [Accepted: 10/14/2023] [Indexed: 10/24/2023] Open
Abstract
BACKGROUND Data regarding the diagnostic value of ultrasound (US)-determined fluid film and joint aspiration prior to revision total hip arthroplasty for suspected periprosthetic joint infections (PJIs) are limited. This study aimed to analyze the value of US-determined fluid film, characterized the preoperative and intraoperative microbiological spectrum and resistance patterns, and compared the concordance between preoperative synovial fluid and intraoperative culture results. METHODS We analyzed 366 US examinations from 324 patients prior to revision total hip arthroplasty. Selected cases were grouped into clearly infected, noninfected, and inconclusive cohorts, according to the International Consensus Meeting 2018 Criteria. For US-determined fluid film <1 mm, no aspiration was performed based on our institutional protocol. Patients were grouped into no aspiration (144 of 366; [39.3%]), dry tap (21 of 366; [5.7%]), and a successful tap (201 of 366; [54.9%]). The microbiological spectrum and antibiograms were compared between preoperative and intraoperative results. RESULTS The absence of US-determined fluid film showed no correlation with the presence of a hip PJI. Overall, 31.9% cases of the no-aspiration group had a PJI. In total, 13.5% discrepancies were found between successful taps and intraoperative cultures. The most prevalent microorganisms in preoperative synovial fluid were Staphylococcus epidermidis and Staphylococcus aureus (20.8%), while intraoperatively S. epidermidis (26.3%) and Cutibacterium acnes (14.5%) were leading. Additional microorganisms were identified in 32.5% of intraoperative cultures. There were no differences between resistance patterns of preoperative and intraoperative concordant microorganisms. CONCLUSIONS Absence of US-determined fluid film cannot rule out the presence of a hip PJI. Combined microbiological results from hip US aspirations and subsequent surgical procedures are crucial to design an effective treatment for suspected hip PJI.
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Affiliation(s)
- Jennyfer A Mitterer
- Michael Ogon Laboratory for Orthopaedic Research, Orthopaedic Hospital Speising, Vienna, Austria
| | - Bernhard J H Frank
- Michael Ogon Laboratory for Orthopaedic Research, Orthopaedic Hospital Speising, Vienna, Austria; 2nd Department, Orthopaedic Hospital Speising, Vienna, Austria
| | - Sujeesh Sebastian
- Michael Ogon Laboratory for Orthopaedic Research, Orthopaedic Hospital Speising, Vienna, Austria
| | - Matthias Guger
- Institute for Radiology, Orthopaedic Hospital Speising, Vienna, Austria
| | - Lukas Schoefberger
- Michael Ogon Laboratory for Orthopaedic Research, Orthopaedic Hospital Speising, Vienna, Austria
| | - Jochen G Hofstaetter
- Michael Ogon Laboratory for Orthopaedic Research, Orthopaedic Hospital Speising, Vienna, Austria; 2nd Department, Orthopaedic Hospital Speising, Vienna, Austria
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14
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Kayani B, Bengoa F, Howard LC, Neufeld ME, Masri BA. Articulating Spacers in Total Hip Arthroplasty: Surgical Technique and Outcomes. Orthop Clin North Am 2024; 55:181-192. [PMID: 38403365 DOI: 10.1016/j.ocl.2023.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/27/2024]
Abstract
Although one-stage exchange arthroplasty is gaining popularity, two-stage exchange arthroplasty remains the gold standard for the treatment of periprosthetic joint infections. Use of an articulating spacer for this procedure offers an avenue for maintaining hip motion and controlled weight-bearing, allowing local antibiotic elution. However, there is no uniform consensus on the optimal surgical protocol for using articulating spacers. This review describes the surgical technique for undertaking a first-stage exchange arthroplasty using an articulating spacer and discusses the pertinent literature on key concepts relating to periprosthetic joint infections in total hip arthroplasty to guide effective surgical decision making in these patients.
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Affiliation(s)
- Babar Kayani
- Division of Lower Limb Reconstruction & Oncology, Vancouver General Hospital, Vancouver, British Columbia V5Z 1M9, Canada; Department of Orthopaedics, University of British Columbia, Vancouver, British Columbia V6T 1Z4, Canada.
| | - Francisco Bengoa
- Division of Lower Limb Reconstruction & Oncology, Vancouver General Hospital, Vancouver, British Columbia V5Z 1M9, Canada; Department of Orthopaedics, University of British Columbia, Vancouver, British Columbia V6T 1Z4, Canada
| | - Lisa C Howard
- Division of Lower Limb Reconstruction & Oncology, Vancouver General Hospital, Vancouver, British Columbia V5Z 1M9, Canada; Department of Orthopaedics, University of British Columbia, Vancouver, British Columbia V6T 1Z4, Canada
| | - Michael E Neufeld
- Division of Lower Limb Reconstruction & Oncology, Vancouver General Hospital, Vancouver, British Columbia V5Z 1M9, Canada; Department of Orthopaedics, University of British Columbia, Vancouver, British Columbia V6T 1Z4, Canada
| | - Bassam A Masri
- Division of Lower Limb Reconstruction & Oncology, Vancouver General Hospital, Vancouver, British Columbia V5Z 1M9, Canada; Department of Orthopaedics, University of British Columbia, Vancouver, British Columbia V6T 1Z4, Canada
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15
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Tarabichi S, Goh GS, Fernández-Rodríguez D, Baker CM, Lizcano JD, Parvizi J. Plasma D-Dimer Is a Promising Marker to Guide Timing of Reimplantation: A Prospective Cohort Study. J Arthroplasty 2023; 38:2164-2170.e1. [PMID: 37172794 DOI: 10.1016/j.arth.2023.04.065] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 04/25/2023] [Accepted: 04/30/2023] [Indexed: 05/15/2023] Open
Abstract
BACKGROUND Two-stage exchange arthroplasty remains the preferred surgical treatment for chronic periprosthetic joint infection. Currently, there is no single reliable marker to determine the optimal timing for reimplantation. The purpose of this prospective study was to assess the diagnostic utility of plasma D-dimer and other serological markers in predicting successful control of infection following reimplantation. METHODS This study enrolled 136 patients undergoing reimplantation arthroplasty between November 2016 and December 2020. Strict inclusion criteria were applied including the need for a two-week "antibiotic holiday" prior to reimplantation. A total of 114 patients were included in the final analysis. Plasma D-dimer, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), and fibrinogen were measured preoperatively. Treatment success was defined using the Musculoskeletal Infection Society Outcome-Reporting Tool. Receiver operating characteristic curves were used to assess the prognostic accuracy of each biomarker in predicting failure following reimplantation at a minimum 1-year follow-up. RESULTS Treatment failure occurred in 33 patients (28.9%) at a mean follow-up of 3.2 years (range, 1.0 to 5.7). Median plasma D-dimer was significantly higher in the treatment failure group (1,604 versus 631 ng/mL, P < .001), whereas median CRP, ESR, and fibrinogen were not significantly different between the success and failure groups. Plasma D-dimer demonstrated the best diagnostic utility (area under the curve [AUC] 0.724, sensitivity 51.5%, specificity 92.6%), outperforming ESR (AUC 0.565, sensitivity 93.3%, specificity 22.5%), CRP (AUC 0.541, sensitivity 87.5%, specificity 26.3%), and fibrinogen (AUC 0.485, sensitivity 30.4%, specificity 80.0%). Plasma D-dimer level of ≥1,604 ng/mL was identified as the optimal cutoff that predicted failure following reimplantation. CONCLUSION Plasma D-dimer was superior to serum ESR, CRP, and fibrinogen in predicting failure after the second stage of a two-stage exchange arthroplasty for periprosthetic joint infection. Based on the findings of this prospective study, plasma D-dimer may be a promising marker in assessing the control of infection in patients undergoing reimplantation surgery. LEVEL OF EVIDENCE Level II.
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Affiliation(s)
- Saad Tarabichi
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Graham S Goh
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Diana Fernández-Rodríguez
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania; Plan de Estudios Combinados en Medicina (PECEM) MD/PhD, Facultad de Medicina, Universidad Nacional Autónoma de México, Mexico City, Mexico
| | - Colin M Baker
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Juan D Lizcano
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Javad Parvizi
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
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16
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Bosco F, Cacciola G, Giustra F, Risitano S, Capella M, Vezza D, Barberis L, Cavaliere P, Massè A, Sabatini L. Characterizing recurrent infections after one-stage revision for periprosthetic joint infection of the knee: a systematic review of the literature. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2023; 33:2703-2715. [PMID: 36867259 PMCID: PMC10504163 DOI: 10.1007/s00590-023-03480-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/25/2022] [Accepted: 01/18/2023] [Indexed: 03/04/2023]
Abstract
BACKGROUND Periprosthetic joint infection (PJI) of the knee represents a severe complication after 1.5% to 2% of primary total knee replacement. Although two-stage revision was considered the gold-standard treatment for PJI of the knee, in the last decades, more studies reported the outcomes of one-stage revisions. This systematic review aims to assess reinfection rate, infection-free survival after reoperation for recurrent infection, and the microorganisms involved in both primary and recurrent infection. MATERIAL AND METHODS A systematic review of all studies reporting the outcome of one-stage revision for PJI of the knee up to September 2022, according to PRISMA criteria and AMSTAR2 guidelines, was performed. Patient demographics, clinical, surgical, and postoperative data were recorded. PROSPERO ID CRD42022362767. RESULTS Eighteen studies with a total of 881 one-stage revisions for PJI of the knee were analyzed. A reinfection rate of 12.2% after an average follow-up of 57.6 months was reported. The most frequent causative microorganism were gram-positive bacteria (71.1%), gram-negative bacteria (7.1%), and polymicrobial infections (8%). The average postoperative knee society score was 81.5, and the average postoperative knee function score was 74.2. The infection-free survival after treatment for recurrent infection was 92.1%. The causative microorganisms at reinfections differed significantly from the primary infection (gram-positive 44.4%, gram-negative 11.1%). CONCLUSION Patients who underwent a one-stage revision for PJI of the knee showed a reinfection rate lower or comparable to other surgical treatments as two-stage or DAIR (debridement, antibiotics, and implant retention). Reoperation for reinfection demonstrates a lower success compared to one-stage revision. Moreover, microbiology differs between primary infection and recurrent infection. Level of evidence Level IV.
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Affiliation(s)
- Francesco Bosco
- Centro Traumatologico Ortopedico (CTO), Department of Orthopaedic Surgery, University of Turin, Via Gianfranco Zuretti, 29, 10126, Turin, Italy
- Department of Orthopaedics and Traumatology, Ospedale San Giovanni Bosco - ASL Città di Torino, Piazza del Donatore di Sangue, 3, 10154, Turin, Italy
| | - Giorgio Cacciola
- Centro Traumatologico Ortopedico (CTO), Department of Orthopaedic Surgery, University of Turin, Via Gianfranco Zuretti, 29, 10126, Turin, Italy
| | - Fortunato Giustra
- Centro Traumatologico Ortopedico (CTO), Department of Orthopaedic Surgery, University of Turin, Via Gianfranco Zuretti, 29, 10126, Turin, Italy.
- Department of Orthopaedics and Traumatology, Ospedale San Giovanni Bosco - ASL Città di Torino, Piazza del Donatore di Sangue, 3, 10154, Turin, Italy.
| | - Salvatore Risitano
- Centro Traumatologico Ortopedico (CTO), Department of Orthopaedic Surgery, University of Turin, Via Gianfranco Zuretti, 29, 10126, Turin, Italy
| | - Marcello Capella
- Centro Traumatologico Ortopedico (CTO), Department of Orthopaedic Surgery, University of Turin, Via Gianfranco Zuretti, 29, 10126, Turin, Italy
| | - Daniele Vezza
- Centro Traumatologico Ortopedico (CTO), Department of Orthopaedic Surgery, University of Turin, Via Gianfranco Zuretti, 29, 10126, Turin, Italy
| | - Luca Barberis
- Centro Traumatologico Ortopedico (CTO), Department of Orthopaedic Surgery, University of Turin, Via Gianfranco Zuretti, 29, 10126, Turin, Italy
| | - Pietro Cavaliere
- Istituto Ortopedico del Mezzogiorno d'Italia "Franco Scalabrino", 98100, Messina, Via Consolare Pompea, Italy
| | - Alessandro Massè
- Centro Traumatologico Ortopedico (CTO), Department of Orthopaedic Surgery, University of Turin, Via Gianfranco Zuretti, 29, 10126, Turin, Italy
| | - Luigi Sabatini
- Centro Traumatologico Ortopedico (CTO), Department of Orthopaedic Surgery, University of Turin, Via Gianfranco Zuretti, 29, 10126, Turin, Italy
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17
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Baek YJ, Lee YJ, Lee JA, Kim JH, Kwon HM, Yeom JS, Park KK, Jeong SJ. Role of α-Defensin and the Microbiome in Prosthetic Joint Infection: A Prospective Cohort Study in Korea. J Clin Med 2023; 12:5964. [PMID: 37762905 PMCID: PMC10532201 DOI: 10.3390/jcm12185964] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Revised: 09/04/2023] [Accepted: 09/12/2023] [Indexed: 09/29/2023] Open
Abstract
The utility of α-defensin (AD), leukocyte esterase (LE) levels, and metagenomics sequencing as diagnostic tools for prosthetic joint infection (PJI) has been suggested, but there are few studies among the Asian population. This study aimed to evaluate the diagnostic performance of various biomarkers for PJI and the role of the microbiome in the synovial fluid of patients with prostheses. Patients with suspected knee PJI were enrolled, and their blood and synovial fluid were collected. The cases were classified into the PJI and non-PJI groups. Significant differences between the two groups were observed in the levels of AD (4698 µg/L vs. 296 µg/L, p < 0.001) and positivity for LE (62.5% vs. 21.1%, p = 0.01). AD had 94.4% sensitivity and 89.5% specificity for diagnosing PJI, whereas LE had 37.5% sensitivity and 100% specificity. Microbiome taxonomic profiling showed high sensitivity. The number of operational taxonomic units and the richness of the microbiome in the synovial fluid were higher in the non-PJI than in the PJI group. AD has shown encouraging results in the Asian population as a diagnostic biomarker for PJI, and LE can be used as a diagnostic adjunct. The bacterial richness of the synovial fluid is likely associated with infections.
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Affiliation(s)
- Yae Jee Baek
- Division of Infectious Diseases, Department of Internal Medicine, Soonchunhyang University Seoul Hospital, Soonchunhyang University College of Medicine, Seoul 04401, Republic of Korea;
| | - Youn-Jung Lee
- Division of Infectious Diseases, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul 03722, Republic of Korea
| | - Jung Ah Lee
- Division of Infectious Diseases, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul 03722, Republic of Korea
| | - Jung Ho Kim
- Division of Infectious Diseases, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul 03722, Republic of Korea
| | - Hyuck Min Kwon
- Department of Orthopedic Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul 03722, Republic of Korea
| | - Joon-Sup Yeom
- Division of Infectious Diseases, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul 03722, Republic of Korea
| | - Kwan Kyu Park
- Department of Orthopedic Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul 03722, Republic of Korea
| | - Su Jin Jeong
- Department of Orthopedic Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul 03722, Republic of Korea
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18
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Quinlan ND, Jennings JM. Joint aspiration for diagnosis of chronic periprosthetic joint infection: when, how, and what tests? ARTHROPLASTY 2023; 5:43. [PMID: 37658416 PMCID: PMC10474645 DOI: 10.1186/s42836-023-00199-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Accepted: 06/14/2023] [Indexed: 09/03/2023] Open
Abstract
Diagnosing chronic periprosthetic joint infection (PJI) requires clinical suspicion in combination with both serological and synovial fluid tests, the results of which are generally applied to validated scoring systems or consensus definitions for PJI. As no single "gold standard" test exists, the diagnosis becomes challenging, especially in the setting of negative cultures or equivocal test results. This review aims to address the workup of chronic PJI and considerations for clinical evaluation to guide treatment. Following aspiration of the joint in question, a multitude of tests has been developed in an attempt to assist with diagnosis, including cell synovial white blood cell count, gram stain, cultures, leukocyte esterase, alpha-defensin, synovial C-reactive protein, multiplex polymerase chain reaction, next-generation sequencing, and interleukins. Each test has advantages and disadvantages and should be used in conjunction with the overall clinical picture to guide further clinical evaluation and treatment in this complex patient population.
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Affiliation(s)
- Nicole Durig Quinlan
- Colorado Joint Replacement, 2535 S. Downing Street, Ste 100, Denver, CO, 80210, USA
| | - Jason M Jennings
- Colorado Joint Replacement, 2535 S. Downing Street, Ste 100, Denver, CO, 80210, USA.
- Department of Mechanical and Materials Engineering, University of Denver, 2155 E. Wesley Ave, Denver, CO, 80210, USA.
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19
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Sousa R, Carvalho A, Soares D, Abreu MA. Interval between two-stage exchanges: what is optimal and how do you know? ARTHROPLASTY 2023; 5:33. [PMID: 37403130 PMCID: PMC10320898 DOI: 10.1186/s42836-023-00185-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Accepted: 04/04/2023] [Indexed: 07/06/2023] Open
Abstract
BACKGROUND Two-stage exchange arthroplasty remains the most popular option for the treatment of chronic periprosthetic joint infection (PJI). Determining infection eradication and optimal timing of reimplantation can be challenging. Information to allow for a truly informed evidence-based decision is scarce. METHODS We conducted a critical review of available evidence on the presently available tests to help determine timing of reimplantation. RESULTS Serology is traditionally used to follow up patients after the first stage. Despite tradition mandates waiting for normal inflammatory markers, there is actually no evidence that they correlate with persistent infection. The role of synovial fluid investigation between stages is also explored. Cultures lack sensitivity and neither differential leukocyte counts nor alternative biomarkers have proven to be accurate in identifying persistent infection with a spacer in situ. We also examined the evidence regarding the optimal time interval between resection and reimplantation and whether there is evidence to support the implementation of a two week "antibiotic holiday" prior to proceeding with reimplantation. Finally, wound healing and other important factors in this setting will be discussed. CONCLUSION Currently there are no accurate metrics to aid in the decision on the optimal timing for reimplantation. Decision must therefore rely on the resolution of clinical signs and down trending serological and synovial markers.
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Affiliation(s)
- Ricardo Sousa
- Department of Orthopedics, Centro Hospitalar Universitário de Santo António, 4099-001, Porto, Portugal.
- Porto Bone and Joint Infection Group (GRIP), Centro Hospitalar Universitário de Santo António and CUF Hospitais E Clínicas, 4099-001, Porto, Portugal.
| | - André Carvalho
- Department of Orthopedics, Centro Hospitalar Universitário de Santo António, 4099-001, Porto, Portugal
- Porto Bone and Joint Infection Group (GRIP), Centro Hospitalar Universitário de Santo António and CUF Hospitais E Clínicas, 4099-001, Porto, Portugal
| | - Daniel Soares
- Department of Orthopedics, Centro Hospitalar Universitário de Santo António, 4099-001, Porto, Portugal
- Porto Bone and Joint Infection Group (GRIP), Centro Hospitalar Universitário de Santo António and CUF Hospitais E Clínicas, 4099-001, Porto, Portugal
| | - Miguel Araújo Abreu
- Porto Bone and Joint Infection Group (GRIP), Centro Hospitalar Universitário de Santo António and CUF Hospitais E Clínicas, 4099-001, Porto, Portugal
- Department of Infectious Diseases, Centro Hospitalar Universitário de Santo António, 4099-001, Porto, Portugal
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20
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Li H, Li R, Erlong N, Chai W, Hao L, Xu C, Fu J, Chen J, Zhu F. It can be unnecessary to combine common synovial fluid analysis and alpha-defensin tests for periprosthetic joint infection diagnosis. BMC Musculoskelet Disord 2023; 24:529. [PMID: 37386394 PMCID: PMC10308702 DOI: 10.1186/s12891-023-06594-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Accepted: 06/01/2023] [Indexed: 07/01/2023] Open
Abstract
BACKGROUND Periprosthetic joint infection is a serious complication after total joint arthroplasty. Despite that alpha-defensin was used as diagnostic test in the 2018 ICM (international consensus meeting) criteria, its position in the PJI diagnostic pipeline was controversial. Therefore, we performed a retrospective pilot study to identify whether synovial fluid alpha-defensin test was necessary when corresponding synovial fluid analysis (WBC count, PMN% and LE tests) was performed. METHODS Between May 2015 and October 2018, a total of 90 suspected PJI patients who underwent revisions after TJA were included in this study. Based on the 2018 ICM criteria, the interobserver agreements between preoperative diagnostic results and postoperative diagnostic results and the interobserver reliability between preoperative diagnostic results and postoperative diagnostic results with or without synovial fluid alpha-defensin tests were calculated. After that, the ROC analysis, and the direct cost-effectiveness of adding alpha-defensin was performed. RESULTS There were 48,16 and 26 patients in the PJI group, inconclusive group and non-PJI group, respectively. Adding the alpha-defensin tests into 2018 ICM criteria can't change the preoperative diagnostic results, postoperative diagnostic results, and the concordance between preoperative and postoperative diagnostic results. Moreover, the Risk-benefit Ratio is over 90 per changed decision and the direct cost-effectiveness of alpha-defensin was more than $8370($93*90) per case. CONCLUSIONS Alpha-defensin assay exhibit high sensitivity and specificity for PJI detection as a standalone test based on the 2018 ICM criteria. However, the additional order of Alpha-defensin can't offer additional evidence for PJI diagnosis when corresponding synovial fluid analysis was performed (synovial fluid WBC count, PMN% and LE strip tests). EVIDENCE LEVEL Level II, Diagnostic study.
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Affiliation(s)
- Hao Li
- Medical School of Chinese PLA, Beijing, People’s Republic of China
- Department of Orthopedic Surgery, The First Medical Center, Chinese PLA General Hospital, 28 Fuxing Road, Beijing, People’s Republic of China
- Senior Department of Orthopedics, Fourth Medical Center of PLA General Hospital, Beijing, People’s Republic of China
| | - Rui Li
- Department of Orthopedic Surgery, The First Medical Center, Chinese PLA General Hospital, 28 Fuxing Road, Beijing, People’s Republic of China
- Senior Department of Orthopedics, Fourth Medical Center of PLA General Hospital, Beijing, People’s Republic of China
| | - Niu Erlong
- Department of Orthopedics, 305 Hospital of PLA, Beijing, People’s Republic of China
| | - Wei Chai
- Department of Orthopedic Surgery, The First Medical Center, Chinese PLA General Hospital, 28 Fuxing Road, Beijing, People’s Republic of China
- Senior Department of Orthopedics, Fourth Medical Center of PLA General Hospital, Beijing, People’s Republic of China
| | - LiBo Hao
- Department of Orthopedic Surgery, The First Medical Center, Chinese PLA General Hospital, 28 Fuxing Road, Beijing, People’s Republic of China
- Senior Department of Orthopedics, Fourth Medical Center of PLA General Hospital, Beijing, People’s Republic of China
| | - Chi Xu
- Department of Orthopedic Surgery, The First Medical Center, Chinese PLA General Hospital, 28 Fuxing Road, Beijing, People’s Republic of China
- Senior Department of Orthopedics, Fourth Medical Center of PLA General Hospital, Beijing, People’s Republic of China
| | - Jun Fu
- Department of Orthopedic Surgery, The First Medical Center, Chinese PLA General Hospital, 28 Fuxing Road, Beijing, People’s Republic of China
- Senior Department of Orthopedics, Fourth Medical Center of PLA General Hospital, Beijing, People’s Republic of China
| | - Jiying Chen
- Department of Orthopedic Surgery, The First Medical Center, Chinese PLA General Hospital, 28 Fuxing Road, Beijing, People’s Republic of China
- Senior Department of Orthopedics, Fourth Medical Center of PLA General Hospital, Beijing, People’s Republic of China
| | - Fangzheng Zhu
- Medical School of Chinese PLA, Beijing, People’s Republic of China
- Department of Orthopedic Surgery, The First Medical Center, Chinese PLA General Hospital, 28 Fuxing Road, Beijing, People’s Republic of China
- Department of Orthopaedics, PLA Rocket Force Characteristics Medical Center, Beijing, 100088 China
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21
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Hanusrichter Y, Frieler S, Gessmann J, Schulte M, Krejczy M, Schildhauer T, Baecker H. Does the Implementation of the PRO-IMPLANT Foundation Treatment Algorithm Improve the Outcome of Chronic Periprosthetic Knee Infections? Mid-Term Results of a Prospective Study. ZEITSCHRIFT FUR ORTHOPADIE UND UNFALLCHIRURGIE 2023; 161:260-270. [PMID: 34753193 DOI: 10.1055/a-1562-2874] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND Several treatment options for chronic periprosthetic joint infections have been published in the current literature, with an on-going discussion to determine effective management algorithms. OBJECTIVES To compare outcomes of the two-stage exchange procedure in revision TKA prior to and after implementation of the PRO-IMPLANT Foundation treatment algorithm. The primary endpoints were defined as (i) revisions during the interval time, (ii) duration of the interval time and (iii) successful PJI eradication. MATERIAL AND METHODS Between 02/2013 and 09/2016, 122 patients were included in a single-centre cohort analysis. 55 patients were treated according to the previously used algorithm (K1) and 67 according to the PRO-IMPLANT Foundation algorithm (K2). A minimum follow-up period of 3 years was set as the inclusion criterion. Successful eradication of infection was defined in accordance with the consensus criteria by Diaz-Ledezma et al. RESULTS: Successful eradication was achieved in 42 (67%) patients in K1 and 47 (85.5%) in K2 (p ≤ 0.005). The mean interval time was 88 days (range 51 - 353) in K1 and 52 days (range 42 - 126) in K2 (p ≤ 0.005). In K1, a mean of 0.8 (range 0 - 6) revisions were necessary during the interval period compared with 0.5 (range 0 - 4) in K2 (p = 0.066). CONCLUSION Implementation of the PRO-IMPLANT treatment algorithm led to significant improvement in the outcome of periprosthetic joint infections. During mid-term follow-up, infection eradication was highly successful, with decreases in the interval time as well as the number of revisions.
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Affiliation(s)
- Yannik Hanusrichter
- Department of General and Trauma Surgery, BG University Hospital Bergmannsheil, Ruhr-University Bochum, Bochum, Germany
| | - Sven Frieler
- Department of General and Trauma Surgery, BG University Hospital Bergmannsheil, Ruhr-University Bochum, Bochum, Germany
- Swedish Neuroscience Institute, Swedish Medical Center, Seattle, Washington, United States
- Seattle Science Foundation, Seattle Science Foundation, Seattle, Washington, United States
- Hansjörg Wyss Hip and Pelvic Center, Swedish Hospital, Seattle, Washington, United States
| | - Jan Gessmann
- Department of General and Trauma Surgery, BG University Hospital Bergmannsheil, Ruhr-University Bochum, Bochum, Germany
| | - Martin Schulte
- Department of General and Trauma Surgery, BG University Hospital Bergmannsheil, Ruhr-University Bochum, Bochum, Germany
| | - Martin Krejczy
- Department of General and Trauma Surgery, BG University Hospital Bergmannsheil, Ruhr-University Bochum, Bochum, Germany
| | - Thomas Schildhauer
- Department of General and Trauma Surgery, BG University Hospital Bergmannsheil, Ruhr-University Bochum, Bochum, Germany
| | - Hinnerk Baecker
- Department of General and Trauma Surgery, BG University Hospital Bergmannsheil, Ruhr-University Bochum, Bochum, Germany
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22
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Fraval A, Wang J, Tarabichi S, Parvizi J. Optimal timing for reimplantation in the setting of two stage revision for prosthetic joint infection. Rev Esp Cir Ortop Traumatol (Engl Ed) 2023; 67:246-252. [PMID: 36787833 DOI: 10.1016/j.recot.2023.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 02/10/2023] [Indexed: 02/14/2023] Open
Affiliation(s)
- A Fraval
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA, United States.
| | - J Wang
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA, United States
| | - S Tarabichi
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA, United States
| | - J Parvizi
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA, United States
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23
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Fraval A, Wang J, Tarabichi S, Parvizi J. Optimal timing for reimplantation in the setting of two stage revision for prosthetic joint infection. Rev Esp Cir Ortop Traumatol (Engl Ed) 2023; 67:T246-T252. [PMID: 36940848 DOI: 10.1016/j.recot.2023.02.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 02/10/2023] [Indexed: 03/22/2023] Open
Affiliation(s)
- A Fraval
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pensilvania, Estados Unidos.
| | - J Wang
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pensilvania, Estados Unidos
| | - S Tarabichi
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pensilvania, Estados Unidos
| | - J Parvizi
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pensilvania, Estados Unidos
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24
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Tarabichi S, Chen AF, Higuera CA, Parvizi J, Polkowski GG. 2022 American Association of Hip and Knee Surgeons Symposium: Periprosthetic Joint Infection. J Arthroplasty 2023:S0883-5403(23)00065-7. [PMID: 36738863 DOI: 10.1016/j.arth.2023.01.045] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 01/23/2023] [Accepted: 01/24/2023] [Indexed: 02/06/2023] Open
Abstract
Periprosthetic joint infection (PJI) is the leading cause of failure in patients undergoing total joint arthroplasty. This article is a brief summary of a symposium on PJI that was presented at the annual AAHKS meeting. It will provide an overview of current technqiues in the prevention, diagnosis, and management of PJI. It will also highlight emerging technologies in this setting.
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Affiliation(s)
- Saad Tarabichi
- Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Antonia F Chen
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Carlos A Higuera
- Levitetz Department of Orthopaedic Surgery, Cleveland Clinic Florida, Weston, Florida
| | - Javad Parvizi
- Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Gregory G Polkowski
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
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25
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Frank BJH, Simon S, Aichmair A, Dominkus M, Hofstaetter JG. Clinical impact of microbiological results in two-stage revision arthroplasty with spacer exchange. Arch Orthop Trauma Surg 2023:10.1007/s00402-023-04770-9. [PMID: 36689002 DOI: 10.1007/s00402-023-04770-9] [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: 01/13/2022] [Accepted: 01/07/2023] [Indexed: 01/24/2023]
Abstract
INTRODUCTION Patients who require a spacer exchange as part of a two-stage procedure for the treatment of periprosthetic hip and knee joint infections (PJI) have high failure rates. Little is known about the clinical impact of microbiological results and changes in the microbiological spectrum and resistance pattern in these patients. MATERIAL AND METHODS Between 01/2011 and 12/2019, 312 patients underwent a total of 327 two-stage revision arthroplasties at our institution. A spacer exchange was required in 52/312 (16.7%) patients (27 knee/25 hip). Microbiological results, antibiotic resistance patterns, patient's host factors as well as re-revision and re-infection rates at a median follow-up of 47.8 months (range 12.2-116.7 months) were analyzed. A propensity score (PS)-matched analysis of patients who underwent spacer exchange and patients treated with standard two-stage procedure was performed. RESULTS We found a high number of microbiological spectrum changes in patients with multiple culture positive procedures between explantations and spacer exchanges (10/12 [83.3%]), spacer exchanges and reimplantations (3/4 [75%]) as well as between reimplantations and subsequent re-revision surgeries (5/6 [83.3%]). In 9/52 (17.3%) patients, same microorganisms were detected repeatedly in two different procedures. We observed changes in the antibiotic resistance patterns in 6/9 (66.7%) of these patients. High re-infection rates were found in patients with culture positive reimplantations (10/12 [83.3%]), and low re-infection rates were found in patients with culture negative reimplantations (2/40 [5%]; p < 0.001). Between patients with and without spacer exchange, no differences were found in the re-revision rates (13/52 [25%] with vs. 13/52 [25%] without; p = 1.00) as well as re-infection rates (12/52 [23.1%] with vs. 8/52 [15.4%] without; p = 0.32). CONCLUSIONS Changes in microbiological spectrum and antibiotic resistance patterns between stages are common in patients who require a spacer exchange. If eradication of the microorganism at reimplantation can be accomplished, comparable re-revision rates to standard two-stage procedures can be achieved.
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Affiliation(s)
- Bernhard J H Frank
- Michael Ogon Laboratory for Orthopaedic Research, Orthopaedic Hospital Vienna-Speising, Speisinger Strasse 109, 1130, Vienna, Austria.,2nd Department, Orthopaedic Hospital Vienna-Speising, Speisinger Strasse 109, 1130, Vienna, Austria
| | - Sebastian Simon
- Michael Ogon Laboratory for Orthopaedic Research, Orthopaedic Hospital Vienna-Speising, Speisinger Strasse 109, 1130, Vienna, Austria.,2nd Department, Orthopaedic Hospital Vienna-Speising, Speisinger Strasse 109, 1130, Vienna, Austria
| | - Alexander Aichmair
- Michael Ogon Laboratory for Orthopaedic Research, Orthopaedic Hospital Vienna-Speising, Speisinger Strasse 109, 1130, Vienna, Austria.,2nd Department, Orthopaedic Hospital Vienna-Speising, Speisinger Strasse 109, 1130, Vienna, Austria
| | - Martin Dominkus
- 2nd Department, Orthopaedic Hospital Vienna-Speising, Speisinger Strasse 109, 1130, Vienna, Austria.,School of Medicine, Sigmund Freud University Vienna, Freudplatz 1, 1020, Vienna, Austria
| | - Jochen G Hofstaetter
- Michael Ogon Laboratory for Orthopaedic Research, Orthopaedic Hospital Vienna-Speising, Speisinger Strasse 109, 1130, Vienna, Austria. .,2nd Department, Orthopaedic Hospital Vienna-Speising, Speisinger Strasse 109, 1130, Vienna, Austria.
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26
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Liu D, Xiao WF, Li YS. The Diagnostic and Prognostic Value of Synovial Fluid Analysis in Joint Diseases. Methods Mol Biol 2023; 2695:295-308. [PMID: 37450127 DOI: 10.1007/978-1-0716-3346-5_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/18/2023]
Abstract
Liquid biopsy is an emergent test method for the diagnosis and prognosis in the clinic. Joint fluid, also known as synovial fluid, contains a variety of bioactive constituents that can be selectively detected and further evaluated in a convenient fashion. Therefore, synovial fluid analysis functions as a specific form of liquid biopsy and plays a vital role in numerous joint diseases. In spite of the component analysis of aspirated synovial fluid beingconsidered as the gold standard for diagnosis of joint infections, biopsy of joint fluid benefits the initial diagnosis and long-term prognosis of degenerative, inflammatory, autoimmune, traumatic, congenital, and even neoplastic joint diseases. The convenience and accuracy for disease evaluation are significantly elevated as a result of the combination of synovial fluid analysis and other novel clinical technologies. In this review, we shed light on the latent role of synovial fluid in the diagnosis and prognosis of articular diseases and proposed future prospects for relevant research in this field.
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Affiliation(s)
- Di Liu
- Department of Orthopaedics, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Wen-Feng Xiao
- Department of Orthopaedics, Xiangya Hospital, Central South University, Changsha, Hunan, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Yu-Sheng Li
- Department of Orthopaedics, Xiangya Hospital, Central South University, Changsha, Hunan, China.
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, Hunan, China.
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27
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Huguet S, Bernaus M, Gómez L, Cuchí E, Soriano A, Font-Vizcarra L. Role of joint aspiration before re-implantation in patients with a cement spacer in place. World J Orthop 2022; 13:615-621. [PMID: 35949711 PMCID: PMC9244963 DOI: 10.5312/wjo.v13.i6.615] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Revised: 02/04/2022] [Accepted: 05/14/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND The usefulness of a mandatory joint aspiration before re-implantation in patients with a cement spacer already in place is unclear.
AIM To evaluate the role of culturing synovial fluid obtained by joint aspiration before re-implantation in patients who underwent a two-stage septic revision.
METHODS A retrospective observational study was conducted, including patients that underwent a two-stage septic revision (hip or knee) from 2010 to 2017. After the first stage revision and according to intraoperative culture results, all patients were treated with an antibiotic protocol for 6-8 wk. Following 2 wk without antibiotics, a culture of synovial fluid was obtained. The results of these cultures were recorded and compared with cultures obtained during re-implantation surgery.
RESULTS Forty-one patients (20 hip and 21 knee spacers) were included in the final analysis. In 39 cases, the culture of synovial fluid was negative, while in the remaining 2 cases (knee spacers) no analysis was possible due to dry tap. In 5 of the patients, two or more intraoperative cultures taken during the re-implantation surgery were positive.
CONCLUSION We found no evidence to support mandatory joint aspiration before re-implantation in patients with a cement spacer in place.
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Affiliation(s)
- Sandra Huguet
- Department of Traumatology and Orthopaedics, Hospital Universitari Mútua Terrassa, Terrassa 08221, Spain
- Department of Traumatology and Orthopaedics, Consorci Sanitari de l’Alt Penedès - Garraf, Vilafranca del Penedès 08720, Spain
| | - Martí Bernaus
- Department of Traumatology and Orthopaedics, Osteoarticular Infections Unit, Hospital Universitari Mútua Terrassa, Terrassa 08221, Spain
| | - Lucía Gómez
- Osteoarticular Infections Unit, Hospital Universitari Mútua Terrassa, Terrassa 08221, Spain
| | - Eva Cuchí
- Osteoarticular Infections Unit, Hospital Universitari Mútua Terrassa, Terrassa 08221, Spain
- Department of Microbiology, CATLAB, Viladecavalls 08232, Spain
| | - Alex Soriano
- Department of Infectious Diseases, Osteoarticular Infections Unit, Hospital Clínic, Barcelona 08036, Spain
| | - Lluís Font-Vizcarra
- Department of Traumatology and Orthopaedics, Osteoarticular Infections Unit, Hospital Universitari Mútua Terrassa, Terrassa 08221, Spain
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28
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Barretto JM, Campos ALS, Ooka NHM. Periprosthetic Knee Infection - Part 2: Treatment. Rev Bras Ortop 2022; 57:193-199. [PMID: 35652024 PMCID: PMC9142269 DOI: 10.1055/s-0041-1729936] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Accepted: 12/17/2020] [Indexed: 11/29/2022] Open
Abstract
Several treatment modalities are proposed for periprosthetic infections, with variable success rates. However, efficacy is related to the appropriate selection of cases for each type of treatment. Debridement with implant retention is indicated in acute infections with fixed implant, and its success depends on the type of infection, comorbidities of the host, and virulence of the etiological agent. One- or two-stage revision is required in cases in which biofilm is forming, or of implant loosening. The choice between performing the review in one or two stages depends on factors such as etiological agent identification, pathogen virulence, local and systemic host factors. Rescue procedures such as arthrodesis, amputation, resection arthroplasty or even antibiotic suppression are reserved for cases in which the infection has not been eradicated.
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Affiliation(s)
- João Maurício Barretto
- Coordenador de Ortopedia da Clínica São Vicente da Gávea, Rede D'or São Luiz, Rio de Janeiro, RJ, Brasil
| | - André Luiz Siqueira Campos
- Departamento de Ortopedia e Traumatologia, Hospital Federal dos Servidores do Estado, Rio de Janeiro, RJ, Brasil
| | - Nelson Hiroyuki Miyabe Ooka
- Departamento de Ortopedia e Traumatologia, Hospital Universitário Pedro Ernesto, Rio de Janeiro, RJ, Brasil
- Departamento de Ortopedia e Traumatologia, Hospital Universitário Clementino Fraga Filho, Rio de Janeiro, RJ, Brasil
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29
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Nishino T, Oshima T, Teramura S, Taniguchi Y, Kanamori A, Mishima H, Yamazaki M. Development of a Self-made Cement Bead Maker and Its Clinical Application for the Treatment of Periprosthetic Joint Infection. Arthroplast Today 2022; 13:188-193. [PMID: 35118182 PMCID: PMC8792394 DOI: 10.1016/j.artd.2021.10.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Revised: 10/16/2021] [Accepted: 10/31/2021] [Indexed: 11/29/2022] Open
Abstract
Antibiotic-loaded acrylic cement beads have a large surface area and excellent sustained-release properties. However, there are some difficulty manufacturing reasonably sized beads and their careful handling. We developed a self-made cement bead maker using a mold of a sphere with a diameter of 8 and 10 mm with a 2-mm-diameter connecting hole. With this instrument, approximately 32 beads can be made from 40 g of bone cement. We clinically applied this technique to 11 cases of periprosthetic joint infection. There was no recurrence of infection noted. The advantages of this device were that it was possible to adjust the combination of antimicrobial agents and that the shape was uniform and easy to handle during surgery.
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Affiliation(s)
- Tomofumi Nishino
- Department of Orthopaedic Surgery, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
- Corresponding author. 1-1-1 Tennodai, Tsukuba, Ibaraki, 305-8575, Japan. Tel.: +81-29-853-3219.
| | | | - Shin Teramura
- Department of Orthopaedic Surgery, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Yu Taniguchi
- Department of Orthopaedic Surgery, Ichihara Hospital, Tsukuba, Ibaraki, Japan
| | - Akihiro Kanamori
- Department of Orthopaedic Surgery, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Hajime Mishima
- Department of Orthopaedic Surgery, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Masashi Yamazaki
- Department of Orthopaedic Surgery, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
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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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31
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Fontalis A, Berry DJ, Shimmin A, Slullitel PA, Buttaro MA, Li C, Malchau H, Haddad FS. Prevention of early complications following total hip replacement. SICOT J 2021; 7:61. [PMID: 34851264 PMCID: PMC8634898 DOI: 10.1051/sicotj/2021060] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Accepted: 10/29/2021] [Indexed: 01/01/2023] Open
Abstract
Total hip arthroplasty (THA) has been quoted as "the operation of the century", owing to its efficacy and the substantial improvements evidenced with respect to functional patient outcomes and quality of life. However, early postoperative complications are often inevitable, hence it is imperative to take every step to prevent them and minimise morbidity and mortality. This manuscript focuses on the most common early complications following THA, namely venous thromboembolism (VTE), prosthetic joint infection, periprosthetic fracture, instability, and leg length inequality. It aims to outline effective risk stratification strategies and prevention measures that could apply to the wider Orthopaedic community.
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Affiliation(s)
- Andreas Fontalis
- Department of Trauma and Orthopaedic Surgery, University College London Hospitals, London NW1 2BU, UK - University College London, Division of Surgery and Interventional Science, Gower Street, London, WC1E 6BT, UK
| | | | - Andrew Shimmin
- Melbourne Orthopaedic Group, Windsor, Victoria 3181, Australia - Monash University, Windsor, Ontario N9B 3P4, Australia
| | - Pablo A Slullitel
- Institute of Orthopaedics "Carlos E. Ottolenghi", Italian Hospital of Buenos Aires, Buenos Aires, Argentina
| | - Martin A Buttaro
- Institute of Orthopaedics "Carlos E. Ottolenghi", Italian Hospital of Buenos Aires, Buenos Aires, Argentina
| | - Cao Li
- Department of Orthopaedics, First Affiliated Hospital of Xinjiang Medical University, 137 South LiYuShan Road, Urumqi, Xinjiang 830054, China
| | - Henrik Malchau
- Harvard Medical School, Harvard University, Boston, MA 02115, USA
| | - Fares S Haddad
- Department of Trauma and Orthopaedic Surgery, University College London Hospitals, London NW1 2BU, UK - University College London, Division of Surgery and Interventional Science, Gower Street, London, WC1E 6BT, UK
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32
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Li ZY, Lin YC, Chang CH, Chen SY, Lu TW, Lee SH. Trend of serum C-reactive protein is associated with treatment outcome of hip Periprosthetic joint infection undergoing two-stage exchange arthroplasty: a case control study. BMC Musculoskelet Disord 2021; 22:1007. [PMID: 34856956 PMCID: PMC8641244 DOI: 10.1186/s12891-021-04893-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Accepted: 11/17/2021] [Indexed: 01/09/2023] Open
Abstract
Background Serum C-reactive protein (CRP) trends are critical for monitoring patients’ treatment response following a two-stage exchange arthroplasty for periprosthetic joint infection (PJI) of the hip. However, CRP trends are poorly described in the literature. The primary aim of this study was to identify the relationships between PJI treatment outcomes and our proposed CRP trend definitions, parameters, and microbiological data. The secondary aim was to investigate CRP trends after the occurrence of spacer-related complications. Methods We conducted a retrospective review of 74 patients treated with a two-stage exchange protocol for PJI in a tertiary referral joint center between 2014 and 2016. Patients with factors that may affect CRP levels (inflammatory arthritis, concomitant infections, liver and kidney diseases, and intensive care admissions) were excluded. CRP trends were categorized into five types and PJI treatment outcome was defined as “success” or “failure” according to the Delphi criteria. Results Treatment was successful in 67 patients and failed in 7 patients. Multivariate logistic regression analysis showed that type 5 CRP, defined as serum CRP fluctuation without normalization after first stage surgery (odds ratio [OR]: 17.4; 95% confidence interval [CI]: 2.3–129.7; p = 0.005), and methicillin-resistant Staphylococcus aureus (MRSA; OR: 14.5; 95% CI: 1.6–131.7; p = 0.018) were associated with treatment failure. Spacer-related complications occurred in 18 patients. Of these, 12 had elevated CRP levels at later follow-up, while six had no elevation in CRP levels. Conclusions We found that MRSA infection and type 5 CRP were associated with PJI treatment failure.
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Affiliation(s)
- Zhong-Yan Li
- Department of Biomedical Engineering, National Taiwan University, No. 1, Sec. 4, Roosevelt Rd., Taipei, 10617, Taiwan, Republic of China
| | - Yu-Chih Lin
- Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, Linkou, No.5, Fuxing St., Guishan Dist., Taoyuan, 33305, Taiwan, Republic of China.,Bone and Joint Research Center, Chang Gung Memorial Hospital, Linkou, No.5, Fuxing St., Guishan Dist., Taoyuan, 33305, Taiwan, Republic of China
| | - Chih-Hsiang Chang
- Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, Linkou, No.5, Fuxing St., Guishan Dist., Taoyuan, 33305, Taiwan, Republic of China.,Bone and Joint Research Center, Chang Gung Memorial Hospital, Linkou, No.5, Fuxing St., Guishan Dist., Taoyuan, 33305, Taiwan, Republic of China
| | - Szu-Yuan Chen
- Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, Linkou, No.5, Fuxing St., Guishan Dist., Taoyuan, 33305, Taiwan, Republic of China.,Bone and Joint Research Center, Chang Gung Memorial Hospital, Linkou, No.5, Fuxing St., Guishan Dist., Taoyuan, 33305, Taiwan, Republic of China
| | - Tung-Wu Lu
- Department of Medicine, Chang Gung University, No.259, Wenhua 1st Rd., Guishan Dist., Taoyuan, 33302, Taiwan, Republic of China
| | - Sheng-Hsun Lee
- Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, Linkou, No.5, Fuxing St., Guishan Dist., Taoyuan, 33305, Taiwan, Republic of China. .,Bone and Joint Research Center, Chang Gung Memorial Hospital, Linkou, No.5, Fuxing St., Guishan Dist., Taoyuan, 33305, Taiwan, Republic of China. .,Department of Medicine, Chang Gung University, No.259, Wenhua 1st Rd., Guishan Dist., Taoyuan, 33302, Taiwan, Republic of China. .,Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, Linkou, No.5, Fuxing St., Guishan Dist., Taoyuan, 333, Taiwan, Republic of China.
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Analysis of Failed Two-Stage Procedures with Resection Arthroplasty as the First Stage in Periprosthetic Hip Joint Infections. J Clin Med 2021; 10:jcm10215180. [PMID: 34768700 PMCID: PMC8584448 DOI: 10.3390/jcm10215180] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Revised: 10/27/2021] [Accepted: 11/02/2021] [Indexed: 01/18/2023] Open
Abstract
Resection arthroplasty can be performed as the first stage of a two-stage procedure in some patients with severe periprosthetic hip joint infections with poor bone stock. This retrospective study aimed to evaluate factors associated with the subsequent failure or success of these patients. Between 2011 and 2020; in 61 (26.4%) of 231 patients who underwent a two-stage protocol of periprosthetic hip joint infections; no spacer was used in the first stage. The minimum follow-up period was 12 months. Patient's demographics and various infection risk factors were analyzed. In total, 37/61 (60.7%) patients underwent a successful reimplantation, and four patients died within the follow-up period. Patients within the failure group had a significantly higher Charlson comorbidity index (p = 0.002); number of operations prior to resection arthroplasty (p = 0.022) and were older (p = 0.018). Failure was also associated with the presence of a positive culture in the first- and second-stage procedures (p = 0.012). Additional risk factors were persistent high postoperative CRP values and the requirement of a negative-pressure wound therapy (p ≤ 0.05). In conclusion, multiple factors need to be evaluated when trying to predict the outcome of patients undergoing resection arthroplasty as the first stage of a two-stage procedure in patients with challenging periprosthetic hip joint infections.
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Delayed Rifampin Administration in the Antibiotic Treatment of Periprosthetic Joint Infections Significantly Reduces the Emergence of Rifampin Resistance. Antibiotics (Basel) 2021; 10:antibiotics10091139. [PMID: 34572721 PMCID: PMC8469909 DOI: 10.3390/antibiotics10091139] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2021] [Revised: 09/18/2021] [Accepted: 09/19/2021] [Indexed: 11/16/2022] Open
Abstract
Rifampin is one of the most important biofilm-active antibiotics in the treatment of periprosthetic joint infection (PJI), and antibiotic regimens not involving rifampin were shown to have higher failure rates. Therefore, an emerging rifampin resistance can have a devastating effect on the outcome of PJI. The aim of this study was to compare the incidence of rifampin resistance between two groups of patients with a PJI treated with antibiotic regimens involving either immediate or delayed additional rifampin administration and to evaluate the effect of this resistance on the outcome. In this retrospective analysis of routinely collected data, all patients who presented with an acute/chronic PJI between 2018 and 2020 were recorded in the context of a single-center comparative cohort study. Two groups were formed: Group 1 included 25 patients with a PJI presenting in 2018-2019. These patients received additional rifampin only after pathogen detection in the intraoperative specimens. Group 2 included 37 patients presenting in 2019-2020. These patients were treated directly postoperatively with an empiric antibiotic therapy including rifampin. In all, 62 patients (32 females) with a mean age of 68 years and 322 operations were included. We found a rifampin-resistant organism in 16% of cases. Rifampin resistance increased significantly from 12% in Group 1 to 19% in Group 2 (p < 0.05). The treatment failure rate was 16% in Group 1 and 16.2% in Group 2 (p = 0.83). The most commonly isolated rifampin-resistant pathogen was Staphylococcus epidermidis (86%) (p < 0.05). The present study shows a significant association between the immediate start of rifampin after surgical revision in the treatment of PJI and the emergence of rifampin resistance, however with no significant effect on outcome.
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35
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Webb ML. CORR Insights®: Synovial Cell Count Before Reimplantation Can Predict the Outcome of Patients with Periprosthetic Knee Infections Undergoing Two-stage Exchange. Clin Orthop Relat Res 2021; 479:2069-2071. [PMID: 34283817 PMCID: PMC8373549 DOI: 10.1097/corr.0000000000001900] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Accepted: 06/24/2021] [Indexed: 01/31/2023]
Affiliation(s)
- Matthew L Webb
- Stanford University, School of Medicine, Department of Orthopaedic Surgery, Redwood City, CA, USA
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36
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The Natural Course of Serum D-Dimer, C-Reactive Protein, and Erythrocyte Sedimentation Rate Levels After Uneventful Primary Total Joint Arthroplasty. J Arthroplasty 2021; 36:3118-3122. [PMID: 34088567 DOI: 10.1016/j.arth.2021.04.031] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Revised: 04/12/2021] [Accepted: 04/25/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND This study aimed to assess the baseline levels of D-dimer, C-reactive protein (CRP), and erythrocyte sedimentation rate (ESR) and monitor the natural course of these serum markers after uneventful primary total joint arthroplasty. METHODS This prospective study enrolled 81 patients undergoing primary total knee arthroplasty or total hip arthroplasty. The level of serum D-dimer, CRP, and ESR was measured preoperatively and on postoperative days 1, 3, 5, 15, and 45. Mean peak values, peak times, and distribution were compared between D-Dimer, CRP, and ESR. RESULTS The mean preoperative serum D-dimer, CRP, and ESR level was 412 ± 260 (range 200-980) ng/mL, 2.93 ± 2.1 (range 1-18) mg/L, and 22.88 ± 17.5 (range 3-102) mm/h, respectively. The highest mean peak for D-dimer, CRP, and ESR was at postoperative day 1, 3, and 5, respectively. CONCLUSION D-dimer levels reached peak levels on postoperative day 1 and then declined rapidly to a plateau level by postoperative day 3. A second, albeit small, peak in the level of D-dimer occurred on postoperative day 15. The level of CRP and ESR remained elevated for much longer with CRP returning to baseline on postoperative day 45 and the level of ESR had not returned back to normal on postoperative day 45.
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Ludwick L, Chisari E, Wang J, Clarkson S, Collins L, Parvizi J. Emergence of Antibiotic Resistance Across Two-Stage Revision for Periprosthetic Joint Infection. J Arthroplasty 2021; 36:2946-2950. [PMID: 33934949 DOI: 10.1016/j.arth.2021.04.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Revised: 03/25/2021] [Accepted: 04/07/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND The current preferred treatment for chronic hip and knee periprosthetic joint infection (PJI) involves both surgical intervention and antibiotic treatment as part of a two-stage revision. The purpose of this study is to determine how often patients who underwent a two-stage revision for chronic PJI developed a subsequent antibiotic-resistant infection. METHODS We retrospectively reviewed the clinical records of 142 patients who underwent a two-stage revision for a chronic culture-positive PJI from January 2014 to May 2019. Demographic data and risk factors for PJI were identified. Resistance was defined in accordance with microbiology laboratory report and minimum inhibitory concentration. Statistical analysis consisted of descriptive statistics and univariate analysis. RESULTS Only 10 of the 142 patients (7.04%) demonstrated emergence of resistance to antibiotics across their two-stage revision. At reimplantation, 25 (17.6%) patients had positive cultures. Of these, 16 patients presented with a novel organism and 9 patients had positive culture for the same organism as the initial infection. During the entire course of the two-stage revision, including spacer exchanges and irrigation and debridement procedures, 15 (10.56%) patients demonstrated persistent infections, whereas 25 (17.6%) patients presented with novel infections. 26 (18.3%) patients had reinfection of the same joint within one year. CONCLUSION In the given cohort, there does not appear to be a major emergence of antibiotic resistant organisms in patients undergoing two-stage exchange arthroplasty and antibiotic treatment.
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Affiliation(s)
- Leanne Ludwick
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA
| | - Emanuele Chisari
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA
| | - Jasmine Wang
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA
| | - Samuel Clarkson
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA
| | - Lacee Collins
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA
| | - Javad Parvizi
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA
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Bielefeld C, Engler H, JÄger M, Wegner A, Wassenaar D, Busch A. Synovial Alpha-defensin at Reimplantation in Two-stage Revision Arthroplasty to Rule Out Persistent Infection. In Vivo 2021; 35:1073-1081. [PMID: 33622904 DOI: 10.21873/invivo.12352] [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: 11/23/2020] [Revised: 12/06/2020] [Accepted: 12/07/2020] [Indexed: 11/10/2022]
Abstract
BACKGROUND/AIM Owing to the lack of a diagnostic gold standard, ruling out persistent periprosthetic joint infection (PJI) before second-stage surgery in the setting of two-stage revision arthroplasty constitutes a major challenge. We evaluated if the alpha-defensin-1 (AD-1) test could predict successful infection eradication before reimplantation of a new prosthesis. PATIENTS AND METHODS Our prospective study included 20 patients who underwent two-stage revision arthroplasty for treatment of PJI. A standard quantitative enzyme AD-1 immunoassay of synovial fluid, the synovial leukocyte esterase test and routine laboratory blood testing were performed prior to explantation and reimplantation. Treatment failure was defined according to the Delphi-based consensus criteria after a minimum follow-up of 1 year. RESULTS A 15% of our patients met the Delphi Criteria within 1 year. None of the markers investigated were significantly different in patients with and without reinfection. CONCLUSION Further research is necessary to identify biomarkers more suitable for indicating persistent infection before reimplantation.
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Affiliation(s)
- Charlotte Bielefeld
- Department of Orthopaedics, Trauma and Reconstructive Surgery, St. Marien Hospital, Mülheim an der Ruhr, Germany.,Department of Orthopaedics and Trauma Surgery, University of Duisburg-Essen, Mülheim an der Ruhr, Germany
| | - Harald Engler
- Institute of Medical Psychology and Behavioral Immunobiology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Marcus JÄger
- Department of Orthopaedics, Trauma and Reconstructive Surgery, St. Marien Hospital, Mülheim an der Ruhr, Germany; .,Department of Orthopaedics and Trauma Surgery, University of Duisburg-Essen, Mülheim an der Ruhr, Germany
| | - Alexander Wegner
- Department of Orthopaedics, Trauma and Reconstructive Surgery, St. Marien Hospital, Mülheim an der Ruhr, Germany.,Department of Orthopaedics and Trauma Surgery, University of Duisburg-Essen, Mülheim an der Ruhr, Germany
| | - Dennis Wassenaar
- Department of Orthopaedics, Trauma and Reconstructive Surgery, St. Marien Hospital, Mülheim an der Ruhr, Germany.,Department of Orthopaedics and Trauma Surgery, University of Duisburg-Essen, Mülheim an der Ruhr, Germany
| | - Andre Busch
- Department of Orthopaedics, Trauma and Reconstructive Surgery, St. Marien Hospital, Mülheim an der Ruhr, Germany.,Department of Orthopaedics and Trauma Surgery, University of Duisburg-Essen, Mülheim an der Ruhr, Germany
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Frank BJH, Aichmair A, Simon S, Schwarz GM, Dominkus M, Hofstaetter JG. Analysis of Culture Positive First and Second Stage Procedures in Periprosthetic Knee and Hip Joint Infections. J Arthroplasty 2021; 36:2158-2164. [PMID: 33608181 DOI: 10.1016/j.arth.2021.01.074] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Revised: 01/24/2021] [Accepted: 01/27/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND A positive microbiological result at reimplantation may lead to a failed 2-stage revision arthroplasty in the treatment of periprosthetic joint infections. Little is known about changes in microbiological spectrum and resistance pattern between culture positive first and second stage procedures in revision knee and hip arthroplasty. METHODS Between January 2011 and December 2019, we performed 327 two-stage revision arthroplasties on 312 patients. There were 37 of 312 (11.9%) patients (20 hips/17 knees) who had a positive microbiological culture during the first and second stage procedure. We analyzed the microbiological spectrum, antimicrobial resistance pattern, and clinical outcome of culture positive first and second stage procedures as well as subsequent re-revisions. RESULTS Re-revision was necessary in 40.5% (15/37) of patients with culture positive first and second stage procedure at a median follow-up of 3.5 years. We found microbiological changes in 83.8% (31/37) of patients between the first and second stage and in 88.9% (8/9) between the second stage and subsequent culture positive re-revision. Polymicrobial infections were found in 21.6% (8/37) of first and in 16.2% (6/37) of second stage procedures. In 27% (10/37) of patients, microorganisms persisted between the first and second stage procedure. The antimicrobial resistance pattern changed in 60% of persistent microorganisms between the first and second stage procedure. CONCLUSION Changes in microbiological spectrum and resistance pattern are common between culture positive first and second stage procedures as well as subsequent re-revisions. This has to be considered in the antimicrobial treatment of periprosthetic joint infections.
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Affiliation(s)
- Bernhard J H Frank
- Michael Ogon Laboratory for Orthopaedic Research, Orthopaedic Hospital Vienna-Speising, Vienna, Austria
| | - Alexander Aichmair
- Michael Ogon Laboratory for Orthopaedic Research, Orthopaedic Hospital Vienna-Speising, Vienna, Austria; 2nd Department, Orthopaedic Hospital Vienna-Speising, Vienna, Austria
| | - Sebastian Simon
- Michael Ogon Laboratory for Orthopaedic Research, Orthopaedic Hospital Vienna-Speising, Vienna, Austria; 2nd Department, Orthopaedic Hospital Vienna-Speising, Vienna, Austria
| | - Gilbert M Schwarz
- Michael Ogon Laboratory for Orthopaedic Research, Orthopaedic Hospital Vienna-Speising, Vienna, Austria; Department of Orthopaedics and Trauma-Surgery, Medical University of Vienna, Vienna, Austria
| | - Martin Dominkus
- 2nd Department, Orthopaedic Hospital Vienna-Speising, Vienna, Austria; School of Medicine, Sigmund Freud University Vienna, Vienna, Austria
| | - Jochen G Hofstaetter
- Michael Ogon Laboratory for Orthopaedic Research, Orthopaedic Hospital Vienna-Speising, Vienna, Austria; 2nd Department, Orthopaedic Hospital Vienna-Speising, Vienna, Austria
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Xiong Z, Cao S, Zhou L, Zhang X, Liu Q, Hu J, Liu F, Li Y. Intraoperative periarticular injection can alleviate the inflammatory response and enhance joint function recovery after hip arthroplasty in elderly patients with osteoporotic femoral neck fractures. Medicine (Baltimore) 2021; 100:e24596. [PMID: 33607792 PMCID: PMC7899865 DOI: 10.1097/md.0000000000024596] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Accepted: 01/13/2021] [Indexed: 01/05/2023] Open
Abstract
PURPOSE This study aimed to investigate the potential beneficial effects of periarticular injection (PAI) of multimodal drugs on the inflammatory response and joint function after hip arthroplasty in elderly patients with osteoporotic femoral neck fractures. METHODS Fifty six elderly patients with unilateral osteoporotic femoral neck fractures were randomly allocated to 2 groups: the PAI group, which received the multimodal drug PAI intraoperatively before incision closure, and the control group, which received an injection of saline at the same time as placebo. The C-reactive protein (CRP), interleukin-1β (IL-1β), and IL-6 levels as well as the erythrocyte sedimentation rate (ESR) in peripheral venous blood samples were measured, along with the Visual Analogue Scale (VAS) score with activity and Harris hip score preoperation at 1, 2, 4, 7, and 14 days as well as 1 and 3 months post-operation. RESULTS The 2 groups were comparable in sex and age, and no significant differences were observed in the preoperative CRP, IL-1β, and IL-6 levels, ESR, VAS score, or Harris hip score between the 2 groups (all P > .05). However, during the postoperative period, the PAI group exhibited significantly lower levels of CRP, IL-1β, and IL-6 as well as a lower ERS and VAS score compared with the control group (P < .05), while the Harris hip score was significantly higher postoperatively in the PAI group (P < .05). CONCLUSION Multimodal drug PAI can alleviate the inflammatory response and enhance hip function recovery after hip arthroplasty in elderly patients with osteoporotic femoral neck fractures.
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Affiliation(s)
- Zhizheng Xiong
- Department of Orthopaedics, Second People's Hospital of Yueyang
- Yueyang Hospital Affiliated to Hunan Normal University, Hunan, PR China
| | - Shuai Cao
- Department of Orthopaedics, Second Affiliated Hospital of Medical College of Xi’an Jiaotong University, Xi’an, Shaanxi, PR China
| | - Lingling Zhou
- Department of Orthopaedics, Second People's Hospital of Yueyang
- Yueyang Hospital Affiliated to Hunan Normal University, Hunan, PR China
| | - Xu Zhang
- Department of Orthopaedics, Second People's Hospital of Yueyang
- Yueyang Hospital Affiliated to Hunan Normal University, Hunan, PR China
| | - Qi Liu
- Department of Orthopaedics, Second People's Hospital of Yueyang
- Yueyang Hospital Affiliated to Hunan Normal University, Hunan, PR China
| | - Jinxi Hu
- Department of Orthopaedics, Second People's Hospital of Yueyang
- Yueyang Hospital Affiliated to Hunan Normal University, Hunan, PR China
| | - Fang Liu
- Department of Orthopaedics, Second People's Hospital of Yueyang
- Yueyang Hospital Affiliated to Hunan Normal University, Hunan, PR China
| | - Yongwei Li
- Department of Orthopaedics, Second Affiliated Hospital of Medical College of Xi’an Jiaotong University, Xi’an, Shaanxi, PR China
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Rossmann M, Minde T, Citak M, Gehrke T, Sandiford NA, Klatte TO, Abdelaziz H. High Rate of Reinfection With New Bacteria Following One-Stage Exchange for Enterococcal Periprosthetic Infection of the Knee: A Single-Center Study. J Arthroplasty 2021; 36:711-716. [PMID: 32863076 DOI: 10.1016/j.arth.2020.08.015] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 08/05/2020] [Accepted: 08/06/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND A wide range of success rates following the surgical management of enterococcal periprosthetic joint infection (PJI) with a tendency toward worse outcomes have been reported. However, the role of 1-stage exchange remains under-investigated. Therefore, we aimed to evaluate our results after the 1-stage knee exchange for enterococcal PJI. METHODS Forty patients were retrospectively included between 2002 and 2017 with a mean follow-up of survivors of 80 months (range 22-172; standard deviation [SD] = 5). Polymicrobial infections occurred in 45% (18/40) of patients. Patients' characteristics, joint-related data, and antibiotic therapy were recorded. Rates of enterococcal infection relapse, reinfection with new microorganisms, and re-revision for any reason were determined. Bivariate analysis was conducted to identify risk factors of infection recurrence. RESULTS Revision surgery was required in 22 cases (55%) with a mean time to revision surgery of 27 months (range 1-78; SD = 25). Indications for aseptic revisions (18%) included aseptic loosening (10%), periprosthetic fracture (5%), and patellar instability (3%). The most common cause of re-revision was a subsequent PJI (15/22; 68%) after a mean time of 22 months (range 1-77; SD = 24). Overall infection recurrence rate was 37.5% (15/40), substantially due to entirely non-enterococcal infections (9/15; 60%). Infection relapse with Enterococci occurred in 4 cases (10%) within 16 months postoperatively. Older patients (P = .05) and male gender (P = .05) were associated with a higher risk of infection recurrence. CONCLUSION Overcoming the Enterococci using the 1-stage exchange for knee PJI is achievable but the rate of reinfection due to new microorganisms is high . However, the overall infection recurrence rate is comparable to other treatment approaches.
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Affiliation(s)
- Markus Rossmann
- Department of Joint Replacement Surgery, Helios ENDO-Klinik Hamburg, Hamburg, Germany
| | - Thore Minde
- Department of Joint Replacement Surgery, Helios ENDO-Klinik Hamburg, Hamburg, Germany
| | - Mustafa Citak
- Department of Joint Replacement Surgery, Helios ENDO-Klinik Hamburg, Hamburg, Germany
| | - Thorsten Gehrke
- Department of Joint Replacement Surgery, Helios ENDO-Klinik Hamburg, Hamburg, Germany
| | | | - Till Orla Klatte
- Department of Trauma, Hand, and Reconstructive Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Hussein Abdelaziz
- Department of Joint Replacement Surgery, Helios ENDO-Klinik Hamburg, Hamburg, Germany
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Frieler S, Hanusrichter Y, Bellova P, Geßmann J, Schildhauer TA, Baecker H. Facing multidrug-resistant pathogens in periprosthetic joint infections with self-administered outpatient parenteral antimicrobial therapy-A prospective cohort study. J Orthop Res 2021; 39:320-332. [PMID: 33174643 DOI: 10.1002/jor.24906] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Accepted: 11/08/2020] [Indexed: 02/04/2023]
Abstract
A key factor in the successful management of periprosthetic joint infection (PJI) besides the surgical regime is a consistent antimicrobial therapy. Recently, oral versus intravenous (IV) antibiotics for bone and joint infection trial demonstrated the noninferiority of oral antimicrobial therapy compared to IV, implying that an early transition to oral administration is reasonable. It is likely that the international consensus meeting of musculoskeletal Infections and the European Bone and Joint Infection Society will consider these findings. However, rising levels of antimicrobial resistance are challenging and recommendations for dealing with multidrug-resistant (MDR) pathogens resistant to oral antibiotics are lacking. This study focuses on establishing guidance towards their management in PJI. From December 2015 to June 2019, patients with MDR pathogens were included in a single-center prospective cohort study and treated with self-administered outpatient parenteral antimicrobial therapy (S-OPAT) based on a two-stage revision strategy. Demographics, pathogens, antimicrobial agents, and outcomes were recorded. A total of 1738 outpatient days in 26 patients were analyzed. The incidence of pathogens resistant to oral antibiotics in PJI was 4%, most frequently encountered were staphylococcus epidermidis. The Kaplan-Meier-estimated infection-free survival after 3 years was 90% (95% confidence interval, 84.6%-95.5%). We recorded adverse events in 6 of 54 (11%) S-OPAT episodes (3.45/1000 S-OPAT days). (i) S-OPAT in two-stage revision arthroplasty to counter increasing numbers of MDR pathogens resistant to oral agents can achieve a high infection eradication rate and (ii) should therefore be taken into account at the next society's consensus treatment updates.
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Affiliation(s)
- Sven Frieler
- Department of Orthopaedics and Trauma Surgery, BG University Hospital Bergmannsheil, Ruhr University Bochum, Bochum, Germany.,Hansjörg Wyss Hip and Pelvic Center, Swedish Hospital, Seattle, Washington, USA.,Swedish Neuroscience Institute, Swedish Medical Center, Seattle, Washington, USA.,Seattle Science Foundation, Seattle, Washington, USA
| | - Yannik Hanusrichter
- Department of Orthopaedics and Trauma Surgery, BG University Hospital Bergmannsheil, Ruhr University Bochum, Bochum, Germany
| | - Petri Bellova
- Department of Orthopaedics and Trauma Surgery, University Hospital Dresden, Dresden, Germany
| | - Jan Geßmann
- Department of Orthopaedics and Trauma Surgery, BG University Hospital Bergmannsheil, Ruhr University Bochum, Bochum, Germany
| | - Thomas A Schildhauer
- Department of Orthopaedics and Trauma Surgery, BG University Hospital Bergmannsheil, Ruhr University Bochum, Bochum, Germany
| | - Hinnerk Baecker
- Department of Orthopaedics and Trauma Surgery, BG University Hospital Bergmannsheil, Ruhr University Bochum, Bochum, Germany
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Slullitel PA, Oñativia JI, Cima I, Zanotti G, Comba F, Piccaluga F, Buttaro MA. Patients with no recurrence of infection five years after two-stage revision hip arthroplasty may be classified as periprosthetic infection 'in remission'. Bone Joint J 2021; 103-B:79-86. [PMID: 33380194 DOI: 10.1302/0301-620x.103b1.bjj-2020-0955.r1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
AIMS We aimed to report the mid- to long-term rates of septic and aseptic failure after two-stage revision surgery for periprosthetic joint infection (PJI) following total hip arthroplasty (THA). METHODS We retrospectively reviewed 96 cases which met the Musculoskeletal Infection Society criteria for PJI. The mean follow-up was 90 months (SD 32). Septic failure was assessed using a Delphi-based consensus definition. Any further surgery undertaken for aseptic mechanical causes was considered as aseptic failure. The cumulative incidence with competing risk analysis was used to predict the risk of septic failure. A regression model was used to evaluate factors associated with septic failure. The cumulative incidence of aseptic failure was also analyzed. RESULTS There were 23 septic failures at final follow-up, with a cumulative incidence of 14% (95% confidence interval (CI) 8% to 22%) at one year, 18% (95% CI 11% to 27%) at two years, 22% (95% CI 14% to 31%) at five years, and 23% (95% CI 15% to 33%) at ten years. Having at least one positive culture (hazard ratio (HR) 2.38 (interquartile range (IQR) 1.19 to 4.74); p = 0.013), or a positive intraoperative frozen section (HR 2.55 (IQR 1.06 to 6.15); p = 0.037) was significantly associated with septic failure after reimplantation. With dislocation being the most common cause of aseptic revision (5.2%), the cumulative incidence of aseptic failure was 1% (95% CI 0% to 5%) at one year, 6% (95% CI 1% to 8%) at five years, and 8% (95%CI 3% to 17%) at ten years. CONCLUSION If there is no recurrent infection in the five years following reimplantation, the chances of further infection thereafter are remote. While the results of a frozen section may be a reliable guide to the timing of reimplantation, intraoperative culture has, currently, only prognostic value. Surgeons should be aware that instability remains a potential indication for further revision surgery. Cite this article: Bone Joint J 2021;103-B(1):79-86.
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Affiliation(s)
- Pablo A Slullitel
- 'Sir John Charnley' Hip Surgery Unit, Institute of Orthopaedics 'Carlos E. Ottolenghi', Italian Hospital of Buenos Aires, Buenos Aires, Argentina
| | - José I Oñativia
- 'Sir John Charnley' Hip Surgery Unit, Institute of Orthopaedics 'Carlos E. Ottolenghi', Italian Hospital of Buenos Aires, Buenos Aires, Argentina
| | - Ignacio Cima
- 'Sir John Charnley' Hip Surgery Unit, Institute of Orthopaedics 'Carlos E. Ottolenghi', Italian Hospital of Buenos Aires, Buenos Aires, Argentina
| | - Gerardo Zanotti
- 'Sir John Charnley' Hip Surgery Unit, Institute of Orthopaedics 'Carlos E. Ottolenghi', Italian Hospital of Buenos Aires, Buenos Aires, Argentina
| | - Fernando Comba
- 'Sir John Charnley' Hip Surgery Unit, Institute of Orthopaedics 'Carlos E. Ottolenghi', Italian Hospital of Buenos Aires, Buenos Aires, Argentina
| | - Francisco Piccaluga
- 'Sir John Charnley' Hip Surgery Unit, Institute of Orthopaedics 'Carlos E. Ottolenghi', Italian Hospital of Buenos Aires, Buenos Aires, Argentina
| | - Martin A Buttaro
- 'Sir John Charnley' Hip Surgery Unit, Institute of Orthopaedics 'Carlos E. Ottolenghi', Italian Hospital of Buenos Aires, Buenos Aires, Argentina
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Diagnostic value of the CD 15 focus score in two-stage revision arthroplasty of periprosthetic joint infections : High specificity in diagnosing infect eradication. Z Rheumatol 2020; 81:342-351. [PMID: 33306153 DOI: 10.1007/s00393-020-00941-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/15/2020] [Indexed: 12/16/2022]
Abstract
INTRODUCTION The purpose of this study is to use the CD15 focus score (FS) to determine the sensitivity and specificity of bacterial infection persistence in spacer-based two-stage revision arthroplasty. METHODS The analysis comprises 112 cases that were subjected to revision due to the presence of infection upon replacement of a joint endoprosthesis. The histopathological data were collected in accordance with the synovial-like interface membrane (SLIM) classification and the CD15-FS and correlated with the microbiological data (MD). The quantifying evaluation of the CD15-FS was performed without knowledge regarding the microbiological data (MD). Correlation with the MD was performed after a 14-day cultivation period. RESULTS With a single evaluation (1 focus, field area: 1.2 mm2) with a score value of 42, the CD15-FS showed a sensitivity for the eradication of infections of 0.64 and a specificity of 0.79 (PPV = 0.5; NPV = 0.87). With tenfold evaluation (10 foci, field area: 12 mm2) with a score value of 220, the sensitivity for the eradication was 0.68, the specificity 0.91 (PPV = 0.7; NPV = 0.89). No statistically significant correlation between the score values and the different infectious species could be detected. Based on the MD in 112 cases the rate of infection eradication was 75%. Polymethylmethacrylate-particles (PMMA) were detected in the perispacertissue in 64 cases (58%). No significant correlation could be established between microbiological pathogen detection and the presence of PMMA. CONCLUSION In all cases (n = 112), periimplant synovial tissue (SLIM) with variable fibroblastic cellularity, capillary proliferation, leukocytic infiltration, fibrin deposition, new formation of woven bone and detection of PMMA particles was observed. These cases were classified as type IX perispacer synovialis/SLIM: type IX‑A with histopathological infection eradication and type IX‑B with histopathological infection persistence.
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Frieler S, Yilmaz E, Goodmanson R, Hanusrichter Y, Schildhauer TA, Baecker H. Conversion From Knee Arthrodesis Back to Arthroplasty: A Particular Challenge in Combination With Fungal Periprosthetic Joint Infection. Arthroplast Today 2020; 6:1038-1044. [PMID: 33385048 PMCID: PMC7772458 DOI: 10.1016/j.artd.2020.10.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Revised: 10/19/2020] [Accepted: 10/24/2020] [Indexed: 11/17/2022] Open
Abstract
A 58-year-old female treated at an outside facility with knee arthrodesis due to persistent periprosthetic joint infection fulfilled all prerequisites for a conversion back to arthroplasty, as part of a 2-stage revision. Owing to the detection of Candida parapsilosis, the treatment concept was converted to a three-stage procedure. A scheduled spacer exchange with additional amphotericin B-loaded polymethylmethacrylate was conducted as an intermediate revision before reimplantation. Conversion in the setting of fungal periprosthetic joint infection presents a challenge, and successful treatment hinges on the use of proper antifungal and antimicrobial protocols, advanced surgical techniques, and a multidisciplinary team approach. At the 3-year follow-up, successful infection eradication as measured by the Delphi-based consensus definition was achieved with a range of motion of 0°-100°.
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Affiliation(s)
- Sven Frieler
- Department of Orthopedics and Trauma Surgery, BG University Hospital Bergmannsheil, Ruhr University Bochum - RUB, Bochum, Germany
- Hansjörg Wyss Hip and Pelvic Center, Swedish Hospital, Seattle, WA, USA
- Swedish Neuroscience Institute, Swedish Medical Center, Seattle, WA, USA
- Seattle Science Foundation, Seattle, WA, USA
- Corresponding author. 550 17th Avenue, Suite 600, Seattle, WA 98122, USA. Tel.: +1 206 475 9514.
| | - Emre Yilmaz
- Department of Orthopedics and Trauma Surgery, BG University Hospital Bergmannsheil, Ruhr University Bochum - RUB, Bochum, Germany
| | - Ryan Goodmanson
- Swedish Neuroscience Institute, Swedish Medical Center, Seattle, WA, USA
- Seattle Science Foundation, Seattle, WA, USA
| | - Yannik Hanusrichter
- Department of Orthopedics and Trauma Surgery, BG University Hospital Bergmannsheil, Ruhr University Bochum - RUB, Bochum, Germany
| | - Thomas A. Schildhauer
- Department of Orthopedics and Trauma Surgery, BG University Hospital Bergmannsheil, Ruhr University Bochum - RUB, Bochum, Germany
| | - Hinnerk Baecker
- Department of Orthopedics and Trauma Surgery, BG University Hospital Bergmannsheil, Ruhr University Bochum - RUB, Bochum, Germany
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Zheng QY, Zhang GQ. Application of leukocyte esterase strip test in the screening of periprosthetic joint infections and prospects of high-precision strips. ARTHROPLASTY 2020; 2:34. [PMID: 35236471 PMCID: PMC8796411 DOI: 10.1186/s42836-020-00053-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Accepted: 10/12/2020] [Indexed: 12/19/2022] Open
Abstract
Periprosthetic joint infection (PJI) represents one of the most challenging complications after total joint arthroplasty (TJA). Despite the availability of a variety of diagnostic techniques, the diagnosis of PJI remains a challenge due to the lack of well-established diagnostic criteria. The leucocyte esterase (LE) strips test has been proved to be a valuable diagnostic tool for PJI, and its weight in PJI diagnostic criteria has gradually increased. Characterized by its convenience, speed and immediacy, leucocyte esterase strips test has a prospect of broad application in PJI diagnosis. Admittedly, the leucocyte esterase strips test has some limitations, such as imprecision and liability to interference. Thanks to the application of new technologies, such as machine reading, quantitative detection and artificial intelligence, the LE strips test is expected to overcome the limitations and improve its accuracy.
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Abstract
Essential treatment methods for infected knee arthroplasty involve DAIR (debridement, antibiotics, and implant retention), and one and two-stage exchange arthroplasty.Aggressive debridement with the removal of all avascular tissues and foreign materials that contain biofilm is mandatory for all surgical treatment modalities.DAIR is a viable option with an acceptable success rate and can be used as a first surgical procedure for patients who have a well-fixed, functioning prosthesis without a sinus tract for acute-early or late-hematogenous acute infections with no more than four weeks (most favourable being < seven days) of symptoms. Surgeons must focus on the isolation of the causative organism with sensitivities to bactericidal treatment as using one-stage exchange.One-stage exchange is indicated when the patients have:minimal bone loss/soft tissue defect allowing primary wound closure,easy to treat micro-organisms,absence of systemic sepsis andabsence of extensive comorbidities.There are no validated serum or synovial biomarkers to determine optimal timing of re-implantation for two-stage exchange.Antibiotic-free waiting intervals and joint aspiration before the second stage are no longer recommended. The decision to perform aspiration should be made based on the index of suspicion for persistent infection.Re-implantation can be performed when the treating medical team feels that the clinical signs of infection are under control and serological tests are trending downwards. Cite this article: EFORT Open Rev 2020;5:672-683. DOI: 10.1302/2058-5241.5.190069.
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Affiliation(s)
- Ismail Remzi Tözün
- Department of Orthopaedic Surgery and Traumatology, Acibadem Mehmet Ali Aydınlar University, School of Medicine, Acibadem Maslak Hospital, Sarıyer/Istanbul, Turkey
| | - Vahit Emre Ozden
- Department of Orthopaedic Surgery and Traumatology, Acibadem Mehmet Ali Aydınlar University, School of Medicine, Acibadem Maslak Hospital, Sarıyer/Istanbul, Turkey
| | - Goksel Dikmen
- Department of Orthopaedic Surgery and Traumatology, Acibadem Mehmet Ali Aydınlar University, School of Medicine, Acibadem Maslak Hospital, Sarıyer/Istanbul, Turkey
| | - Kayahan Karaytuğ
- Department of Orthopaedic Surgery and Traumatology, Acibadem Mehmet Ali Aydınlar University, School of Medicine, Acibadem Maslak Hospital, Sarıyer/Istanbul, Turkey
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Lehner B, Omlor GW, Schwarze M. [Periprosthetic joint infections : Latest developments, strategies and treatment algorithms]. DER ORTHOPADE 2020; 49:648-659. [PMID: 32642942 DOI: 10.1007/s00132-020-03950-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Due to their multidimensional consequences, periprosthetic joint infections are a serious complication in arthroplasty. There are disagreements in the literature regarding their classification. At the same time, a consequence for the practical procedure cannot always be derived. THERAPEUTIC PROCEDURES In addition to debridement with antibiotics and implant retention, there are options for a one or two-stage change in the therapeutic procedure. Although the preservation of implants is only possible in the case of acute infections with a short duration of symptoms, prosthesis changes are indicated with a longer symptom duration. For both procedures, there are interinstitutional deviating indication criteria, weighing pros and cons. Both have specific problems, such as, in particular, the duration of the antibiotics course, the question of anchoring the prosthesis and, in the case of a two-stage procedure, the shape of the spacer.
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Affiliation(s)
- B Lehner
- Klinik für Orthopädie und Unfallchirurgie, Zentrum für Orthopädie, Unfallchirurgie und Paraplegiologie, Universitätsklinikum Heidelberg, Schlierbacher Landstraße 200a, 69118, Heidelberg, Deutschland.
| | - G-W Omlor
- Klinik für Orthopädie und Unfallchirurgie, Zentrum für Orthopädie, Unfallchirurgie und Paraplegiologie, Universitätsklinikum Heidelberg, Schlierbacher Landstraße 200a, 69118, Heidelberg, Deutschland
| | - M Schwarze
- Klinik für Orthopädie und Unfallchirurgie, Zentrum für Orthopädie, Unfallchirurgie und Paraplegiologie, Universitätsklinikum Heidelberg, Schlierbacher Landstraße 200a, 69118, Heidelberg, Deutschland
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Bin G, Xinxin Y, Fan L, Shenghong W, Yayi X. Serum Fibrinogen Test Performs Well for the Diagnosis of Periprosthetic Joint Infection. J Arthroplasty 2020; 35:2607-2612. [PMID: 32446625 DOI: 10.1016/j.arth.2020.04.081] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Revised: 04/14/2020] [Accepted: 04/23/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Serum fibrinogen (FIB) is an acute-phase glycoprotein in the infection response that may stop excessive bleeding. The purposes of this study are to determine the value of FIB that can be used to differentiate between periprosthetic joint infection (PJI) and aseptic loosening of the prosthesis, and to determine the clinical significance of FIB for analyzing infection outcomes after first-stage surgery. METHODS This retrospective study included 90 patients undergoing total knee arthroplasty or total hip arthroplasty revision from January 2015 to August 2019. PJI was confirmed in 53 patients (group A), and the other 37 patients were diagnosed with aseptic loosening of the prosthesis (group B). Only 21 patients in group A documented the results for serum FIB, C-reactive protein (CRP), and erythrocyte sedimentation rate (ESR) after spacer insertion, so the postoperative serological marker levels of the these patients were also assessed. RESULTS The FIB, CRP, and ESR levels were significantly higher in group A than in group B (P < .001). The area under the receiver operating characteristic curve was highest for FIB at 0.928. Analyses of FIB levels revealed a sensitivity of 79.25% and a specificity of 94.59%. FIB levels were significantly lower in patients with PJI after spacer insertion (P < .001). CONCLUSION FIB is an adequate test to aid in diagnosing PJI, and it is not inferior to CRP and ESR in distinguishing between PJI and aseptic loosening of the prosthesis. It is an especially useful tool in assessing infection outcomes after first-stage surgery.
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Affiliation(s)
- Geng Bin
- Department of Orthopaedics, Lanzhou University Second Hospital, Lanzhou, Gansu, People's Republic of China
| | - Yang Xinxin
- Department of Orthopaedics, Lanzhou University Second Hospital, Lanzhou, Gansu, People's Republic of China
| | - Lu Fan
- Department of Orthopaedics, Lanzhou University Second Hospital, Lanzhou, Gansu, People's Republic of China
| | - Wang Shenghong
- Department of Orthopaedics, Lanzhou University Second Hospital, Lanzhou, Gansu, People's Republic of China
| | - Xia Yayi
- Department of Orthopaedics, Lanzhou University Second Hospital, Lanzhou, Gansu, People's Republic of China
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Chisari E, Parvizi J. Accuracy of blood-tests and synovial fluid-tests in the diagnosis of periprosthetic joint infections. Expert Rev Anti Infect Ther 2020; 18:1135-1142. [PMID: 32715785 DOI: 10.1080/14787210.2020.1792771] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
INTRODUCTION Periprosthetic joint infection (PJI) is one of the most complex complications following total joint arthroplasty. Despite significant progress in recent years, the use of blood and synovial biomarkers to diagnose PJI remains a challenge. AREAS COVERED A combination of serological, synovial, microbiological, histological, and radiological investigations is suggested by consensus and international guidelines. Novel biomarkers and molecular methods have shown promise in recent years. The purpose of this review is to provide an update about the biomarkers used to diagnose PJI and highlight their sensitivity and specificity. In addition, guidance on the diagnostic steps and clinical workflow will be included. EXPERT OPINION The diagnostic algorithm developed and validated by the international consensus meeting group is still the most valuable resource to approach PJI diagnosis. The current combination of blood and synovial biomarkers yield acceptable results and good performance. However, there is a need for new biomarkers and further research to understand the limitations of current tests better, as well as explore new options such as alpha-defensin, D-dimer, interleukin-6, and leukocyte esterase.
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Affiliation(s)
- Emanuele Chisari
- Rothman Orthopaedic Institute, Thomas Jefferson University , Philadelphia, PA, USA
| | - Javad Parvizi
- Rothman Orthopaedic Institute, Thomas Jefferson University , Philadelphia, PA, USA
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