Treatment of infectious nonspecific coxitis in HIV-positive patients using an antibiotic-loaded spacer for the hip joint

Antibiotic Treatment and Timing of Reimplantation

BACKGROUNDThe usual treatment of septic shoulder arthritis consists of arthroscopic or open lavage and debridement. However, in patients with advanced osteoarthritic changes and/or massive rotator cuff tendon tears, infection eradication can be challenging to achieve and the functional outcome is often not satisfying even after successful infection eradication. In such cases a two-stage approach with initial resection of the native infected articular surfaces, implantation of a cement spacer before final treatment with a total shoulder arthroplasty in a second stage is gaining popularity in recent years with the data in literature however being still limited.AIMTo evaluate the results of a short interval two-stage arthroplasty approach for septic arthritis with concomitant advanced degenerative changes of the shoulder joint.METHODSWe retrospectively included five consecutive patients over a five-year period and evaluated the therapeutic management and the clinical outcome assessed by disability of the arm, shoulder and hand (DASH) score and subjective shoulder value (SSV). All procedures were performed through a deltopectoral approach and consisted in a debridement and synovectomy, articular surface resection and insertion of a custom made antibiotic enriched cement spacer. Shoulder arthroplasty was performed in a second stage.RESULTSMean age was 61 years (range, 47-70 years). Four patients had previous surgeries ahead of the septic arthritis. All patients had a surgical debridement ahead of the index procedure. Mean follow-up was 13 mo (range, 6-24 mo). Persistent microbiological infection was confirmed in all five cases at the time of the first stage of the procedure. The shoulder arthroplasties were performed 6 to 12 wk after insertion of the antibiotic-loaded spacer. There were two hemi and three reverse shoulder arthroplasties. Infection was successfully eradicated in all patients. The clinical outcome was satisfactory with a mean DASH score and SSV of 18.4 points and 70% respectively.CONCLUSIONShort interval two-stage approach for septic shoulder arthritis is an effective treatment option. It should nonetheless be reserved for selected patients with advanced disease in which lavage and debridement have failed.

Spacers

In Germany, rates of primary total knee arthroplasty procedures and exchange arthroplasty procedures continue to rise. Late-onset peri-prosthetic infection constitutes a serious complication whose management may be dependent upon the spectrum of micro-organisms involved. The aim of this study was to provide a retrospective analysis of the effectiveness of initial eradication measures performed as part of a two-stage procedure. Between 2002 and 2008, a total of 328 patients who had received a first-time diagnosis of chronic peri-prosthetic knee infection following total knee arthroplasty (TKA) subsequently underwent surgery at our clinic. The surgical approach consisted of a two-stage procedure, with the initial procedure consisting of the removal of the prosthesis and radical debridement, followed by insertion of an antibiotic-loaded static spacer. The effectiveness of the procedure was assessed after six weeks, with each patient undergoing a number of clinical and laboratory-based tests, including knee joint aspiration. Staphylococcus aureus strains were responsible for 68% (n=223) of the total number of cases of peri-prosthetic knee infection. 19% of cases (n=62) showed evidence of gram-negative bacteria, while MRSA accounted for 15% (n=49) of cases. Six weeks after completion of the above-named treatment regimen, eradication of infection was considered successful in 289 patients (88.1%). Eradication was unsuccessful in 22% of MRSA infections (n=11) and 7% of MSSA infections (n=23). The treatment regimen outlined in this report is capable of achieving satisfactory results in the management of late-onset peri-prosthetic knee infection, with one exception: patients with infections caused by MRSA showed high failure rates.

In case of periprosthetic hip infections the implantation of antibiotic-loaded PMMA spacers is accepted for an adequate treatment option. Although their indication for the treatment of destructive, bacterial infections of the proximal femur would make sense, literature data are scarce. Hence, the aim of this study was to evaluate the efficacy of antibiotic-impregnated spacers in the treatment of proximal femur infections.In 10 consecutive patients (5 M/ 5 F, mean age 66 y.) with bacterial proximal femur infections, a femoral head/neck resection was prospectively performed with a subsequent implantation of an antibiotic-loaded spacer. The joint-specific outcome was evaluated by the Merle d´Aubigne and the Mayo hip score, the general outcome by SF-36. The time periods were divided into “infection situation”, “between stages” and meanly 1 year “after prosthesis implantation”.The spacers were meanly implanted over 90 [155-744] days. In all cases an infection eradication could be achieved. After infection eradication, a prosthesis implantation was performed in 8 cases. The general scores showed significant increases at each time period. With regard to the dimension “pain”, both scores demonstrated a significant increase between “infection situation” and “between stages”, but no significance between “between stages” and “after prosthesis implantation”.Spacers could be indicated in the treatment of proximal femur infections. Besides an infection eradication, a pain reduction is also possible.

BackgroundOutcome data on two-stage revision surgery for deep infection after septic hip arthritis are limited and inconsistent. This study presents the medium-term results of a new, standardized two-stage arthroplasty with preformed hip spacers and cementless implants in a consecutive series of adult patients with septic arthritis of the hip treated according to a same protocol.MethodsNineteen patients (20 hips) were enrolled in this prospective, non-randomized cohort study between 2000 and 2008. The first stage comprised femoral head resection, debridement, and insertion of a preformed, commercially available, antibiotic-loaded cement hip spacer. After eradication of infection, a cementless total hip arthroplasty was implanted in the second stage. Patients were assessed for infection recurrence, pain (visual analog scale [VAS]) and hip joint function (Harris Hip score).ResultsThe mean time between first diagnosis of infection and revision surgery was 5.8 ± 9.0 months; the average duration of follow up was 56.6 (range, 24 - 104) months; all 20 hips were successfully converted to prosthesis an average 22 ± 5.1 weeks after spacer implantation. Reinfection after total hip joint replacement occurred in 1 patient. The mean VAS pain score improved from 48 (range, 35 - 84) pre-operatively to 18 (range, 0 - 38) prior to spacer removal and to 8 (range, 0 - 15) at the last follow-up assessment after prosthesis implantation. The average Harris Hip score improved from 27.5 before surgery to 61.8 between the two stages to 92.3 at the final follow-up assessment.ConclusionsSatisfactory outcomes can be obtained with two-stage revision hip arthroplasty using preformed spacers and cementless implants for prosthetic hip joint infections of various etiologies.

Comparing the use of preformed vs hand-made antibiotic spacer cement in two stages revision of hip periprosthetic infection

Although the Harris hip score frequently is used to assess the outcome of total hip replacement, only a few minor validity tests have been presented. The aim of this study was to perform a validity test of the Harris hip score and to test its reliability. Two cohorts were studied. First, 58 patients who had undergone total hip replacement 2 to 10 years earlier were evaluated by an orthopaedic surgeon and an experienced physiotherapist using the Harris hip score. The patients also answered the Western Ontario and McMaster University Osteoarthritis Index and the Medical Outcomes Study 36-Item Short-Form Health Survey. Second, 1,056 patients answered the Western Ontario and McMaster University Osteoarthritis Index and the Medical Outcomes Study 36-Item Short-Form Health Survey questionnaires. The results were compared with those of a subcohort of 344 patients who were evaluated using the Harris hip score. The following items were tested: content validity, convergent and divergent construct validity, criterion validity, test and retest reliability, internal consistency reliability, and interobserver reliability. The Medical Outcomes Study 36-Item Short-Form Health Survey, Western Ontario and McMaster University Osteoarthritis Index, and the Harris hip score showed high validity and reliability. The Harris hip score can be used by a physician or a physiotherapist to study the clinical outcome of hip replacement.

Background. Assessing the potential risk of recurrence in patients with periprosthetic joint infection (PJI) of the knee serves as the basis for determining the optimal surgical treatment strategy and may increase its effectiveness. The aim of the study was to develop and clinically validate an algorithm for staged surgical treatment of patients with periprosthetic joint infection following primary total knee arthroplasty. Methods. The retrospective part of the study was based on the data from 161 patients with PJI after total knee arthroplasty who underwent staged treatment between January 2007 and January 2017. To identify additional risk factors for recurrence, patients were divided into two comparison groups: Group 1 — patients with recurrent PJI after the first stage of treatment (n = 48); Group 2 — patients with PJI who successfully completed staged treatment without recurrence (n = 113). Subsequently, a prospective validation of the developed algorithm was performed in 100 patients with PJI after primary total knee arthroplasty. Results. Using classification tree analysis on the retrospective dataset, we determined the weight of each risk factor, the interval thresholds characterizing the likelihood of surgical failure, and an analogous indicator for the total recurrence risk score (TRRS), which allows for the practical application of the obtained data. The resulting algorithm, based on the TRRS and additional factors, enabled the stratification of the probability of treatment failure. Among 100 patients in the prospective cohort with knee PJI after spacer implantation, infection eradication was achieved in 95 patients (effectiveness = 95.0%). Among the 5 patients with recurrent PJI, a high risk (TRRS = 4) was identified in 2 cases; one patient required knee arthrodesis, and the remaining patients successfully completed staged treatment. Overall, infection eradication was achieved in 88% of cases, while recurrence occurred in 12%. Conclusion. Clinical validation of the proposed algorithm helped determine the optimal treatment strategy in controversy clinical situations, thereby improving the effectiveness of staged therapy. However, the prospective part of the study demonstrated limited predictive performance of the algorithm, indicating the need for further research, likely including a broader range of clinical, laboratory, and instrumental data.

Periprosthetic joint infection (PJI) is a devastating complication for the patient and the health care providers. Its incidence is between 1% and 3% in primary and 4% and 6% in revision total joint arthroplasties. The diagnosis can be straightforward with purulent discharge from the joint but may also be confusing especially when associated with medical morbidities. Often, infection leads to multiple operations, prolonged use of antibiotics, extensive utilization of medical resources, and substantial social, economic, or even psychological impacts on the patients, family, hospitals, physicians, and payers. It is estimated that the direct medical cost for treating a PJI is 3 times to the medical cost without infection in revisions and 10 times to the medical cost with uneventful primary cases. As the demand for total joint arthroplasties and the burden of PJI increase globally, knowledge and technologies for detecting, preventing, and managing PJI need to be shared to provide better care to patients. In this special issue, we included studies of economic analysis on the treatment of PJI (D. Hernandez-Vaquero et al.), animal models of implant-associated infection (M. Haenle et al. and A. I. Stavrakis et al.), methods to improve the diagnosis (D. S. Evangelopoulos et al. and M. S. Lee et al.), efficacy and the potential use of preformed antibiotic-loaded cement spacer (D. Regis et al. and D. W. Chen et al.), and clinical studies of using antibiotic-loaded cement spacer in hip and knee infections (S. S. Ahmad et al. and K. Uchiyama et al.). The notion to publish the special issue is to bridge the basic studies with the clinical studies. Because PJI is a great mimic that many failed joint arthroplasties initially attributed to aseptic loosening are found to be caused by infection in many occasions. M. Haenle et al. and A. I. Stavrakis et al. highlighted the importance of biofilm formation and the possibility of implant-associated infection with comparatively low dose of bacterial inocula. Sonication of the retrieved prosthesis (D. S. Evangelopoulos et al.) and the use of molecular probes for bacteria-specific genes (M. S. Lee et al.) can improve the accuracy of diagnosis. It therefore can help differentiating easy-to-treat or difficult-to-treat cases (S. S. Ahmad et al.) and the choice of antibiotics in fabricating the cement spacers. This special issue cannot cover all the issues dealing with PJI. However, by increasing the clinicians and surgeons awareness about PJI, the burdens and challenges could be met by putting more efforts to prevent infection, to design novel bacteria-resistant implants, to improve diagnostic sensitivity and accuracy, to make better antibiotic-loaded spacers, and to develop strategies in treating drug-resistant strains or fungal infections. These works need the collaboration between academic researchers and clinicians to translate basic science to clinical practice. Mel S. Lee Andrew Freiberg Wolfgang Klauser Christopher S. Mow Shin-Yoon Kim

Background:Periprosthetic joint infection (PJI) continues to be one of the leading causes of failure following hip and knee surgery. The diagnostic workflow of PJI includes detailed clinical examination, serum markers, imaging and aspiration/biopsy of the affected joint. The goals of treatment are eradication of the infection, alleviation of pain, and restoration of joint function. Surgical management of PJI consists of debridement, antibiotics and implant retention (DAIR) and single or two-stage revision procedures. Two-stage revision remains the gold standard for treatment of PJIs. We aim to discuss the two stage procedure in this article and report the outcomes.Methods: The first stage of the two stages consists of removal of all components and associated cement with aggressive debridement and placement of an antibiotic-loaded cement spacer. Patients are then treated with variable periods of parenteral antibiotics, followed by an antibiotic free period to help ensure the infection has been eradicated. If the clinical evaluation and serum inflammatory markers suggest infection control, then the second stage can be undertaken and this involves removal of the cement spacer, repeat debridement, and placement of a new prosthesis.Results:Common themes around the two-stage revision procedure include timing of the second stage, antibiotics used in the interim period, length of the interim period before consideration of reimplantation and close liaising with microbiologists.Conclusion: Successful eradication of infection and good functional outcome using the two stage procedure is dependent on a multidisciplinary approach and having a standard reproducible startegy.

Background: Arthroscopic debridement with graft preservation has been advocated as the treatment of choice for septic arthritis after anterior cruciate ligament (ACL) reconstruction, but no previous studies have investigated if hardware removal, while retaining the graft in situ, improves the success rate. Moreover, it is unclear whether the premature removal of fixation devices may affect graft integration and knee stability. Purpose/Hypothesis: The purpose was to assess the clinical and functional outcomes of patients with septic arthritis after ACL reconstruction who underwent arthroscopic debridement, while retaining the graft in situ but removing fixation devices, and to determine if premature hardware removal affects graft integrity and function. The hypothesis was that arthroscopic debridement with hardware removal would be effective in eradicating infections while not compromising graft integration and function. Study Design: Case series; Level of evidence, 4. Methods: From a cohort of 2384 cases of arthroscopic ACL reconstruction, 24 patients with postoperative septic arthritis were included for the analysis; 18 patients were available for a clinical evaluation using the International Knee Documentation Committee (IKDC) form, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Lysholm score, and Tegner score at a minimum 12-month follow-up. Knee laxity was assessed clinically with standardized manual laxity tests and instrumentally using an arthrometer and a triaxial accelerometer. Additionally, 3-T magnetic resonance imaging (MRI) at final follow-up was performed, focusing on the graft signal, the cartilage status, and the occurrence of arthrofibrosis. Results: Eradication of the infection was achieved in all cases, and only 1 graft removal was performed because of insufficient tension. Among the remaining 23 patients, a single arthroscopic debridement procedure with hardware removal while preserving the graft was effective in 21 cases (91%) at a mean of 30 ± 37 days from ACL reconstruction to debridement. At last follow-up, 2 patients required a further ACL revision procedure. The mean IKDC, WOMAC, Lysholm, and Tegner scores of the patients available for the clinical evaluation were 75 ± 19, 90 ± 8, 79 ± 21, and 6 ± 2, respectively. No abnormal laxity was reported on manual testing, and arthrometric and accelerometer tests also demonstrated good knee stability (mean KT-1000 arthrometer side-to-side difference was 1.6 ± 1.2 mm at manual maximum force). On MRI, a good graft signal was found in 50% of cases, while concomitant signs of arthrofibrosis were detected in 81% of patients. Severe cartilage defects (International Cartilage Repair Society grade ≥3) were reported in 63% of cases. Conclusion: Arthroscopic debridement with hardware removal was effective in the eradication of infections after ACL reconstruction with extra-articular fixation while preserving graft integrity without compromising knee stability. Patients and surgeons should be aware of complications that might affect the outcome, particularly arthrofibrosis and chondrolysis.

Objective To investigate the efficacy of using an extended trochanteric osteotomy as part of a two-stage exchange procedure for periprosthetic hip infection. Methods We retrospectively analyzed 16 patients (16 hips) including 9 males and 7 females who had extended trochanteric osteotomy as part of two-stage revision procedure for periprosthetic hip infection from January 2008 to January 2012, the average age was 65.2±6.4 years at the time of operation. The two-stage revision protocol included taking out of all implants using extended trochanteric osteotomy, meticulous debridement, restoration of the osteotomies and fixed with cerclage wiring, implantation of antibiotic bone cement spacer in first stage. After sequential therapy of antibiotics through peripheral vein and enteral prescription, the prosthesis was implanted in the second stage. Harris hip score was used to evaluate the hip function. X-ray radiograph was conducted to evaluate the healing of osteotomy, eradication of infection, prosthesis stability, displacement and looseness. Results All patients were followed-up for 24-90 months (53.4±7.2 months on the average). The interval between the first and second surgery was 8.6±2.1 months with a range from 5-18 months. All osteotomies healed uneventfully, with the average heal time 13.2 ± 1.3 weeks (range from 8 to 16 weeks). The infection was eradicated in 15 hips (93.8%) at the second surgery. One hip with staphylococcus epidermidis infection was confirmed by bacterial culture of synovial fluid in second surgery. Infection symptom disappeared after sequential antibiotic therapy. At the last follow-up, all patients had successful eradication of infection, with Harris score improved from 38.6 ± 5.4 preoperatively to 86.4 ± 3.2. Thirteen patients achieved bone ingrowths, while the other 3 patients had fibrous ingrowths. Two cases had intraoperative fracture, 2 had postoperative spacer dislocation. Conclusion Extended trochanteric osteotomy as part of a two-stage exchange arthroplasty can be performed safely and effectively in periprosthetic hip infection, with reliable osteotomy healing. Furthermore, it does not influence the effects of infection treatment and component stability. Key words: Arthroplasty, replacement, hip; Osteotomy; Prosthesis-related infections; Reoperation

Objective To evaluate the mid-term outcomes of patients with chronic infected total hip arthroplasty (THA) after partial single-stage revision. Methods From July 2000 to October 2013, a total of 31 patients (18 males and 13 females, mean age 54 years, mean BMI 24.7 kg/m2) with chronic infected THA underwent partial single-stage revision in our hospital were retrospectively analyzed in the present study. According to the fixation type and the material of the prosthesis, selective revision of the acetabular cup or femoral stem was performed by preoperative imaging and intraoperative evaluation. The characteristics of procedure included changing femoral head and liner components, aggressive soft tissue debridement, retention of the well-fixed femoral stem or acetabular cup, thorough exposed component brushing, adequate surgical area soaking by iodine and vancomycin powder used in medullary space. Pre- and post-operative outcomes were evaluated with the Harris hip score. The frequency of infection recurrence was recorded and the failure treatment of infection was defined as recurrence of infection in the same hip. Results Acetabular cups were revised in 22 patients and femoral stems in nine patients. The average follow-up was 7.2±2.6 years (4.8-15.1 years). There were 4 (13%) failures during the study period at an average of 15 months (9-21 months) after partial single-stage revision. Two cases of them had grade A incision healing and another two cases had grade B incision healing. Of the 31 patients, a total of 27 (87%) patients had satisfactory outcomes with grade A incision healing and required no additional surgical or medical treatment for recurrence of infection. The Harris hip score was improved from 45.2±5.4 pre-operatively to 70.1±4.3 at one year post-operatively. The Harris hip score at 2 years and 5 years after surgery were 75.3±5.1 and 73.2±5.3, respectively. Conclusion In treating chronic infected THA, partial single-stage revision can be conducted fairly effective in eradication of infection and achieving acceptable functional outcomes while reducing surgical injury, which indicated that this is an attractive alternation in selected patients. Key words: Arthroplasty, replacement, hip; Prosthesis-related infections; Postoperative complications

Introduction. Van Praagh A3 variant of truncus arteriosus (TA A3) is a condition when the one pulmonary artery branch origins from the TA, the other is filled through the patent ductus arteriosus (PDA). PDA constriction in the early neonatal period can cause absence of blood supply to the one pulmonary artery branch. To prevent this, prolonged infusion of prostaglandin E1, PDA stenting or systemic-to-pulmonary shunt are used. These methods allow to postpone total repair (TR) and reduce mortality risks associated with neonatal period. The aim. To analyze research papers dedicated to endovascular approach of TA A3 staged treatment and to present our own experience. Materials and methods. We conducted a systematic literature search and analyzed various options for the TA A3 staged treatment. After the review, we used endovascular approach as the first stage of treatment in our clinical case. We studied a newborn weighing 4 kg with TA A3 (left pulmonary artery branch origins from the non-coronary sinus of the truncal valve, right pulmonary artery branch filling through the PDA). Nakata index was 83 mm2/m2. McGoon ratio was 1. We decided to perform PDA stenting with the aim of postponing surgical correction until the patient’s optimal age and weight. Discussion. In total, the number of publications about TA A3 staged treatment is limited. Most institutions prefer TA A3 staged treatment in newborns, because it is associated with a lower risk of complications than early TR. In our clinical case, the first step was PDA stenting. The staged approach allowed us to perform TR with a good result at the age of 3 months. Before TR, Nakata index and McGoon ratio were increased to 248 mm2/m2 and 1.9, respectively. Conclusions. The current trend of TA A3 repair has few different options of staged treatment. Staged approach helps to get out of the newborn period and achieves the optimal condition for TR. Our patient successfully received PDA stenting as the first stage of treatment, which created conditions for the pulmonary artery branches growth. The second stage was TR with good long-term results. After analyzing the publications, we noted that the use of endovascular PDA stenting is a good and safe alternative to surgical palliative treatment.