Placement Of Antibiotic Spacer Research Articles

In vitro analysis of various antibiotic and cement combinations against S. epidermidis and S. lugdunensis for treatment of periprosthetic shoulder infection

BackgroundPeriprosthetic joint infections (PJIs) are devastating potential complications after arthroplasty surgery with significant therapeutic challenges. Many authors advocate for two-stage revision arthroplasty for PJI of the shoulder which includes explanation with antibiotic spacer placement. The optimal antibiotic/cement combination for PJI in the shoulder is not known. The purpose of this study is to analyze various cement and antibiotic concentrations against Coagulase negative staphylococcus species, S. epidermidis and S. lugdunensis. MethodsFive strains of coagulase negative Staph were taken from clinically documented orthopedic infections Both Simplex and Palacos cement were used to create antibiotic laden beads and mixed with either ertapenem, vancomycin, gentamicin, or a combination of ertapenem + vancomycin or ertapenem + gentamicin. The bacteria were plated on lysogeny broth agar plates and 3 beads were added per plate. Samples were analyzed for zone of inhibition at 24 hours, 72 hours, and 1 week. After 1 week, beads were transferred to new plates with bacteria and the process was repeated for 6 weeks. ResultsResults showed that ertapenem beads with both Simplex and Palacos cement showed the largest zones of inhibition for all samples. Vancomycin in Palacos cement and vancomycin in combination with ertapenem in Simplex and Palacos cement showed consistent zones of inhibition for the duration of the experiments. Ertapenem in combination with either vancomycin or gentamicin may allow for a powerful initial burst of killing followed by consistent antibiotic elution as opposed to gentamicin alone. ConclusionWhile many premade spacers on the market are infused with gentamicin, our in vitro models demonstrate more efficacious bacterial eradication for antibiotics such as ertapenem and vancomycin specifically for certain low virulence organisms that are commonly found in PJI around the shoulder.

The Utility of Flap Coverage for Limb Salvage in Patients With Severe Prosthetic Joint Infections of the Knee Requiring Implant Exchange.

Prosthetic joint infection (PJI) is a challenging complication of knee arthroplasty, which can require amputation in severe cases. This study analyzes the utility of flap reconstruction in PJIs requiring hardware removal and extensive soft tissue debridement. This was a retrospective analysis of patients who were treated according to a multistage extremity salvage protocol between 2018 and 2022. The protocol involved at least 3 planned surgeries including (1) hardware removal with antibiotic spacer placement and soft tissue debridement, (2) spacer exchange with flap coverage, and (3) hardware reimplantation with simultaneous or delayed extensor mechanism reconstruction. All patients had large periprosthetic tissue defects that would necessitate an amputation if not reconstructed. Primary outcomes were extremity salvage and successful defect coverage. Fifty-two patients (25 female) underwent 62 reconstructions (52 primary, 10 salvage). Flap techniques included pedicled muscular (n = 32), fasciocutaneous (n = 4), combined muscular and fasciocutaneous (n = 2), and free flaps (n = 24). Overall rate of successful defect coverage was 95% (98% in primary and 80% in salvage reconstructions). At a median follow-up of 11 months, 41 patients completed the treatment protocol with a 68% (n = 28) extremity salvage rate (reimplantation arthroplasty, n = 15; permanent knee fusion, n = 13). On the multivariate model including demographic factors, defect size, and flap type, no single factor independently predicted limb salvage. Alongside intensive orthopedic surgical treatment, flap coverage may aid in extremity salvage in severe knee PJIs by reestablishing healthy soft tissue coverage and allowing reimplantation arthroplasty. We recommend a multispecialty approach including plastic surgeons for this challenging condition.

Success of staged revision reverse total shoulder arthroplasty in eradication of periprosthetic joint infection.

Management of periprosthetic joint infection (PJI) in shoulder arthroplasty remains a challenge, with no established gold standard treatment. This study presents the unique experience of a high-volume single-surgeon, single-institution approach on staged revision reverse total shoulder arthroplasty (RTSA) for infection. The authors theorize that staged revision RTSA is an effective treatment for PJI. Between 2013 and 2018, 38 patients underwent a staged RTSA for treatment of PJI. Patient histories were collected and classified using Cierny-Mader classification. Infection workup for all patients included radiographs, laboratory indices, and computed tomographic aspiration arthrogram. PJI was identified based on high clinical and radiographic suspicion, elevated serologic markers, and/or aspirate culture results per 2018 International Consensus Meeting Shoulder guidelines on Orthopedic Infections. All patients underwent first stage with implant removal, irrigation and débridement, and antibiotic spacer placement. Next, intravenous antibiotics were administered by infectious disease consultants for a minimum of 6 weeks. Infection workup was then repeated and, if normalized, final-stage revision commenced with antibiotic spacer removal and revision to RTSA. If indices were persistently abnormal, an additional stage of débridement and spacer placement procedure was performed. Treatment failure was defined as recurrent periprosthetic infection after final prosthesis implantation or persistently elevated indices despite adequate débridement and spacer placement. Mean age of the cohort was 68(standard deviation [SD] 8.9) years and mean follow-up was 33(SD 14) months with 34 Cierny-Mader C hosts and 4 B hosts. Patients underwent a mean of 2(SD 1.1) previous surgeries. The staged revision protocol was successful in 34 (89.5%) patients for management of PJI. Four patients (10.5%) were considered failures with recurrent infections at a mean of 13 months (range 2-26 months) after the final RTSA implantation and underwent repeat staged revisions. Of the 34 patients who had successful infection eradication, 31 had 2-stage treatment and 3 had to undergo 3 stages. There were no treatment-associated mortalities and 10 major complications (26%), including permanent neuropathy, instability, and periprosthetic fractures. The most common cultured microorganism was Cutibacterium acnes (18%), with no polymicrobial infections detected. Although there are multiple treatment options for PJI management, staged revision remains an effective means of treatment. Although there were several patients who required an additional stage of treatment, and a significant complication rate, staged revision RTSA proved successful in the ultimate eradication of the PJI.

Early perioperative magnetic resonance findings in patients with foot drop following total hip Arthroplasty: A descriptive case-series

PurposeThis study aims to characterize iatrogenic sciatic nerve injury patterns in the early, perioperative period following posterior-approach total hip arthroplasty (THA) with magnetic resonance imaging (MRI). MethodsThis was an IRB-approved retrospective analysis of patients acquired from a longitudinal, single site radiology database of patients who underwent MRI for “foot drop” within 4 weeks following posterior-approach THA surgery, over a 20-year period. ResultsMRI exams from 51 patients (mean age 62 years; 32 females) who met inclusion criteria were evaluated. Mean time to MRI was 2.4 days. Of 51 patients, 43 underwent primary THA, 6 revision THA and 2 explantation with antibiotic spacer placement. Ten exams revealed a normal appearance of the sciatic nerve. Nineteen showed compression of the sciatic nerve by edema or a fluid collection, without intrinsic nerve abnormality. Fifteen demonstrated perineural tethering or scar/granulation tissue encasement of the nerve, and in half of these cases the sciatic nerve was enlarged and/or hyperintense on fluid-sensitive sequences. Six patients had sciatic nerve compression secondary to quadratus femoris retraction. Six patients had complete resolution of the foot drop at a mean follow-up of 37.3 months following surgery, and in these cases the sciatic nerve appeared normal on the initial postoperative MRI. Remaining patients all had persistent weakness and paresthesias in the sciatic nerve distribution at a mean follow-up duration of 34.3 months. ConclusionThis retrospective case series demonstrates various sciatic nerve injury patterns in the early perioperative period on MRI and proposes a targeted MRI protocol to evaluate the sciatic nerve post THA surgery.

Hematoma Following Shoulder Arthroplasty: Incidence, Management, and Outcomes.

A paucity of data regarding the implications of postoperative hematoma formation on outcomes after shoulder arthroplasty exists. Previous studies on major joint arthroplasty have associated postoperative hematoma formation with high rates of prosthetic joint infection (PJI) and reoperation. A total of 6,421 shoulder arthroplasty cases were retrospectively reviewed from an institutional database (5,941 primary cases, 480 revision) between December 2008 and July 2017. Patients who developed a postoperative hematoma were identified through direct chart review. Cases with a history of shoulder infection treated with explant and antibiotic spacer placement were excluded. Demographics, surgical characteristics, treatment course, and outcomes were collected. Hematoma occurred in 105 (1.6%; 105/6421) cases within the first three postoperative weeks and was more common following revision (3.3%; 16/480) compared to primary cases (1.5 %; 89/5941; P=0.002). Overall, postoperative shoulder hematoma was successfully managed with nonoperative treatment in 87% of cases via observation (62%, 62/105) and aspiration (25%, 26/105). A total of 14 patients (0.22%, 14/6421) underwent reoperation for hematoma. Eight patients (7.6%, 8/105) that required reoperation for hematoma were diagnosed with PJI. Postoperative hematoma is a complication of shoulder arthroplasty. While many postoperative hematomas can be managed without operative intervention, this analysis reiterates the association between hematoma formation and the development of PJI.

Augmentation of Internal Fixation With Multiplanar External Fixator in High Risk Hind Foot Fusion Patients

Category:Hindfoot; Ankle; DiabetesIntroduction/Purpose:Achieving adequate fixation is a critical component for successful fusion. Internal fixation can be compromised in the setting of poor bone quality due to open trauma, infection, osteoporosis, neuropathic arthropathy resulting in published ankle non-union rates of 38% in high risk patients. These failures may be magnified by weightbearing non-compliance.While the use of multiplanar external fixation (MEF) alone can be utilized - it can often require an extended period of time within the frame (mean 18 weeks, range 9-28 weeks) and complications such as pin site infections. We hypothesized that hybrid fixation, MEF in conjunction with internal fixation, will provide adequate stability elevating the fusion rates in complex fusion cases while allowing early weight bearing and reduces the MEF time and infection rate.Methods:Eleven patients were identified that demonstrate significant risk factors for a successful fusion (infection, charcot, neuropathy, smoking, history of non-union) that were treated with internal fixation augmented with MEF. Patients with an active infection underwent surgical irrigation and debridement, placement of an antibiotic spacer and a course of intravenous antibiotics six weeks prior to placement of internal fixation. In these cases, MEF was placed at the time of surgical irrigation and debridement to allow for stability. In those patient’s without an active fixation, both the internal fixation and MEF were placed at the same time. Internal fixation construct was based on surgeon preference. Patients were allowed to transfer weight bear at the time of surgery and could advance as tolerated after 2 weeks. CT was utilized to assess fusion. Outcomes measured were fusion rate and occurrence of internal fixation infection.Results:The mean age of patients was 55 (range 26-75), eight patients had diabetes, three were current smokers, two were former smokers, two patients had open trauma, one patient had peripheral neuropathy and one patient had a history of a non- union with known non-compliance. Six patients had an active infection and underwent irrigation and debridement, placement of antibiotic spacer and MEF during antibiotic treatment. Seven patients underwent intramedullary nail fixation, three patients underwent plate and screw constructs and one patient underwent screw only fixation. CT demonstrated fusion in all patients (100%). The mean time for external fixation was 72 days (range 41-111). There were no cases of infected internal fixation.Conclusion:The findings of the current study suggest high rates of hind foot fusion with the use of internal fixation augmented with MEF in a complex patient group with identified high non-union risk factors. Using internal fixation, patients time in the frame is much reduced than published studies evaluating MEF alone for fusion fixation. MEF did not result in any cases of infected internal fixation. Patients with hybrid fixation also benefit from early weight bearing. We emphasize the importance of good surgical technique and infection management using this technique.

Safety Profile of Artelon Use for Soft Tissue Reconstruction in Foot and Ankle Surgery

Category:Basic Sciences/Biologics; Ankle; Hindfoot; Midfoot/Forefoot; SportsIntroduction/Purpose:Artelon is a synthetic degradable polyurethaneurea graft which has been investigated and utilized for soft tissue reconstruction in a variety of orthopaedic settings. However, in the field of foot and ankle surgery, there is very limited reported clinical data on outcomes of surgery utilizing Artelon. The goal of this study was look at outcomes of foot and ankle surgery in which Artelon is used, including post-op VAS scores and complications including adverse foreign body reaction, infection, repeat surgery, and implant failure. Our hypothesis was that soft tissue reconstruction procedures utilizing artelon will have a low complication rate, similar to established complication rates for other soft tissue reconstruction procedures such as those utilizing allograft, autograft, or other synthetic tissue.Methods:The treating surgeon’s first 55 consecutive patients 18 years and older who were treated with artelon graft as part of a foot and ankle surgery are being included in this IRB-approved study. Through retrospective chart review, outcome measures including the procedure for which artelon was utilized, pre and post-op Visual Analogue Scale (VAS) scores, and complications including repeat surgery for graft failure, foreign body reaction, wound healing issues, infection, and osteolysis were assessed.Statistical analysis was done utilizing Student’s t-test for continuous variables and chi square test for categorical variables.Results:Average follow-up time was 246.5 days. The majority of patients had artelon placed for spring ligament reconstruction, brostrom procedures, or achilles tendon reconstruction. VAS scores dropped significantly from before surgery to 3 weeks post- operatively (5.6 to 3.2, p<0.05). VAS scores stabilized after 3 weeks, with final follow-up score at 2.9. There were no reports of osteolysis in the area of the graft placement, adverse foreign body reaction, or episodes of graft failure. There were two major complications involving artelon surgical sites: one patient required a free flap for wound coverage, and another required an operative debridement with hardware and artelon removal, antibiotic spacer placement, and subsequent hindfoot fusion. Other minor complications not requiring operative intervention included cellulitis (3 patients) and delayed wound healing (5).Conclusion:Artelon is a safe and effective implant that can be utilized for soft tissue reconstruction in the foot and ankle, with similar post-operative pain recovery and wound complication rates compared to established historical data for these procedures. Additional studies must be done looking at long-term patient outcomes with utilization of artelon, and direct comparative studies with other soft tissue reconstruction techniques and materials in the foot and ankle.

Early results of reverse total shoulder arthroplasty using a patient-matched glenoid implant for severe glenoid bone deficiency

Reverse total shoulder arthroplasty (rTSA) in the presence of significant glenoid bone loss remains a challenge. This study presents preliminary clinical and radiographic outcomes of primary and revision rTSA using a patient-matched, 3-dimensionally printed custom metal glenoid implant to address severe glenoid bone deficiency. Between September 2017 and November 2018, 19 patients with severe glenoid bone deficiency underwent primary (n = 9) or revision rTSA (n = 10) using the Comprehensive Vault Reconstruction System (VRS) (Zimmer Biomet, Warsaw, IN, USA) at a single institution. Preoperative and postoperative values for the Disabilities of the Arm, Shoulder and Hand score, Constant score, American Shoulder and Elbow Surgeons score, Simple Shoulder Test score, Single Assessment Numeric Evaluation score, and visual analog scale pain scoreand active range of motion were compared using the Wilcoxon signed rank testwith the level of statistical significance set at P < .05. Complications occurred in 4 patients (21%), including a nondisplaced greater tuberosity fracture treated conservatively in 1, intraoperative cortical perforation during humeral cement removal treated with an allograft strut in 1, and recurrent instability and hematoma formation treated with humeral component revision in 1. One patient with an early periprosthetic infection was treated with component removal and antibiotic spacer placement at an outside facility and was subsequently lost to follow-up. Eighteen patients with 1-year minimum clinical and radiographic follow-up were evaluated (mean, 18.2 months; range, 12-27 months). Significant improvements were noted in the mean Disabilities of the Arm, Shoulder and Hand score (57.4 ± 16.5 vs. 29.4 ± 19.5, P < .001), mean Constant score (24.6 ± 10.2 vs. 60.4 ± 14.5, P < .001), mean American Shoulder and Elbow Surgeons score (32 ± 18.2 vs. 79 ± 15.6, P < .001), mean Simple Shoulder Test score (4.5 ± 2.6 vs. 9.3 ± 1.8, P < .001), mean Single Assessment Numeric Evaluation score (25.4 ± 13.7 vs. 72.2 ± 17.8, P < .001), mean visual analog scale pain score (6.2 ± 2.9 vs. 0.7 ± 1.3, P < .001), mean active forward flexion (53° ± 27° vs. 124° ± 23°, P < .001), and mean active abduction (42° ± 17° to 77° ± 15°, P < .001). Mean external rotation changed from 17° ± 19° to 32° ± 24° (P = .06). No radiographic evidence of component loosening, scapular notching, or hardware failure was observed at last follow-up in any patient. The preliminary results of rTSA using the VRS to manage severe glenoid bone deficiency are promising, but longer follow-up is necessary to determine the longevity of this implant.

Review of Use of Amniotic Membrane Allograft in Total Ankle Replacements

Category:Ankle ArthritisIntroduction/Purpose:Wound complications after total ankle replacement (TAR) lead to increased postoperative morbidity with lasting consequences. Previous studies demonstrate delayed wound healing in 6.6% to 28% of all TARs. Soft tissue breakdown along the anterior incision can cause exposure of anterior tendons and the implants. In addition, adhesions of the extensor tendons can develop causing significant morbidity. Recent publications advocate for the use of dehydrated human amnion/chorion membrane allograft (dHACM) during closure of anterior ankle incisions during TAR. dHACM is shown to promote increased epithelial cell proliferation, recruitment, and differentiation and reduce the likelihood of tendon adhesions. The goal of this study was to review the use of dHACMs in TARs and to investigate the number and type of postoperative wound complications including extensor tendon adhesions.Methods:We retrospectively reviewed 92 TARs performed between April, 2016 through August, 2018 by two board certified, fellowship trained foot and ankle orthopaedic surgeons. A standard anterior approach was done in all cases. All TARs had dHACM graft placed deep to the tibialis anterior and extensor longus tendon and along the extensor retinaculum prior to final closure of the wound. Upon data review, we identified the subset of patients who had anterior wound dehiscence postoperatively requiring an additional procedure(s) for wound coverage. We compared the demographics, medical comorbidities, and operative characteristics of those with and without perioperative wound complications.Results:12 patients who underwent TARs sustained wound dehiscence below the subcutaneous tissue and required operative intervention (13%). Of these 12 cases, 5 required bipedical or rotational fasciocutaneous flap coverage (5.4%), 6 required less extensive soft tissue surgery (6.5%) and one case involved a deep periprosthetic infection that resulted in explant and antibiotic spacer placement (1.1%). 6 of the 12 cases required a split thickness skin graft application (6.5%) and 2 cases required tenolysis of extensor tendon adhesions (2.2%). Normal excursion of extensor tendons was seen in 90 patients (97.8%). Except for the one infected ankle, there were no cases with wound dehiscence that communicated with the joint. There were no statistically significant differences in medical comorbidities/operative characteristics between patients with wound complications and those without.Conclusion:Wound complications after total ankle replacements often lead to poor long-term outcomes for patients. Our data suggests that the application of the amniotic membrane allograft and its inherent healing potential decreases postoperative tendon adhesions and significant wound dehiscence. This may lead to less deep wound infections that communicate with the joint and may be protective against total ankle replacement failures due to these complications.

Drug reaction with eosinophilia and systemic symptoms syndrome after total knee arthroplasty infection and placement of antibiotic spacer

Though 2-stage revision is considered the gold standard in North America for treatment of periprosthetic joint infection, complications can be associated with use of antibiotic-impregnated spacers. We present a unique case of drug reaction with eosinophilia and systemic symptoms syndrome in a patient with retained antibiotic-impregnated spacer placed for the treatment of a periprosthetic joint infection. Although drug reactions in general are common, severe drug reactions like the one described in this article are exceedingly rare. After discontinuation of intravenous antibiotics and the initiation of corticosteroids, the patient’s symptoms resolved, despite retention of the spacer. Steroid administration and supportive care may result in resolution of symptoms without the need for surgical intervention for spacer removal.

Diagnostic Criteria and Treatment of Acute and Chronic Periprosthetic Joint Infection of Total Ankle Arthroplasty.

Background:Prosthetic joint infection (PJI) after total ankle arthroplasty (TAA) is a serious complication that results in significant consequences to the patient and threatens the survival of the ankle replacement. PJI in TAA may require debridement, placement of antibiotic spacer, revision arthroplasty, conversion to arthrodesis, or potentially below the knee amputation. While the practice of TAA has gained popularity in recent years, there is some minimal data regarding wound complications in acute or chronic PJI of TAA. However, of the limited studies that describe complications of PJI of TAA, even fewer studies describe the criteria used in diagnosing PJI. This review will cover the current available literature regarding total ankle arthroplasty infection and will propose a model for treatment options for acute and chronic PJI in TAA.Methods:A review of the current literature was conducted to identify clinical investigations in which prosthetic joint infections occurred in total ankle arthroplasty with associated clinical findings, radiographic imaging, and functional outcomes. The electronic databases for all peer-reviewed published works available through January 31, 2018, of the Cochrane Library, PubMed MEDLINE, and Google Scholar were explored using the following search terms and Boolean operators: “total ankle replacement” OR “total ankle arthroplasty” AND “periprosthetic joint infection” AND “diagnosis” OR “diagnostic criteria.” An article was considered eligible for inclusion if it concerned diagnostic criteria of acute or chronic periprosthetic joint infection of total ankle arthroplasty regardless of the number of patients treated, type of TAA utilized, conclusion, or level of evidence of study.Results:No studies were found in the review of the literature describing criteria for diagnosing PJI specific to TAA.Conclusions:Literature describing the diagnosis and treatment of PJI in TAA is entirely reliant on the literature surrounding knee and hip arthroplasty. Because of the limited volume of total ankle arthroplasty in comparison to knee and hip arthroplasty, no studies to our knowledge exist describing diagnostic criteria specific to total ankle arthroplasty with associated reliability. Large multicenter trials may be required to obtain the volume necessary to accurately describe diagnostic criteria of PJI specific to TAA.Level of Evidence:Level III, systematic review.

Treatment of Prosthetic Joint Infection: Established Patient Relationships May Impact Medical Decision-Making

BackgroundChoosing the intervention for prosthetic joint infections, whether debridement, antibiotics, and implant retention (DAIR), or explant and antibiotic spacer placement, is multifactorial. One characteristic that may influence this decision is a previously established relationship with the patient. We hypothesized that patients receiving their arthroplasty at an outside institution and presenting with infection would be more likely to undergo removal of their implant without an attempt at DAIR compared to patients who underwent primary arthroplasty at the investigating institution. MethodsThe institutional database was queried for primary total hip and knee arthroplasty infections. Manual review of medical records was performed, excluding patients who did not meet the Musculoskeletal Infection Society definition of infection. Patient demographics, medical comorbidities, presenting infection characteristics, and surgical intervention were collected. Multivariable analysis was performed to determine the independent predictors of treatment. ResultsA total of 270 patients were included for analysis. McPherson score (P < .001) and duration of symptoms (P < .001) were associated with subsequent treatment. Additionally, when controlling for age, gender, symptom duration category, procedure, McPherson score, and American Society of Anesthesiologists category, patients with index procedures at outside hospitals were more likely to undergo implant removal (odds ratio, 36.30; 95% confidence interval, 8.16-161.51; P < .001). ConclusionPatients receiving their primary arthroplasty at an outside hospital and presenting with infection are more likely to undergo removal of hardware as their initial treatment. To avoid treatment bias, institutional protocols should be implemented to guide the shared decision-making process.

High Rate of Positive Cultures in Patients Referred With Antibiotic Spacers as Part of 2-Stage Exchange

BackgroundTwo-stage exchange for periprosthetic joint infection (PJI) in total knee arthroplasty (TKA) remains the gold standard treatment in North America. Occasionally, patients with knee PJI are referred for definitive management after resection and antibiotic spacer placement. Currently, little literature exists to suggest how these patients should be managed. The purpose of this study is to report the clinical outcomes of these patients. MethodsWe retrospectively identified 54 patients (54 knees) from 2000 to 2012 treated for PJI with initial TKA resection and spacer placement performed somewhere other than the definitive treatment center. The mean age at reimplantation was 64 years, with 59% being male. Redebridement and antibiotic spacer exchange was performed for all patients. Mean follow-up was 6.5 years. ResultsOf the 54 knees, 22 (41%) grew an organism from a culture taken at the time of redebridement and spacer exchange. The most common organism identified at redebridement was Staphylococcus aureus (41%). Obtaining positive cultures at redebridement was not associated with presenting erythrocyte sedimentation rate (P = .46), C-reactive protein (P = .57), or the presence of retained cement (P = .13). Forty-nine of 54 (91%) knees were ultimately reimplanted. Two-year survivorship free of infection in reimplanted knees was 98%. ConclusionPatients referred with an antibiotic knee spacer for PJI have a high rate of positive cultures at the time of redebridement. Neither the presenting serology nor the identification of retained cement was associated with obtaining positive cultures at the time of redebridement. Nevertheless, this unique cohort of patients has favorable outcomes when redebrided with spacer exchange prior to reimplantation.

Outcomes of Shoulder Arthroplasty Performed for Postinfectious Arthritis.

BackgroundThe purpose of this study was to evaluate the functional outcomes, infection rate, and complications associated with shoulder arthroplasty for sequelae of prior septic arthritis.MethodsThis is a retrospective cohort study of 17 patients who underwent shoulder arthroplasty for sequelae of septic arthritis. Patients were analyzed for patient-reported outcomes, complications, and reoperations.ResultsThe 17 patients in this cohort were an average age of 65.4 ± 12.2 years old, were 58.8% male, and had an average body mass index of 27.9 ± 4.1 kg/m2. These patients underwent 14 reverse shoulder arthroplasties (RSAs; 11 after antibiotic spacer placement), one anatomic total shoulder arthroplasty after antibiotic spacer placement, and two hemiarthroplasties (both after antibiotic spacer placement). Two patients underwent reoperation (dislocated RSAs). There were four complications (23.5%): two RSA dislocations, one acromial stress fracture, and one atraumatic rotator cuff tear after hemiarthroplasty. There were no cases of postoperative wound complications or infection. At an average of 4.1 ± 1.8 years of follow-up for all 17 of 17 cases, the average visual analogue scale pain score was 4.6 ± 2.3, average Single Assessment Numeric Evaluation Score was 59.3 ± 23.7, average American Shoulder and Elbow Surgeons Score was 57.6 ± 15.5, and average Simple Shoulder Test was 6.9 ± 2.6 based on “yes” responses.ConclusionsShoulder arthroplasty after septic arthritis had inconsistent functional outcomes and high complication rates but no reinfection.

Risk Factors for Repeat Debridement, Spacer Retention, Amputation, Arthrodesis, and Mortality After Removal of an Infected Total Knee Arthroplasty With Spacer Placement

BackgroundChronic periprosthetic joint infection (PJI) after total knee arthroplasty (TKA) is most commonly addressed with a 2-stage exchange procedure. The purpose of this study is to examine the natural history of patients who have undergone prosthesis removal and spacer placement and evaluate risk factors for outcomes other than reimplantation. MethodsPatients who underwent removal of an infected TKA and placement of an antibiotic spacer for PJI were identified in a Medicare database. Patients with a study outcome within 1 year were then identified: (1) in hospital mortality, (2) knee arthrodesis, (3) amputation, (4) repeat debridement procedure without reimplantation, and (5) reimplantation. Independent risk factors for these outcomes were evaluated with a multivariate logistic regression analysis. ResultsA total of 18,533 patients were included. Within 1 year postoperatively, 691 patients (3.7%) died in a hospital setting, 852 patients (4.5%) underwent a knee arthrodesis, 574 patients (3.1%) underwent an amputation, 2683 patients (14.5%) underwent a repeat debridement procedure without being reimplanted, 2323 patients (12.5%) retained their spacer, and 11,420 patients (61.6%) underwent spacer removal and reimplantation within 1 year. Numerous independent patient-related risk factors for these outcomes were identified. ConclusionA large number of patients (38.4%) do not undergo reimplantation within 1 year of prosthesis removal and spacer placement. Outcomes after prosthesis removal and antibiotic spacer placement are variable, and there are several independent risk factors for such outcomes that may be used to develop and improve existing treatment strategies for patients presenting with chronic PJI after TKA.

Medial Gastrocnemius Flap in the Course of Treatment for an Infection at the Site of a Total Knee Arthroplasty.

The pedicled medial gastrocnemius flap provides a robust coverage option for most soft-tissue deficiencies over the distal anterior aspect of the knee encountered in the setting of an infection after total knee arthroplasty. Position the patient supine with an ipsilateral sterile thigh tourniquet to allow room for harvest of a split-thickness skin graft as needed. Perform the arthroplasty to address the underlying deep infection (e.g., irrigation and debridement with exchange of modular components, component removal with antibiotic spacer placement, antibiotic spacer exchange, or second-stage reimplantation) prior to the medial gastrocnemius flap that is utilized for soft-tissue coverage. Use one of two different surgical approaches for the exposure and elevation of the medial gastrocnemius muscle and the identification of its vascular pedicle: the medial approach or the posterior midline approach. Protect the sural artery pedicle in the popliteal fossa because it is key to raising a viable medial gastrocnemius flap. Rotate the flap and transpose it anteriorly over the defect either through a subcutaneous tunnel or by dividing the intervening skin bridge. Complete the layered skin closure and place a split-thickness skin graft over the remaining exposed muscle flap and a nonadherent compressive bolster dressing or negative-pressure device over the skin graft to prevent hematoma under the skin graft. Progress range of motion of the knee once the flap and graft show evidence of survival, while an appropriate antibiotic regimen is completed. We recently reported the largest English-language series, to our knowledge, of medial gastrocnemius flaps performed for soft-tissue coverage in the course of treatment for infection after total knee arthroplasty13.

Complications Following Partial and Total Wrist Arthroplasty: A Single-Center Retrospective Review

To describe our institution's experience with complications following partial and total wrist arthroplasty (TWA). We performed a retrospective review of 105 wrist surgeries in 100 patients who underwent surgery with prosthetic replacement of the distal radius, the proximal carpus, or both at a single institution. Patient factors including age, sex, body mass index, handedness, underlying disease, and previous injury were recorded. Outcomes focused particularly on postoperative complications and need for revision surgery. Forty-seven TWAs, 52 distal radius hemiarthroplasties, and 6 proximal carpal hemiarthroplasties were reviewed with a mean follow-up duration of 35 ± 28 months. Overall complication and revision rates were 51% (53 of 105) and 39% (41 of 105), respectively. Postoperative contracture accounted for the largest number of complications needing additionalsurgery (20%), followed by component failure (15%). Deep infections occurred in 2 TWAs and 1 distal radius hemiarthroplasty and required removal of hardware, antibiotic spacer placement, and a prolonged course of intravenous antibiotics prior to a definitive operation. Of those patients requiring additional surgery, 41% (n= 10) underwent at least 2 procedures, and 10% (n= 4) underwent at least 6 additional surgeries. Although TWA and partial wrist arthroplasty are attractive treatment options for the painful arthritic wrist, there remains a noteworthy potential for complications requiring additional surgery. A detailed understanding of these risks is essential for surgeons so that patients may be counseled accordingly and that alternative treatment options may be considered. Therapeutic IV.

What Factors Influence the Success of Medial Gastrocnemius Flaps in the Treatment of Infected TKAs?

Soft tissue defects after TKA are a potentially devastating complication. Medial gastrocnemius flaps occasionally are used to provide soft tissue coverage, most commonly with a periprosthetic joint infection. We asked: (1) What were the rates of persistent or recurrent infection, implant survivorship, flap-related complications, and reoperation for patients who underwent medial gastrocnemius flap reconstruction for soft tissue coverage after TKA? (2) What were the Knee Society clinical and functional scores for patients who underwent medial gastrocnemius flap reconstruction for soft tissue defects after TKA? (3) What were the risk factors for failure of medial gastrocnemius flap reconstruction after TKA, with failure defined as recurrent or new periprosthetic joint infection or inability to reimplant the TKA prosthesis? Between 2003 and 2011, four surgeons at one institution performed 31 medial gastrocnemius flaps for soft tissue coverage over an infected TKA. Of those, 27 (87%) were available for followup at a minimum of 2 years (mean, 4 years; range, 2-6 years), although patients experiencing complications or treatment failures before two years were included. The study group consisted of 15 men and 12 women with a mean age of 61 years at the time of surgery (range, 36-86 years). The general indication for using a gastrocnemius flap in this setting was full-thickness soft tissue deficiency over the anterior knee during the course of treatment for concomitant deep infection. Six flaps were performed at prosthetic explantation and antibiotic spacer placement, eight at a spacer exchange, eight at second-stage TKA prosthesis reimplantation, and five at débridement with polyethylene exchange. The decision regarding when during staged treatment to place the flap was based solely on when the soft tissues were deemed insufficient, and not based on a belief that placement at one stage versus another was advantageous. Failure was defined as inability to undergo reimplantation of a TKA prosthesis or recurrence of periprosthetic joint infection. Patient and procedural characteristics were tested for association with failure. Survivorship was calculated by Cox proportional hazards modeling. Outcomes scores were drawn from a longitudinal institutional registry. Fourteen of 27 (52%) patients had a persistent or recurrent infection; survivorship of the TKA prosthesis at 4 years was 48% (95% CI, 31%-66%). Although there were no flap-related complications, 12 patients had a total of 19 reoperations during the study period. Overall, the mean (± SD) Knee Society knee (38 ± 18 vs 65 ± 20; p < 0.001) and function (20 ± 22 vs 37 ± 25; p = 0.002) scores were improved at most recent followup. No factors were identified as associated with failure when a Bonferroni correction was applied. Gastrocnemius flaps were used to address difficult soft tissue defects in this series, in the presence of deep infections; the high proportion of patients experiencing persistent or recurrent infections reflects the case complexity and not necessarily a problem with the flaps. However, this series highlights the need to continue to explore alternative approaches to managing this difficult clinical problem. Future studies should aim to establish an evidence-based reconstructive algorithm, focusing on host, wound, and timing characteristics that may maximize outcomes. Level IV, therapeutic study.

Topical Tranexamic Acid Use in Knee Periprosthetic Joint Infection Is Safe and Effective.

Tranexamic acid (TXA) has been shown to decrease hemoglobin loss and reduce the need for transfusions in primary hip and knee arthroplasty. Our study evaluated the safety and efficacy of topical TXA in revision TKA for periprosthetic joint infection (PJI). We performed a retrospective review of patients who underwent removal of hardware with antibiotic spacer placement (stage 1) and/or revision TKA (stage 2) for PJI at our institution between September 2007 and July 2013. During that time, 49 patients underwent stage-1 procedures (20 knees with TXA, 29 without TXA) and 47 patients underwent stage-2 revisions (28 with TXA, 19 without TXA). We evaluated hemoglobin loss, need for transfusion, reinfection rate, length of stay (LOS), complications, and mortality with and without the use of TXA in these patients. All data sets were analyzed with a two-sample t-test. Average follow-up was 3.15 years (range, 1-7 years). TXA use led to a significantly lower percentage drop in the postoperative lowest hemoglobin compared with the preoperative hemoglobin in stage-1 surgeries (19.8 vs. 30.05%, p = 0.0004) and stage-2 revisions (24.5 vs 32.01%, p = 0.01). In both groups, TXA use was associated with a significant reduction in transfusion rates (stage-1, 25 vs 51.7%, p = 0.04; stage-2, 25 vs. 52.6%, p = 0.05). There was a nonstatistical decreased LOS in both groups in which TXA was used (stage 1, 5.15 vs. 6.72 days, p = 0.055; stage 2, 5.21 vs. 6.84 days, p = 0.09). There was no difference in the reinfection rate (4 vs. 4, p = 0.56) or mortality rate between groups (0 vs. 2 non-TXA group). A single upper extremity deep vein thrombosis occurred in a stage-1 patient who received TXA, and no pulmonary embolism occurred. We show that topical TXA is safe and effective for use in both stages of revision TKA for PJI. Previous studies have shown TXA to aggravate a staphylococcal infection in mice; however, topical TXA doesn't appear to negatively effect on the treatment of PJI in our patients and did not increase the reinfection, complication, or mortality rate.

Wrist Arthroplasty: A Complicated Matter: Level 4 Evidence

Despite continued advances in implant design for partial and total wrist arthroplasty, these surgeries present a high incidence of complications, many of which require revision surgery with the potential of a complicated post-operative course. We hypothesize that the incidence of complication is higher then the current reported literature. Follow up duration averaged 2.6 years with longest being 12.4 years. A retrospective review of 105 wrist surgeries in 100 patients who underwent surgery with prosthetic replacement of the distal radius, the proximal carpus or both at a single institution (2005-2014) was performed. Patient factors including age, sex, BMI, handedness, underlying disease and previous injury were recorded. Outcomes were focused particularly on post-operative complications and need for revision surgery. Fourty-seven total wrist arthroplasties (TWA), 52 distal radius hemi-arthroplasties (DRH), and 6 proximal carpal hemiarthroplasties (CH) were performed. Majority (61.7%) of TWA were performed for Rheumatoid Arthritis (RA) or other inflammatory arthropathies, whereas degenerative or post-traumatic arthritis represented the underlying condition for majority of both the DRH (76.9%), and CH (66.7%) groups. Overall complication rate was 50.1% (53/105). Post-operative contracture accounted for the largest number of complications needing additional surgery (20%) though the incidence was much higher in DRH than in TWA (42.3 vs. 16.7%). Component failure composed 15% of all complications, with TWA having the highest incidence across the groups with 24%. Superficial infections occurred at 7.1 and 7.6% in TWA and DRH, respectively. One superficial infection resulted in wound dehiscence that was operatively debrided and closed. All other superficial infections resolved with a short course of oral antibiotics. Deep infections occurred in 4.7 and 3.8% of TWA and DRH, respectively. They were associated with a high number of medical co-morbidities and multiple prior surgeries. All deep infections required removal of hardware, antibiotic spacer placement, and a prolonged course of IV antibiotics prior to a definitive operation. •Though total and partial wrist arthroplasty can provide significant pain relief for the arthritic wrist, there remains a significant potential for complications and need for further surgery.•Patients should be counseled on the potential risks and post-operative course.•It should be noted that the likelihood of failure of wrist arthroplasty tends to increase as time from surgery increases.•Certain patients should be screened with great caution, particularly those with multiple medical co-morbidities, and those pre-disposed to wound issues such as those with low BMI, or poor skin quality.