Infected Total Joint Arthroplasty Research Articles

Outcome of Infected Total Joint Replacement

Numerous protocols are used to treat an infected total joint arthroplasty. We evaluated survival outcomes of patients with infected total joint arthroplasties over 35 years to determine if one treatment is more effective than others.Of 17,561 total joint arthroplasties performed at our facility, 116 (0.66%) were diagnosed with deep infection, 22 of which (18.97%) were hematogenous. Success rates among resection, 1-stage, and 2-stage reimplantation arthroplasty were compared in each joint, as were organism types. After excluding 8 patients (6.9%) who died within 1 year of final treatment and 8 lost to follow-up, 30 hips and 70 knees were studied. Seventeen hips were treated with 2-stage arthroplasty; 70.6% succeeded after the first attempt, and 82.4% succeeded after the second. Fifty-one 2-stage knees had 54.9% success after the first attempt and 66.7% success after the second. Five of 5 hips treated with 1-stage arthroplasty succeeded after the first attempt, while 1 of 3 one-stage knees succeeded after the first attempt; none of these 8 joints had a hematogenous infection. No joints requiring a third treatment were successful after the third attempt. There were no differences in survival between different bacteria.Treatment of deep prosthetic joint infection is difficult once the first attempt has failed and becomes more so after failure of the second attempt. Two-stage arthroplasty provides good results in most cases (82% in hips, 67% in knees), but a third attempt does not increase these percentages. The organism type does not significantly affect success in infected joint treatment.

Risk factors for total joint arthroplasty infection in patients receiving tumor necrosis factor α-blockers: a case-control study

IntroductionThe objective of this study was to assess natural microbial agents, history and risk factors for total joint arthroplasty (TJA) infections in patients receiving tumor necrosis factor (TNF)α-blockers, through the French RATIO registry and a case-control study.MethodsCases were TJA infections during TNFα-blocker treatments. Each case was compared to two controls (with TJA and TNFα-blocker therapy, but without TJA infection) matched on age (±15 years), TJA localization, type of rheumatic disorder and disease duration (±15 years). Statistical analyses included univariate and multivariate analyses with conditional logistic regression.ResultsIn the 20 cases (18 rheumatoid arthritis), TJA infection concerned principally the knee (n = 12, 60%) and the hip (n = 5, 25%). Staphylococcus was the more frequent microorganism involved (n = 15, 75%). Four patients (20%) were hospitalized in an intensive care unit and two died from infection. Eight cases (40%) versus 5 controls (13%) had undergone primary TJA or TJA revision for the joint subsequently infected during the last year (P = 0.03). Of these procedures, 5 cases versus 1 control were performed without withdrawing TNFα-blockers (P = 0.08). In multivariate analysis, predictors of infection were primary TJA or TJA revision for the joint subsequently infected within the last year (odds ratio, OR = 88.3; 95%CI 1.1-7,071.6; P = 0.04) and increased daily steroid intake (OR = 5.0 per 5 mg/d increase; 1.1-21.6; P = 0.03). Case-control comparisons showed similar distribution between TNFα-blockers (P = 0.70).ConclusionsIn patients receiving TNFα-blockers, TJA infection is rare but potentially severe. Important risk factors are primary TJA or TJA revision within the last year, particularly when TNFα-blockers are not interrupted before surgery, and the daily steroid intake.

Effect of intra-articular hyaluronic acid agents on subsequent rate of infection following total knee arthroplasty

The aim of our study was to discover any relation between infection, including deep infections, after knee total joint arthroplasty in patients who had previous intra-articular hyaluronic acid injections compared to those who had not. We performed a retrospective review of 1776 patients who had osteoarthritis and received hyaluronic acid injections and then a subsample of 415 patients who subsequently underwent total joint arthroplasty: a large primary researchable database from 2002-2008. Surgery was conducted in a university academic network, while the hyaluronic acid injections were delivered in a large primary care arthritis referral center. The 415 patients had at least one year follow-up after total joint arthroplasty. Outcomes included demographics, pre-post total joint arthroplasty Western Ontario McMaster score, and clinical outcomes (knee flexion and extension), as well as adverse events including infection rates. Infections were determined on clinical grounds and confirmed with laboratory investigations. In the injection group there were 18 cases of infected total joint arthroplasty versus 21 in the no-hyaluronic-acid-injection group. However, when the type of hyaluronic acid derivative was considered, more infections with higher versus lower molecular weight (15 vs. 3) were observed. Hence, prior intra-articular hyaluronic acid does not increase the risk of subsequent infection post total joint arthroplasty.

Morbidly Obese, Diabetic, Younger, and Unilateral Joint Arthroplasty Patients Have Elevated Total Joint Arthroplasty Infection Rates

The study aims to delineate the deep infection rates and infection risk factors for primary total knee and total hip arthroplasty patients. A retrospective review was conducted on 6108 patients from 1991 to 2004. The deep infection cases were compared to the noninfected cohort whereby infection risk factors were identified. Of the 8494 joint arthroplasties, 43 (0.51%) developed a deep infection (30 total knee arthroplasties, 13 total hip arthroplasties). Patients with a body mass index greater than 50 had an increased odds ratio of infection of 21.3 ( P < .0001). Diabetic patients were 3 times as likely to become infected compared to nondiabetic patients ( P = .0027). Simultaneous bilateral total joint arthroplasties were found to have developed infection 3 times less frequently than those performed as unilateral procedures ( P = .0024). The average age in our infection cohort was 64.3 and 68.4 in the noninfected cohort. In this retrospective review study, obesity, diabetes, and younger age were found to be risk factors for joint arthroplasty infection.

Direct Demonstration of Viable Staphylococcus aureus Biofilms in an Infected Total Joint Arthroplasty

Stoodley, Paul PhD1; Nistico, Laura PhD1; Johnson, Sandra BS1; Lasko, Leslie-Ann PA-C1; Baratz, Mark MD1; Gahlot, Vikram MD1; Ehrlich, Garth D. PhD1; Kathju, Sandeep MD, PhD1 Author Information

Initial Results of Managing Severe Bone Loss in Infected Total Joint Arthroplasty Using Customized Articulating Spacers

Twenty-three cases of infected total joint arthroplasty with substantial bone loss were treated with a cement spacer, which was customized intraoperatively to achieve joint stability and to allow motion. All but one of the patients were ambulatory with the spacer in place. Spacer dislocation occurred in 1 hip patient (9%) and in none of the knee patients. Articulating antibiotic-impregnated spacers with intraoperative customization is our preferred treatment of cases of infected total joint arthroplasty even in the presence of bone loss.

Risk Factors in Total Joint Arthroplasty: Comparison of Infection Rates in Patients with Different Socioeconomic Backgrounds

Infection after total joint arthroplasty is a serious complication. Several risk factors have been shown to increase the risk of total joint infections. The purpose of this study was to evaluate whether socioeconomic background was a risk factor for infection in primary total joint arthroplasty. A retrospective chart review was conducted over a 4-year period on a single surgeon’s split practice between private patients with mostly private insurance and Medicare and county based patients with predominately indigent county health coverage and Medicaid. An infection rate was calculated for each population in both primary total knee and hip arthroplasty. The two populations were statistically analyzed for differences in age, preoperative diagnoses, and socioeconomic background. To our knowledge, this is the first study showing an increased risk of infection in total joint arthroplasty based on socioeconomic background.

Risk Factors in Total Joint Arthroplasty: Comparison of Infection Rates in Patients With Different Socioeconomic Backgrounds

Infection after total joint arthroplasty is a serious complication. Several risk factors have been shown to increase the risk of total joint infections. The purpose of this study was to evaluate whether socioeconomic background was a risk factor for infection in primary total joint arthroplasty. A retrospective chart review was conducted over a 4-year period on a single surgeon's split practice between private patients with mostly private insurance and Medicare and county based patients with predominately indigent county health coverage and Medicaid. An infection rate was calculated for each population in both primary total knee and hip arthroplasty. The two populations were statistically analyzed for differences in age, preoperative diagnoses, and socioeconomic background. To our knowledge, this is the first study showing an increased risk of infection in total joint arthroplasty based on socioeconomic background.

The role of intraoperative cultures at the time of reimplantation in the management of infected total joint arthroplasty

We reported our experience with the usefulness and interpretation of the significance of cultures at the second-stage exchange of infected arthroplasty in a prospective, 3-year follow-up study. When such intraoperative cultures were negative, patients received no therapy; when at least two cultures showed the same microorganism, results were interpreted as infection and patients were treated with antibiotics for 6-8 weeks with no more surgical procedures. Genotypic analysis (pulsed-field gel electrophoresis) was performed to analyse coagulase-negative Staphylococcus (CoNS) infections. Among 25 patients, 18 had negative cultures at the second-stage (group 1) and seven had positive cultures (group 2) receiving glycopeptides. Follow-up medians were 30 months for group 1 and 35 months for group 2; no patients in either group had persistence or recurrence of infection. All patients from group 2 had infection by CoNS at the second-stage; in six cases CoNS were also responsible for the initial infection. Genetic studies confirm that second-stage strains show different clonal identity than first-stage ones suggesting a superinfection rather than a real persistence of initial infection. Our results support the role of intraoperative cultures at the second-stage to identify patients at risk of recurrent infection who could benefit from early antibiotic therapy. The persistence of initial infections and the presence of new superinfections should be better defined according to genotypic studies.

The Use of Linezolid in the Treatment of Infected Total Joint Arthroplasty

Fourteen patients with a diagnosis of infected total joint arthroplasty treated by 1 or 2-stage revision and a course of oral linezolid were reviewed. Patients were assessed according to McPherson stage, inflammatory markers, nature of surgery, use of antibiotics, pathogen isolated, and outcome at follow-up. Pathogens isolated were coagulase-negative staphylococcus, multiresistant Staphylococcus aureus, Enterobacter cloacae, and mixed growth. McPherson stages were 1 IB2, 1 IA3, 1 II A2, 3IIIA2, 2 IIIB1, 3 IIIB2, 1 IIIB3, 1 IIIC2, and 1 IIIC3. All patients showed resolution of infection, with normalization of inflammatory markers after treatment. Mean length of follow-up is 32.7 months (range, 9-44 months). Comparison is drawn with previous studies highlighting the good results achievable with the use of this antibiotic. Although no substitute for adequate surgical management, it does allow oral treatment and therefore avoids the difficulties associated with long-term intravenous antibiotic therapy.

Use of 99mTc-Sulesomab for the Diagnosis of Prosthesis Infection after Total Joint Arthroplasty

This study aimed to evaluate the diagnostic efficacy of antigranulocyte scintigraphy using the antibody fragment (99m)Tc-sulesomab (LeukoScan) for the diagnosis of prosthesis infection in patients with total hip or knee arthroplasty. The results from 19 patients with suspected total joint arthroplasty infection who had undergone a three-phase bone scan and a subsequent examination with (99m)Tc-sulesomab during a 1-year period were reviewed. Twelve patients were shown to have prosthesis infection on culture of aspirated synovial fluid or intra-operative samples. The overall sensitivity, specificity, positive and negative predictive values, and diagnostic accuracy for (99m)Tc-sulesomab were 75%, 86%, 90%, 66% and 79%, respectively, compared with 54%, 83%, 88%, 45% and 63%, respectively, for the three-phase bone scan. This study showed that (99m)Tc-sulesomab had good diagnostic value for the detection of prosthesis infection. The combination of (99m)Tc-sulesomab with other laboratory or imaging examinations may improve diagnostic performance in prosthesis infection and should be investigated further.

A Motion Maintaining Antibiotic Delivery System

Two-stage radical debridement with implant removal, antibiotic therapy, and delayed reimplantation remains the treatment of choice for deep infection in total joint arthroplasty. Studies have shown that articulating vs static spacers better improve functional results, increase patient satisfaction, prevent bone loss, and facilitate reimplantation without increasing risk of infection. Articulating spacers fabricated from cement provide a vehicle for prolonged local delivery of antibiotics. We currently use a mold system for creating antibiotic-laden articulating cement spacers. Disposable femoral and tibial molds are injection-filled with low-viscosity cement vacuum mixed with 3.6 to 4.8 g of tobramycin or gentamicin and 3.0 to 4.0 g of vancomycin per 40-g unit and massaged to fill any voids. After curing, the temporary spacers are removed from the molds, trimmed smooth, and cemented loosely into the joint space.

Antibiotic-impregnated Cement Spacer for Bone Defects of the Forearm and Hand

Management of bone loss, particularly in the face of open or contaminated wounds, presents a reconstructive challenge. Polymethylmethacrylate impregnated with antibiotics has been used successfully in the treatment of infected total joint arthroplasty and open fractures. The cement delivers high-dose local concentrations of antibiotics while filling a space. This article presents our use of an antibiotic-impregnated cement spacer for bone loss in the forearm or hand in the face of open or infected wounds. The cement spacer fills a potential space, prevents the involution of the surrounding soft tissue, and delivers appropriate antibiotics. When the spacer is removed, the remaining sheath serves to hold and contain the cancellous bone graft.

The management of peri-prosthetic infection in total joint arthroplasty

Deep peri-prosthetic infection following total joint arthroplasty is a major complication. Although it only occurs in a small percentage of patients it results in substantial morbidity and a decline in functional outcome. The risk of infection is generally quoted as being 1%. The lowest reported

Long-term suppression of infection in total joint arthroplasty.

Optimal treatment for a chronic infected prosthesis is the removal of infected and necrotic tissue and all the components of the prosthesis with staged revision in conjunction with systemic antibiotics. If this is not possible because of the poor general condition of the patient, because of unacceptable functional results secondary to removal of the prosthesis, or because the patient refuses surgery in an attempt to salvage the infected prosthesis, a reasonable alternative is long-term oral suppressive antibiotic therapy for maintenance of a functioning prosthesis. Prompt recognition with rapid debridement and initiation of antibiotic therapy seems crucial. Our study confirms a favorable outcome of maintenance of functioning prostheses in 86.2% of patients after a mean followup of 5 years. All patients had initial debridement with 4 to 6 weeks of systemic antibiotic therapy. Advanced age did not seem to predict poor outcome. Joint location, duration of symptoms, and the time of onset of infection did not predict success or failure. The overall success rate for Staphylococcus aureus prosthetic joint infection was 69% after a mean followup of 5 years. The ideal regimen and optimal duration of oral suppressive therapy for a favorable outcome is not well-established and needs additional data with prospective multicenter studies.

Efficacy of combined technetium-99m sulfur colloid/indium-111 leukocyte scans to detect infected total hip and knee arthroplasties

The reliability of combined indium-111 leukocyte/technetium-99m sulfur colloid scans, with and without the addition of blood pooling and blood flow studies, in the diagnosis of infected total joint arthroplasty was investigated. Both scans were performed on 58 patients before reoperation of total hip or knee arthroplasty in the period 1996–1999. Results for imaging alone included 100% specificity, 46% sensitivity, 100% positive predictive value, 84% negative predictive value, and 88% accuracy. Inclusion of blood pooling and flow phase data improved results to 66% sensitivity, 89% negative predictive value, and 90% accuracy, with reductions in specificity (98%) and positive predictive value (91%). Routine use of these radionuclide scans is not supported by these data.

Emerging Antibiotic-Resistant Bacteria

Successful treatment of an infected total joint arthroplasty can be achieved in approximately 90% of cases. This outcome may be jeopardized by the emergence of antibiotic resistance in bacteria common to these infections. Staphylococci are the most frequently isolated bacteria in total joint infections, and the prevalence of antibiotic resistance in these organisms among all nosocomial and community-acquired infections has been increasing. As many as 46.7% of Staphylococcus aureus strains and 85.7% of coagulase-negative staphylococci strains are methicillin-resistant. Enterococci also are commonly isolated from infected total joint arthroplasties. The prevalence of vancomycin-resistant enterococci among all enterococci strains is estimated at 23%. As the prevalence of these resistant bacteria continues to increase among all infections, it is anticipated that they will be encountered more regularly in total joint infections. Knowledge of the mechanisms of resistance of these bacteria and currently available and newly developed antimicrobials is key to preventing the expansion of antimicrobial resistance and ensuring the future successful treatment of total joint infections.

AIR CONTAMINATION DURING SKIN PREPARATION AND DRAPING IN JOINT REPLACEMENT SURGERY

Despite the use of ultraclean air, there are still cases of infection in total joint arthroplasty. One possible route by which bacteria may enter the wound is indirectly by contamination of instruments during skin preparation and draping. We found that bacterial air counts were 4.4 times higher during preparation and draping for hip or knee arthroplasty using an unscrubbed, ungowned leg holder than during the operation itself. With the leg holder scrubbed and gowned during preparation and draping, the air counts were reduced but were still 2.4 fold greater than intraoperatively. On some occasions, the air counts during preparation and draping exceeded the standards for ultraclean air irrespective of the attire of the leg holder. We recommend that the leg is held by a scrubbed and gowned member of the team. More importantly, we consider that instrument packs should be opened only after skin preparation and draping have been completed.

Molecular genetic diagnosis of infected total joint arthroplasty

Molecular genetic diagnosis of infected total joint arthroplasty

A Comparison of Gentamicin-Impregnated Polymethylmethacrylate Bead Implantation to Conventional Parenteral Antibiotic Therapy in Infected Total Hip and Knee Arthroplasty

A multicenter study of infected total knee and total hip arthroplasties was conducted from 1985 until 1990. Twenty-eight patients (22 total hip arthroplasties and six total knee arthroplasties) who had periprosthetic infections were treated according to a prospective, randomized protocol. After initial debridement for their infections, patients were randomized into one of the two following groups: Group I, debridement and the implantation of gentamicin-polymethylmethacrylate (PMMA) beads; and Group 2, debridement and conventional parenteral systemic antibiotic therapy. After initial treatment, the patients were then scheduled for a delayed reconstruction total joint arthroplasty. Of the 28 patients, 25 subsequently had delayed total arthroplasty, and if acrylic bone cement was used for fixation at the time of reimplantation, antibiotics were not added to the cement. The average follow-up period was three years (range, six months to 5.6 years). Infection recurred in two patients treated by debridement and the implantation of gentamicin-PMMA beads (15%) and in four patients treated with debridement and conventional systemic antibiotic therapy (30%). All recurrences occurred in patients who had infected total hip arthroplasties; none occurred in patients with total knee arthroplasties. The conditions that were common in patients with recurrent infection were (1) multiple previous surgeries, (2) host compromise and malnutrition, (3) extensive infection, and (4) inadequate debridement. The recurrence of infection was not statistically significantly more common in either treatment group. The outcome of treatment in patients with infected total joint arthroplasties using debridement, gentamicin-PMMA bead implantation,and a two-stage delayed reconstruction was similar to that of patients treated with debridement combined with conventional parenteral systemic arthroplasty and two-stage reconstruction.