Late Hematogenous Infection Research Articles

Minimum 10 years clinical results of an anatomical short stem with a proximal hydroxyapatite coating

Objectives The CentPillar stem (Stryker Orthopaedics), an anatomical short stem, was designed to match the proximal femoral canal shape in both patients with normal hips and those with developmental dysplasia of the hip (DDH). The long-term outcomes of the CentPillar stem was examined herein. Methods In total, 222 hips that underwent total hip arthroplasty using the CentPillar stem were analyzed. DDH was the main reason for surgery (79.3%). Implant survivorship was assessed using Kaplan–Meier analysis. For radiographic evaluation, stress shielding was assessed using the Engh classification. For functional evaluation, patients’ ability to perform deep hip bending activities (sit on the floor, squat, and sit straight) was assessed. Results During a median follow-up of 13.1 years, 2 stem revisions were performed (aseptic loosening and late hematogenous periprosthetic infection), and the overall cumulative implant survival rate was 99.0% at 15 years. In the radiographic evaluation, grade >3 stress shielding was found in only one hip. More than 80% of the patients were able to perform each of the three deep hip bending activities. Conclusions Good fixation at the proximal part of the femur was obtained, and the implant survival rate of the CentPillar stem was excellent during a long-term follow-up.

Do trabecular metal and cancellous titanium implants reduce the risk of late haematogenous infection? An experimental study in rabbits.

This study evaluated the late resistance to haematogenous contamination by microbial pathogens of implants and bone-implant interface and the development of late clinical infection when cementless components with different surface or structural properties are implanted. 50 adult male New Zealand white rabbits were divided into 5 groups of 10 animals each. In Group A smooth titanium, in Group B grit blasted titanium, in Group C HA-coated titanium, in Group D trabecular metal and in group E cancellous titanium rods were implanted in the right proximal tibia. Four weeks later, 1 ml of inoculum of a standardised CA-MRSA strain (3 × 108 cfu/ml) was injected through a femoral artery catheter (groups B, C, D, E) while in group A, 1 ml of sterile saline was injected in a similar way (control group). Subjects were killed 8 weeks after the initial procedure and 3 samples of each tibial specimen were subjected to conventional cultures and PCR studies. The number of the specimens (conventional cultures and PCR studies) contaminated by the standardized pathogen was as follows: Group A: 0/10, Group B: 7/10, Group C: 6/10, Group D; 5/10 and Group E: 5/10. Comparing the number of colony form units isolated from the implant samples, Group B (GB titanium) showed statistically significantly higher values (Mann-Whitney test) compared to Group C (p = 0.044), Group D (p = 0.040) and Group E (p = 0.038). Local active infection was observed in 6 animals: 3 in Group B; 1 in Group C, 1 in Group D, and 1 in Group E. Modern cementless implants (trabecular metal and cancellous titanium) showed a lower risk of implant contamination and late clinical haematogenous infection.

Core set of unfavorable events of shoulder arthroplasty: an international Delphi consensus process

Shoulder arthroplasty (SA) complications require standardization of definitions and are not limited to events leading to revision operations. We aimed to define an international consensus core set of clinically relevant unfavorable events of SA to be documented in clinical routine practice and studies. A Delphi exercise was implemented with an international panel of experienced shoulder surgeons selected by nomination through professional societies. On the basis of a systematic review of terms and definitions and previous experience in establishing an arthroscopic rotator cuff repair core set, an organized list of SA events was developed and reviewed by panel members. After each survey, all comments and suggestions were considered to revise the proposed core set including local event groups, along with definitions, specifications, and timing of occurrence. Consensus was reached with at least two-thirds agreement. Two online surveys were required to reach consensus within a panel involving 96 surgeons. Between 88% and 100% agreement was achieved separately for local event groups including 3 intraoperative (device, osteochondral, and soft tissue) and 9 postoperative event groups. Experts agreed on a documentation period that ranged from 3 to 24 months after SA for 4 event groups (peripheral neurologic, vascular, surgical-site infection, and superficial soft tissue) and that was lifelong until implant revision for other groups (device, osteochondral, shoulder instability, pain, late hematogenous infection, and deep soft tissue). A structured core set of local unfavorable events of SA was developed by international consensus to support the standardization of SA safety reporting. Clinical application and scientific evaluation are needed.

Late Reinfection May Recur More Than 5 Years After Reimplantation of THA and TKA: Analysis of Pathogen Factors.

Two-stage reimplantation has consistently yielded high rates of success for patients with chronic prosthetic joint infection, although results more than 5 years after reimplantation are not commonly reported. Numerous factors may contribute to the risk of reinfection, although these factors-as well as the at-risk period after reimplantation-are not well characterized. (1) What is the risk of reinfection after reimplantation for prosthetic joint infection at a minimum of 5 years? (2) Is the bacteriology of the index infection associated with late reinfection? (3) Is the presence of bacteria at the time of reimplantation associated with late reinfection? Between 1995 and 2010, we performed 97 two-stage revisions in 93 patients for prosthetic joint infection of the hip or knee, and all are included in this retrospective study. During that time, the indications for this procedure generally were (1) infections occurring more than 3 months after the index arthroplasty; and (2) more acute infections associated with prosthetic loosening or resistant organisms. One patient (1%) was lost to followup; all others have a minimum of 5 years of followup (mean, 11 years; range, 5-20 years) and all living patients have been seen within the last 2 years. Patients were considered free from infection if they did not have pain at rest or constitutional symptoms such as fever, chills, or malaise. The patients' bacteriology and resistance patterns of these organisms were observed with respect to recurrence of infection. Odds ratios and Fisher's exact test were performed to analyze the data. The incidence of reinfection was determined using cumulative incidence methods that considered death as a competing event. Reinfection occurred in 12 of the 97 joints resulting in implant revision. The estimated 10-year cumulative incidence of infection was 14% (95% confidence interval [CI], 7%-23%) and incidence of infection from the same organism was 5% (95% CI, 1%-11%). Five occurred early or within 2 years and three were resistant pathogens (methicillin-resistant Staphylococcus aureus, methicillin-resistant Staphylococcus epidermidis, or vancomycin-resistant Enterococcus). Seven late hematogenous infections occurred and all were > 4 years after reimplantation and involved nonresistant organisms. Three of the five (60%) early infections were caused by resistant bacteria, whereas all seven late infections were caused by different organisms or a combination of different organisms than were isolated in the original infection. The early reinfections were more often caused by resistant organisms, whereas late infections involved different organisms than were isolated in the original infection and none involved resistant organisms. With the numbers available, we found no difference between patients in whom bacteria were detected at the time of reimplantation and those in whom cultures were negative in terms of the risk of reinfection 5 years after reimplantation (18.6% [18 of 97] versus 81.4% [79 of 97], odds ratio 1.56 [95% CI, 0.38-6.44]; p = 0.54); however, with only 93 patients, we may have been underpowered to make this analysis. In our study, resistant organisms were more often associated with early reinfection, whereas late failures were more commonly associated with new pathogens. We believe the most important finding in our study is that substantial risk of late infection remains even among patients who seemed free from infection 2 years after reimplantation for prosthetic joint infections of the hip or knee. This highlights the importance of educating our patients about the ongoing risk of prosthetic joint infection. Level III, therapeutic study.

Superficial and Deep Infections Rate in Primary Total Ankle Replacement through Anterior Approach versus Lateral Transfibular Approach

Category: Ankle, Ankle Arthritis, Periprosthetic Infections Introduction/Purpose: Periprosthetic joint infections represent a relatively infrequent complication following total ankle replacement (TAR), with reported incidence ranging from 2% to 8,6%. Early treatment of any wound infection is the key to prevent disastrous outcomes. One of the most recent TARs (Zimmer Trabecular Metal Total Ankle, Zimmer Biomet, Warsaw, IN) requires implantation through a lateral transfibular approach. Potential advantages of this approach include the supposed decreased risk of wound complications, thanks to a preservation of the distal leg angiosomes. The purpose of this study is to retrospectively compare the rate of superficial and deep infections between TARs performed through an anterior approach and TARs performed through a lateral transfibular approach at 12-months follow-up. Methods: This study included 150 consecutive primary TARs performed between May 2011 and July 2015 with at least 1-year follow up. The 3-component uncemented Hintegra implant (Newdeal SA, Lyon, France) was used in 81 TARs (54.0%) through an anterior approach (group A). The 2-component uncemented Zimmer Trabecular Metal Total Ankle prosthesis, was implanted in 69 TARs (46.0%) through a lateral transfibular approach (Group B). Operative time, tourniquet time and superficial and deep infections were recorded up to 1-year follow-up. All patients were clinically and radiologically evaluated postoperatively at two, six and twelve months. Superficial wound infections were classified as dehiscence, eschar, or wound drainage according to criteria of the Centers for Disease Control and Prevention for surgical wound infection. Deep infections were classified according to Fitzgerald’s classification: acute postoperative, deep late infections, late hematogenous infections. We compared the incidence of superficial and deep infections as well as the operative time. Results: In group A there were 4 (4.9%) superficial infections. Two of these patients developed a deep infection. Overall, there were 3 (3.7%) deep infections in group A that required: intravenous antibiotics and vacuum assisted closure; replacement of the tibial component and polyethylene liner; polyethylene exchange and VAC treatment. In group B, there were 2 (2.9%) superficial infections. One of these patients developed the only deep infection (1.4%) that was treated with antibiotic-impregnated cement spacer. There was no statistically significant difference in terms of superficial (P= 0.687) and deep infections (P= 0.625). The mean operative time in group A was 115.2 minutes (65-150) and 179.5 minutes (105-333) in group B. Operative time was statistically different between group A and group B (P <0.001). Conclusion: This study demonstrates a lower superficial and deep infection rate in the lateral transfibular approach group compared to the anterior approach group. Nonetheless, this difference was not statistically significant. The significantly longer operative time in the lateral approach group did not seem to affect the infection rates. In conclusion, TARs performed through a lateral approach appear to be as safe as TARs done through an anterior approach in terms of the infection rate within the first postoperative year. Further studies on larger cohorts and longer follow-up are essential to validate the findings from this study.

The Direct Anterior Approach for Complex Primary Total Hip Arthroplasty: The Extensile Acetabular Approach on a Regular Operating Room Table

BackgroundThe direct anterior approach on a regular operating room table has been reported with low dislocation rates. This might be beneficial for complex primary total hip arthroplasty (THA) such as in patients with cerebral palsy or following femoral or pelvic osteotomies. Extending the approach is often required to overcome problems such as acetabular deformities or severe contractures. MethodsWe retrospectively evaluated the results and complications of 29 patients with 37 complex primary THA in which an extensile approach was used. The extensile approach is described. Functional scores were collected in case the patient was ambulatory independently (n = 17). ResultsThe average age was 35 years (range 15-85) with a mean follow-up of 39 months (range 12-60). There were 3 (8%) intra-operative and 4 (11%) early post-operative complications (<3 months), of which 3 (8%) were anterior dislocations. Late complications (>3 months) consisted of a fibrous ingrown stem, a socket loosening following a pelvic fracture, and a late hematogenous infection (8%). Seventy-one percent of the complications occurred in the first 18 cases (49%) indicating a learning curve. The mean post-operative Harris Hip Score was 79 (range 56-97). ConclusionComplex THA can be safely conducted through the extensile anterior approach on a regular operating room table with the use of conventional implants, even in cases with a high risk of dislocation.

Management of acute or late hematogenous infection after shoulder arthroplasty with irrigation, débridement, and component retention

Irrigation and débridement (I&D) with component retention is an appealing alternative to both patients and surgeons for the management of acute or late hematogenous deep periprosthetic shoulder infection (PSI). However, the success rate and results of I&D are poorly documented. This study reports the outcomes and complications of this treatment strategy for acute and delayed-onset acute hematogenous PSI. Between 1980 and 2010, 10 shoulders (9 patients) underwent I&D with component retention for the management on an acute or delayed-onset acute hematogenous PSI at a single institution. Outcome data, including pain, range of motion, need for chronic oral antibiotic suppression therapy, eradication of infection, and need for further surgery were retrospectively collected. Deep infection recurred in 3 shoulders, which were eventually treated with resection arthroplasty. Of the remaining 6 patients (7 shoulders), 5 were prescribed chronic antibiotic suppression. At the most recent follow-up, pain was graded as none in 3 shoulders, mild in 1, moderate with activity in 3, moderate in 2, and severe in 1. Among shoulders with retained components, forward elevation was greater than 110° in 6 (median, 140°; range, 30°-160°), and external rotation was greater than 40° in all shoulders (median, 50°; range, 40°-90°). I&D allowed component retention in 70% of shoulders presenting with an acute or delayed-onset acute hematogenous infection. Most patients were prescribed chronic antibiotic suppression, and reasonable motion was maintained.

Bilateral periprosthetic joint infection with Ureaplasma urealyticum in an immunocompromised patient

This case study discusses how we diagnosed and treated a patient with a late haematogenous bilateral periprosthetic joint infection (PJI) after total knee arthroplasties caused by Ureaplasma urealyticum. This has never been reported before. We will discuss how we used a PET-CT, synovial fluid cell count, and synovial fluid analysis by 16S rRNA gene sequencing to diagnose this PJI. We will also discuss how we treated this patient to obtain full recovery.

Treatment of Arthritis Associated With Legg–Calve–Perthes Disease With Modular Total Hip Arthroplasty

Legg–Calve–Perthes (LCP) disease can result in morphological deformities and associated adult hip arthritis. Thirty-five consecutive total hip arthroplasties (THA) were performed in 28 patients with a history of LCP using a non-cemented modular femoral component. There was one revision for late hematogenous infection and no evidence of prosthesis failure. Harris hip scores, on average, improved from 49.8 (26–73) to 93.9 (82–100) (P<0.05) after a minimum of 2years follow-up (average, 8.2years, range 2–14years). Clinically, patients demonstrated diminished or no limping (94%, 33/35) and improved leg length equality post-operatively (100%, 35/35). This style of stem accommodated metaphyseal/diaphyseal size mismatch in 80% (28/35), allowed for abnormal anteversion in 71% (25/35), and resulted in radiographic improvements in trochanteric height (P<0.05), body weight lever arm (P<0.05), and leg length (P<0.05).

Irrigation and Debridement

Irrigation and Debridement

Mitigation and Education

Mitigation and Education

Antibiotic Prophylaxis for Dental Procedures at Risk of Causing Bacteremia Among Post-Total Joint Arthroplasty Patients: A Survey of Canadian Orthopaedic Surgeons and Dental Surgeons

To elicit current practice and attitudes toward use of antibiotic-prophylaxis among TJA patients prior to dental procedures, a cross-sectional survey of practicing Canadian orthopaedic (OS) and dental surgeons (DS) was undertaken. Of respondents, 77% of OS and 71% of DS routinely prescribe antibiotic-prophylaxis, but while 63% of OS advocate lifelong use, only 22% of DS choose to do so (P<0.0001). Both groups nonetheless recognize the importance of treatment within 2-years post-TJA as per AAOS/ADA guidelines. However, greater duration of practice pointed to potential inadequacy of these guidelines based on reported experience with late-hematogenous infection post-TJA. While discrepancies in attitude toward antibiotic-prophylaxis between surgeon groups remain, both groups agreed that the evidence to support decision making regarding antibiotic-prophylaxis for TJA patients undergoing dental procedures remains inadequate.

CAUSES OF REVISION SURGERY AFTER UNICOMPARTMENTAL KNEE ARTHROPLASTY

Objective - to study the structure of complications developing after unicompartmental knee arthroplasty and to analyze its causes. Material and methods. The causes of 18 revision interventions after 142 consecutive UKA that have been performed in 137 patients since 2001 till 2012 were evaluated. The main reason for revision surgeries in these series was traumatic damage of different knee structures (7 cases): 3 - medial femur or tibia condyle fractures due to fall from height or collision, 1 - ACL rupture and one bearing dislocation both during mountain skiing injury, 1 - lateral menisci tear after rotational trauma, 1 - loose body formation caused by direct blow. All traumatic events took place during first five years after surgery. Other indications for revision were aseptic loosening of tibial component in 6 patients (after 4,8 years in average), disease progression in 2 (after 3 years in average), early infection in 1 and late hematogenous infection in 2 cases. In 16 patients revision TKA were performed with 10 cruciate-retaining, 5 posterior stabilized and 1 varus-valgus constrained implants. In 2 patients with lateral menisci tear and loose body arthroscopical intervention resolved the problem. Surprisingly in this cohort of patients acute trauma especially during sport activities shared the first place with aseptic loosening among the reasons for revision after UKA. This indirectly evidences that patients after UKA retained high level of physical activities and less restricted in sport that after TKA.

Late Hematogenous Bacterial Infections of Breast Implants

Late infections of breast implants are rare occurrences. We present 2 cases of late infections of breast implants, resulting from hematogenous spread from bacterial infection from distant sites. The first case involves a late implant infection following development of a chronic foot sore, caused by Achromobacter xylosoxidans, an aerobic pathogen. The second case describes a late infection, after extensive dental treatment, caused by Streptococcus viridans, a bacterium that normally lives in close association with the teeth and gingiva. On the basis of these 2 cases and others in the literature, systemic antibiotic therapy should be considered in breast implant patients who are exposed to potential bacterial inoculation and bacteremia to prevent late breast infections and subsequent capsular contractures.

Optimal Irrigation and Debridement of Infected Joint Implants: An In Vitro Methicillin-Resistant Staphylococcus aureus Biofilm Model

Acute postoperative and acute, late hematogenous prosthetic joint infections have been treated with 1-stage irrigation and debridement with polyethylene exchange. Success rates, however, are highly variable. Reported studies demonstrate that detergents are effective at decreasing bacterial colony counts on orthopedic implants. Our hypothesis is that the combination of a detergent and an antiseptic would be more effective than using a detergent alone to decrease colony counts from a methicillin-resistant Staphylococcus aureus biofilm-coated titanium alloy disk simulating an orthopedic implant. In our study of various agents tested, chlorhexidine gluconate scrub (antiseptic and detergent) was the most effective at decreasing bacterial colony counts both prereincubation and postreincubation of the disks; pulse lavage and scrubbing were not more effective than pulse lavage alone.

Infection of a total hip arthroplasty with actinomyces israelii: Report of a case

Context:Infection of following total hip arthroplasties can be classified based on the timing of infection. Late infections with Actinomyces israelii are extremely rare with only 3 previously reported cases in literature. We present another case of a late infection with Actinomyces israelii in a total hip arthroplasty 9 years following implantation.Case Report:A 71-year-old male with diabetes mellitus presented with right hip pain 9 years following a total hip arthroplasty. Physical examination revealed localised pain and biochemical investigations showed elevated inflammatory markers. X-rays were suspicious for infection and a collection around the prosthesis was confirmed by MRI scan. The patient underwent debridement and removal of prosthesis. Peri-operative specimen cultures isolated Actinomyces israelii. The patient responded to a combination of vancomycin followed by ciprofloxacin and linezolid therapy before undergoing a successful second-stage reimplantation surgery.Conclusion:This is the first reported case of late haematogenous infection by Actinomyces israelii in a total hip arthroplasty in a patient with diabetes mellitus as the only risk factor. The patient was successfully treated with antibiotic therapy and two-stage reimplantation arthroplasty.

Significance of sentinel infective events in haematogenous prosthetic knee infections

Infection after primary knee arthroplasty is devastating. The aim of this study was to determine the significance of sentinel infective events prior to the development of haematogenous prosthetic knee infection. A retrospective single-centre case control study of 1641 primary knee arthroplasties was conducted between 1998 and 2006. Seventeen haematogenous prosthesis infections were identified and were matched with 51 controls. Perioperative data were collected prospectively, and co-morbidities, infection parameters and sentinel events were collected from patient files and questionnaires. Analysis was performed between controls and the 17 haematogenous infections. The overall prosthetic infection rate was 2.2%. Acute infections accounted for 1.2% with late haematogenous accounting for 1%. The mean time to infection in the haematogenous infection group was 2.3 years (range 3 months to 11 years), and the mean follow-up was 3.8 years (range 7 months to 11 years). Significant risk factors included the number of co-morbidities (relative risk 3.4) and a sentinel event of cellulitis (relative risk 2.7). Fifteen of 17 cases described a sentinel event prior to infection compared with 31 of 51 controls (P= 0.041). The commonest preceding event was skin or soft tissue infection in nine (53%) cases. The most common infecting organism was Staphylococcus aureus in 12 patients (four methicillin-resistant Staphylococcus aureus, eight methicillin-sensitive Staphylococcus aureus). Fifteen of 17 (88%) patients who developed late haematogenous infection had a preceding sentinel event with the commonest source being skin and soft tissue infection. Haematogenous infections are more likely to occur in patients with multiple co-morbidities.

Unexplained Pain After THR: What Should I Do?

Early causes of hip pain within the first year of total hip replacement (THR) include failure of fixation, infection, instability, other sources of pain (eg, lumbar spine), and mechanical dysfunction such as psoas tendon impingement or other soft tissue irritation. Metal-on-metal THRs may present with pain due to hypersensitivity within the first 1 to 3 years after arthroplasty. Late causes of pain include loosening, wear reactions, or mechanical dysfunction such as subluxation associated with wear of the articular couple. Late hematogenous infection is often sudden in onset, but may be subtle. Other sources of pain such as spinal stenosis or lumbar degenerative disk disease may also present as hip pain. Evaluation of the painful hip should start with a careful history: is the current pain similar or different to the preoperative symptoms? A review of the preoperative radiographs will provide clues as to the extent of the pathology, and if not obvious, may suggest other sources for the pain syndrome. Careful comparison of serial radiographs is necessary to identify loosening. Serologic tests should include a sedimentation rate and C-reactive protein; if both are elevated, aspiration of the joint under radiograph control for culture is indicated. In the absence of abnormalities in the studies described above, serial Technetium bone scans performed every 6 to 12 months may suggest loosening if progressive increases in uptake are observed about a component. Malposition of the acetabular component may be associated with psoas tendon impingement (symptomatic with active flexion of the hip) and may be confirmed by computed tomography scan or a psoas tenosynogram. Hypersensitivity of metal-on-metal THRs should be suspected in the presence of early (subtle) osteolysis, and the presence of predominantly mononuclear cells on the sterile aspirate. Perseverance and patience are encouraged in the pursuit of an accurate diagnosis, and objective analysis of the data is necessary. Do not operate without sufficient cause.

Modular Femoral Sleeve and Stem Implant Provides Long-term Total Hip Survivorship

A femoral implant with a modular sleeve and stem has been designed to allow independent and complete metaphyseal-diaphyseal fit and fill as well as independent rotation to accommodate anteversion at the time of THA. In a prospective study we asked whether such a modular femoral sleeve and stem implant used during THA could provide (1) high long-term survivorship; (2) radiographically stable implants without radiolucencies, stress shielding, or osteolysis; and (3) high clinical scores in patients 15 to 20 years after a primary THA. We prospectively evaluated 31 hips that underwent a primary THA using a modular femoral component for clinical outcome (Harris hip score) and radiographic outcome (implant stability, femoral loosening, osteolysis and stress shielding) at a minimum followup of 15 years (mean, 17 years; range, 15-20.2 years). There were no femoral revisions for aseptic loosening; all hips had radiographic evidence of bone ingrowth. Two well-ingrown components were revised for late hematogenous infection. Some degree of proximal femoral disuse atrophy from stress shielding occurred in 23 hips (74%) but was nonprogressive and did not result in any failures or complications. Femoral osteolysis occurred in 18 hips (58%), but we cannot definitively determine whether or not the modular junction contributed to this. These data suggest this modular femoral stem can provide long-term survivorship with no cases of aseptic loosening at 15 to 20 years after primary THA. However, it may be prudent when using this femoral stem to consider an articulation with an alternative bearing or, if the modularity is not needed to address femoral anteversion and metaphyseal-diaphyseal mismatch, to consider a nonmodular femoral stem. Level III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Late Hematogenous Infection of First Metatarsophalangeal Joint Replacement: A Case Presentation

Late hematogenous infection of previously asymptomatic orthopedic implants is extremely rare and usually associated with total joint replacements, such as those of the hip or knee. We present the case of an otherwise healthy female who developed a deep space infection 18 months after a first metatarsophalangeal joint implant arthroplasty. The patient presented with pain and swelling at the site, and over the course of several days developed fever and tachycardia and leukocytosis. Cultures of the surrounding soft tissues and the implant grew Streptococcus pneumoniae. The patient reported a 1- to 2-week history of symptoms consistent with an upper respiratory tract infection and it is believed that this distant focus of infection was the probable source of late hematogenous seeding of the first metatarsophalangeal joint implant.