Prosthetic Infection Research Articles

Role of Penile Prosthesis in Priapism: A Review.

Ischemic priapism is a urological emergency that has been associated with long-standing and irreversible adverse effects on erectile function. Studies have demonstrated a linear relationship between the duration of critically ischemic episodes and the subsequent development of corporal fibrosis and irreversible erectile function loss. Placement of a penile prosthesis is a well-established therapeutic option for the management of erectile dysfunction secondary to ischemic priapism, and will be the focus of this review. Review of the current literature demonstrates a growing utilization of penile prostheses in the treatment of erectile dysfunction secondary to ischemic priapism. Unfortunately, there is a paucity of randomized-controlled trials describing the use of prosthesis in ischemic priapism. As a result, there is a lack of consensus regarding the type of prosthesis (malleable vs. inflatable), timing of surgery (acute vs. delayed), and anticipated complications for each approach. Both types of prostheses yielded comparable complication rates, but the inflatable penile prosthesis have higher satisfaction rates. Acute treatment of priapism was associated with increased risk of prosthetic infection, and could potentially cause psychological trauma, whereas delayed implantation was associated with greater corporal fibrosis, loss of penile length, and increased technical difficulty of implantation. The paucity of high-level evidence fuels the ongoing discussion of optimal use and timing of penile prosthesis implantation. Current guidance is based on consensus expert opinion derived from small, retrospective studies. Until more robust data is available, a patient-centered approach and joint decision-making between the patient and his urologist is recommended.

Self Made Xeno-pericardial Aortic Tubes to Treat Native and Aortic Graft Infections

The most appropriate material for reconstruction of the aorta for native or graft infection remains a matter for debate. This study examines the mid-term outcome of patients and graft durability after in situ aortic reconstruction with self made bovine pericardial tube grafts. This was a retrospective analysis of all patients who underwent in situ aortic reconstruction using self made bovine pericardial tube grafts between January 2008 and December 2015 at a tertiary referral centre. Peri-operative and mid-term outcomes including mortality and re-infection were analysed at the end of January 2017. Available follow-up imaging was reviewed to assess graft durability. Bovine pericardial aortic tube grafts were used in 35 patients (86% male) with a median age of 69 years (range 38–84) to reconstruct the ascending aorta or the aortic arch (7), the descending (7), the thoraco-abdominal (7), or the abdominal (14) aorta. Twelve patients (34%) were treated for infection of the native aorta and 23 (66%) for prosthetic graft infection. Twenty-two patients (63%) underwent emergency surgery. Thirty day mortality was 31% (n = 11). Additionally, six patients died during follow-up after a median of 33 months (range 3–70). For the remaining patients, mean follow-up was 48 months (± 26) with a mean Follow-Up Index of 0.98 ± 0.08. There were no readmissions or re-operations for re-infection or graft related complications. Follow-up imaging showed no signs of graft degeneration after a median of 15 months (range 3–68). Surgical treatment of native and aortic graft or endograft infection remains high risk. Self made bovine pericardial tube grafts for in situ reconstruction are a promising option offering many advantages. Despite high early mortality rates, early radiological and mid-term clinical results are good. Definitive eradication of the infection seems feasible after in situ insertion of xeno-pericardial material for aortic repair.

Diagnosis Of Persistent Infection In Prosthetic Two-Stage Exchange: PCR analysis of Sonication fluid From Bone Cement Spacers.

Introduction: When treating periprosthetic joint infections with a two-stage procedure, antibiotic-impregnated spacers are used in the interval between removal of prosthesis and reimplantation. According to our experience, cultures of sonicated spacers are most often negative. The objective of our study was to investigate whether PCR analysis would improve the detection of bacteria in the spacer sonication fluid.Methods: A prospective monocentric study was performed from September 2014 to January 2016. Inclusion criteria were two-stage procedure for prosthetic infection and agreement of the patient to participate in the study. Beside tissues samples and sonication, broad range bacterial PCRs, specific S. aureus PCRs and Unyvero-multiplex PCRs were performed on the sonicated spacer fluid.Results: 30 patients were identified (15 hip, 14 knee and 1 ankle replacements). At reimplantation, cultures of tissue samples and spacer sonication fluid were all negative. Broad range PCRs were all negative. Specific S. aureus PCRs were positive in 5 cases. We had two persistent infections and four cases of infection recurrence were observed, with bacteria different than for the initial infection in three cases.Conclusion: The three different types of PCRs did not detect any bacteria in spacer sonication fluid that was culture-negative. In our study, PCR did not improve the bacterial detection and did not help to predict whether the patient will present a persistent or recurrent infection. Prosthetic 2-stage exchange with short interval and antibiotic-impregnated spacer is an efficient treatment to eradicate infection as both culture- and molecular-based methods were unable to detect bacteria in spacer sonication fluid after reimplantation.

Diagnostic accuracy of synovial fluid, blood markers, and microbiological testing in chronic knee prosthetic infections.

This retrospective study was undertaken to define cut-off values for synovial fluid (SF) leukocyte count and neutrophil percentage for differentiating aseptic failure and periprosthetic joint infection (PJI) and to evaluate the diagnostic accuracy of blood inflammatory markers, and microbiological testing according to the criteria proposed by the International Consensus Meeting (ICM) of Philadelphia. All patients who underwent revision total knee arthroplasty from January 2010 to July 2015 were included: we identified and classified 31 PJIs and 136 aseptic joints. The diagnostic performance of single test was assessed by receiver operating characteristic curve analyses. The sensitivity and specificity were calculated for each of the cut-off values and the area under the curve (AUC) was calculated. The median SF leukocyte count as well as the neutrophil percentage and inflammatory markers were significantly higher in patients with PJI than in those with aseptic failure (p<0.001). A leukocyte count of>2.8×103/μL had a sensitivity of 83.8% and a specificity of 89.7% whereas a neutrophil percentage of>72% yielded a marginally higher sensitivity of 84% and a specificity of 91%. Applying the ICM criteria we found a significant correlation between all these diagnostic measures and PJI (p<0.001) except for a single positive culture. The most accurate criterion of the ICM was the synovial neutrophil differential (AUC=0.89; 95% CI 0.81-0.97), followed by SF leukocyte count (AUC=0.86; 95% CI 0.78-0.94), increased inflammatory markers (AUC=0.85; 95% CI 0.76-0.93), and two positive periprosthetic cultures (AUC=0.84; 95% CI 0.73-0.94). The presence of sinus tract communicating with the joint and a single positive culture showed unfavourable diagnostic accuracy (AUC=0.60, 95% CI 0.47-0.72; AUC=0.49, 95% CI 0.38-0.61, respectively) CONCLUSIONS: The present study highlights the adequate ability of fluid cell count and neutrophil differential to distinguish between PJI and aseptic loosening. The clinical utility of fluid analysis in diagnosing infection can be improved by evaluation of other diagnostic criteria. Level I Diagnostic Study.

Salvage penile prosthetic surgery utilizing temporary malleable implants.

The inflatable penile prosthesis (IPP) is an effective erectile dysfunction (ED) treatment modality when oral and injectable therapies fail to achieve satisfactory results. Unfortunately, infection of the prosthetic remains a dreaded complication occurring in a small fraction of patients despite advances in device design and surgical techniques. With a prosthetic infection or erosion, classic management has included removal of all hardware with thorough irrigation of the infected spaces. To prevent corporal fibrosis and scarring that can make a subsequent implant challenging, an immediate salvage procedure with a three-piece prosthesis has been advocated when possible. However, there has been recent interest in using malleable devices during salvage procedures to serve as a temporary implant and further improve outcomes. Based on a literature review of immediate salvage procedures for infected penile prostheses, management with typical Mulcahy washout and IPP reimplant may be quite successful in appropriately selected patients. Based on one case series and a second multicenter trial of malleable salvage procedures, utilizing a malleable as a temporary implant is similarly, if not more, successful at eradicating prosthetic infection. The malleable implant not only serves as a temporary space-filling corporal implant to prevent fibrosis, but may also prove an adequate destination therapy for some given the lower than expected rate of delayed conversion to inflatable prosthesis. Future studies are needed to better characterize the role of malleable devices for penile prosthetic salvage and query patient satisfaction with the malleable device and repeated surgeries.

Incidence of hip and knee prosthetic infections in a specialised centre of Mexico City

Incidence of hip and knee prosthetic infections in a specialised centre of Mexico City

Social profile and cost analysis of deep infection following total hip replacement surgery

ObjectiveTo characterize the socio-economic and demographic profile of patients undergoing surgery for revision total hip arthroplasty regarding the diagnosis of deep prosthetic infection. MethodsTwenty patients were retrospectively studied, admitted in the period between 2009 and 2010 by the Hip Surgery Group with the diagnosis of deep prosthetic infection, whose proposed treatment was surgical. This study was carried out in the presence of the patient by completing two forms applied by the social worker of the Group. ResultsIn a 20-patient sample, 40% were male, 45% were working age, 50% of patients originated from the capital, 85% depended on benefits, 70% were retired, 60% of patients were from this hospital, and 40% were from other services. The average cost of patients to the public system was R$ 55,821.62 per patient and the total spent on treatment of patients in the study exceeded one million Brazilian reals, totalling R$ 1,116,432.40. ConclusionInfection from total hip arthroplasty generates a major expense to the social security system and to the public healthcare system. Physicians must always be alert to the possible risk factors and perioperative care, striving to minimize this complication.

Cryopreserved Allograft in the Management of Native and Prosthetic Aortic Infections

Masabni, Khalil MD; Balraj, Praveen MD; Liang, Liang; Shepard, Alexander D. MD, FACS; Nypaver, Timothy J. MD, FACS; Weaver, Mitchell R. MD, FACS; Kabbani, Loay MD Author Information

How to treat aortic graft infection? With a special emphasis on xeno-pericardial aortic tube grafts.

Infection of a vascular prosthesis or endovascular stent-graft is probably the most serious complication that may occur after implantation and dramatically affects the patient's outcome. The most common etiology of graft and/or prosthetic valve infection is usually wound-related infection, followed by seeding from distant infection sites (lung, urinary tract). Surgical treatment is almost always required but even after surgery, morbidity can be significant. Operative procedure must be tailored according to the individual patient and to the experience of the surgical team. Complete resection of the infected foreign material with débridement of the surrounding tissue gives most probably the best results. Orthotopic reconstruction is the best option for all thoracic and thoraco-abdominal pathologies and the use of coated prostheses, industrially fabricated bio-conduits, homografts or self-made vascular tubes from xenopericardial tissue has to be discussed from case to case. In some exceptional situations, endovascular stent-graft can be performed as bridging to a more complete treatment if general condition of the patient has to be stabilized.

Early and late results of the treatment of native and prosthetic abdominal aortic infections with cryopreserved arterial allografts

Early and late results of the treatment of native and prosthetic abdominal aortic infections with cryopreserved arterial allografts

Cryopreserved Cadaveric Arterial Allograft for Arterial Reconstruction in Patients with Prosthetic Infection

The aim of this study was to report outcomes of cryopreserved arterial allografts used as a vascular substitute in the setting of prosthetic material infection. A retrospective analysis of prospectively collected data was conducted including all consecutive interventions performed with cryopreserved arterial allografts used for vascular reconstruction in the setting of prosthetic material infection between January 2005 and December 2014. Five year outcomes included allograft related re-interventions, survival, primary patency, and limb salvage rates. Fifty-three procedures were performed using cryopreserved allografts for vascular prosthetic infection: 25 procedures (47%) were performed at aorto-iliac level (Group 1) and 28 procedures (53%) at peripheral level (Group 2). The mean follow-up was 52 months. Five year allograft related re-intervention was 55% in Group 1 (6 allograft ruptures and 5 allograft aneurysm degenerations) and 33% in Group 2 (2 allograft ruptures and 7 allograft aneurysm degenerations). Five year survival was 40% and 68%, primary patency was 89% and 59% and limb salvage was 100% and 89% for Group 1 and 2 respectively. Use of cryopreserved arterial allografts provides acceptable results but is tempered by suboptimal 5 year outcomes with high re-intervention rates.

Self Made Xeno-pericardial Aortic Tubes to Treat Native and Aortic Graft Infections

The most appropriate material for reconstruction of the aorta for native or graft infection remains a matter for debate. This study examines the mid-term outcome of patients and graft durability after in situ aortic reconstruction with self made bovine pericardial tube grafts. This was a retrospective analysis of all patients who underwent in situ aortic reconstruction using self made bovine pericardial tube grafts between January 2008 and December 2015at a tertiary referral centre. Peri-operative and mid-term outcomes including mortality and re-infection were analysed at the end of January 2017. Available follow-up imaging was reviewed to assess graft durability. Bovine pericardial aortic tube grafts were used in 35 patients (86% male) with a median age of 69 years (range 38-84) to reconstruct the ascending aorta or the aortic arch (7), the descending (7), the thoraco-abdominal (7), or the abdominal (14) aorta. Twelve patients (34%) were treated for infection of the native aorta and 23 (66%) for prosthetic graft infection. Twenty-two patients (63%) underwent emergency surgery. Thirty day mortality was 31% (n=11). Additionally, six patients died during follow-up after a median of 33 months (range 3-70). For the remaining patients, mean follow-up was 48 months (± 26) with a mean Follow-Up Index of 0.98±0.08. There were no readmissions or re-operations for re-infection or graft related complications. Follow-up imaging showed no signs of graft degeneration after a median of 15 months (range 3-68). Surgical treatment of native and aortic graft or endograft infection remains high risk. Self made bovine pericardial tube grafts for in situ reconstruction are a promising option offering many advantages. Despite high early mortality rates, early radiological and mid-term clinical results are good. Definitive eradication of the infection seems feasible after in situ insertion of xeno-pericardial material for aortic repair.

Commentary on “Cryopreserved Cadaveric Arterial Allograft for Arterial Reconstruction in Patients with Prosthetic Graft Infection”

Commentary on “Cryopreserved Cadaveric Arterial Allograft for Arterial Reconstruction in Patients with Prosthetic Graft Infection”

Cryopreserved arterial allografts for in situ reconstruction of abdominal aortic native or secondary graft infection

ObjectiveThe objective of this study was to evaluate the early and long-term outcome of cryopreserved arterial allografts (CAAs) used for in situ reconstruction of abdominal aortic native or secondary graft infection and to identify predictors of mortality. MethodsWe retrospectively included 71 patients (mean age, 65.2 years [range, 41-84 years]; men, 91.5%) treated for abdominal aortic native or secondary graft infection (65 prosthetic graft infections; 16 of them had secondary aortoenteric fistula, 2 venous graft infections, and 4 mycotic aneurysms) by in situ reconstruction with CAA in the university hospitals of Clermont-Ferrand and Saint-Etienne from 2000 to 2016. The cryopreservation protocol was identical in both centers (−140°C). Early (<30 days) and late (>30 days) mortality and morbidity, reinfection, and CAA patency were assessed. Computed tomography was performed in all survivors. Survival was analyzed with the Kaplan-Meier method. Univariate analyses were performed with the log-rank test and multivariate analysis with the Cox regression model. ResultsMean follow-up was 45 months (0-196 months). Early postoperative mortality rate was 16.9% (11/71). Early postoperative CAA-related mortality rate was 2.8% (2/71); both patients died of proximal anastomotic rupture on postoperative days 4 and 15. Early CAA-related reintervention rate was 5.6% (4/71); all had an anastomotic rupture, and two were lethal. Early postoperative reintervention rate was 15.5% (11/71). Intraoperative bacteriologic samples were positive in 56.3%, and 31% had a sole microorganism. Escherichia coli was more frequently identified in the secondary aortoenteric fistula and Staphylococcus epidermidis in the infected prosthesis. Late CAA-related mortality rate was 2.8%: septic shock at 2 months in one patient and proximal anastomosis rupture at 1 year in one patient. Survival at 1 year, 3 years, and 5 years was 75%, 64%, and 54%, respectively. Multivariate analysis identified type 1 diabetes (hazard ratio, 2.49; 95% confidence interval, 1.05-5.88; P = .04) and American Society of Anesthesiologists class 4 (hazard ratio, 2.65; 95% confidence interval, 1.07-6.53; P = .035) as predictors of mortality after in situ CAA reconstruction. Reinfection rate was 4% (3/71). Late CAA-related reintervention rate was 12.7% (9/71): proximal anastomotic rupture in one, CAA branch stenosis/thrombosis in five, ureteral-CAA branch fistula in one, and distal anastomosis false aneurysm in two. Primary patency at 1 year, 3 years, and 5 years was 100%, 93%, and 93%, respectively. Assisted primary patency at 1 year, 3 years, and 5 years was 100%, 96%, and 96%, respectively. No aneurysm or dilation was observed. ConclusionsThe prognosis of native or secondary aortic graft infections is poor. Aortic in situ reconstruction with CAA offers acceptable early and late results. Patients with type 1 diabetes and American Society of Anesthesiologists class 4 are at higher risk of mortality.

P4539Assessment of the diagnostic accuracy of 18fluorodesoxyglucose positron emission tomography/computed tomography in prosthetic heart valve and cardiac implantable electronic device infection

P4539Assessment of the diagnostic accuracy of 18fluorodesoxyglucose positron emission tomography/computed tomography in prosthetic heart valve and cardiac implantable electronic device infection

A Strategic Protocol to Improve the Process and Outcomes of Two-stage Revision Total Hip Arthroplasty.

Two-stage revision total hip arthroplasty (THA) is the most commonly used treatment approach for deep prosthetic infection. However, in this approach the interval between the first and second stage tends to be prolonged. We devised a strategic protocol for improving the infection eradication rate and shortening the interval between the stages in two-stage revision THA. This study analyzed a series of 14 patients (14 hips) from 2008 to 2012, who were treated using an antibiotic-loaded acrylic cement (ALAC) spacer at the first stage and re-implantation at the second stage. The ALAC included vancomycin and amikacin for most of the cases. Patients with MRSA infection were additionally administered intravenous vancomycin in combination with either oral rifampicin or trimethoprim-sulfamethoxazole. The average interval between the stages was 54.2 days overall, and 58.7 days for cases with MRSA infection. Our infection eradication rate was 100%, with no reported recurrence of infection. The presence of MRSA tended to be associated with a longer interval between the two stages. Our protocol for two-stage revision THA was associated with a high eradication rate of infection and a shortened interval between the stages.

Safety aspects of preoperative high-dose glucocorticoid in primary total knee replacement

BackgroundPreoperative single high-dose glucocorticoid may have early outcome benefits in total hip arthroplasty (THA) and knee arthroplasty (TKA), but long-term safety aspects have not been evaluated. MethodsFrom October 2013, the departments reporting to the prospective Lundbeck Foundation Database for Fast-track Hip and Knee Replacement introduced preoperative methylprednisolone (MP) 125 mg as part of a multimodal analgesic protocol in TKA. We analysed the risk of length of hospital stay (LOS) >4 days, 30 and 90 day readmissions in patients with MP vs patients having TKA before the use of MP and adjusted for comorbidity and place of surgery. An unadjusted comparison was specifically done to evaluate deep prosthetic infections. ResultsOf a total of 3927 TKA procedures, 1442 received MP. Median LOS was 2 days in both groups, but the fraction with LOS >4 days was 6.0% vs 11.5% (P<0.001) in patients with MP vs those without, and with a reduced risk of LOS >4 days in adjusted analysis [odds ratio (OR) 0.51; confidence interval (CI) 0.39–0.68; P<0.001]. Readmission rates were 5.6% (CI 4.5–6.9) vs 4.4% (P=0.095) and 7.8% vs 7.3% (P=0.53) at 30 and 90 days with and without MP, respectively.Adjusted analysis did not identify MP to be associated with 30 day (OR 1.18; CI 0.89–1.56; P=0.25) or 90 day (OR 1.12; CI 0.86–1.46; P=0.39) readmissions. The incidence of deep infections requiring surgical intervention was 0.8% vs 0.7% with MP vs without, respectively (P=0.78). ConclusionsIn this detailed prospective cohort study, preoperative high-dose glucocorticoid administration was not associated with LOS >4 days, readmissions or infectious complications in TKA patients without contraindications. Clinical trial registrationNCT01515670.

Infections after shoulder arthroplasty are correlated with higher anesthetic risk score: a case-control study in Brazil

PurposesShoulder arthroplasty (SA) has been performed by many years for the treatment of several conditions, including osteoarthritis and proximal humeral fractures following trauma. Surgical site infection (SSI) following Shoulder arthroplasty remains a challenge, contributing to increased morbidity and costs. Identification of risk factors may help implementing adequate strategies to prevent infection. We aimed to identify pre- and intra-operative risk factors associated with deep infections after Shoulder arthroplasty. MethodsAn unmatched case-control study was conducted to describe the prevalence, clinical and microbiological findings, and to evaluate patient and surgical risk factors for prosthetic shoulder infection (PSI), among 158 patients who underwent SA due to any reason, at a tertiary public university institution. Risk factors for PSI was assessed by uni- and multivariate analyses using multiple logistic regression. Results168 SA from 158 patients were analyzed, with an overall infection rate of 9.5% (16/168 cases). Subjects undergoing SA with American Society of Anesthesiologists (ASA) grade III or higher (odds ratio [OR]=5.30, 95% confidence interval [CI]=1.58–17.79, p<0.013) and presenting local hematoma after surgery (odds ratio [OR]=7.10, 95% confidence interval [CI]=1.09–46.09, p=0.04) had higher risk for PSI on univariate analysis. However, only ASA score grade III or higher remained significant on multivariate analysis (OR=4.74, 95% CI=1.33–16.92, p=0.016). Gram-positive cocci and Gram-negative bacilli were equally isolated in 50% of cases; however, the most commonly detected bacterium was Pseudomonas aeruginosa (18.7%). ConclusionThis study provides evidence suggesting that patient-related known factors such as higher ASA score predisposes to shoulder arthroplasty-associated infection. Furthermore, unusual pathogens associated with PSI were identified.

18F-FDG PET for diagnosing painful arthroplasty/prosthetic joint infection

Up to now, there were some studies about the role of 18F-FDG PET or PET/CT in the diagnosis of prosthetic joint infection after arthroplasty with different values of sensitivity and specificity. The purpose of this study was to systematically review the published data regarding the diagnostic performance of positron emission tomography (PET) or PET/computed tomography (PET/CT) in prosthetic infection after arthroplasty. A comprehensive computer literature search of studies published regarding PET or PET/CT in patients suspicious of prosthetic infection was performed. Pooled sensitivity, specificity and area under the receiver operating characteristic (ROC) curve of PET or PET/CT in patients suspicious of prosthetic infection on a per prosthesis-based analysis were calculated. Sixteen studies comprising 1101 prosthesis with suspicious of prosthetic infection after arthroplasty were included in this meta-analysis. The pooled sensitivity of PET or PET/CT in detecting prosthetic infection was 87% [95% confidence interval (CI) 83–90%] on a per prosthesis-based analysis. The pooled specificity of PET or PET/CT in detecting prosthetic infection was 87% (95% CI 85–89%) on a per prosthesis-based analysis. The area under the ROC curve was 0.94 on a per prosthesis-based analysis. 18F-FDG PET or PET/CT demonstrated high sensitivity and specificity in subjects suspicious of prosthetic infection. However, various degrees of uptake in the asymptomatic patients are very common. Physicians should recognize these characteristics, and then 18F-FDG PET or PET/CT can act as an effective method in the diagnosis of prosthetic infection.

Prosthetic Joint Infection after Total Hip Arthroplasty: Results of an Online Questionnaire about Current Diagnostic and Therapeutic Procedures in 107 German Hospitals

Background Prosthetic hip joint infection is a common severe complication with a high socio-economic impact. The inconsistency of the available data and the absence of binding guidelines lead to a variety of diagnostic and therapeutic strategies. The aim of this study is to present the current diagnostic and therapeutic approach to treating infections after total hip arthroplasties in German hospitals, link it with current evidence, and evaluate the willingness of these hospitals to participate in prospective multicentre trials. Material and Methods An online questionnaire for digital processing was sent to hospitals performing joint replacement procedures. These institutions included district hospitals, private hospitals, non-university maximum care facilities, statutory accident insurance hospitals, and university hospitals. Results A total of 107 hospitals took part in the survey, corresponding to a response rate of 27.6%. These hospitals perform approximately 2,951 revisions of infected total hip arthroplasties per year. Two-stage revision arthroplasty is the preferred procedure after prosthetic hip infections. The algorithm proposed by Zimmerli et al. is widely recognised. There is a lack of uniformity in the key features for revision of prosthetic joint infections - long vs. short interval in case of two-stage revision, duration of intravenous and oral administration of antibiotics, cemented vs. cement-free implant procedures, and follow-up intervals after revision surgery. The willingness to participate in clinical trials is high. Conclusion The controversial data leads to multiple treatment approaches. The high willingness to participate in adequately funded clinical trials offers a potential for multicentre trials to be conducted. There is an urgent need for funding to make this research possible.