Treatment Of Periprosthetic Joint Infection Research Articles

No differences in outcomes with stopping or continuing antibiotic suppression in periprosthetic joint infections

No differences in outcomes with stopping or continuing antibiotic suppression in periprosthetic joint infections

Association Between Periprosthetic Joint Infection and Mortality Following Primary Total Hip Arthroplasty

Background: Periprosthetic joint infection (PJI) remains a dreaded and unpredictable complication after total hip arthroplasty (THA). In addition to causing substantial morbidity, PJI may contribute to long-term mortality risk. Our objective was to determine the long-term mortality risk associated with PJI following THA. Methods: This population-based, retrospective cohort study included adult patients (≥18 years old) in Ontario, Canada, who underwent their first primary elective THA for arthritis between April 1, 2002, and March 31, 2021. The primary outcome was death within 10 years after the index THA. Mortality was compared between propensity-score-matched groups (PJI within 1 year after surgery versus no PJI within 1 year after surgery) with use of survival analyses. Patients who died within 1 year after surgery were excluded to avoid immortal time bias. Results: A total of 175,432 patients (95,883 [54.7%] women) with a mean age (and standard deviation) of 67 ± 11.4 years underwent primary THA during the study period. Of these, 868 patients (0.49%) underwent surgery for a PJI of the replaced joint within 1 year after the index procedure. After matching, patients with a PJI within the first year had a significantly higher 10-year mortality rate than their counterparts (11.4% [94 of 827 patients] versus 2.2% [18 of 827 patients]; absolute risk difference, 9.19% [95% confidence interval (CI), 6.81% to 11.6%]; hazard ratio, 5.49 [95% CI, 3.32 to 9.09]). Conclusions: PJI within 1 year after surgery is associated with over a fivefold increased risk of mortality within 10 years. The findings of this study underscore the importance of prioritizing efforts related to the prevention, diagnosis, and treatment of PJIs. Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Local antibiotic delivery via intra-articular catheter infusion for the treatment of periprosthetic joint infection: a systematic review.

There is an increasing interest in the use of intra-articular (IA) antibiotic infusion as a stand-alone or adjuvant therapy to standard revision surgery for periprosthetic joint infection (PJI). The objective of this systematic review is to evaluate the evidence with respect to this up-and-coming treatment modality. A systematic review of studies published until April 2023 was conducted using PubMed, Embase, MEDLINE and Cochrane databases. Quality assessment was performed with the National Institute of Health quality assessment tool. Inclusion criteria were adult patients (≥ 18years) with a mean follow-up of ≥ 11months and a score ≥ 6 on the National Institute of Health quality assessment tool. Primary outcome was eradication of infection. 15 articles, encompassing 631 PJIs in 626 patients, were included in the final analysis, all level IV case series. The majority was treated with single-stage revision with adjuvant IA antibiotic infusion (79.1%). The remaining PJIs were treated with stand-alone IA antibiotic infusion (12.2%), DAIR (debridement, antibiotics and implant retention) with adjuvant IA antibiotic infusion (5.7%) or two-stage revision with adjuvant IA antibiotic infusion (3.0%). Mean duration of IA antibiotic infusion was 19days (range 3-50). An overall failure rate of approximately 11% was found. In total 117 complications occurred, 71 were non-catheter-related and 46 were catheter-related. The most common catheter-related complications were premature loss of the catheter (18/46) and elevated blood urea nitrogen (BUN) and creatinine levels (12/46). Due to the lack of comparative studies the (added) benefit of IA antibiotic infusion in the treatment of PJI remains uncertain. Based on the current evidence, we would advise against using it as a stand-alone treatment. A prospective randomized controlled trial using a well-described infusion protocol is needed to see if the potential benefits justify the increased costs and potential complications of this treatment modality.

Evaluating Modern Spacer Options and Outcomes in Revision Hip Arthroplasty

IntroductionA two-stage revision continues to be the standard treatment for periprosthetic joint infection (PJI) in hip arthroplasty. The use of “functional” spacers may allow patients to return to daily living while optimizing their health for revision surgery. We aimed to evaluate the clinical outcomes of different spacer types regarding infection eradication, mechanical complications, and functional outcomes. MethodsPatients who have complete Musculoskeletal Infection Society (MSIS) criteria for diagnosis of PJI that underwent one-stage or two-stage revision were queried in an institutional surgical database between 2002 and 2022. Out of 286 patients, 210 met our inclusion criteria and were retrospectively reviewed for demographics, laboratory values, functional and patient-reported outcomes, and subsequent revisions. The study population had 54.3% females, a mean age of 61.7 years old, and a mean follow-up of 3.7 ± 3.2 years. There was no difference between age, body mass index (BMI), or Charlson Comorbidity Index (CCI) scores between each cohort. Spacers were categorized as nonfunctional static, nonfunctional articulating, or functional articulating. Functional spacers were defined as those that allowed full weightbearing with no restrictions. Delphi criteria were used to define revision success, and failure was defined as a recurrent or persistent infection following definitive surgery. ResultsThere was a significantly lower re-operation rate after a definitive implant in the functional articulating cohort (P = 0.003), with a trending higher infection eradication rate and a lower rate of spacer failure compared to the nonfunctional spacer cohort. At 5 years, functional articulating spacers had a 94.1% survivorship rate, nonfunctional articulating spacers had an 81.2% survival rate, and nonfunctional static spacers had a 71.4% survival rate. In the functional articulating spacer cohort, 14.6% had yet to get reimplanted, with an average follow-up time of 1.4 years. ConclusionWithin this large cohort of similar demographics, functional articulating spacers may result in better clinical outcomes and infection eradication during two-stage revision arthroplasty for PJI.

Culture-negative periprosthetic joint infections: Do we have an issue?

Culture-negative periprosthetic joint infection (PJI) poses a significant challenge in clinical settings. The lack of information on causative organism(s) leads to uncertainties regarding the choice of antimicrobial treatment, which can potentially adversely influence the outcome. Recent advances in molecular-based diagnostic methods have the potential to address the difficulties associated with culture-negative PJIs. These technologies offer a solution to the existing clinical dilemma by providing identification of pathogens and guiding appropriate antimicrobial treatment.In this narrative review, we provide information regarding: 1) incidence and risk factors for culture-negative PJI; 2) the optimal antimicrobial therapy and duration of treatment for culture-negative PJI; 3) outcome comparison between culture-positive and culture-negative PJI; and 4) utilization of novel molecular diagnostic methods in culture-negative PJI, including pathogen identification, and the implementation of an antibiotic stewardship program.

Surgical procedures for the treatment of fungal periprosthetic infection following hip arthroplasty: a systematic scoping review.

There has been limited literature synthesizing the therapeutic effects of surgical procedures for fungal periprosthetic joint infection (PJI) following hip arthroplasty. The authors' current study aims to comprehensively review and analyze those relevant literature, and carefully make recommendations for future clinical practices. Our current study was carried out in accordance with the PRISMA 2020 statement. Studies regarding the surgical management of fungal PJI following hip arthroplasty were collected via a thorough search of PubMed, Embase and Google scholar databases. The search was lastly performed in March 2023. Non-English language, reviews, articles with duplicated data, and articles without clear information about the type of fungal pathogens and treatment options were excluded. The authors evaluated their systematic review compliance by using AMSTAR 2 criteria and fell in moderate quality. Clinical outcomes of different surgical procedures were evaluated, and a binary logistic regression model was used to identify the risks associated with treatment failure. Data analyses were performed using the SPSS version 19.0. A total of 33 articles encompassing 80 patients with fungal PJI following hip arthroplasty were identified. Candida albicans was the most frequently isolated fungus (56.3%, 45/80). The overall treatment success was achieved in 71.1% (54/76) of the reported cases. Univariate analysis showed that the differences of success rate were not significant between publication periods, genders, ages, specimen collection methods, and fungal pathogens. Treatment success rate was 47.4% (9/19) in fungal PJI cases with bacterial co-infection, significantly lower than those without [vs. 79.0% (45/57), P=0.017]. The pooled success rate for surgical debridement, spacer implantation, resection arthroplasty, one-stage revision, and two-stage revision was 50.0% (4/8), 42.9% (3/7), 55.0% (11/20), 86.7% (13/15), and 88.5% (23/26), respectively, with significant differences between them (P=0.009). A binary logistic regression model showed that bacterial co-infection and surgical option were the two significant risk factors associated with treatment failure for fungal PJI following hip arthroplasty. Regarding the surgical treatment of fungal PJI following hip arthroplasty, patients with bacterial co-infection, and those treated with surgical procedures such as debridement, spacer implantation, and resection arthroplasty should be aware of the higher risks of failure. Nonetheless, future multiple-centre cohort studies are required to establish the optimal treatment.

Effects of Vancomycin/Tobramycin-Doped Ceramic Composite (PVA-VAN/TOB-PDCPD) in a Rat Femur Model Implanted with Contaminated Porous Titanium Cylinders

Periprosthetic joint infection (PJI) remains common and problematic. We hypothesized that using a bioceramic that has rapid release of an antibiotic (vancomycin [VAN] or vancomycin/tobramycin [VAN/TOB]) from a polyvinyl alcohol composite (PVA) combined with a delayed and sustained antibiotic release from polymeric dicalcium phosphate dihydrate (P-DCPD) ceramic would inhibit S. aureus-associated implant infection. A total of fifty male Sprague Dawley rats were randomly divided into 5 experimental groups: I-negative control; II-bacteria only; III-bacteria+saline wash; IV-bacteria+PVA-VAN-PDCPD, and V-bacteria+PVA-VAN-TOB-PDCPD. A porous titanium (Ti) implant was press-fit into the rat knee. S. aureus-containing broth was added into the joint space to create a PJI. After one week, the joints from groups III to V were washed with saline and the fluid collected for bacterial quantification. This was followed by saline irrigation treatment (groups III to V) and application of the antibiotic-loaded PVA-PDCPD bioceramic (groups IV and V). On day 21, joint fluid was collected, and the implants were harvested for bacterial quantification. No bacteria were isolated from the negative control (group I). The positive control (group II) was positive on both days 7 and 21. Bacteria were still present on day 21 in the fluid and implant in Group III. Groups (IV and V) showed a decrease in the bacterial burden in the fluid and implant on day 21. There were significant differences in bacteria levels in the collected wash fluid and on the implant at day 21 between the saline wash (Group III) and treatment groups (IV and V). In this rat model of acute periprosthetic infection, treatment with PVA-VAN-PDCPD and PVA-VAN/TOB-PDCPD reduced the bacterial load in the infected joint and the infected Ti implant. Application of PVA-VAN-PDCPD and/or PVA-VAN/TOB-PDCPD after saline irrigation could be used as an addition to the treatment of PJI.

SUCCESS RATE AFTER 2-STAGE SPACER-FREE TOTAL HIP ARTHROPLASTY EXCHANGE AND RISK FACTORS FOR REINFECTION: A PROSPECTIVE COHORT STUDY OF 187 PATIENTS

Two-stage prosthesis exchange is the treatment of choice for chronic periprosthetic joint infection (PJI) of a total hip arthroplasty (THA), especially when the bone and surrounding soft tissues are compromised or difficult-to-treat pathogens are implicated. (1) to determine the outcome of two-stage prosthesis exchange for the treatment of PJI after THA; and (2) to determine risk factors for reinfection leading to subsequent revision surgeries after reimplantation. We prospectively enrolled 187 consecutive patients who underwent a two-stage THA exchange with resection arthroplasty for PJI from 2013 to 2019. The mean (± SD [standard deviation]) duration of follow-up was 54.2 ± 24.9 months (range, 36 to 96), and the mean interval until reimplantation was 9.8 ± 8.9 weeks (range, 2 to 38). All patients remained in a spacer-free girdlestone situation between the two stages of treatment. Patients who remained infection-free after their two-stage treatment were considered to have achieved treatment success. The overall success rate was 85.6%. The cumulative probability of reinfection was 11.5% after one year and 14% after two years after reimplantation. High virulence or DTT (difficult-to-treat) pathogens were significant and independent risk factors for reinfection (HR [hazard ratio] = 3.71, 95% CI [confidence interval]: 1.47 to 9.36, P = 0.006 and HR = 3.85, 95% CI: 1.73 to 8.57, respectively, P = 0.001), as was previous two-stage hip prosthesis exchange (HR = 3.58, 95% CI: 1.33 to 9.62, P = 0.01). Overall reoperation and revision rates were 26.2 and 16.6%, respectively. Re-infected patients had an 80% higher probability of reoperation than non-infected ones (P < 0.001, log-rank = 102.6), and they were 55% more likely to undergo revision surgery during their follow-up (P < 0.001, log-rank = 55.4). Reinfection rates after two-stage spacer-free THA revision for PJI still remain high, but are comparable to those including cement spacers. Patients who have had prior failed two-stage implant exchanges or are infected by high-grade or difficult-to-treat pathogens are at high risk for treatment failure.

Modular fluted tapered stems in two-stage reimplantation of previously infected total hip arthroplasties.

Uncemented implants are now commonly used at reimplantation of a two-stage revision total hip arthoplasty (THA) following periprosthetic joint infection (PJI). However, there is a paucity of data on the performance of the most commonly used uncemented femoral implants - modular fluted tapered (MFT) femoral components - in this setting. This study evaluated implant survival, radiological results, and clinical outcomes in a large cohort of reimplantation THAs using MFT components. We identified 236 reimplantation THAs from a single tertiary care academic institution from September 2000 to September 2020. Two designs of MFT femoral components were used as part of an established two-stage exchange protocol for the treatment of PJI. Mean age at reimplantation was 65 years (SD 11), mean BMI was 32 kg/m2 (SD 7), and 46% (n = 109) were female. Mean follow-up was seven years (SD 4). A competing risk model accounting for death was used. The 15-year cumulative incidence of any revision was 24%. There were 48 revisions, with the most common reasons being dislocation (n = 25) and infection (n = 16). The 15-year cumulative incidence of any reoperation was 28%. Only 13 revisions involved the fluted tapered component (FTC), for a 15-year cumulative incidence of any FTC revision of 8%. Only two FTCs were revised for aseptic loosening, resulting in a 15-year cumulative incidence of FTC revision for aseptic loosening of 1%. Stem subsidence ≥ 5 mm occurred in 2% of unrevised cases. All stems were radiologically stable at most recent follow-up. Mean Harris Hip Score was 69 (SD 20) at most recent follow-up. This series demonstrated that MFT components were durable and reliable in the setting of two-stage reimplantation THA for infection. While the incidence of aseptic loosening was very low, the incidence of any revision was 24% at 15 years, primarily due to dislocation and recurrent PJI.

Changing the definition of treatment success alters treatment outcomes in periprosthetic joint infection: a systematic review and meta-analysis

Abstract. Background: Variability in the definition of treatment success poses difficulty when assessing the reported efficacy of treatments for hip and knee periprosthetic joint infection (PJI). To address this problem, we determined how definitions of PJI treatment success have changed over time and how this has affected published rates of success after one-stage and two-stage treatments for hip and knee PJI. Methods: A systematic review following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines was conducted to identify one-stage and two-stage revision hip and knee PJI publications in major databases (2006–2021). Definition of treatment success, based on Musculoskeletal Infection Society tier criteria, was identified for each study. Publication year, number of patients, minimum follow-up, and study quality were also recorded. The association of success definitions and treatment success rate was measured using multi-variable meta-regression. Results: Study quality remained unchanged in the 245 publications included. Over time, no antibiotics (tier 1) and no further surgery (tier 3) (40.7 % and 54.5 %, respectively) became the two dominant criteria. After controlling for type of surgery, study quality, study design, follow-up, and year of publication, studies with less strict success definitions (tier 3) reported slightly higher odds ratios of 1.05 [1.01, 1.10] (p=0.009) in terms of treatment success rates compared to tier 1. Conclusions: PJI researchers have gravitated towards tier-1 and tier-3 definitions of treatment success. While studies with stricter definitions had lower PJI treatment success, the clinical significance of this is unclear. Study quality, reflected in the methodological index for non-randomized studies (MINORS) score, did not improve. We advocate for improving PJI study quality, including clarification of the definition of treatment success.

Validity of a preoperative scoring system for surgical management of periprosthetic hip infection: one-stage vs. two-stage revision.

There are no widely accepted algorithms for determining optimal treatment for periprosthetic joint infection (PJI). Our study aimed to confirm the validity of a previously published scoring system in a larger number of patients to support a rational surgical treatment strategy for periprosthetic hip infection. Between February 2001 and December 2020, we performed 155 consecutive revision total hip arthroplasties (THAs) for PJI, with mean follow-up of 6 years. One-stage revision THA was performed in 56 hips and two-stage revision THA in 99 hips. Prosthesis survival from recurrent infection was determined by Kaplan-Meier analysis, using implant removal as the endpoint. The pre-operative scoring system (full score of 12 points), including 6 essential elements, was retrospectively evaluated. The 10-year survival rates were 98% for one-stage (95% confidence interval [CI], 94-100) and 87% (95% CI, 79-96) for two-stage revision THA. Multivariate Cox regression analysis provided a total preoperative score as an independent risk factor for implant removal (hazard ratio, 0.17; 95% CI, 0.06-0.49; p < 0.001). The sensitivity and specificity at the cut-off of 4 points on the scoring system were 80% and 91%, respectively. The average score for one-stage revision THA in successful and failed cases were 8.9 and 6.0, and for two-stage revision THA were 6.5 and 3.9, respectively. We found significant differences between successful cases in one- and two-stage revision THA (p < 0.05). The preoperative scoring system was useful for managing PJI. One-stage revision THA is recommended in patients scoring ≥ 9 points, and meticulously performed two-stage revision THA is encouraged for patients scoring ≥ 4 points.

Systemic Inflammation Response Index (SIRI) and Monocyte-to-Lymphocyte Ratio (MLR) Are Predictors of Good Outcomes in Surgical Treatment of Periprosthetic Joint Infections of Lower Limbs: A Single-Center Retrospective Analysis.

Periprosthetic joint infection (PJI) is a devastating complication that develops after total joint arthroplasty (TJA), whose incidence is expected to increase over the years. Traditionally, surgical treatment of PJI has been based on algorithms, where early infections are preferably treated with debridement, antibiotics, and implant retention (DAIR) and late infections with two-stage revision surgery. Two-stage revision is considered the "gold standard" for treatment of chronic prosthetic joint infection (PJI) as it enables local delivery of antibiotics, maintenance of limb-length and mobility, and easier reimplantation. Many studies have attempted to identify potential predicting factors for early diagnosis of PJI, but its management remains challenging. In this observational retrospective study, we investigated the potential role of inflammatory blood markers (neutrophil-to-lymphocyte ratio (NLR), monocyte-to-lymphocyte ratio (MLR), platelet-to-lymphocyte ratio (PLR), systemic inflammatory index (SII), systemic inflammatory response index (SIRI), and aggregate index of systemic inflammation (AISI)) as prognostic factors in two-stage exchange arthroplasty for PJI. A single-center retrospective analysis was conducted, collecting clinical data and laboratory parameters from patients submitted to prosthetic explantation (EP) for chronic PJI. Laboratory parameters (PCR, NLR, MLR, PLR, SIRI, SII, and AISI) were evaluated at the explantation time; at 4, 6, and 8 weeks after surgery; and at reimplantation time. The correlation between laboratory parameters and surgery success was evaluated and defined as infection absence/resolution at the last follow-up. A total of 57 patients with PJI were evaluated (62% males; average age 70 years, SD 12.14). Fifty-three patients with chronic PJI were included. Nine patients underwent DAIR revision surgery and chronic suppressive therapy; two patients died. Nineteen patients completed the two-stage revision process (prosthetic removal, spacer placement, and subsequent replanting). Among them, none showed signs of reinfection or persistence of infection at the last available follow-up. The other twenty-three patients did not replant due to persistent infection: among them, some (the most) underwent spacer retention; others (fewer in number) were submitted to resection arthroplasty and arthrodesis (Girdlestone technique) or chronic suppressive antibiotic therapy; the remaining were, over time, lost to follow-up. Of the patients who concluded the two-stage revision, the ones with high SIRI values (mean 3.08 SD 1.7 and p-value 0.04) and MLR values (mean 0.4 SD 0.2 and p-value 0.02) at the explantation time were associated with a higher probability of infection resolution. Moreover, higher variation in the SIRI and PCR, also defined, respectively, as delta-SIRI (mean -2.3 SD 1.8 and p-value 0.03) and delta-PCR (mean -46 SD 35.7 and p-value 0.03), were associated with favorable outcomes. The results of our study suggest that, in patients with PJI undergoing EP, the SIRI and MLR values and delta-SIRI and delta-PCR values could be predictive of a favorable outcome. The evaluation of these laboratory indices, especially their determination at 4 weeks after removal, could therefore help to determine which patients could be successfully replanted and to identify the best time to replant. More studies analyzing a wider cohort of patients with chronic PJI are needed to validate the promising results of this study.

Debridement, Antibiotic Pearls, and Retention of the Implant (DAPRI) in the Treatment of Early Periprosthetic Knee Joint Infections: A Literature Review.

(1) Background: Periprosthetic joint infections (PJIs) are severe and frightening complications in orthopaedic surgery, and they are generally divided into three categories: early infections (those occurring within the first 4-6 weeks), delayed infections (those occurring between 3 and 24 months), and late infections (those occurring more than 2 years after surgery). PJI treatment comprises "debridement, antibiotics, and implant retention" (DAIR), single-stage revision, and double-stage revision. Nowadays, to improve the chances of retaining an infected implant and to improve the traditional DAIR method, a modified surgical technique has been developed, named DAPRI (debridement, antibiotic pearls, and retention of the implant). Our study aims to present an up-to-date concept evaluation of the DAPRI technique and its success rate. (2) Methods: Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) standards were followed, applying a protocol defined by the authors: a total of 765 articles were identified, and at the end of the screening process only 7 studies were included. (3) Results: Currently, the DAPRI procedure can be performed only on patients who have had PJI symptoms for less than 4 weeks, and in order to achieve the highest success rate, indications are quite strict: it is appropriate in patients with acute, superficial infections without sinus tract presence, and well-fixed implants with known sensitive bacteria. The DAPRI surgical method follows a step-by-step process consisting of a first phase of biofilm identification with intra-articular injection of methylene blue, followed by biofilm removal (thermic, mechanical, and chemical aggression), and a last step consisting of prevention of PJI recurrence by using calcium sulphate antibiotic-added beads. (4) Conclusions: The DAPRI approach improves the traditional DAIR technique. It is a correct treatment for acute and early haematogenous PJI, and improves the DAIR success rate.

Safety Profile of Seven-Day Intra-articular Antibiotic Irrigation for the Treatment of Chronic Periprosthetic Joint Infection: A Prospective Randomized Phase II Comparative Study

BackgroundSystemic intravenous antimicrobials yield poor outcomes during treatment of periprosthetic joint infection due to the inability to obtain minimum biofilm eradication concentrations. This study evaluated the safety of a novel method of optimized local delivery of intra-articular antibiotics (IAAs). MethodsThis was a Phase II, multicenter, prospective randomized trial evaluating safety of a rapid (seven-day) two-stage exchange arthroplasty with IAA irrigation compared to standard two-stage exchange. The Experimental Group received irrigation using 80 mg tobramycin daily with a 2-hour soak, followed by hourly irrigation using 125 mg vancomycin with a 30-minute soak via an intramedullary irrigation device. The Control Group received an antibiotic-loaded cement spacer with vancomycin (average 8.4 g) and tobramycin (average 7.1 g, total 16 g antibiotics). Both groups received 12 weeks of systemic antibiotics following Stage 2. Safety measures included adverse events, peak vancomycin/tobramycin serum concentrations (Experimental Group), blood transfusion, and mortality. There were thirty-seven patients randomized to the Experimental Group and 39 to control. There was no difference in baseline demographics or comorbidities. ResultsThere were no antibiotic medication-related adverse events and 2 serious adverse events related to antibiotic instillation. Of 188 vancomycin peak measurements, 69% had detectable serum level concentrations, with all concentrations well below the maximum acceptable trough threshold of 20 μg/mL. Of the 103 tobramycin peak measurements, 45% had detectable levels, with all below the maximum acceptable peak threshold of 18 to 24 μg/mL. There was no difference in blood transfused per subject (Experimental: 655 mL versus Control: 792 mL; P = .4188). There were two (2) deaths in the Experimental Group and four (4) in the control. ConclusionsThe use of IAA is safe with minimal systemic antibiotic exposure. There was no difference in the rates or severity of serious adverse events between groups. Further research is being conducted to examine treatment efficacy.

Comparison of Delphi Consensus Criteria and Musculoskeletal Infection Society Outcome Reporting Tool Definitions of Successful Surgical Treatment of Periprosthetic Knee Infection

BackgroundAgreement on success following surgical treatment for periprosthetic joint infection (PJI) is important for comparing the efficacy of different surgical approaches with varying consequences and outcomes and setting patient expectations. We compared success rates following two-stage exchange arthroplasty for knee PJI using two expert-consensus definitions of success. MethodsProspectively documented data for 57 knees treated by a single surgeon at an academic tertiary care center were retrospectively reviewed. Treatment outcomes were quantified using the Delphi Consensus Criteria and the Musculoskeletal Infection Society Outcome Reporting Tool (MSIS ORT). ResultsSuccess rates were 81% using the Delphi Consensus Criteria and 56% using the MSIS ORT (P = .008). The MSIS ORT success rates increased to 76% when aseptic revisions and deaths unrelated to PJI were not penalized as failures of treatment. Predicted probabilities of successful treatment in a hypothetical case scenario were lowest based on the MSIS ORT and similarly higher using Delphi Consensus Criteria and MSIS ORT modified for both women (53.0, 90.8, and 88.7%) and men (29.1, 89.1, and 89.3%). ConclusionsStudy observations underscore the need for a uniformly accepted single definition of surgical treatment success.

Similar Efficacy and Lower Cost Associated With Ceftazidime Compared to Tobramycin Coupled With Vancomycin in Antibiotic Spacers in the Treatment of Periprosthetic Joint Infection

BackgroundVancomycin and tobramycin have traditionally been used in antibiotic spacers. In 2020, our institution replaced tobramycin with ceftazidime. We hypothesized that the use of ceftazidime/vancomycin (CV) in antibiotic spacers would not lead to an increase in treatment failure compared to tobramycin/vancomycin (TV). MethodsFrom 2014 to 2022, we identified 243 patients who underwent a stage I revision for periprosthetic joint infection. The primary outcome was a recurrent infection requiring antibiotic spacer exchange. We were adequately powered to detect a 10% difference in recurrent infection. Patients who had a prior failed stage I or two-stage revision for infection, acute kidney injury prior to surgery, or end-stage renal disease were excluded. Given no other changes to our spacer constructs, we estimated cost differences attributable to the antibiotic change. Chi-square and t-tests were used to compare the two groups. Multivariable logistic regressions were utilized for the outcomes. ResultsThe combination of TV was used in 127 patients; CV was used in 116 patients. Within one year of stage I, 9.8% of the TV group had a recurrence of infection versus 7.8% of the CV group (P = .60). By final follow-up, results were similar (12.6 versus 8.6%, respectively, P = .32). Adjusting for potential risk factors did not alter the results. Cost savings for ceftazidime versus tobramycin are estimated to be $68,550 per one hundred patients treated. ConclusionsReplacing tobramycin with ceftazidime in antibiotic spacers yielded similar periprosthetic joint infection eradication success at a lower cost. While larger studies are warranted to confirm these efficacy and cost-saving results, our data justifies the continued investigation and use of ceftazidime as an alternative to tobramycin in antibiotic spacers.

Augmented Articulating Spacers in Infected Total Knee Arthroplasty: Surgical Technique.

Periprosthetic joint infections (PJIs) are a prominent subject of discussion in orthopedics and are frequently debated at conferences and congresses. In the context of PJIs affecting the knee, the decision between following a one-stage or two-stage treatment approach has historically been a pivotal consideration. The first option is limited by indications and potentially devastating complications in case of failure, whereas the second is widely accepted as the gold standard. Initially, the spacer was conceived solely to restore and maintain knee space after removal of the implant. An articulating spacer was introduced to mitigate patient limitations and improve knee function and quality of life. Two main types of articulating spacers are utilized in knee PJI treatment: the mold spacer and the metal-on-poly spacer. This text outlines a technique for metal-on-poly spacer implants. Based on our experience and the existing literature, this approach facilitates early full weight bearing and faster recovery of the knee's range of motion, ultimately improving the quality of life after surgery, thus allowing the spacer retention for an extended period, as suggested by the 1.5-stage revision.

The Orthopaedic Device Infection Network: Building an Evidence Base for the Treatment of Periprosthetic Joint Infection Through International Collaboration

The Orthopaedic Device Infection Network: Building an Evidence Base for the Treatment of Periprosthetic Joint Infection Through International Collaboration

Periprosthetic Joint Infection as a Socio-Economic Problem of Modern Orthopedics

Periprosthetic joint infection is the main social and economic problem of modern orthopedics with a recurrence rate of chronic forms of up to 23.2–31.5%. The aim of this review is to inform various specialties doctors about the features of pathogenesis, etiology and treatment of periprosthetic joint infection, which significantly differ it from of other surgical site infections. The severity of infectious complications is due to the suppression of the patient’s immune system and microbial biofilms. Surgical treatment of periprosthetic joint infection involves debridement with preservation or removal of the implants, resection arthroplasty and arthrodesis. Today, in the treatment of more than 80% of cases of chronic infection, a two-stage approach is used, which allows to restore joint function after an average of 1.0–1.5 years. An integral part of the treatment of patients is high-dose, long-term and combined antibiotic therapy, which allows you to effectively deal with the leading pathogens of periprosthetic infection Staphylococcus aureus and S. epidermidis, the share of which is 46.5–57.5%. In the conditions of growing resistance of bacteria to antibiotics, the interest of researchers in the possibilities of using bacteriophages in the complex therapy of infections of bones and joints has increased. The cost of treatment exceeds the cost of “aseptic” joint replacement by 2–24 times and is characterized by a high level of disability and mortality of patients. Taking into account the numerous factors affecting the course and effectiveness of complex treatment of patients with periprosthetic infection, a multidisciplinary approach is currently considered the main component of success. The medical and social significance and high financial costs of treating patients with periprosthetic infection indicate the need for further research and the active implementation of effective scientific developments in the practical healthcare system.

Do one-stage indications predict success following two-stage arthroplasty for chronic periprosthetic joint infection?

Introduction: The 2018 International Consensus Meeting (ICM) proposed criteria for one-stage exchange arthroplasty in treating periprosthetic joint infection (PJI). Our study aimed to determine what proportion of PJI patients met the 2018 ICM criteria and how this affected infection-free survivorship for patients. Methods: All chronic PJI patients treated with two-stage exchange within our institution between 2017-2020 were retrospectively reviewed. Included cases met 2011 Musculoskeletal Infection Society (MSIS) criteria for PJI and had a 2-year minimum follow-up. Treatment success was defined as Tier 1A in the 2019 MSIS working group definition. ICM one-stage criteria included non-immunocompromised host, absence of sepsis, adequate soft tissue for closure, known preoperative pathogen, and susceptibility. Immunocompromised host was analyzed as two separate definitions. Kaplan-Meier survivorship, Cox regression, and univariate analyses were performed. Results: A total of 293 chronic PJI patients were included. Overall, treatment failure occurred in (21.8 %) patients. Only 13 % () met ICM criteria definition no.1 for one-stage exchange; 12 % () met definition no.2. In both definitions, infection-free survivorship at 2years did not differ between patients who met and did not meet criteria (). Cox proportional hazard regression analyses demonstrated that the only variable predicting treatment failure was knee joint involvement (). Conclusions: We found that a very limited number of chronic PJI patients were suitable for a one-stage exchange. Furthermore, the supposition that healthier hosts with known pathogens (the basis of the ICM criteria) yield better PJI treatment outcomes was not observed. These results justify the ongoing multicenter randomized control trial comparing one-stage versus two-stage treatment for chronic PJI.