The use of augmented antibiotic-loaded cement spacer in periprosthetic joint infection patients with acetabular bone defect

Abstract Background Spacer complications may affect final clinical outcome of the two-stage approach in periprosthetic joint infection (PJI) patients. This study aimed to investigate clinical outcomes and complications of augmented antibiotic-loaded cement spacer in PJI patients with acetabular bone defect. Methods Data on PJI patients with acetabular bone defect receiving two-stage revision from January 2009 to December 2016, in our hospital were retrospectively reviewed. Screw-cement-shell was used to improve the stability of the hip with acetabular wall defect. Handmade acetabular spacer could prevent femoral spacer entering into pelvis in patients with acetabular internal wall defect. A total of 26 patients (11 males and 15 females) were included in the current study. Their mean age was 46.7 ± 15.4 years old. Clinical outcomes and complications were measured. Results Twenty-one of total 26 hips (21/26, 80.8%) showed positive cultures and 15/26 (57.7%) samples were cultured with staphylococcus. Of enrolled patients, 5/26 (19.2%) developed mixed infection. There was one patient (3.8%) with spacer dislocation and two (7.7%) with spacer fracture. One patient developed acute PJI 5 years after the second-stage revision, so overall success rate among these patients was 96.2%. Differences in Paprosky classifications before the first and second stage did not reach significant level (p > 0.05). Hip Harris score was raised from 40.9 ± 14.0 to 81.2 ± 11.2 (p < 0.05). Conclusions Augmented antibiotic-loaded cement spacer could achieve satisfactory clinical outcomes in PJI patients with acetabular bone defect. It provided joint mobility, increased additional joint stability, and decreased iatrogenic bone defect caused by acetabular wear.

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Repeat two-stage exchange arthroplasty for recurrent periprosthetic hip or knee infection: what are the chances for success?

Archives of Orthopaedic and Trauma Surgery ◽

10.1007/s00402-021-04330-z ◽

2022 ◽

Author(s):

A. C. Steinicke ◽

J. Schwarze ◽

G. Gosheger ◽

B. Moellenbeck ◽

T. Ackmann ◽

...

Keyword(s):

Risk Factors ◽

Periprosthetic Joint Infection ◽

Joint Infection ◽

Rank Test ◽

Success Rates ◽

Two Stage ◽

Second Stage ◽

Exchange Arthroplasty ◽

Parametric Testing

Abstract Introduction Two-stage revision is a frequently chosen approach to treat chronic periprosthetic joint infection (PJI). However, management of recurrent infection after a two-stage exchange remains debated and the outcome of a repeat two-stage procedure is unclear. This study investigates the success rates of repeat two-stage exchange arthroplasty and analyzes possible risk factors for failure. Materials and methods We retrospectively identified 55 patients (23 hips, 32 knees) who were treated with repeat resection arthroplasty and planned delayed reimplantation for recurrent periprosthetic joint infection between 2010 and 2019 after a prior two-stage revision at the same institution. The minimum follow-up was 12 months with a median follow-up time of 34 months (IQR 22–51). The infection-free survival, associated revision surgeries, and potential risk factors for further revision were analyzed using Kaplan–Meier survival curves and comparative non-parametric testing. Results 78% (43/55) underwent reimplantation after a repeat implant removal. Of those who completed the second-stage surgery, 37% (16/43) underwent additional revision for infection and 14% (6/55) underwent amputation. The reinfection-free implant survivorship amounted to 77% (95% CI 64–89%) after 1 year and 38% (95% CI 18–57%) after 5 years. Patients with a higher comorbidity score were less likely to undergo second-stage reimplantation (median 5 vs. 3, p = 0.034). Furthermore, obese patients (p = 0.026, Fisher’s exact test) and diabetics (p < 0.001, log-rank test) had a higher risk for further infection. Most commonly cultures yielded polymicrobial growth at the repeat two-stage exchange (27%, 15/55) and at re-reinfection (32%, 9/28). Pathogen persistence was observed in 21% (6/28) of re-reinfected patients. Conclusion The success rates after repeat two-stage exchange arthroplasty are low. Patients must be counseled accordingly and different modes of treatment should be considered.

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Reconstruction of Paprosky type III Acetabular Defects by the Three-dimensional Printed Porous Augment: Techniques and Clinical Outcomes of 18 Consecutive Cases

10.21203/rs.3.rs-94006/v1 ◽

2020 ◽

Author(s):

Jun Fu ◽

Ming Ni ◽

Xiang Li ◽

Wei Chai ◽

Libo Hao ◽

...

Keyword(s):

Clinical Outcomes ◽

Bone Defect ◽

Three Dimensional ◽

Acetabular Bone ◽

Type Iii ◽

Acetabular Bone Defect ◽

3D Printed ◽

The Mean ◽

Acetabular Defects

Abstract Background and Purpose: A major challenge posed by primary and revision total hip arthroplasty (THA) is the management of severe acetabular bone defect. Previous surgical techniques have certain limitations in the anatomical reconstruction and accurate match of severe acetabular defects. Until now, reports are scanty on the clinical outcomes of acetabular reconstruction by the three-dimensional (3D) printed porous augments in bone defect patients. This study reported the clinical outcomes of reconstruction of Paprosky type III acetabular defects by 3D printed porous augments.Methods: 18 patients with Paprosky type III acetabular defects receiving reconstructive surgery by 3D printed porous augments were included in current study. Their data, including general information, intra-operative findings, imaging results, functional scores and complications were retrospectively analyzed.Results: The mean follow-up time lasted 33.3 ± 2.0 (24-56) months. The average limb-length discrepancy (LLD) was 31.7 ± 4.2 (3-59) mm preoperatively, 7.7 ± 1.4 (1-21) mm postoperatively (p<0.0001) and 7.5 ± 1.2 (0-18) mm at the latest follow-up. The mean vertical position of hip center of rotation (HCOR) from the inter teardrop line changed from preoperative 50.7 ± 3.9 (23.3-75.3) mm to postoperative 22.9 ± 1.9 (10.1-40.3) mm (p<0.0001), with the latest follow-up revealing an HCOR of 22.3 ± 1.7 (11.0-40.5) mm. Follow-up study showed that no hip had radiolucencies and radiological loosening of the acetabular components and augment. The average HHS improved from 40.3 ± 4.5 (10.5-71) before operation to 88.4 ± 1.9 (75-97) at the last follow-up (p<0.0001). Moreover, follow-up exhibited that no periprosthetic joint infection, hip dislocation, fracture and re-revision occurred. Conclusion: Surgical treatment of Paprosky type III acetabular defect with 3D printed porous augment was simple, achieved good match between porous augment and the defect bone surface and the acetabular component, ideally restored LLD and HCOR after operation, significantly improved HHS score and attained good early clinical outcomes. It is a promising personalized solution for patients with severe acetabular bone defect.

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Is There a Role for Spacer Exchange in Two-Stage Exchange Arthroplasty for Periprosthetic Joint Infection?

Journal of Clinical Medicine ◽

10.3390/jcm9092901 ◽

2020 ◽

Vol 9 (9) ◽

pp. 2901 ◽

Cited By ~ 1

Author(s):

Elie Kozaily ◽

Emanuele Chisari ◽

Javad Parvizi

Keyword(s):

Periprosthetic Joint Infection ◽

Joint Infection ◽

The United States ◽

Conclusive Evidence ◽

Cement Spacer ◽

Two Stage ◽

Local Antibiotics ◽

Additional Surgery ◽

Surgeon Experience ◽

Hip And Knee Arthroplasty

Periprosthetic joint infection (PJI) continues to be one of the most serious complications after hip and knee arthroplasty. The choice of surgical treatment depends on a multitude of factors like chronicity of infection, host factors, and institutional or surgeon experience. Two-stage exchange remains one of the most commonly used technique for chronic PJI in the United States of America. The intended two-stage revision may involve an additional interim procedure where the initial antibiotic cement spacer is removed and a new spacer is inserted. Mostly, the rationale behind spacer exchange is an additional load of local antibiotics before proceeding to reimplantation. There is no conclusive evidence whether a spacer exchange confers additional benefits, yet it delays reimplantation and exposes already fragile patients to the risks and morbidity of an additional surgery.

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Elevated ESR and CRP Prior to Second-Stage Reimplantation Knee Revision Surgery for Periprosthetic Joint Infection Are Associated with Increased Reinfection Rates

The Journal of Knee Surgery ◽

10.1055/s-0041-1733902 ◽

2021 ◽

Author(s):

Christian Klemt ◽

Anand Padmanabha ◽

John G. Esposito ◽

Samuel Laurencin ◽

Evan J. Smith ◽

...

Keyword(s):

Revision Surgery ◽

Periprosthetic Joint Infection ◽

Joint Infection ◽

Elevated Serum ◽

Revision Total Knee Arthroplasty ◽

Optimal Timing ◽

Two Stage ◽

Second Stage ◽

Knee Revision Surgery ◽

Knee Revision

Abstract Purpose Although two-stage revision surgery is considered as the most effective treatment for managing chronic periprosthetic joint infection (PJI), there is no current consensus on the predictors of optimal timing to second-stage reimplantation. This study aimed to compare clinical outcomes between patients with elevated erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) prior to second-stage reimplantation and those with normalized ESR and CRP prior to second-stage reimplantation. Methods We retrospectively reviewed 198 patients treated with two-stage revision total knee arthroplasty for chronic PJI. Cohorts included patients with: (1) normal level of serum ESR and CRP (n = 96) and (2) elevated level of serum ESR and CRP prior to second-stage reimplantation (n = 102). Outcomes including reinfection rates and readmission rates were compared between both cohorts. Result At a mean follow-up of 4.4 years (2.8–6.5 years), the elevated ESR and CRP cohort demonstrated significantly higher reinfection rates compared with patients with normalized ESR and CRP prior to second-stage reimplantation (33.3% vs. 14.5%, p < 0.01). Patients with both elevated ESR and CRP demonstrated significantly higher reinfection rates, when compared with patients with elevated ESR and normalized CRP (33.3% vs. 27.6%, p = 0.02) as well as normalized ESR and elevated CRP (33.3% vs. 26.3%, p < 0.01). Conclusion This study demonstrates that elevated serum ESR and/or CRP levels prior to reimplantation in two-stage knee revision surgery for chronic PJI are associated with increased reinfection rate after surgery. Elevation of both ESR and CRP were associated with a higher risk of reinfection compared with elevation of either ESR or CRP, suggesting the potential benefits of normalizing ESR and CRP prior to reimplantation in treatment of chronic PJI.

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The Use of Cell Salvage During Second-stage Reimplantation for the Treatment of Chronic Hip Periprosthetic Joint Infection: a Retrospective Cohort Study

10.21203/rs.3.rs-1012018/v1 ◽

2021 ◽

Author(s):

Zunhan Liu ◽

Xuetao Yang ◽

En-Ze Zhao ◽

Xufeng Wan ◽

Guorui Cao ◽

...

Keyword(s):

Blood Transfusion ◽

Periprosthetic Joint Infection ◽

Joint Infection ◽

Control Group ◽

Published Data ◽

Cell Salvage ◽

Two Stage ◽

Reinfection Rate ◽

Second Stage ◽

Intraoperative Cell Salvage

Abstract Introduction Given the possibility of undetectable infection, the use of cell salvage is relatively contraindicated in cases of reimplantation for chronic hip periprosthetic joint infection (PJI). However, there is no published data supporting this assertion. The purpose of the current study was to compare the reinfection rate and rate of in second-stage reimplantation for PJI with or without intraoperative cell salvage reinfusion.Materials and methods We identified 125 patients who underwent two-stage exchange for chronic hip PJI between November 2012 and April 2019. The groups of patients who had and had not received intraoperative cell salvage reinfusion were compared with respect to the curative infection-free rate and need for postoperative ABT. We identified independent factors associated with ABT using multiple regression analysis.Results The log-rank survival curve with an endpoint of infection eradication failure was not significantly different between the cell salvage group (98.4%, 95% CI 95.3-99.9%) and the control group (95.3%, 95% CI 90.2-99.9%) at one year (log rank, P = .330). Meanwhile, the rates of postoperative ABT in the cell salvage group were significantly lower than those in the control group (11.5% vs 26.6%, P = .041). In multivariable models, patient age, body mass index (BMI), preoperative haemoglobin level, and intraoperative cell salvage were independent predictors of ABT exposure (P < .05).Conclusions The use of cell salvage during reimplantation in two-stage exchange for chronic hip PJI did not appear to increase the reinfection rate, while it significantly reduced the rate of postoperative allogeneic red blood transfusion. Greater age, lower BMI, lower preoperative haemoglobin, and non-intraoperative cell salvage reinfusion were associated with higher rate of allogeneic red blood transfusion.

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Two-stage treatment of acetabular bone defect in tuberculosis of the hip by intended ankylosis followed by total hip arthroplasty: a case report

Cases Journal ◽

10.1186/1757-1626-2-6532 ◽

2009 ◽

Vol 2 (1) ◽

pp. 6532 ◽

Cited By ~ 1

Author(s):

Els E Vogelpoel ◽

Jurjen J Been ◽

Arthur A de Gast

Keyword(s):

Case Report ◽

Total Hip Arthroplasty ◽

Bone Defect ◽

Hip Arthroplasty ◽

Two Stage ◽

Acetabular Bone ◽

Total Hip ◽

Acetabular Bone Defect

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The management of infected shoulder arthroplasty by two-stage revision

Shoulder & Elbow ◽

10.1177/1758573219841057 ◽

2019 ◽

Vol 12 (1_suppl) ◽

pp. 70-80

Author(s):

Matthew Brown ◽

Kelechi Eseonu ◽

Will Rudge ◽

Simon Warren ◽

Addie Majed ◽

...

Keyword(s):

Joint Infection ◽

Case Series ◽

Revision Arthroplasty ◽

Late Presentation ◽

Coagulase Negative Staphylococcus ◽

Cement Spacer ◽

Two Stage ◽

Musculoskeletal Infection ◽

Second Stage ◽

Standard Management

Background There remains no gold standard management for deep shoulder periprosthetic joint infection (PJI). This case series aims to present our experience of two-stage revision arthroplasty, including eradication of infection and reoperation rates. Methods We retrospectively reviewed patients undergoing revision arthroplasty for shoulder PJI between 2006 and 2015. Cases were confirmed using Musculoskeletal Infection Society (MSIS) and American Academy of Orthopaedic Surgeons (AAOS) guidelines. TSA removal, debridement and irrigation preceded antibiotic-loaded cement spacer insertion and a minimum of six weeks intravenous antibiotics. Reimplantation was performed as a second stage following a negative aspirate. Results Twenty-eight patients underwent a first stage procedure (mean age 69 years; 16 male, 12 female). Propionibacterium acnes, Methicillin-sensitive Staphylococcus aureus, Coagulase-negative Staphylococcus and Staphylococcus epidermidis were the commonest microorganisms cultured. Five cases had mixed growths and six cases provided no growth. Three patients did not proceed to a second stage. Twenty-five patients underwent reimplantation (mean interval 6.7 months), with 80% remaining infection-free (mean follow-up 38.3 months). Discussion Managing complex and late presentation shoulder PJI with two-stage revision is associated with high rates of infection eradication (80%). In the absence of a management consensus, our experience supports two-stage revision arthroplasty for eradicating infection in this complex patient group.

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Salmonella sp. as the Cause of Periprosthetic Joint Infection of the Hip: Report of a Rare Case and Review of Past 10-year Literatures

Open Access Macedonian Journal of Medical Sciences ◽

10.3889/oamjms.2020.4585 ◽

2020 ◽

Vol 8 (C) ◽

pp. 117-120

Author(s):

Asep Santoso ◽

Pamudji Utomo ◽

Iwan Budiwan Anwar ◽

Tangkas Sibarani ◽

Bintang Soetjahjo ◽

...

Keyword(s):

Case Report ◽

Total Hip Arthroplasty ◽

Literature Review ◽

Hip Arthroplasty ◽

Periprosthetic Joint Infection ◽

Rare Case ◽

Joint Infection ◽

Cement Spacer ◽

Two Stage ◽

Revision Procedure

BACKGROUND: Periprosthetic joint infection (PJI) due to Salmonella sp. is rare. It is sometimes difficult to treat and need prolonged antibiotic treatment. CASE REPORT: We reported a case of PJI of the hip in a 67-year-old female who received prior left total hip arthroplasty. Two-stage revision surgery with antibiotic-loaded cement spacer had been performed to the patient and successfully control the infection. CONCLUSION: Although literature review showed that there has been no consensus for the treatment of Salmonella PJI, a two-stage revision procedure has been more commonly performed to control the infection by previous authors and might be the safest way to control Salmonella PJI recently.

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