Three-stage revision arthroplasty for the treatment of fungal periprosthetic joint infection: outcome analysis of a novel treatment algorithm

Aims Fungal periprosthetic joint infections (fPJIs) are rare complications, constituting only 1% of all PJIs. Neither a uniform definition for fPJI has been established, nor a standardized treatment regimen. Compared to bacterial PJI, there is little evidence for fPJI in the literature with divergent results. Hence, we implemented a novel treatment algorithm based on three-stage revision arthroplasty, with local and systemic antifungal therapy to optimize treatment for fPJI. Methods From 2015 to 2018, a total of 18 patients with fPJI were included in a prospective, single-centre study (DKRS-ID 00020409). The diagnosis of PJI is based on the European Bone and Joint Infection Society definition of periprosthetic joint infections. The baseline parameters (age, sex, and BMI) and additional data (previous surgeries, pathogen spectrum, and Charlson Comorbidity Index) were recorded. A therapy protocol with three-stage revision, including a scheduled spacer exchange, was implemented. Systemic antifungal medication was administered throughout the entire treatment period and continued for six months after reimplantation. A minimum follow-up of 24 months was defined. Results Eradication of infection was achieved in 16 out of 18 patients (88.8%), with a mean follow-up of 35 months (25 to 54). Mixed bacterial and fungal infections were present in seven cases (39%). The interval period, defined as the period of time from explantation to reimplantation, was 119 days (55 to 202). In five patients, a salvage procedure was performed (three cementless modular knee arthrodesis, and two Girdlestone procedures). Conclusion Therapy for fPJI is complex, with low cure rates according to the literature. No uniform treatment recommendations presently exist for fPJI. Three-stage revision arthroplasty with prolonged systemic antifungal therapy showed promising results. Cite this article: Bone Jt Open 2021;2(8):671–678.

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Streptococcus bovis Hip and Knee Periprosthetic Joint Infections: A Series of 9 Cases

Journal of Bone and Joint Infection ◽

10.7150/jbji.36923 ◽

2020 ◽

Vol 5 (1) ◽

pp. 1-6 ◽

Cited By ~ 1

Author(s):

Jeremy C. Thompson ◽

Ashton H. Goldman ◽

Aaron J. Tande ◽

Douglas R. Osmon ◽

Rafael J. Sierra

Keyword(s):

Symptom Onset ◽

Joint Infection ◽

Revision Arthroplasty ◽

Recurrent Infection ◽

Streptococcus Bovis ◽

Loss To Follow Up ◽

Joint Infections ◽

Prosthetic Joint ◽

Mucosal Abnormality

Abstract. Introduction: Prosthetic joint infection (PJI) due to Streptococcus bovis group (SBG), specifically S. bovis biotype I (S. gallolyticus), is rare and associated with colorectal carcinoma. Little has been published regarding SBG PJI. We analyzed nine cases of SBG PJI at our institution, the largest series to date.Methods: The medical records of patients diagnosed with SBG PJI between 2000-2017 were reviewed. Patients were followed until death, failure, or loss to follow-up. Mean follow-up was 37 months (range 0.5-74 months).Results: Nine PJI in 8 patients with mean prosthesis age at diagnosis of 8 years (range 4 weeks-17 years) were identified. The median duration between symptom onset and treatment was 38 weeks (range 0.3 weeks-175 weeks). 8/9 had their PJI eradicated with treatment based on acuity of symptoms. Acute PJI (2) was treated with DAIR, and chronic PJI (7) was treated with 2-stage revision arthroplasty. 1 PJI with chronic PJI developed recurrent infection after initial treatment. All patients received post-operative IV antibiotics. 7/8 patients received Ceftriaxone. Three patients received lifelong oral antibiotics. 7/8 patients underwent colonoscopy. 5/7 patients were found to have polyps following PJI diagnosis with one carcinoma and two dysplastic polyps. The two patients without polyps had identifiable gastrointestinal (GI) mucosal abnormality: tooth extraction prior to symptom onset and diverticulosis on chronic anticoagulation.Conclusion: SBG PJI is typically due to hematologic seeding. Colonoscopy should be pursued for patients with SBG PJI. Surgical treatment dictated by infection acuity and 6-week course of Ceftriaxone seems sufficient to control infection.

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Should all patients with a culture-negative periprosthetic joint infection be treated with antibiotics?

The Bone & Joint Journal ◽

10.1302/0301-620x.104b1.bjj-2021-0693.r2 ◽

2022 ◽

Vol 104-B (1) ◽

pp. 183-188

Author(s):

Maxime van Sloten ◽

Joan Gómez-Junyent ◽

Tristan Ferry ◽

Nicolò Rossi ◽

Sabine Petersdorf ◽

...

Keyword(s):

Primary Outcome ◽

Joint Infection ◽

Recurrent Infection ◽

Molecular Techniques ◽

Secondary Outcome ◽

International Consensus ◽

Joint Infections ◽

Causative Microorganism ◽

Culture Negative

Aims The aim of this study was to analyze the prevalence of culture-negative periprosthetic joint infections (PJIs) when adequate methods of culture are used, and to evaluate the outcome in patients who were treated with antibiotics for a culture-negative PJI compared with those in whom antibiotics were withheld. Methods A multicentre observational study was undertaken: 1,553 acute and 1,556 chronic PJIs, diagnosed between 2013 and 2018, were retrospectively analyzed. Culture-negative PJIs were diagnosed according to the Muskuloskeletal Infection Society (MSIS), International Consensus Meeting (ICM), and European Bone and Joint Society (EBJIS) definitions. The primary outcome was recurrent infection, and the secondary outcome was removal of the prosthetic components for any indication, both during a follow-up period of two years. Results None of the acute PJIs and 70 of the chronic PJIs (4.7%) were culture-negative; a total of 36 culture-negative PJIs (51%) were treated with antibiotics, particularly those with histological signs of infection. After two years of follow-up, no recurrent infections occurred in patients in whom antibiotics were withheld. The requirement for removal of the components for any indication during follow-up was not significantly different in those who received antibiotics compared with those in whom antibiotics were withheld (7.1% vs 2.9%; p = 0.431). Conclusion When adequate methods of culture are used, the incidence of culture-negative PJIs is low. In patients with culture-negative PJI, antibiotic treatment can probably be withheld if there are no histological signs of infection. In all other patients, diagnostic efforts should be made to identify the causative microorganism by means of serology or molecular techniques. Cite this article: Bone Joint J 2022;104-B(1):183–188.

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Two-stage revision arthroplasty in the treatment of periprosthetic hip infections with severe bone loss: Results from 182 cases

Orthopedic Reviews ◽

10.4081/or.2020.8545 ◽

2020 ◽

Vol 12 (2) ◽

Author(s):

Jerzy Białecki ◽

Maciej Kogut ◽

Sławomir Chaberek ◽

Paweł Bartosz ◽

Marcin Obrębski ◽

...

Keyword(s):

Bone Loss ◽

Joint Infection ◽

Revision Arthroplasty ◽

Bone Defects ◽

Harris Hip Score ◽

Two Stage ◽

Retrospective Assessment ◽

Severe Bone Loss ◽

Paprosky Classification

The optimum treatment for periprosthetic joint infection (PJI) of the hip with substantial bone defects remains controversial. A retrospective assessment was performed for 182 patients treated for PJI with a two-stage protocol from 2005 to 2015. Implant removal and debridement were followed by Girdlestone arthroplasty or spacer implantation. The results of the Girdlestone and spacer groups were compared. There were 71 cases that received spacers, and 111 Girdlestone procedures were performed. After the first stage, 26.37% of cultures were negative, and among patients with a detected pathogen, methicillin-sensitive Staphylococcus aureus was the most common organism (41.79%). Acetabular and femoral bone defects, according to the Paprosky classification, were more severe in the Girdlestone group (P<0.05). During the follow-up (mean, 5.95 years), the overall incidence of complications was 21.42%. The mean Harris hip score was significantly lower in the Girdlestone group (68.39 vs 77.79; P<0.0001). The infection recurrence rate reached 8.79%. Despite satisfactory infection control, the number of complications and poor functional outcomes associated with resection arthroplasty indicate the necessity for development of different approaches for patients with advanced bone loss.

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Cement Arthrodesis of the Knee with a Custom Long Recon Nail After Failed Total Knee Arthroplasty: Surgical Technique and Results

The Open Orthopaedics Journal ◽

10.2174/1874325001812010554 ◽

2018 ◽

Vol 12 (1) ◽

pp. 554-566

Author(s):

Malcolm R. DeBaun ◽

Stuart B. Goodman ◽

David W. Lowenberg

Keyword(s):

Total Knee Arthroplasty ◽

Knee Arthroplasty ◽

Joint Infection ◽

Treatment Algorithm ◽

Case Series ◽

Cement Spacer ◽

Knee Arthrodesis ◽

Retrospective Case ◽

Total Knee

Background and Objective: Persistent periprosthetic joint infection (PJI) is a devastating complication after Total Knee Arthroplasty (TKA). We hypothesize that our novel treatment algorithm utilizing a customized knee spanning recon nail combined with an antibiotic eluting cement spacer improves ambulation status and prevents recurrent PJI in patients with failed TKA and severe bone loss. Methods: In a retrospective case series, 15 consecutive patients who underwent knee arthrodesis after failed ipsilateral TKA secondary to infection from 2004-2017 with at least 1 year of follow-up were enrolled. The average age of patients at the time surgery was 68 (range 50-81) years with an average follow-up of 3.2 (range 1-6) years. Post-surgical ambulation status and eradication of index infection were analyzed as primary outcomes using McNemar’s test for before-and-after study design with p<0.05 for significance. Results: Cement arthrodesis significantly improved ambulation with 67% (10/15) of patients unable to ambulate before arthrodesis and 93% (14/15) of patients able to ambulate at final follow-up (p=0.004). The complication rate was 20% (3/15). There were no periprosthetic fractures. Amongst patients who presented with active PJI, 91% (10/11) had eradication of their index infection final follow-up (p=0.002). Overall prevention of recurrent index infection was 93% (14/15) (p=0.0001). Conclusion: Cement arthrodesis utilizing a custom knee spanning recon nail combined with an antibiotic eluting spacer improves ambulation status and prevents or treats recurrent infection in the majority of patients who have failed total knee arthroplasty.

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On the Necessity of a Customized Knee Spacer in Peri-Prosthetic Joint Infection Treatment: 3D Numerical Simulation Results

Journal of Personalized Medicine ◽

10.3390/jpm11101039 ◽

2021 ◽

Vol 11 (10) ◽

pp. 1039

Author(s):

Marco Balato ◽

Carlo Petrarca ◽

Vincenzo de Matteo ◽

Marco Lenzi ◽

Enrico Festa ◽

...

Keyword(s):

Ad Hoc ◽

Joint Infection ◽

Revision Arthroplasty ◽

High Morbidity ◽

Virtual Planning ◽

Joint Infections ◽

Prosthetic Joint ◽

Infection Treatment ◽

Prosthetic Joint Infections ◽

Surgical Complexity

Peri-prosthetic joint infections (PJIs) dramatically affect human health, as they are associated with high morbidity and mortality rates. Two-stage revision arthroplasty is currently the gold standard treatment for PJI and consists of infected implant removal, an accurate debridement, and placement of antimicrobial impregnated poly-methyl-metha-acrylate (PMMA) spacer. The use of antibiotic-loaded PMMA (ALPMMA) spacers have showed a success rate that ranges from 85% to 100%. ALPMMA spacers, currently available on the market, demonstrate a series of disadvantages, closely linked to a low propensity to customize, seen as the ability to adapt to the patients’ anatomical characteristics, with consequential increase of surgical complexity, surgery duration, and post-operative complications. Conventionally, ALPMMA spacers are available only in three or four standard sizes, with the impossibility of guaranteeing the perfect matching of ALPMMA spacers with residual bone (no further bone loss) and gap filling. In this paper, a 3D model of an ALPMMA spacer is introduced to evaluate the cause- effect link between the geometric characteristics and the correlated clinical improvements. The result is a multivariable-oriented design able to effectively manage the size, alignment, stability, and the patients’ anatomical matching. The preliminary numerical results, obtained by using an “ad hoc” 3D virtual planning simulator, clearly point out that to restore the joint line, the mechanical and rotational alignment and the surgeon’s control on the thicknesses (distal and posterior thicknesses) of the ALPMMA spacer is mandatory. The numerical simulations campaign involved nineteen patients grouped in three different scenarios (Case N° 1, Case N° 2 and Case N° 3) whose 3D bone models were obtained through an appropriate data management strategy. Each scenario is characterized by a different incidence rate. In particular, the observed rates of occurrence are, respectively, equal to 17% (Case N° 1), 74% (Case N° 2), and 10% (Case N° 3).

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381. Clinical Outcome of Polymicrobial Prosthetic Joint Infection Managed with Debridement, Antibiotics, and Implant Retention (DAIR)

Open Forum Infectious Diseases ◽

10.1093/ofid/ofz360.454 ◽

2019 ◽

Vol 6 (Supplement_2) ◽

pp. S198-S198

Author(s):

Babak Hooshmand ◽

Dima Youssef ◽

Kathleen M Riederer ◽

Susan M Szpunar ◽

Ashish Bhargava

Keyword(s):

Joint Infection ◽

Surgical Site Infections ◽

International Classification Of Diseases ◽

Implant Removal ◽

Suppressive Therapy ◽

Joint Infections ◽

Prosthetic Joint ◽

Prosthetic Joint Infections ◽

Implant Retention

Abstract Background Polymicrobial (PM) prosthetic joint infections (PJIs) account for 4% to 37% of all PJIs. There is limited literature on surgical debridement, antibiotics and implant retention (DAIR) in PMPJIs. We aimed to assess clinical outcomes of PMPJIs managed with DAIR. Methods A retrospective cohort was studied at three Ascension hospitals in Detroit from January 2012 to December 2018. Cases were identified using the International Classification of Diseases, 9th and 10th Revision code specific for PJIs. Patient’s electronic medical records were reviewed. Results Twenty-six PMPJIs managed with DAIR were identified. Mean age of the infected patients was 66 years. 18 (69%) patients were female and 19 (73%) were caucasians. Infected sites were hip in 15 (58%), knee in 10 (38%) and ankle in 1 (4%) patient. 22 (85%) patients had osteoarthritis, 3 (12%) had diabetes, 3 (12%) were on steroids and 1 (4%) had rheumatoid arthritis. Symptom onset of less than a week was noted in 14 (58%) and 3 or more weeks in 8 (31%) patients. Pain, swelling and drainage were present in 21 (81%), 13 (50%) and 18 (69%) cases. Fever on admission was noted in 7 (27%) patients. 11 (42%) patients were re-admitted in the following 12 months after DAIR. 2 (19%) patients developed superficial surgical site infection (SSI) while 9 (81%) had deep SSI. Implant removal was needed in 6 (55%) patients. 5 (2 superficial and 3 deep) patients required further debridement and antibiotics. 5 (19%) had good outcome with 3–6 months of antibiotics. 3 (12%) patients required long-term chronic suppressive therapy. One patient died from a cardiac event during follow-up. Conclusion In our study, PMPJIs managed with DAIR had high readmission rates and deep surgical site infections. DAIR failure, noted in 23% of our cases, required implant removal within 12 months of follow-up. Disclosures All authors: No reported disclosures.

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Two-Stage Revision Arthroplasty for Periprosthetic Hip Infection: Mean Follow-Up of Ten Years

BioMed Research International ◽

10.1155/2015/345475 ◽

2015 ◽

Vol 2015 ◽

pp. 1-7 ◽

Cited By ~ 4

Author(s):

Szu-Yuan Chen ◽

Chi-Chien Hu ◽

Chun-Chieh Chen ◽

Yu-Han Chang ◽

Pang-Hsin Hsieh

Keyword(s):

Hip Arthroplasty ◽

Cox Regression ◽

Joint Infection ◽

Revision Arthroplasty ◽

Revision Hip Arthroplasty ◽

Harris Hip Score ◽

Two Stage ◽

Eradication Of Infection ◽

The Mean

Background. Two-stage revision hip arthroplasty is the gold standard for treatment of patients with chronic periprosthetic joint infection (PJI), but few studies have reported outcomes beyond short-term follow-up.Methods. A total of 155 patients who underwent two-stage revision arthroplasty for chronic PJI in 157 hips were retrospectively enrolled in this study between January 2001 and December 2010. The mean patient age was 57.5 years, the mean prosthetic age was 3.6 years, and the interim interval was 17.8 weeks. These patients were followed up for an average of 9.7 years.Results. At the latest follow-up, 91.7% of the patients were free of infection. The mean Harris hip score improved significantly from 28.3 points before operation to 85.7 points at the latest follow-up. Radiographically, there was aseptic loosening of the stem or acetabular components in 4 patients. In the multivariate survival analysis using a Cox regression model, repeated debridement before final reconstruction, an inadequate interim period, bacteriuria or pyuria, and cirrhosis were found to be the independent risk factors for treatment failure.Conclusion. Our data show that two-stage revision hip arthroplasty provides reliable eradication of infection and durable reconstruction of the joint in patients with PJI caused by a variety of pathogens.

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Pasteurella multocidaNon-Native Joint Infection after a Dog Lick: A Case Report Describing a Complicated Two-Stage Revision and a Comprehensive Review of the Literature

Canadian Journal of Infectious Diseases and Medical Microbiology ◽

10.1155/2015/963529 ◽

2015 ◽

Vol 26 (4) ◽

pp. 212-217 ◽

Cited By ~ 4

Author(s):

Lam Philip W ◽

Andrea V Page

Keyword(s):

Pasteurella Multocida ◽

Joint Infection ◽

Revision Arthroplasty ◽

Review Of The Literature ◽

Coagulase Negative Staphylococci ◽

Two Stage ◽

Oral Flora ◽

Comprehensive Review ◽

Joint Infections ◽

Prosthetic Joint Infections

Prosthetic joint infections (PJIs) are commonly caused by pathogens such asStaphylococcus aureusand coagulase-negative staphylococci; however, other microbial etiologies and specific risk factors are increasingly recognized.Pasteurella multocidais a Gram-negative coccobacillus that is part of the normal oral flora in many animals, and is particularly common in dogs and cats. PJIs caused byP multocidahave been reported only rarely in the literature and typically occur in the context of an animal bite or scratch. The present article describes aP multocidajoint infection that occurred after a dog lick and complicated a two-stage revision arthroplasty. A comprehensive review of the literature regardingP multocidaPJIs follows.

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Clinical and Microbiological Characteristics of Bacteroides Prosthetic Joint Infections

Journal of Bone and Joint Infection ◽

10.7150/jbji.17129 ◽

2017 ◽

Vol 2 (3) ◽

pp. 122-126 ◽

Cited By ~ 2

Author(s):

Neel Shah ◽

Douglas Osmon ◽

Aaron J. Tande ◽

James Steckelberg ◽

Rafael Sierra ◽

...

Keyword(s):

Joint Infection ◽

Significant Proportion ◽

Resection Arthroplasty ◽

Joint Infections ◽

Prosthetic Joint ◽

Microbiological Characteristics ◽

Prosthetic Joint Infections ◽

Implant Retention ◽

History Of

Abstract. Clinical and microbiological characteristics of patients with Bacteroides prosthetic joint infection (PJI) have not been well described in the literature. The aim of this retrospective cohort study was to assess the outcome of patients with Bacteroides PJI and to review risk factors associated with failure of therapy. Between 1/1969 and 12/2012, 20 episodes of Bacteroides PJI in 17 patients were identified at our institution. The mean age of the patients in this cohort at the time of diagnosis was 55.6 years; 59% (n=10) had knee involvement. Twenty four percent (n=4) had diabetes mellitus, and 24% had a history of either gastrointestinal (GI) or genitourinary (GU) pathology prior to the diagnosis of PJI. Thirty five percent (n=6) were immunosuppressed. The initial medical/surgical strategy was resection arthroplasty (n=9, 50%) or debridement and implant retention (n=5, 28%). Thirty seven percent (n=7) were treated with metronidazole. Eighty percent (n=4) of patients that failed therapy had undergone debridement and retention of their prosthesis, as compared to none of those treated with resection arthroplasty. Seventy percent (n=14) of patient episodes were infection free at their last date of follow up. In conclusion, a significant proportion of patients with Bacteroides PJI are immunosuppressed and have an underlying GI or GU tract pathology. Retention and debridement of the prosthesis is associated with a higher risk of treatment failure.

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Continuous Cefazolin Infusion To Treat Bone and Joint Infections: Clinical Efficacy, Feasibility, Safety, and Serum and Bone Concentrations

Antimicrobial Agents and Chemotherapy ◽

10.1128/aac.00389-08 ◽

2008 ◽

Vol 53 (3) ◽

pp. 883-887 ◽

Cited By ~ 35

Author(s):

Valérie Zeller ◽

Frédérick Durand ◽

Marie-Dominique Kitzis ◽

Luc Lhotellier ◽

Jean-Marc Ziza ◽

...

Keyword(s):

Joint Infection ◽

Outpatient Basis ◽

Home Therapy ◽

Parenteral Antibiotic ◽

Joint Infections ◽

Bone And Joint Infections ◽

Median Serum ◽

Strong Candidate ◽

Microbiological Assays

ABSTRACT Cefazolin has been used for many years to treat bone and joint infections. Because of its time-dependent antimicrobial activity, continuous infusion would potentially be beneficial. We report on the feasibility, safety, and efficacy of prolonged continuous intravenous cefazolin therapy in a cohort of 100 patients, their serum cefazolin levels, and the concomitant bone cefazolin concentrations in 8 of them. This retrospective cohort study included all the patients treated for bone or joint infection with a continuous cefazolin infusion administered over a 12-h period twice daily for ≥2 weeks. Drug monitoring was performed at least twice for all the patients. Serum and bone cefazolin concentrations were determined by standardized disk diffusion microbiological assays. The absence of clinical, biological, and radiological signs of infection after 2 years of follow-up and the same criteria after 1 year of follow-up defined cures and probable cures, respectively. The median treatment duration was 42 days, and the median daily cefazolin dose was 6 g. Half of the patients received parenteral antibiotic therapy on an outpatient basis. Two moderate-grade adverse events were observed. The median serum cefazolin concentrations were 63 μg/ml (range, 13 to 203 μg/ml) and 57 μg/ml (range, 29 to 128 μg/ml) on days 2 to 10 and days 11 to 21, respectively. The median bone cefazolin concentration reached 13.5 μg/g (range, 3.5 to 29 μg/g). The median bone concentration/serum concentration ratio was 0.25 (range, 0.06 to 0.41). Among 88 patients with a median follow-up of 25 months (range, 12 to 53 months), 52 were considered cured and 29 were considered probably cured. Thus, the treatment of bone and joint infections with a prolonged continuous intravenous cefazolin infusion was feasible, effective, well-tolerated, safe, and convenient, making it a strong candidate for home therapy.

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