Prosthetic joint infection (PJI) is one of the most devastating complications after total hip arthroplasty (THA), and comorbidities increase the risk. We examined whether there was a temporal change ...in the demographics, especially regarding comorbidities, of patients who have PJIs and were treated over a 13-year study period at a high-volume academic joint arthroplasty center. In addition, the surgical methods used and the microbiology of the PJIs were assessed.
Revisions (n = 423, 418 patients) due to PJI of the hip performed at our institution between 2008 and September 2021 were identified. All included PJIs fulfilled the 2013 International Consensus Meeting diagnostic criteria. The surgeries were categorized into one of the following categories: debridement, antibiotics, and implant retention, 1-stage revision, and 2-stage revision. Infections were classified as early, acute hematogenous, and chronic infections.
There was no change in the median age of the patients, but the proportion of ASA-class 4 patients increased from 10.5% to 20%. The incidence of early infections increased from 0.11 per 100 primary THAs in 2008 to 1.09 in 2021. The incidence of 1-stage revisions increased the most, rising from 0.10 per 100 primary THAs in 2010 to 0.91 per 100 primary THAs in 2021. Furthermore, the proportion of infections caused by Staphylococcus aureus increased from 26.3% in 2008 to 2009 to 40% in 2020 to 2021.
The comorbidity burden of PJI patients increased during the study period. This increase may present a treatment challenge, as comorbidities are known to have a negative effect on PJI treatment outcomes.
Abstract Cobalt (Co) and its compounds are widely distributed in nature and are part of numerous anthropogenic activities. Although cobalt has a biologically necessary role as metal constituent of ...vitamin B12 , excessive exposure has been shown to induce various adverse health effects. This review provides an extended overview of the possible Co sources and related intake routes, the detection and quantification methods for Co intake and the interpretation thereof, and the reported health effects. The Co sources were allocated to four exposure settings: occupational, environmental, dietary and medical exposure. Oral intake of Co supplements and internal exposure through metal-on-metal (MoM) hip implants deliver the highest systemic Co concentrations. The systemic health effects are characterized by a complex clinical syndrome, mainly including neurological (e.g. hearing and visual impairment), cardiovascular and endocrine deficits. Recently, a biokinetic model has been proposed to characterize the dose-response relationship and effects of chronic exposure. According to the model, health effects are unlikely to occur at blood Co concentrations under 300 μg/l (100 μg/l respecting a safety factor of 3) in healthy individuals, hematological and endocrine dysfunctions are the primary health endpoints, and chronic exposure to acceptable doses is not expected to pose considerable health hazards. However, toxic reactions at lower doses have been described in several cases of malfunctioning MoM hip implants, which may be explained by certain underlying pathologies that increase the individual susceptibility for Co-induced systemic toxicity. This may be associated with a decrease in Co bound to serum proteins and an increase in free ionic Co2+ . As the latter is believed to be the primary toxic form, monitoring of the free fraction of Co2+ might be advisable for future risk assessment. Furthermore, future research should focus on longitudinal studies in the clinical setting of MoM hip implant patients to further elucidate the dose-response discrepancies.
Modular dual-mobility (DM) articulations are increasingly used during total hip arthroplasty (THA). However, concerns remain regarding the metal liner modularity. This study aims to correlate metal ...artifact reduction sequence (MARS)-MRI abnormalities with serum metal ion levels in patients with DM articulations.
A total of 45 patients (50 hips) with a modular DM articulation were included with mean follow-up of 3.7 years (SD 1.2). Enrolled patients with an asymptomatic, primary THA and DM articulation with over two years' follow-up underwent MARS-MRI. Each patient had serum cobalt, chromium, and titanium levels drawn. Patient satisfaction, Oxford Hip Score, and Forgotten Joint Score-12 (FJS-12) were collected. Each MARS-MRI was independently reviewed by fellowship-trained musculoskeletal radiologists blinded to serum ion levels.
Overall, two patients (4.4%) had abnormal periprosthetic fluid collections on MARS-MRI with cobalt levels > 3.0 μg/l. Four patients (8.9%) had MARS-MRI findings consistent with greater trochanteric bursitis, all with cobalt levels < 1.0 μg/l. A seventh patient had a periprosthetic fluid collection with normal ion levels. Of the 38 patients without MARS-MRI abnormalities, 37 (97.4%) had cobalt levels < 1.0 μg/l, while one (2.6%) had a cobalt level of 1.4 μg/l. One patient (2.2%) had a chromium level > 3.0 μg/l and a periprosthetic fluid collection. Of the 41 patients with titanium levels, five (12.2%) had titanium levels > 5.0 μg/l without associated MARS-MRI abnormalities.
Periprosthetic fluid collections associated with elevated serum cobalt levels in patients with asymptomatic DM articulations occur infrequently (4.4%), but further assessment is necessary due to implant heterogeneity.
One-stage and two-stage revision strategies are the two main options for treating established chronic peri-prosthetic joint infection (PJI) of the hip; however, there is uncertainty regarding which ...is the best treatment option. We aimed to compare the risk of re-infection between the two revision strategies using pooled individual participant data (IPD). Observational cohort studies with PJI of the hip treated exclusively by one- or two-stage revision and reporting re-infection outcomes were retrieved by searching MEDLINE, EMBASE, Web of Science, The Cochrane Library, and the WHO International Clinical Trials Registry Platform; as well as email contact with investigators. We analysed IPD of 1856 participants with PJI of the hip from 44 cohorts across four continents. The primary outcome was re-infection (recurrence of infection by the same organism(s) and/or re-infection with a new organism(s)). Hazard ratios (HRs) for re-infection were calculated using Cox proportional frailty hazards models. After a median follow-up of 3.7 years, 222 re-infections were recorded. Reinfection rates per 1000 person-years of follow-up were 16.8 (95% CI 13.6-20.7) and 32.3 (95% CI 27.3-38.3) for onestage and two-stage strategies respectively. The age- and sex-adjusted HR of re-infection for two-stage revision was 1.70 (0.58-5.00) when compared with one-stage revision. The association remained consistently absent after further adjustment for potential confounders. The HRs did not vary importantly in clinically relevant subgroups. Analysis of pooled individual patient data suggest that a one-stage revision strategy may be as effective as a two-stage revision strategy in treating PJI of the hip.
Data regarding the diagnostic value of ultrasound (US)–determined fluid film and joint aspiration prior to revision total hip arthroplasty for suspected periprosthetic joint infections (PJIs) are ...limited. This study aimed to analyze the value of US-determined fluid film, characterized the preoperative and intraoperative microbiological spectrum and resistance patterns, and compared the concordance between preoperative synovial fluid and intraoperative culture results.
We analyzed 366 US examinations from 324 patients prior to revision total hip arthroplasty. Selected cases were grouped into clearly infected, noninfected, and inconclusive cohorts, according to the International Consensus Meeting 2018 Criteria. For US-determined fluid film <1 mm, no aspiration was performed based on our institutional protocol. Patients were grouped into no aspiration (144 of 366; 39.3%), dry tap (21 of 366; 5.7%), and a successful tap (201 of 366; 54.9%). The microbiological spectrum and antibiograms were compared between preoperative and intraoperative results.
The absence of US-determined fluid film showed no correlation with the presence of a hip PJI. Overall, 31.9% cases of the no-aspiration group had a PJI. In total, 13.5% discrepancies were found between successful taps and intraoperative cultures. The most prevalent microorganisms in preoperative synovial fluid were Staphylococcus epidermidis and Staphylococcus aureus (20.8%), while intraoperatively S. epidermidis (26.3%) and Cutibacterium acnes (14.5%) were leading. Additional microorganisms were identified in 32.5% of intraoperative cultures. There were no differences between resistance patterns of preoperative and intraoperative concordant microorganisms.
Absence of US-determined fluid film cannot rule out the presence of a hip PJI. Combined microbiological results from hip US aspirations and subsequent surgical procedures are crucial to design an effective treatment for suspected hip PJI.
Abstract Introduction Despite the excellent outcomes associated with primary total hip arthroplasty (THA), implant failure and revision continues to burden the healthcare system. The most common ...causes of THA failure include osteolysis, loosening, dislocation, and infection. However, the predominant etiology of THA failure has evolved and displays variability throughout the literature depending on study design. In order to thoroughly understand how THAs are failing and how to reduce this burden, it is essential to assess modes of implant failure on a large-scale. This study aims to update the current literature on rates of revision THA in the US population. Specifically, we report on: 1) etiologies for revision THA; 2) frequencies of revision THA procedures; 3) patient demographics, payor type, and US Census Region of revision THA patients; and 4) the length of stay and total costs based on type of revision THA procedure. Methods The National Inpatient Sample (NIS) database was used to identify all revision THA procedures performed between January 1, 2009 and December 31, 2013. Demographic, clinical, and economic data were obtained for 258,461 revision THAs during this time period. Patients were stratified according to etiology of failure, age, sex, race, US census region, and primary payor class in order to determine the prevalence of revision procedure performed. Results Dislocation was the main indication for revision THA (17.3%), closely followed by mechanical loosening (16.8%). The most common revision THA procedure performed was all-component revision (41.8%). Patients were most commonly white (77.4%), aged 75 years and older (31.6%), and resided in the South US census region (37.0%). The average length of stay for all procedures was 5.29 days, with arthrotomy procedures demonstrating the longest stays (10.31 days). The mean total charge for revision THA procedures was $77,851.24, with arthrotomy procedures accounting for the greatest costs ($107,371.65). Conclusion With nearly equal prevalence, dislocation and mechanical loosening make up the predominant indications for revision total hip arthroplasty in the United States. Our findings are concerning, given that these etiologies have persisted despite advancements in surgical technique and implant design. With the frequency of revision THAs projected to double in the next decade, orthopaedists must take steps to mitigate this potentially devastating complication.
Despite the availability of a battery of tests, the diagnosis of periprosthetic joint infection (PJI) continues to be challenging. Serum D-dimer assessment is a widely available test that detects ...fibrinolytic activities that occur during infection. We hypothesized that patients with PJI may have a high level of circulating D-dimer and that the presence of a high level of serum D-dimer may be a sign of persistent infection in patients awaiting reimplantation.
This prospective study was initiated to enroll patients undergoing primary and revision arthroplasty. Our cohort consisted of 245 patients undergoing primary arthroplasty (n = 23), revision for aseptic failure (n = 86), revision for PJI (n = 57), or reimplantation (n = 29) or who had infection in a site other than a joint (n = 50). PJI was defined using the Musculoskeletal Infection Society criteria. In all patients, serum D-dimer level, erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP) level were measured preoperatively.
The median D-dimer level was significantly higher (p < 0.0001) for the patients with PJI (1,110 ng/mL range, 243 to 8,487 ng/mL) than for the patients with aseptic failure (299 ng/mL range, 106 to 2,571 ng/mL). Using the Youden index, 850 ng/mL was determined as the optimal threshold value for serum D-dimer for the diagnosis of PJI. Serum D-dimer outperformed both ESR and serum CRP, with a sensitivity of 89% and a specificity of 93%. ESR and CRP had a sensitivity of 73% and 79% and a specificity of 78% and 80%, respectively. The sensitivity and specificity of ESR and CRP combined was 84% (95% confidence interval CI, 76% to 90%) and 47% (95% CI, 36% to 58%), respectively.
It appears that serum D-dimer is a promising marker for the diagnosis of PJI. This test may also have a great utility for determining the optimal timing of reimplantation.
Diagnostic Level II. See Instructions for Authors for a complete description of levels of evidence.
Total hip arthroplasty (THA) for femoral neck fracture (FNF) can be performed through different surgical approaches. This study compared the revision rates and patient-reported outcome measures by ...surgical approach.
Data from the New Zealand Joint Registry were analyzed for patients undergoing primary THA for FNF from January 2000 to December 2021. A total of 5,025 THAs were performed for FNF; the lateral approach was used in 2,499 (49.7%), the posterior in 2,255 (44.9%), and the anterior in 271 (4.3%). The primary outcome measure was the all-cause revision rate. Secondary outcome measures included revision rates for: dislocation, aseptic femoral component loosening, periprosthetic fracture, and infection. Oxford Hip Scores (OHS) were also collected. Age, sex, body mass index, American Society of Anesthesiologists score, femoral head size, dual mobility use, femoral fixation, and surgeon experience were assessed as potential confounding variables.
There was no difference in the revision rates between lateral and posterior (P = .156), lateral and anterior (P = .680), or posterior and anterior (P = .714) approaches. There was no difference in the reasons for revision between the lateral and posterior approaches or 6-month OHS (P = .712). There was insufficient data to compare the anterior approach.
There is no difference in the overall revision rates, reasons for revision, or OHS between the lateral and posterior surgical approaches for THA performed for FNF. Insufficient data on the anterior approach is available for an accurate comparison.
Level III.
Outcomes After Pseudomonas Prosthetic Joint Infections Kim, Billy I; Schwartz, Andrew M; Wixted, Colleen M ...
Journal of the American Academy of Orthopaedic Surgeons,
2024-May-15, Letnik:
32, Številka:
10
Journal Article
Recenzirano
Pseudomonas species are a less common but devastating pathogen family in prosthetic joint infections (PJIs). Despite advancements in management, Pseudomonas PJIs remain particularly difficult to ...treat because of limited antibiotic options and robust biofilm formation. This study aimed to evaluate Pseudomonas PJI outcomes at a single institution and review outcomes reported in the current literature.
All hip or knee PJIs at a single institution with positive Pseudomonas culture were evaluated. Forty-two patients (24 hips, 18 knees) meeting inclusion criteria were identified. The primary outcome of interest was infection clearance at 1 year after surgical treatment, defined as reassuring aspirate without ongoing antibiotic treatment. Monomicrobial and polymicrobial infections were analyzed separately. A focused literature review of infection clearance after Pseudomonas PJIs was performed.
One-year infection clearance was 58% (n = 11/19) for monomicrobial PJIs and 35% (n = 8/23) for polymicrobial PJIs. Among monomicrobial infections, the treatment success was 63% for patients treated with DAIR and 55% for patients treated with two-stage exchange. Monotherapy with an oral or intravenous antipseudomonal agent (minimum 6 weeks) displayed the lowest 1-year clearance of 50% (n = 6/12). Resistance to antipseudomonal agents was present in 16% (n = 3/19), and two of eight patients with monomicrobial and polymicrobial PJIs developed resistance to antipseudomonal therapy in a subsequent Pseudomonas PJI. Polymicrobial infections (55%) were more common with a mortality rate of 44% (n = 10/23) at a median follow-up of 3.6 years.
Pseudomonas infections often present as polymicrobial PJIs but are difficult to eradicate in either polymicrobial or monomicrobial setting. A review of the current literature on Pseudomonas PJI reveals favorable infection clearance rates (63 to 80%) after DAIR while infection clearance rates (33 to 83%) vary widely after two-stage revision.
Background and purpose - In total hip replacements, stem design may affect the occurrence of periprosthetic femoral fracture. We studied risk factors for fractures around and distal to the 2 most ...used cemented femoral stems in Sweden.
Patients and methods - This is a register study including all standard primary Lubinus SPII and Exeter Polished stems operated in Sweden between 2001 and 2009. The outcome was any kind of reoperation due to fracture around (Vancouver type B) or distal to the stem (Vancouver type C), with use of age, sex, diagnosis at primary THR, and year of index operation as covariates in a Cox regression analysis. A separate analysis of the primary osteoarthritis patient group was done in order to evaluate eventual influence of the surgical approach (lateral versus posterior) on the risk for Vancouver type B fractures.
Results - The Exeter stem had a 10-times (95% CI 7-13) higher risk for type B fractures, compared with the Lubinus, while no statistically significant difference was noticed for type C fractures. The elderly, and patients with hip fracture or idiopathic femoral head necrosis, had a higher risk for both fracture types. Inflammatory arthritis was a risk factor only for type C fractures. Type B fractures were more common in men, and type C in women. A lateral approach was associated with decreased risk for Type B fracture.
Interpretation - Stem design influenced the risk for type B, but not for type C fracture. The influence of surgical approach on the risk for periprosthetic femoral fracture should be studied further.
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