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2018 ICM book updates

Dear Delegates many of you are still waiting to receive a hard copy of the ICM book. The 5000 copies we had are all accounted for at this point. We are planning to have 300-400 copies of the book for distribution at the AAOS either in some of our industry partners’ booth or during off-site activities like the ICM symposium that will be held on Thursday evening at Venetian. In addition, some copies will be distributed in European meetings this month. We hope you will be able to get your hands on a copy soon.

Very sorry if we were unable to get you a copy. We distributed the books on first come first served basis and have ran out of the hard copies at this point. We may consider a second print run in the future.

Please note that the entire document (and the soon to come translations) are available on the App (ICMPhilly) and also the website (www.icmphilly.com).

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Paper of the week: Continuous Antibiotic Therapy Can Reduce Recurrence of Prosthetic Joint Infection in Patients Undergoing 2-Stage Exchange.

Paper of the week: Continuous Antibiotic Therapy Can Reduce Recurrence of Prosthetic Joint Infection in Patients Undergoing 2-Stage Exchange. Ascione T, Balato G, Mariconda M, Rotondo R, Baldini A, Pagliano P. J Arthroplasty. 2018 Dec 20. pii: S0883-5403(18)31218-X. doi: 10.1016/j.arth.2018.12.017

Summary and editorial by Sreeram Penna

The main aim of this observational cohort study is to compare infection recurrence in patients who had continuous antibiotic therapy versus antibiotic holiday period prior to reimplantation following two-stage revision for periprosthetic joint infection (PJI). Researchers also analyzed factors associated with poor outcome in patients undergoing two-stage revision procedure who had normalization of serum markers and improvement of symptoms prior to reimplantation. All patients in the study had two weeks of intravenous antibiotics followed by six weeks targeted oral antibiotics.

A total of 196 patients were included in the study. 110 patients had continuous antibiotic therapy prior to reimplantation, and 82 patients had an antibiotic holiday. Overall 169 (86%) patients had a favorable outcome, and 14% had PJI recurrence. In the group that had continuous antibiotics, the cure rate was 91% (104/110) versus 79% (65/82) in patients who had antibiotic holiday prior to reimplantation, and this result was statistically significant (p=0.029). Further analysis revealed that the cure rate was significantly (p=0.02) better in immunocompromised patients receiving continuous antibiotics (41/46, 89%) versus patients who had an antibiotic holiday (20/31, 65%). Immunocompromised patients included those with diabetes, liver cirrhosis, autoimmune disease, and those who were on immunosuppressive medication.

The study also found that serum markers, body mass index, and positive microbiology at reimplantation did not affect the overall outcome. Immunocompromised patients and culture-negative cases were associated with poor outcome following a two-stage procedure. Of the culture positive cases, patients with Gram-positive cultures had a better outcome compared to Gram-negative cases. In another study done by Herman et al., researchers found that CRP and other classic markers like synovial white cell count and PMN % performed poorly in identifying residual infection prior to reimplantation.[1] In addition as researchers noted in this study that antibiotic holiday was shown to have poor outcomes especially in immunocompromised patients, as conditions for bacterial regrowth are still present. This paper puts forth an important argument to continue antibiotic treatment until reimplantation. However further research is needed to identify the optimal time and predictive factors to calculate the success of reimplantation.

References

[1] Herman A, Albers A, Garbuz DS, Duncan CP, Masri BA. Classic Markers for Infection Perform Poorly in Predicting Residual Infection Prior to Reimplantation. Orthopedics 2019;42:34–40. doi:10.3928/01477447-20190103-03.

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Consensus update: Summary from the Biofilm Workgroup published in Journal of Orthopaedic Research

Hi all,

We are pleased to announce that summary from the biofilm workgroup is published in the Journal of Orthopaedic Research. Please visit the link below to access it.

The 2018 International Consensus Meeting on Musculoskeletal Infection: Summary from the Biofilm Workgroup and consensus on Biofilm related Musculoskeletal Infections.

Biofilm study group: Kordo Saeed, Alex C. McLaren, Edward M. Schwarz, Valentin Antoci, William V. Arnold, Antonia F. Chen, Martin Clauss, Jaime Esteban, Vanya Gant, Edward Hendershot’ Noreen Hickok’ Carlos A. Higuera, Débora C. Coraça‐Huber, Hyonmin Choe, Jessica Amber Jennings, Manjari Joshi, William T. Li, Philip C. Noble, K. Scott Phillips, Paul S. Pottinger, Camilo Restrepo, Holger Rohde, Thomas P. Schaer, Hao Shen, Mark Smeltzer, Paul Stoodley, Jason C. J. Webb, Eivind Witsø.

Journal of Orthopaedic Research®
DOI 10.1002/jor.24229

ICM 2018 Biofilm Working Group

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Paper of the week: Mortality During Total Hip Periprosthetic Joint Infection.

Paper of the week. Mortality During Total Hip Periprosthetic Joint Infection. Natsuhara KM, Shelton TJ, Meehan JP, Lum ZC. J Arthroplasty. 2018 Dec 24. pii: S0883-5403(18)31225-7. doi: 10.1016/j.arth.2018.12.024.

Summary and Editorial by Sreeram Penna

This publication is a systemic review of the literature and its main aim is to identify the mortality rate following two-stage procedure for total hip periprosthetic joint infection (PJI). The review included 23 studies on 19169 patients. Average weighted age of the patients was 65 years and average follow up was 3.7 years. Researchers showed that average overall mortality after total hip PJI was 5.4% and mortality per year increased 4.22% year after year following total hip PJI. This data translates to around 21.12% five-year mortality for total hip PJI. This pooled data result is similar to big studies included in this review. [1,2] Among the issues highlighted by researchers include underreported mortality and inadequate follow up in the studies included in the systemic review. Researchers also noticed no change in trends of mortality rate over time. Although some studies show that a substantial decline in PJI mortality rate without changes in PJI risk over time.[3] Overall this research highlights fact that PJI has considerable mortality and morbidity and considerable research needed to be done in this respect.

References

[1] Zmistowski B, Karam JA, Durinka JB, Casper DS, Parvizi J. Periprosthetic Joint Infection Increases the Risk of One-Year Mortality. The Journal of Bone and Joint Surgery-American Volume 2013;95:2177–2184. doi:10.2106/JBJS.L.00789.

[2] Cancienne JM, Werner BC, Bolarinwa SA, Browne JA. Removal of an Infected Total Hip Arthroplasty: Risk Factors for Repeat Debridement, Long-term Spacer Retention, and Mortality. J Arthroplasty 2017;32:2519–22. doi:10.1016/j.arth.2017.03.018.

[3] Kurtz SM, Lau EC, Son M-S, Chang ET, Zimmerli W, Parvizi J. Are We Winning or Losing the Battle With Periprosthetic Joint Infection: Trends in Periprosthetic Joint Infection and Mortality Risk for the Medicare Population. J Arthroplasty 2018;33:3238–45. doi:10.1016/j.arth.2018.05.042.

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Paper of the week: Reconsidering Strategies for Managing Chronic Periprosthetic Joint Infection in Total Knee Arthroplasty: Using Decision Analytics to Find the Optimal Strategy Between One-Stage and Two-Stage Total Knee Revision

Paper of the Week: Reconsidering Strategies for Managing Chronic Periprosthetic Joint Infection in Total Knee Arthroplasty: Using Decision Analytics to Find the Optimal Strategy Between One-Stage and Two-Stage Total Knee Revision. Srivastava K, Bozic KJ, Silverton C, Nelson AJ, Makhni EC, Davis JJ.J Bone Joint Surg Am. 2019 Jan 2;101(1):14-24. doi: 10.2106/JBJS.17.00874.

Summary and Editorial by Sreeram Penna

In this study, researchers used decision analysis to determine the optimal decision for the management of chronic periprosthetic infection (PJI) following total knee arthroplasty (TKA). Researchers constructed an expected-value decision tree to estimate the quality-adjusted-life-years (QALYs) and costs associated with 1-stage and 2-stage revision. Two decision trees were created one was for all pathogens, a second decision tree was constructed for difficult to treat organisms including methicillin-resistant. A Markov model was used to calculate the QALYs over a 15-year period. The model input was based on values such as mortality rates and reinfection rates published in original studies since 2000. Cost data were obtained from Medicare data.

Results showed that 1-stage revision was the optimal decision in producing greater health utility in both decision trees in the analysis. Some of the issues with research are that there is limited data on infection eradication 1-stage revisions for PJI. Seven studies included in the above simulation for 1-stage revision showed reinfection rates of 7% compared to 15% for 2-stage revision. Researchers contend that even if we assume reinfection rate for 2-stage revision to be around 10% infection rates of 1-stage be more than 30% to be considered non-optimal strategy compared to 2-stage revision as decision model captures significant morbidity and mortality associated with a 2-stage procedure. The simulation also captures cost savings of around $19,000 to $27,000 per infection (depending on pathogen) for 1-stage revision.

Normally in PJI treatment 2 stage revision procedure is considered the gold standard for infection eradication. However, it is known that such strategy place significant morbidity on the patient. In addition, a significant number of patients does not complete the reimplantation procedure in 2-stage operation.[1] This study gives an opportunity for orthopaedic community to rethink options in managing patients with PJI and further research is required.

References
[1] Gomez MM, Tan TL, Manrique J, Deirmengian GK, Parvizi J. The Fate of Spacers in the Treatment of Periprosthetic Joint Infection. J Bone Joint Surg Am 2015;97:1495–502. doi:10.2106/JBJS.N.00958.