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Paper of the week: Periprosthetic joint infection in aseptic total hip arthroplasty revision.

Paper of the week: Periprosthetic joint infection in aseptic total hip arthroplasty revision. Renard G, Laffosse JM, Tibbo M, Lucena T, Cavaignac E, Rouvillain JL, Chiron P, Severyns M, Reina N. Int Orthop. 2019 Jun 25. doi: 10.1007/s00264-019-04366-2.

Summary by Dr Sreeram Penna

Aim of this retrospective study was to evaluate incidence of occult infection in presumed aseptic total hip arthroplasty revisions and to identify associated risk factors. Researchers retrospectively reviewed all patients who underwent aseptic total hip revision between 2009 and 2013. Total of 523 cases (498 patients) were identified. The main indications for revision were aseptic loosening(283/523, 54%), instability (91/523, 17%), periprosthetic fracture (56/523, 11%), wear and osteolysis (35/523, 7%), unexplained pain (12/523, 2%), implant fracture (13/523, 3%), and others (metallosis, squeaking, tumour, aseptic lymphocyte-dominated vascular-associated lesion, psoas impingement)(33/523, 6%). Unexpected positive cultures (UPC) were found in 78 cases (15%). Of these 58 cases were monomicrobial, and 20 cases polymicrobial. Further review identified 36 cases (7%) with positive cultures as true infections and other 42 cases (8%) as contaminants. Infection was identified in 15/91 (16%) cases who underwent revision for instability. Similarly, incidence of infection was 12% in patients with periprosthetic fracture, 3.2% in aseptic loosening and 2.8% in polyethylene wear and osteolysis group. On further analysis researchers found statistically significant difference in early dislocation (with in 3 months) rates in infection group (31%) compared to non-infection group (7%) (p<0.001).

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Paper of the week: Risk Factors for Failure After 1-Stage Exchange Total Knee Arthroplasty in the Management of Periprosthetic Joint Infection.

Paper of the week: Risk Factors for Failure After 1-Stage Exchange Total Knee Arthroplasty in the Management of Periprosthetic Joint Infection. Citak M, Friedenstab J, Abdelaziz H, Suero EM, Zahar A, Salber J, Gehrke T. J Bone Joint Surg Am. 2019 Jun 19;101(12):1061-1069. doi: 10.2106/JBJS.18.00947.

Summary by Dr Sreeram Penna

In this case control study researchers analyzed the causes of and risk factors for failure following 1-stage exchange total knee arthroplasty. In this study cases consist of total knee joints treated for periprosthetic joint infection with 1 stage exchange arthroplasty that subsequently had revision procedures. These were matched with controls who had 1 stage exchange arthroplasty that did not require further revision. Cases included 91 patients, of these patients reason for failure was infection (n = 42), aseptic loosening (n = 37), patellar problems (n=3), periprosthetic fracture (n=3) and knee dislocation (n=1). Risk factors associated with reoperation in 1 stage procedure included weight more than 100, history of DVT, more than 4 prior procedures, history of poly microbial infection, prior one stage exchange, prior two stage exchange, extensive osseous defects requiring tantalum cones, surgical time more than 4 hours, persistent wound drainage, and isolation of enterococcus. Further bivariate analysis of infection subgroup showed all above risk factors except extensive osseous defect. It also identified two additional risk factors including isolation of streptococcus and wound revision due to healing disorders. Please see table below for odds ratios (OR).

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Consensus update: Articles from the Shoulder Workgroup published in Journal of Shoulder and Elbow Surgery

Hi all,

We are pleased to announce that the articles from the shoulder workgroup is published in the Journal of Shoulder and Elbow Surgery. Please visit the links below to access it.

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Paper of the week: Use of incisional vacuum-assisted closure in the prevention of postoperative infection in high-risk patients who underwent spine surgery: a proof-of-concept study.

Paper of the week: Use of incisional vacuum-assisted closure in the prevention of postoperative infection in high-risk patients who underwent spine surgery: a proof-of-concept study. Dyck BA, Bailey CS, Steyn C, Petrakis J, Urquhart JC, Raj R, Rasoulinejad P. J Neurosurg Spine. 2019 May 10:1-10. doi: 10.3171/2019.2.SPINE18947.

Summary by Dr Sreeram Penna

In this study researchers wanted to see if use of incisional vacuum assisted closure resulted in lower surgical site infections in high-risk patients who underwent spine surgery. A total of 64 patients were included In this proof of concept study. 21 patients received incisional vacuum assisted closure and and 43 diagnosis matched patients received standard dressings. Patients undergoing vacuum assisted closure met criteria for high risk of infection including posterior open surgery across the cervicothoracic junction; thoracic kyphosis due to metastatic disease; high-energy trauma; or multilevel revision reconstructive surgery. They also met one or more co-morbidity criteria, including body mass index 35 more, body mass index below 18.5, diabetes, previous radiation at surgical site, chemotherapy, steroid use, bedridden state, large traumatic soft-tissue disruption, or immunocompromised state. Although not statistically significant (p=0.314) vacuum assisted closure had lower infection rate 10% (2/21) compared to standard dressings 21% (9/43). This study demonstrates possible utility of vacuum assisted closure to reduce surgical site infections in high risk spine surgery patients.

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Paper of the Week: Four versus six weeks of antibiotic therapy for osteoarticular infections after implant removal: a randomized trial.

Four versus six weeks of antibiotic therapy for osteoarticular infections after implant removal: a randomized trial. Benkabouche M, Racloz G, Spenchbach H, Lipsky BA, Gaspoz JM, Uçkay I. J Antimicrob Chemother 2019 May 18. Doi: 10.1093/jac/dkz202.

Summary and editorial by Dr. Marjan Wouthuyzen-Bakker

For several decades, osteoarticular infections after implant removal have been treated with antibiotics for a duration of six weeks. In this single-centre, unblinded, randomized trial, 123 patients were randomized to 4 or 6 weeks of systemic antibiotic treatment after infected hardware was removed (i.e. prosthetic joints, orthopaedic plates or nail implants). Most patients received intravenous antibiotics for 4 days before switching to oral. Intraoperative cultures were taken after a minimum antibiotic holiday of 2 weeks before re-implantation of hardware. Microbiological recurrence during reimplantation was observed in 2 of 62 patients in the 4-week arm (3.2%) versus 1 of 61 patients in the 6-week arm (1.6%) (P=0.57). Recurrence of clinical infection occurred in 4 out of 62 patients in the 4-week arm (6.5%) and in 3 out of 61 patients in the 6-week arm (4.9%) (P=0.74) during a minimum follow-up of 6 months (median follow-up of 2.2 years).

Based on these results, the authors demonstrate non-inferiority of a 4-week antibiotic treatment course compared to 6-weeks for osteoarticular infections after implant removal. It should be noted that a large proportion of included infections were acute and thus, its non-inferiority can probably not be extrapolated one on one to chronic infections with the presence of mature biofilm.

The study conducted by Benkabouche et al. again demonstrates that the habit of prescribing long courses of antibiotics can be questioned. Nowadays, several studies suggest that antibiotic duration can be shortened for indications that traditionally have been treated for longer periods, in particular prosthetic joint infections, provided that proper surgical debridement has been performed [1]. In addition, in agreement with the OVIVA trial [2], early switch to oral antibiotics can be safely performed if antibiotics are chosen with adequate oral bioavailability.

References

  1. Lora-Tamayo J, Euba G, Cobo J et al. Short- versus long-duration levofloxacin plus rifampicin for acute staphylococcal prosthetic joint infection managed with implant retention: a randomised clinical trial. Int J Antimicrob Agents. 2016 Sep;48(3):310-6.
  2. Li HK, Rombach I, Zambellas R et al. Oral versus Intravenous Antibiotics for Bone and Joint Infection. N Engl J Med. 2019 Jan 31;380(5):425-436.