RESUMEN
BACKGROUND: The diagnosis of periprosthetic joint infection (PJI) is a major challenge in clinical practice. The role of neutrophils in fighting infection has been increasingly understood, and one mechanism of action of these cells is neutrophil extracellular traps. However, little is known about this process in PJI. QUESTIONS/PURPOSES: (1) Are the biomarkers of neutrophil extracellular trap formation (citrullinated histone H3 [H3Cit], cell-free DNA [cf-DNA], and myeloperoxidase [MPO]) increased in the synovial fluid of patients with PJI? (2) What is the diagnostic accuracy of biomarkers of neutrophil extracellular trap formation for PJI? METHODS: Between May 2020 and March 2021, 43 patients who underwent revision THA or TKA were enrolled in this study. Eleven patients were excluded and 32 patients were categorized into the PJI group (n = 16) or non-PJI group (n = 16) according to the 2018 Second International Consensus Meeting on Musculoskeletal Infection criteria. There were 15 men and 17 women in this study, with a median (range) age of 70 years (60 to 80 years). Twenty-seven patients had TKA and five had THA. We measured cf-DNA, MPO, and H3Cit in synovial fluid. The sensitivity, specificity, and receiver operating characteristic curve were calculated for each biomarker using the Musculoskeletal Infection Society criteria as the gold standard for diagnosis and considering a clinical surveillance of 2 years for patients in the non-PJI group. RESULTS: Patients with PJI had higher levels of synovial fluid cf-DNA (median [range] 130 ng/µL [18 to 179] versus 2 ng/µL [0 to 6]; p < 0.001), MPO (1436 ng/µL [55 to 3996] versus 0 ng/µL [0 to 393]; p < 0.001), and H3Cit (2115 ng/µL [5 to 2885] versus 3 ng/µL [0 to 87]; p < 0.001) than those in the non-PJI group. In receiver operating characteristic curve analyses, we observed near-perfect performance for all biomarkers evaluated, with an area under the curve of 1 (95% CI 0.9 to 1), 0.98 (95% CI 0.9 to 1), and 0.94 (95% CI 0.8 to 0.99) for cf-DNA, MPO, and H3Cit, respectively. The sensitivity for detecting PJI using synovial fluid was 100% for cf-DNA, 94% for MPO, and 88% for H3Cit. The specificity was 100% for cf-DNA and MPO, and 88% for H3Cit. CONCLUSION: Our results show that neutrophils in the periprosthetic microenvironment release neutrophil extracellular traps as part of the bactericidal arsenal to fight infection. These results allow a better understanding of the cellular and molecular processes that occur in this microenvironment, enabling the design of more assertive strategies for identifying new biomarkers and improving the available ones. Novel studies are needed to define whether and how neutrophil extracellular trap-related biomarkers can be useful for diagnosing PJI. LEVEL OF EVIDENCE: Level II, diagnostic study.
Asunto(s)
Artritis Infecciosa , Artroplastia de Reemplazo de Cadera , Artroplastia de Reemplazo de Rodilla , Trampas Extracelulares , Prótesis de la Rodilla , Infecciones Relacionadas con Prótesis , Masculino , Humanos , Femenino , Anciano , Artroplastia de Reemplazo de Rodilla/efectos adversos , Artroplastia de Reemplazo de Rodilla/métodos , Trampas Extracelulares/química , Sensibilidad y Especificidad , Artroplastia de Reemplazo de Cadera/efectos adversos , Artroplastia de Reemplazo de Cadera/métodos , Prótesis de la Rodilla/efectos adversos , Líquido Sinovial/química , Biomarcadores/análisis , Artritis Infecciosa/diagnóstico , ADN , Infecciones Relacionadas con Prótesis/diagnóstico , Infecciones Relacionadas con Prótesis/cirugíaRESUMEN
Introduction: Periprosthetic infection (PPI) is one of the most devastating complications of total knee arthroplasty (TKA). The incidence described in the literature is 2.4% and the most frequently isolated bacteria are Staphylococcus Aureus and Staphylococcus Coagulase-Negative (Gram positive). Polymicrobial infections represent between 10 to 37% and negative cultures between 7 to 15%. Methodology: Descriptive and retrospective study that consisted of reviewing the TKA database of the Regional Hospital of Talca during the 2018-2020 period, where knee PPIs were identified according to the diagnostic criteria validated in 2018. The cultures of patients diagnosed with PPI were reviewed, analyzing the antibiogram and resistance profile. Results: During 2018-2020, 459 TKAs were performed in our center, diagnosing 30 PPIs of the knee. 47% of PPIs were acute and 53% chronic. The results of the cultures were negative in 26.6%, 23.3% Methicillin Sensitive Staphylococcus Aureus; 13.3% Methicillin Resistant Staphylococcus Epidermidis and 13.3% of the cultures were polymicrobial. Discussion: Highlights the high resistance to methicillin, especially of Staphylococcus Epidermidis. This opportunistic pathogen has the ability to form a biofilm and, thanks to its genomic flexibility, rapidly acquires resistance to antibiotics. Polymicrobial infections have a synergistic effect that favors the persistence of the infection, which is why they will require a greater number of surgeries and prolonged antibiotic therapy. Pruebas especiales como la sonicación podrían aumentar las posibilidad de identificar al microorganismo. Conclusion: In these three years of follow-up, the PPI rate has been higher than reported annually in the literature. Gram-positive microorganisms continue to predominate, but with an increase in the rate of resistant to methicillin. Also, highlight the number of negative cultures. There would be a possible benefit theoretical in optimizing antibiotic prophylaxis in view of the large percentage of methicillin resistance and in seeking new ways to reduce negative cultures.
Asunto(s)
Humanos , Femenino , Anciano , Infecciones Relacionadas con Prótesis/cirugía , Infecciones Relacionadas con Prótesis/epidemiología , Artroplastia de Reemplazo de Rodilla/efectos adversos , Staphylococcus aureus , Estudios Retrospectivos , Biopelículas , AntibacterianosRESUMEN
BACKGROUND: The correct diagnosis of a chronic periprosthetic joint infection (PJI) is a major challenge in clinical practice, with the "gold standard" for diagnosis yet to be established. Synovial fluid analysis has been proven to be a useful tool for that purpose. Cell-free DNA (cf-DNA) levels have been shown to be increased in several conditions such as cancer, trauma, and sepsis. Therefore, this study was designed to evaluate the potential of synovial fluid cf-DNA quantification for the diagnosis of chronic periprosthetic infections following total knee arthroplasty. METHODS: A prospective study with patients undergoing total knee arthroplasty revision surgery for any indication was performed. PJI diagnosis was defined according to the Second International Consensus Meeting on Musculoskeletal Infection (2018) criteria. The study cohort consisted of 26 patients classified as infected and 40 as noninfected. Synovial fluid cf-DNA direct quantification by fluorescent staining was made. Sensitivity, specificity, and receiver operating characteristic curve were calculated. RESULTS: The cf-DNA levels were significantly higher in patients who had PJIs (122.5 ± 57.2 versus 4.6 ± 2.8 ng/µL, P < .0001). With a cutoff of 15 ng/µL, the area under the receiver operating characteristic, sensitivity, and specificity of cf-DNA were 0.978, 96.2%, and 100%, respectively. CONCLUSION: The present study has shown that cf-DNA is increased in synovial fluid of patients who have chronic PJIs. It is a promising biomarker for knee PJI diagnosis and further studies are needed to confirm its utility.
Asunto(s)
Artritis Infecciosa , Artroplastia de Reemplazo de Cadera , Ácidos Nucleicos Libres de Células , Infecciones Relacionadas con Prótesis , Humanos , Infecciones Relacionadas con Prótesis/diagnóstico , Infecciones Relacionadas con Prótesis/cirugía , Estudios Prospectivos , Sensibilidad y Especificidad , Líquido Sinovial/química , Artritis Infecciosa/cirugía , Articulación de la Rodilla/cirugía , Biomarcadores/análisis , ADNRESUMEN
BACKGROUND: Identification of infective organism causing periprosthetic joint infections (PJIs) is crucial to tailor the best combination of surgical and antimicrobial treatment. Traditional culture, with all its limitations, has been utilized for this purpose. A synovial fluid antibody assay against some common pathogens has been introduced by a commercial entity recently. This study aimed to determine if the antibody testing could be used as a proxy to traditional culture, and whether it provided additional information, in the setting of PJI. METHODS: A retrospective study was conducted of patients who underwent revision total hip and knee arthroplasty between January 2019 and 2020. Aspirated synovial fluid was sent for analyses including the commercial antibody testing. All patients had samples harvested for culture per standard of care. Results of the antibody testing and culture, in terms of concordance, were compared. Receiver operating characteristic curve and Youden's criterion were used to compare the 2 methods. RESULTS: A total of 419 patients were included. Using the International Consensus Meeting criteria as reference standard for PJI, antibody testing had a sensitivity and specificity of 40.5% and 93.4%, respectively. There were 59.5% false negative results with antibody testing compared with 50% for culture. Of the 12 patients who had positive results in both tests, 5 (41.7%) had discordant pathogens identified in each test. CONCLUSION: Synovial fluid antibody testing does not provide clinical benefit when compared to traditional cultures for PJI diagnosis. The antibody testing had a low sensitivity and a high rate of discordance with culture, when both tests were positive.
Asunto(s)
Artritis Infecciosa , Artroplastia de Reemplazo de Cadera , Artroplastia de Reemplazo de Rodilla , Infecciones Relacionadas con Prótesis , Artritis Infecciosa/cirugía , Artroplastia de Reemplazo de Cadera/efectos adversos , Artroplastia de Reemplazo de Rodilla/efectos adversos , Biomarcadores , Humanos , Infecciones Relacionadas con Prótesis/diagnóstico , Infecciones Relacionadas con Prótesis/cirugía , Estudios Retrospectivos , Sensibilidad y Especificidad , Líquido SinovialRESUMEN
BACKGROUND: Although 2-stage exchange arthroplasty is the preferred surgical treatment for periprosthetic joint infection (PJI) in the United States, little is known about the risk of complications between stages, mortality, and the economic burden of unsuccessful 2-stage procedures. METHODS: The 2015-2019 Medicare 100% inpatient sample was used to identify 2-stage PJI revisions in total hip and knee arthroplasty patients using procedural codes. We used the Fine and Gray sub-distribution adaptation of the conventional Kaplan-Meier method to estimate the probability of completing the second stage of the 2-stage PJI infection treatment, accounting for death as a competing risk. Hospital costs were estimated from the hospital charges using "cost-to-charge" ratios from Centers for Medicare and Medicaid Services. RESULTS: A total of 5094 total hip arthroplasty and 13,062 total knee arthroplasty patients had an index revision for PJI during the study period. In the first 12 months following the first-stage explantation, the likelihood of completing a second-stage PJI revision was 43.1% (95% confidence interval [CI] 41.7-44.5) for hips and 47.9% (95% CI 47.0-48.8) for knees. Following explantation, 1-year patient survival rates for hip and knee patients were 87.4% (95% CI 85.8-88.9) and 91.4% (95% CI 90.6-92.2), respectively. The median additional cost for hospitalizations between stages was $23,582 and $20,965 per patient for hips and knees, respectively. Hospital volume, Northeast or Midwest region, and younger age were associated with reduced PJI costs (P < .05). CONCLUSION: Although viewed as the most preferred, the 2-stage revision strategy for PJI had less than a 50% chance of successful completion within the first year, and was associated with high mortality rates and substantial costs for treatment failure.
Asunto(s)
Artritis Infecciosa , Artroplastia de Reemplazo de Cadera , Infecciones Relacionadas con Prótesis , Anciano , Artritis Infecciosa/cirugía , Artroplastia de Reemplazo de Cadera/efectos adversos , Costos de Hospital , Hospitales , Humanos , Medicare , Infecciones Relacionadas con Prótesis/etiología , Infecciones Relacionadas con Prótesis/cirugía , Reoperación , Estudios Retrospectivos , Estados Unidos/epidemiologíaRESUMEN
BACKGROUND: Proximal femoral replacements (PFRs) are often used in the setting of severe bone loss. As osteolysis has become less common, PFR may be used to address other causes of bone loss such as infection or periprosthetic fracture. The aim of this study is to investigate the clinical outcomes of PFR for non-neoplastic conditions. METHODS: A retrospective review of 46 patients undergoing PFR at a single institution was performed. The electronic records were reviewed to extract relevant information including the reason for use of PFR, surgical variables, follow-up, and complications. Survivorship curves were generated and differences in survivorship were evaluated using the log-rank test. Radiographic evaluation was also performed. RESULTS: Using revision as an endpoint, the Kaplan-Meier analysis of the entire cohort demonstrated a survival rate of 74% at 1 year and 67% at 5 years. Patients with a preoperative diagnosis of periprosthetic joint infection demonstrated the lowest survivorship with a failure rate of 47%. Furthermore, a high dislocation rate at 17.4% (n = 8) was observed. The use of dual-mobility articulation was effective in reducing dislocation. CONCLUSION: PFR is a valuable reconstructive option for patients with massive proximal femoral bone loss. This study demonstrates that patients with periprosthetic joint infection who undergo PFR reconstruction are at very high risk of subsequent failure, most commonly from reinfection and instability. The use of a dual-mobility articulation in association with PFR appears to help mitigate risk of subsequent dislocation.
Asunto(s)
Artroplastia de Reemplazo de Cadera , Prótesis de Cadera , Infecciones Relacionadas con Prótesis , Artroplastia de Reemplazo de Cadera/efectos adversos , Prótesis de Cadera/efectos adversos , Humanos , Diseño de Prótesis , Falla de Prótesis , Infecciones Relacionadas con Prótesis/etiología , Infecciones Relacionadas con Prótesis/cirugía , Reoperación , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
BACKGROUND: Interim spacer exchange may be performed in patients undergoing 2-stage exchange for periprosthetic joint infection. Several studies have demonstrated that interim spacer exchange is associated with poor outcomes. This study investigated the survivorship and risk factors for failure in patients with an interim spacer exchange. METHODS: Two institutional databases identified 182 patients who underwent spacer exchange from 2000 to 2017. Primary outcomes included progression to reimplantation, treatment success, and mortality. Bivariate analysis was performed to evaluate risk factors associated with failure. Kaplan-Meier curves using host and local grades were generated to evaluate for primary outcomes and differences in survivorship. RESULTS: The overall failure rate was 49% in patients with a spacer exchange. Most patients (60%) failed before 2 years. Higher comorbidity scores, elevated erythrocyte sedimentation rate, and non-White race were more prevalent in patients who failed. Negative cultures at the time of exchange were more prevalent in patients who did not fail. Failure rate was higher in immunocompromised conditions, and those who had revision prior to exchange. After considering clinically relevant variables, advanced host grade C was the single factor associated with treatment failure. Although survivorship curves were not significantly different between extremity local grades, higher host grades were associated with treatment failure. CONCLUSION: Almost 1 out of 2 patients with spacer exchange were found to fail the intended 2-stage revision arthroplasty. Benefits of delivering additional antibiotic load with a new spacer should be balanced against poor outcomes in patients with the aforementioned risk factors.
Asunto(s)
Artritis Infecciosa , Artroplastia de Reemplazo de Cadera , Infecciones Relacionadas con Prótesis , Antibacterianos/uso terapéutico , Artritis Infecciosa/cirugía , Humanos , Infecciones Relacionadas con Prótesis/epidemiología , Infecciones Relacionadas con Prótesis/etiología , Infecciones Relacionadas con Prótesis/cirugía , Reoperación , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
Resumo Pacientes portadores de doença arterial obstrutiva periférica com isquemia crítica do membro associada a infecção de prótese vascular apresentam elevadas taxas morbimortalidade e alto risco de perda do membro. Apresentamos o caso de um paciente masculino de 76 anos com isquemia crítica do membro inferior esquerdo associada a infecção de prótese vascular femoropoplítea. Utilizamos abordagem híbrida para o tratamento com acesso cirúrgico das regiões inguinais e poplíteas, sendo a prótese vascular utilizada como acesso endovascular para recanalização direta da artéria femoral superficial devido a obstrução longa e extensa calcificação, que impediram as tentativas iniciais de tratamento endovascular. Após a recanalização endovascular, a prótese infectada foi retirada. O avanço das técnicas e materiais endovasculares em associação com a cirurgia aberta permitem novas soluções para pacientes quando os procedimentos habituais falham.
Abstract Patients with severe arterial obstructive disease and critical limb ischemia associated with vascular graft infection have elevated morbidity and mortality rates and are at high risk of limb loss. We present the case of a 76-year-old male patient with left lower limb critical ischemia and a femoropopliteal vascular graft infection. We used a hybrid treatment approach with an open surgical approach to the inguinal and popliteal regions and used the vascular prosthesis as endovascular access for direct recanalization of the superficial femoral artery, because the long occlusion and extensive calcification had frustrated initial attempts at endovascular treatment. After endovascular recanalization, the infected graft was removed. Used in conjunction with open surgery, advances in endovascular techniques and materials offer new solutions for patients when usual procedures fail.
Asunto(s)
Humanos , Anciano , Infecciones Relacionadas con Prótesis/cirugía , Recuperación del Miembro/métodos , Prótesis Vascular/efectos adversos , Procedimientos Endovasculares/métodos , Isquemia Crónica que Amenaza las Extremidades/cirugíaRESUMEN
Abstract Introduction: Destructive aortic root endocarditis is associated with high mortality rates. The objective of this article was to characterize the clinical and microbiological profiles of these patients, especially concerning an already implanted aortic valve prosthesis. We also focused on prognostic factors. Methods: Eighty patients underwent aortic root replacement due to destructive endocarditis from 1999 to 2018 in our institution. We analyzed their pre, intra, and postoperative data, outcomes, and predictors of mortality. Results: Thirty-one patients had native valve endocarditis (NVE), eight patients had early-onset prosthetic valve endocarditis (PVE), and 41 patients had late-onset PVE. Streptococcus was found in 19.4% of NVE cases and no PVE case. Coagulase-negative Staphylococcus was responsible for 62.5% of the cases of early-onset PVE. Thirty-four (42.5%) patients had received inappropriate antibiotics before admission. No microorganism was associated with higher risk of mortality. Aortoventricular dehiscence was identified as an independent risk factor of mortality along with PVE, concomitant bypass surgery, and delayed diagnosis. The incidence of postoperative complications was similar in all three groups. Rates of long-term survival (P=0.044) and freedom from the composite endpoint (P=0.024) defined as death, stroke, aortic valve reinfection, and aortic valve reoperation were the lowest within the NVE group and the highest among the PVE patients. Conclusion: In endocarditis, prolonged diagnostics, inadequate antimicrobial treatment, and late surgery led to destructive local complications and worsened the prognosis. PVE is associated with higher mortality than NVE.
Asunto(s)
Humanos , Prótesis Valvulares Cardíacas/efectos adversos , Infecciones Relacionadas con Prótesis/cirugía , Implantación de Prótesis de Válvulas Cardíacas/efectos adversos , Endocarditis Bacteriana/cirugía , Válvula AórticaRESUMEN
CASE: We present a case of a 70-year-old woman with simultaneous periprosthetic joint infection (PJI) of both hips and left knee due to a bilateral psoas abscess. The patient underwent debridement and implants removal with the consequent reimplantation in a sequential six-stage revision surgery. At four years of follow-up and in spite of the patient's comorbidities and current PJI presentation, she maintains full activities of daily living without restrictions. CONCLUSION: Accurate and early diagnosis of a psoas abscess is crucial. This case report provides experience of a complex scenario, the decision-making involved and the outcomes of an underdiagnosed complication.
Asunto(s)
Artroplastia de Reemplazo de Cadera/efectos adversos , Artroplastia de Reemplazo de Rodilla/efectos adversos , Diagnóstico Tardío , Infecciones Relacionadas con Prótesis/etiología , Infecciones Relacionadas con Prótesis/cirugía , Absceso del Psoas/complicaciones , Absceso del Psoas/diagnóstico , Reoperación/métodos , Infecciones Estafilocócicas/complicaciones , Infecciones Estafilocócicas/diagnóstico , Staphylococcus aureus , Anciano , Femenino , HumanosRESUMEN
AIMS: There is a paucity of long-term studies analyzing risk factors for failure after single-stage revision for periprosthetic joint infection (PJI) following total hip arthroplasty (THA). We report the mid- to long-term septic and non-septic failure rate of single-stage revision for PJI after THA. METHODS: We retrospectively reviewed 88 cases which met the Musculoskeletal Infection Society (MSIS) criteria for PJI. Mean follow-up was seven years (1 to 14). Septic failure was diagnosed with a Delphi-based consensus definition. Any reoperation for mechanical causes in the absence of evidence of infection was considered as non-septic failure. A competing risk regression model was used to evaluate factors associated with septic and non-septic failures. A Kaplan-Meier estimate was used to analyze mortality. RESULTS: The cumulative incidence of septic failure was 8% (95% confidence interval (CI) 3.5 to 15) at one year, 13.8% (95% CI 7.6 to 22) at two years, and 19.7% (95% CI 12 to 28.6) at five and ten years of follow-up. A femoral bone defect worse than Paprosky IIIA (hazard ratio (HR) 13.58 (95% CI 4.86 to 37.93); p < 0.001) and obesity (BMI ≥ 30 kg/m2; HR 3.88 (95% CI 1.49 to 10.09); p = 0.005) were significantly associated with septic failure. Instability and periprosthetic fracture were the most common reasons for mechanical failure (5.7% and 4.5%, respectively). The cumulative incidence of aseptic failure was 2% (95% CI 0.4 to 7) at two years, 9% (95% CI 4 to 17) at five years, and 12% (95% CI 5 to 22) at ten years. A previous revision to treat PJI was significantly associated with non-septic failure (HR 9.93 (95% CI 1.77 to 55.46); p = 0.009). At the five-year timepoint, 93% of the patients were alive (95% CI 84% to 96%), which fell to 86% (95% CI 75% to 92%) at ten-year follow-up. CONCLUSION: Massive femoral bone loss was associated with greater chances of developing a further septic failure. All septic failures occurred within the first five years following the one-stage exchange. Surgeons should be aware of instability and periprosthetic fracture being potential causes of further aseptic revision surgery. Cite this article: Bone Joint J 2021;103-B(7):1247-1253.
Asunto(s)
Artroplastia de Reemplazo de Cadera , Fémur/patología , Prótesis de Cadera , Infecciones Relacionadas con Prótesis/cirugía , Anciano , Anciano de 80 o más Años , Resorción Ósea/patología , Técnica Delphi , Femenino , Estudios de Seguimiento , Humanos , Incidencia , Estimación de Kaplan-Meier , Masculino , Persona de Mediana Edad , Osteoporosis/patología , Infecciones Relacionadas con Prótesis/epidemiología , Reoperación , Estudios Retrospectivos , Factores de RiesgoRESUMEN
INTRODUCTION: Destructive aortic root endocarditis is associated with high mortality rates. The objective of this article was to characterize the clinical and microbiological profiles of these patients, especially concerning an already implanted aortic valve prosthesis. We also focused on prognostic factors. METHODS: Eighty patients underwent aortic root replacement due to destructive endocarditis from 1999 to 2018 in our institution. We analyzed their pre, intra, and postoperative data, outcomes, and predictors of mortality. RESULTS: Thirty-one patients had native valve endocarditis (NVE), eight patients had early-onset prosthetic valve endocarditis (PVE), and 41 patients had late-onset PVE. Streptococcus was found in 19.4% of NVE cases and no PVE case. Coagulase-negative Staphylococcus was responsible for 62.5% of the cases of early-onset PVE. Thirty-four (42.5%) patients had received inappropriate antibiotics before admission. No microorganism was associated with higher risk of mortality. Aortoventricular dehiscence was identified as an independent risk factor of mortality along with PVE, concomitant bypass surgery, and delayed diagnosis. The incidence of postoperative complications was similar in all three groups. Rates of long-term survival (P=0.044) and freedom from the composite endpoint (P=0.024) defined as death, stroke, aortic valve reinfection, and aortic valve reoperation were the lowest within the NVE group and the highest among the PVE patients. CONCLUSION: In endocarditis, prolonged diagnostics, inadequate antimicrobial treatment, and late surgery led to destructive local complications and worsened the prognosis. PVE is associated with higher mortality than NVE.
Asunto(s)
Endocarditis Bacteriana , Implantación de Prótesis de Válvulas Cardíacas , Prótesis Valvulares Cardíacas , Infecciones Relacionadas con Prótesis , Válvula Aórtica/cirugía , Endocarditis Bacteriana/cirugía , Prótesis Valvulares Cardíacas/efectos adversos , Implantación de Prótesis de Válvulas Cardíacas/efectos adversos , Humanos , Infecciones Relacionadas con Prótesis/cirugíaRESUMEN
BACKGROUND: The current preferred treatment for chronic hip and knee periprosthetic joint infection (PJI) involves both surgical intervention and antibiotic treatment as part of a two-stage revision. The purpose of this study is to determine how often patients who underwent a two-stage revision for chronic PJI developed a subsequent antibiotic-resistant infection. METHODS: We retrospectively reviewed the clinical records of 142 patients who underwent a two-stage revision for a chronic culture-positive PJI from January 2014 to May 2019. Demographic data and risk factors for PJI were identified. Resistance was defined in accordance with microbiology laboratory report and minimum inhibitory concentration. Statistical analysis consisted of descriptive statistics and univariate analysis. RESULTS: Only 10 of the 142 patients (7.04%) demonstrated emergence of resistance to antibiotics across their two-stage revision. At reimplantation, 25 (17.6%) patients had positive cultures. Of these, 16 patients presented with a novel organism and 9 patients had positive culture for the same organism as the initial infection. During the entire course of the two-stage revision, including spacer exchanges and irrigation and debridement procedures, 15 (10.56%) patients demonstrated persistent infections, whereas 25 (17.6%) patients presented with novel infections. 26 (18.3%) patients had reinfection of the same joint within one year. CONCLUSION: In the given cohort, there does not appear to be a major emergence of antibiotic resistant organisms in patients undergoing two-stage exchange arthroplasty and antibiotic treatment.
Asunto(s)
Artroplastia de Reemplazo de Cadera , Artroplastia de Reemplazo de Rodilla , Infecciones Relacionadas con Prótesis , Antibacterianos/uso terapéutico , Artroplastia de Reemplazo de Cadera/efectos adversos , Artroplastia de Reemplazo de Rodilla/efectos adversos , Farmacorresistencia Microbiana , Humanos , Infecciones Relacionadas con Prótesis/tratamiento farmacológico , Infecciones Relacionadas con Prótesis/cirugía , Reoperación , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
BACKGROUND: Synovial fluid alpha-defensin (AD) may improve diagnostic accuracy of periprosthetic joint infection (PJI) following total knee (TKA) and hip (THA) arthroplasty but is only available as send-out test. This study evaluated laboratory result accuracy between send-out test vs hospital labs and if AD made a difference in treatment plan. METHODS: A retrospective review was performed of 152 consecutive patients with a TKA or THA joint aspiration for painful or clinically concerning joint. Synovial fluid was sent to our institution (hospital-based labs, HBL) and send-out immunoassay laboratory (Synovasure). Patients were scored with specific criteria from validated scoring system for PJI using HBL and Synovasure results. The score with and without AD test was compared to determine if AD impacted patient management. RESULTS: Overall, there was strong agreement between institutions for PJI diagnosis (Cohen's kappa score 0.96). Twenty-nine patients had PJI diagnosis (score ≥6), of which 28 (97%) had positive AD with 1 false-negative result. Sixty-three patients had inconclusive score (between 2 and 5) and 60 patients had negative PJI diagnosis (score ≤1). Of these patients, 5 underwent surgery for infection. Two patients had surgery for positive AD, 2 for positive culture, and 1 because of elevated HBL results. The AD test changed the PJI diagnosis and influenced decision for surgery in only 1.3% (2/152) of patients. CONCLUSION: Minimal differences were found in laboratory values between institutions. The addition of AD may be useful in cases of equivocal laboratory results but does not appear to be necessary for routine diagnosis of PJI after TKA/THA. LEVEL EVIDENCE: Level III.
Asunto(s)
Artroplastia de Reemplazo de Cadera , Artroplastia de Reemplazo de Rodilla , Infecciones Relacionadas con Prótesis , alfa-Defensinas , Biomarcadores , Humanos , Infecciones Relacionadas con Prótesis/cirugía , Estudios Retrospectivos , Sensibilidad y Especificidad , Líquido SinovialRESUMEN
BACKGROUND: Early surgical procedures on patients with infective endocarditis (IE) have shown a clearly benefit to reduce embolization at the central nervous system. We conducted a retrospective cohort in Mexican population to evaluate mortality and clinical outcomes in patients with IE with or without surgical intervention. OBJECTIVES: Our aim was to evaluate factors associated with mortality in patients with IE and compare both groups with and without a surgical intervention. METHODS: We evaluated a retrospective cohort of patients who had been diagnosed with IE according to the Duke's criteria at our Institution in SLP, Mexico, from January 2001 to September 2016. We compared the risk factors associated to mortality of patients with or without surgery. Our primary outcome was mortality within 6 months of follow-up after the diagnosis. RESULTS: We included 105 patients, 51 (48.6%) were men, median age 46 [Q1 30, Q3 59] years, 36 patients (34.3%) received surgical treatment (STG), and 69 (65.7%) only medical treatment (MTG) group; 41 patients (39%) died during the study period; in the surgery group eight patients died (22%); and 33 in the MT group (47%) p = 0.049. Adjusted for APACHE II, surgery, creatinine levels and the size of vegetation, the surgery group had lower mortality than patients on MTG (HR 0.36, p = 0.047). CONCLUSION: As previously described in the literature, patients who underwent surgery had lower mortality than the patients who only received medical treatment; however, the Mexican population is different to other populations group, due to higher risk of diabetes mellitus (28%) versus (10%) in global risk of DM in the world and its complications and other chronic diseases as arterial systemic hypertension. Thus, surgical treatment must be elected as goal standard treatment in patient's whit IE and presence of vegetation.
Antecedentes: Los procedimientos quirúrgicos tempranos en pacientes con endocarditis infecciosa (EI) han mostrado un beneficio claro para reducir la embolización en el sistema nervioso central. Realizamos una cohorte retrospectiva en población mexicana para evaluar la mortalidad y los resultados clínicos en pacientes con EI con o sin intervención quirúrgica. Objetivos: Nuestro objetivo fue evaluar los factores asociados a la mortalidad en pacientes con endocarditis infecciosa y comparar ambos grupos con y sin intervención quirúrgica. Métodos: Evaluamos una cohorte retrospectiva de pacientes que habían sido diagnosticados de EI según los criterios de Duke en nuestra Institución en SLP, México, desde enero de 2001 a septiembre de 2016. Comparamos los factores de riesgo asociados a la mortalidad de pacientes con o sin cirugía. Nuestro resultado primario fue la mortalidad dentro de los 6 meses de seguimiento después del diagnóstico. Resultados: Se incluyeron 105 pacientes, 51 (48.6%) eran hombres, mediana de edad46 [Q1 30, Q3 59] años, 36 pacientes (34.3%) recibieron tratamiento quirúrgico (STG) y 69 (65.7%) solo grupo de tratamiento médico (MTG); 41 pacientes (39%) murieron durante el período de estudio; en el grupo de cirugía fallecieron 8 pacientes (22%) y en el grupo de MT (47%) 33 p = 0.049. Ajustado por APACHE II, cirugía, niveles de creatinina y tamaño de la vegetación, el grupo de cirugía tuvo menor mortalidad que los pacientes en MTG (HR 0.36, p = 0.047). Conclusión: Como se ha descrito anteriormente en la literatura, los pacientes que se sometieron a cirugía tuvieron menor mortalidad que los pacientes que solo recibieron tratamiento médico, sin embargo, la población mexicana es diferente a otros grupos poblacionales, debido a un mayor riesgo de diabetes mellitus (28%) vs (10%) en otros países y sus complicaciones y otras enfermedades crónicas como hipertensión arterial sistémica. Por tanto, el tratamiento quirúrgico debe ser elegido como principal método de tratamiento en pacientes con endocarditis infecciosa y presencia de vegetaciones.
Asunto(s)
Antiinfecciosos/uso terapéutico , Bacteriemia/tratamiento farmacológico , Endocarditis/tratamiento farmacológico , Endocarditis/cirugía , Mortalidad Hospitalaria , Infecciones Relacionadas con Prótesis/cirugía , Adulto , Bacteriemia/epidemiología , Endocarditis/microbiología , Endocarditis/mortalidad , Femenino , Prótesis Valvulares Cardíacas/efectos adversos , Humanos , Masculino , México/epidemiología , Persona de Mediana Edad , Infecciones Relacionadas con Prótesis/tratamiento farmacológico , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
BACKGROUND: Alpha-defensin (AD) is a synovial biomarker included as a minor criterion in the scoring system for diagnosing periprosthetic joint infection (PJI). The purpose of this study is to study the impact of AD on diagnosis and management of PJI. METHODS: Synovial fluid from 522 patients after total knee and hip arthroplasty was retrospective reviewed. Synovial white blood cell count, percentage of neutrophils, and culture from the AD immunoassay laboratory were reviewed with serum erythrocyte sedimentation rate and C-reactive protein values from our institution. A modified version of the 2018 scoring system for diagnosis of PJI was used, only scoring white blood cell count, percentage of neutrophils, erythrocyte sedimentation rate, and C-reactive protein. AD was then analyzed with these scores to determine if AD changed diagnostic findings or clinical management. RESULTS: Eight-two patients were categorized as "infected" (score ≥6), of which 76 patients had positive AD. Of the 6 "infected" patients with negative AD, 2 had positive cultures (Staphylococcus epidermidis). Two-hundred thirteen patients were diagnosed as "possibly infected" (score 2-5). Fourteen of these patients had positive AD, of which 5 had positive cultures assisting with the diagnosis. The AD test changed the diagnosis from "possibly infected" to "infected" in 8 patients (1.5%) but only altered treatment plan in 6 patients (1.1%). A score <2 (not infected) was calculated in 227 patients with no patients having positive AD. CONCLUSION: AD may be beneficial in some cases where laboratory values are otherwise equivocal; however, its routine use for the diagnosis of PJI may not be warranted.
Asunto(s)
Artroplastia de Reemplazo de Cadera , Artroplastia de Reemplazo de Rodilla , Infecciones Relacionadas con Prótesis , alfa-Defensinas , Artroplastia de Reemplazo de Cadera/efectos adversos , Artroplastia de Reemplazo de Rodilla/efectos adversos , Biomarcadores , Proteína C-Reactiva/análisis , Humanos , Infecciones Relacionadas con Prótesis/diagnóstico , Infecciones Relacionadas con Prótesis/cirugía , Estudios Retrospectivos , Sensibilidad y Especificidad , Líquido Sinovial/químicaRESUMEN
BACKGROUND: Diagnosis of periprosthetic joint infection (PJI) is a multistep process that involves performing various tests including erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP). The latter two tests, despite being used at all times for PJI diagnosis, are known to be nonspecific and substantially affected by demographic characteristics, including age, gender, race, and body mass index. It is unknown how these variations affect the diagnostic utility of serological markers for PJI. METHODS: Institutional databases were queried to identify patients undergoing revision arthroplasty between 2010 and 2018, in whom preoperative serum ESR and CRP was performed. Patient demographics were collected, and patients were cross-referenced with an internal database to determine their infection status. Analyses were performed to determine how ESR and CRP varied with respect to demographic factors, including age, gender, race, and infection status. Given that patient infection status was known at the time of revision, conclusions were drawn about the effect of these variations in inflammatory markers on the diagnostic utility of ESR and CRP. RESULTS: The value of ESR increased by age was higher in females and African American race. No significant differences were observed in the value of CRP among the demographic factors, although a slight positive trend was observed with respect to age. The variation in inflammatory markers significantly affected the sensitivity, specificity, and accuracy of ESR and CRP for PJI diagnosis. CONCLUSION: Understanding how the accuracy of diagnostic tests varies with respect to demographic factors can help physicians avoid subjecting patients to unnecessary additional testing and reach more accurate diagnoses of PJI.
Asunto(s)
Artroplastia de Reemplazo de Cadera , Artroplastia de Reemplazo de Rodilla , Infecciones Relacionadas con Prótesis , Biomarcadores , Sedimentación Sanguínea , Proteína C-Reactiva/análisis , Demografía , Femenino , Humanos , Infecciones Relacionadas con Prótesis/diagnóstico , Infecciones Relacionadas con Prótesis/epidemiología , Infecciones Relacionadas con Prótesis/cirugía , Sensibilidad y Especificidad , Líquido Sinovial/químicaRESUMEN
AIMS: Our objective is to describe our early and mid-term results with the use of a new simple primary knee prosthesis as an articulating spacer in planned two-stage management for infected knee arthroplasty. As a second objective, we compared outcomes between the group with a retained first stage and those with a complete two-stage revision. METHODS: We included 47 patients (48 knees) with positive criteria for infection, with a minimum two-year follow-up, in which a two-stage approach with an articulating spacer with new implants was used. Patients with infection control, and a stable and functional knee were allowed to retain the initial first-stage components. Outcomes recorded included: infection control rate, reoperations, final range of motion (ROM), and quality of life assessment (QoL) including Western Ontario and McMaster Universities osteoarthritis index, Knee Injury and Osteoarthritis Outcome Score, Oxford Knee Score, 12-Item Short-Form Health Survey questionnaire, and University of California Los Angeles (UCLA) activity score and satisfaction score. These outcomes were evaluated and compared to additional cohorts of patients with retained first-stage interventions and those with a complete two-stage revision. Mean follow-up was 3.7 years (2.0 to 6.5). RESULTS: Eight knees failed directly related to lack of infection control (16%), and two patients (two knees) died within the first year for causes not directly related, giving an initial success rate of 79% (38/48). Secondary success rate after a subsequent procedure was 91% (44/48 knees). From the initially retained spacers, four knees (22%) required a second-stage revision for continuous symptoms and one (5%) for an acute infection. There were no significant differences regarding the failure rate due to infection, ROM, and QoL assessment between patients with a retained first-stage procedure and those who underwent a second-stage operation. CONCLUSION: Our protocol of two-stage exchange for infected knee arthroplasties with an articulating spacer and using new primary knee implants achieves adequate infection control. Retained first-stage operations achieve comparable results in selected cases, with no difference in infection control, ROM, and QoL assessment in comparison to patients with completed two-stage revision surgery. Cite this article: Bone Joint J 2020;102-B(7):852-860.