Two-stage total hip arthroplasty for chronic septic hip arthritis / 中华创伤骨科杂志

Objective:To analyze the clinical efficacy of two-stage total hip arthroplasty in the treatment of chronic septic hip arthritis.Methods:From January 2008 to March 2020, 17 patients with chronic septic hip arthritis (17 hips) received two-stage total hip arthroplasty at Department of Orthopaedic Surgery, The First Affiliated Hospital to of Fujian Medical University. They were 11 males and 6 females, with an average age of 54.5 years (from 19 to 77 years) and 9 left and 8 right hips affected. There were 10 cases of primary septic hip and 7 cases of secondary infection after hip surgery. Three patients had undergone debridement in other hospitals and one patient had developed a sinus tract. In the first stage operation, the diseased femoral head and neck were resected to implant an articulating spacer after thorough debridement; in the second stage operation, the spacer was removed to implant a uncemented artificial hip prosthesis in 16 cases or a cemented artificial hip prosthesis in one case. Recorded were the results of microbial culture, operation time, intraoperative blood loss, and therapeutic outcomes of the patients.Results:Pathogenic data were available in 13 patients and the culture was negative in 4. The pathogens were detected by metagenomic next-generation sequencing in 2 patients with culture negative. In the first stage operation, operation time averaged 140.6 min (from 90 to 176 min) and intraoperative blood loss 361.8 mL(from 100 to 1 000 mL); in the second stage operation, operation time averaged 130.3 min (from 91 to 166 min)and blood loss 291.2 mL(from 50 to 700 mL). The average interval between the first and the second stage operations was 115.0 days(from 66 to 227 d). During the interval, spacer fracture occurred in one case, spacer dislocation in one case and lower extremity deep venous thrombosis in one case. All the patients were followed up for 12 to 82 months (average, 36.7 months) after second stage operation. The inflammatory indexes decreased to normal in all the 17 patients and infection recurrence was observed in none of them.Conclusions:Two-stage total hip arthroplasty may result in a high rate of successful treatment of chronic septic hip arthritis. Specific use of sensitive antibiotics after identification of specific pathogenic microorganisms by multiple methods is the key to a successful treatment.

Staged Revision of Infected-hip Arthroplasty Using an Antibiotics-loaded Intra-articular Cement Spacer: Impact on Cemented and Cementless Stem Retention / 대한고관절학회지

PURPOSE: Currently, standard management of a peri-prosthetic infection is a two-stage revision precedure. However, removal of well-fixed cement is technically demanding and associated with numerous potential complications. For theses reasons, two-stage revision with preservation of the original femoral stem can be considered and several previous studies have achieved successful results. While most prior studies used cemented stems, the use of cementless stems during arthroplasty has been gradually increasing; this study aims to assess the comparative effectiveness of a two-stage revision of infected hip arthroplasties at preserving cemented and cementless stems.MATERIALS AND METHODS: Between December 2001 and February 2017, Inje University Sanggye Paik Hospital treated 45 cases of deep infections following hip arthroplasty with a two stage revisional arthroplasty using antibiotics-loaded cement spacers. This approach was applied in an effort to preserve the previously implanted femoral stem. Of these 45 cases, 20 were followed-up for at least two years and included in this analysis. Perioperative clinical symptoms, radiological findings, function and complications during insertion of an antibiotics-loaded cement spacer were analyzed in this study.RESULTS: Peri-prothetic infections were controlled in 19 of the 20 included cases. Clinical outcomes, as assessed using the Harris hip score, Western Ontario and McMaster University score, also improved. Importantly, similarly improved outcomes were achieved for both cemented and cementless femoral stems.CONCLUSION: In cases of deep infection following hip arthroplasty, two-stage revision arthroplasty to preserve the previously implanted femoral stem (cemented or cementless) effectively controls infections and preserves joint function.

Research progress on periprosthetic joint infection after arthroplasty / 解放军医学杂志

Periprosthetic joint infection (PJI) is a catastrophic complication after artificial joint replacement, and its diagnosis and treatment has always been a great challenge in the field of orthopedics. At present, the treatment strategies for PJI include suppressive antibiotic therapy, debridement antibiotics irrigation of the retained, prosthesis, one-stage revision, two-stage revision, arthrodesis, amputation, and biotherapy, etc. Conventional treatment can not achieve satisfactory results. As a new treatment mode, biotherapy has unique advantages in PJI treatment. This article reviews the risk factors and the source of infection, diagnosis, classification and treatment strategies of PJI, in order to provide valuable reference for clinical treatment of PJI.

The Results of Two-stage Revision for Methicillin-resistant Periprosthetic Joint Infection (PJI) of the Hip

@#Introduction: Periprosthetic joint infection (PJI) of the hip due to methicillin-resistant bacteria is difficult to treat and remain a challenge for arthroplasty surgeon. Material and Methods: Retrospective review was done to the patients who received two-stage revisions with an antibiotic loaded cement-spacer for PJI of the hip between January 2010 to May 2015. We found 65 patients (65 hips) with positive culture findings. Eight patients were lost to follow-up and excluded from the study. Among the rest of the 57 patients, methicillin-resistant infection (MR Group) was found in 28 cases. We also evaluate the 29 other cases that caused by the other pathogen as control group. We compared all of the relevant medical records and the treatment outcomes between the two groups. Results:The mean of follow-up period was 33.7 months in the methicillin-resistant group and 28.4 months in the control group (p = 0.27). The causal pathogens in the methicillinresistant group were: Methicillin-resistant Staphylococcus aureus (MRSA) in 10 cases, Methicillin-resistant Staphylococcus epidermidis (MRSE) in 16 cases and Methicillin-resistant coagulase-negative Staphylococcus (MRCNS) in two cases. The reimplantation rate was 92.8% and 89.6% in the methicillin-resistant and control group, respectively (p= 0.66). The rates of recurrent infection after reimplantation were 23.1% (6/26) in the methicillin-resistant group and 7.6% (2/26) in the control group (p= 0.12). The overall infection control rate was 71.4% (20/28) and 89.6% (26/29) in the methicillin-resistant and control group, respectively (p = 0.08). Both groups showed comparable baseline data on mean age, BMI, gender distribution, preoperative ESR/CRP/WBC and comorbidities. Conclusions: Two-stage revision procedure resulted in low infection control rate and high infection recurrency rate for the treatment of methicillin-resistant periprosthetic joint infection (PJI) of the hip. Development of the treatment strategy is needed to improve the outcome of methicillin resistant periprosthetic joint infection (PJI) of the hip.

Research progress of two-stage revision for periprosthetic joint infection after hip and knee arthroplasties / 中国修复重建外科杂志

Objective: To summarize the research progress of two-stage revision for periprosthetic joint infection (PJI) after hip and knee arthroplasties. Methods: The related literature on two-stage revision for PJI was summarized, and the new progress in the choice of spacers, systemic antibiotic therapy, and risk factors were analyzed. Results: Two-stage revision is a common way to treat infection after hip and knee arthroplasties. The types of spacers used in the one-stage operation are diverse and each has its own advantages and disadvantages. Non-articular spacers are mainly used for the patients with poor soft tissue conditions around the joints and severe bone defects. But the joint mobility is not good after the placement of the spacer. Articular spacers can restore the affected joint movement after operation, which is beneficial to the joint mobility after two-stage operation. The use of antibiotics is an indispensable part of the treatment process, and the effectiveness of short-term antibiotic treatment is similar to long-term treatment. Identifying the relevant risk factors that influence the prognosis of the two-stage revision can help preoperative management and reduce the recurrence rate of infection. Conclusion: There are still controversies about the choice of spacers and systemic antibiotic therapy during the two-stage revision and treatment of PJI. The factors affecting the prognosis of the two-stage revision need to be explored and the further high-quality research is needed.

Mechanical complications with self-made, antibiotic-loaded cement articulating spacers in the treatment of the infected hip replacement / 中国骨伤

<p><b>OBJECTIVE</b>To study the complications and efficacy of self-made, antibiotic-loaded cement articulating spacers in the treatment of the infected hip replacement.</p><p><b>METHODS</b>Between January 2006 and July 2016, 265 patients (266 hips) received a self-made, antibiotic-loaded cement articulating spacer as part of a two-stage protocol. Among those patients, there were 143 males(144 hips) and 122 females(122 hips). The cement articulating spacers with vancomycin and two Steinman pins were made by a self-made mold system. Meanwhile, another antibiotic was added to the spacers according to the drug sensitivity test. Record if the infected prosthesis was removed, related complication with spacer(breakage and dislocation), Harris score, and control rate of infection.</p><p><b>RESULTS</b>The mean age of two-stage revision operation was(57.4±14.2) years. Thirty-nine patients(14.7%) used extended trochanteric osteotomy(ETO) to remove the infected prosthesis. And 38 patients occurred mentioned complications(14.3%). Spacer breakage occurred in 28 cases(10.5%) and dislocation occurred in 10 cases(3.8%). The mean follow-up time was(83.4±14.6) months. The Harris hip score was from 47.56±14.23 preoperatively to 86.43±12.84 at final follow-up(<0.05). The infection of 256 cases(96.6%) got control after revision operation. However, during postoperative follow-up, 4 cases occurred re-infection, and they were reoperated, and the infections obtained effective control after the operation. Thus total infection control rate was 95.1%(252/265).</p><p><b>CONCLUSIONS</b>Antibiotic-loaded cement articulating spacer made by a self-made mold system is effective in controling infection caused by hip replacement. Related complication is less with spacer by a mould enclosing two Steinman pins. Using metallic internal fixation or allograft bone combined with spacer does not affect infection control.</p>

Predictors for outcome of exchange arthroplasty for periprosthetic joint infections after primary total knee arthroplasty / 中华传染病杂志

Objective To evaluate the overall failure rate of one or two-stage exchange arthroplasty for infections in total knee arthroplasty (TKA) and the predictors affecting the outcome of exchange.Methods Thirty-nine cases received one or two-stage exchange arthroplasty for periprosthetic joint infections after primary TKA in Shanghai Sixth People's Hospital affiliated to Shanghai Jiao Tong University School of Medicine and Southeast Hospital affiliated to Xiamen University from January 2012 to November 2014 were reviewed.Periprosthetic tissue and articular fluid of all patients were analyzed by bacterial culture.All patients were followed up for more than one year.C-reactive protein (CRP),erythrocyte sedimentation rate (ESR),procalcitonin (PCT) and blood routine were tested every four weeks,and the evaluation on pain,total periprosthetic function,range of motion and deformation of arthroplasty were conducted.Differences between groups were analyzed using chi-square test or Student's t test when appropriate.A stepwise selection approach in logistic regression analysis was used to screen key predictors for outcome of one or two-stage exchange for infections in TKA.Results There were 39 patients who had undergone one or two-stage exchange for infections in TKA,including 20 males (51.3％) and 19 females (48.7％) with an average age of (62.4±11.7) years.Among the 39 patients,18 gram-positive strains were isolated from specimens,and 6 gram negative strains,2 Mycobacterium tuberculosis and 1 candida albicans.Ten of 39 reimplantations developed reinfection.Between the success and failure groups,there were significant differences in the time from primary TKA to revision (P =0.023),operative time (P =0.029),multidrug resistant organisms (P =0.045),the preoperative and post-operative ESR (P=0.002 and P＜0.001,respectively) and post-operative CRP (P=0.018).Multivariable logistic regression analysis demonstrated that time from primary TKA to revision (OR =0.96,95％CI:0.92-1.00,P=0.025),preoperative ESR (OR=0.97,95％CI:0.95-1.00,P=0.045) and post-operative ESR (OR =0.94,95％ CI:0.91-0.98,P =0.002) were independent indicators associated with the outcome of one or two-stage revision.Conclusions The failure rate after revision for infected TKA is relatively high.The time from primary TKA to revision,preoperative and post-operative ESR could predict the outcome of one or two-stage revision effectively.

Treatment for culture-negative periprosthetic joint infection after total hip arthroplasty with revision / 局解手术学杂志

Objectives To compare the effect of one-stage revision and two-stage revision for the treatment of culture-negative peripros-thetic joint infection after total hip arthroplasty.Methods A retrospective study was conducted with the clinical data of 41 patients who had chronic periprosthetic joint infection after total hip arthroplasty and then underwent one or two-stage revision surgery from February 2006 to February 2014.The patients were divided into two groups according to different surgical way,namely the 16 patients who received the one-stage revision surgery were regarded as the OSR group,and the other 25 cases who underwent the two-stage revision surgery were regarded as the TSR group.The clinical efficacy of the two surgical way were assessed with Harris Hip score,visual analogue scale (VAS),and rate of infection clearance.Results The average duration of follow up was 29.7 months (9 to 48 months).At the last follow-up,Harris Hip score of TSR group was higher than that of the OSR group,and the difference was statistically significant (P =0.04),and the VAS score of TSR group was lower than that of the OSR group with statistical differences (P =0.02).Additionally,the rate of infection clearance in TSR group was significantly higher than OSR group (P =0.04).Conclusion Culture-negative periprosthetic joint infection can be effectively controled by one or two-stage revision surgery.However,patients got a better prognosis after two-stage revision surgery.

Two-Stage Total Knee Arthroplasty for Prosthetic Joint Infection

PURPOSE: This retrospective review was conducted to identify prognostic factors for two-stage reimplantation for infected total knee arthroplasty (TKA) and the rate of reinfection following revision TKA. MATERIALS AND METHODS: Out of 88 patients diagnosed with post-TKA infection between 1998 and 2011, 76 underwent two-stage reimplantation and were reviewed in this study. The 76 patients were divided into two groups-those who experienced reinfection and those who did not. Comorbidities, culture results, and inflammation indices were analyzed and compared between the two groups. RESULTS: Of the 76 patients who underwent a two-stage reimplantation, 18 (23.7%) experienced reinfection. Patients with more than three comorbidities had significantly higher reinfection rates than those with less than three comorbidities (47.1% vs. 4.8%, p=0.032). The reinfection rate between the culture positive prosthetic joint infection group and the culture negative prosthetic joint infection group was not significantly different (p=0.056). Inflammation indices (erythrocyte sedimentation rate [ESR] and C-reactive protein [CRP]) showed a statistically significant difference between patients with reinfection and those without reinfection at 4 weeks after the first-stage surgery. CONCLUSIONS: Reimplantation must be carefully performed when the risk of reinfection is high, particularly in patients with more than three systemic or local comorbidities and higher inflammation indices (ESR and CRP) prior to revision TKA.

Two-Stage Revision for Infected Total Knee Arthroplasty: Based on Autoclaving the Recycled Femoral Component and Intraoperative Molding Using Antibiotic-Impregnated Cement on the Tibial Side

BACKGROUND: The purpose of this study was to determine the degree of infection control and postoperative function for new articulating metal-on-cement spacer. METHODS: A retrospective study of 19 patients (20 cases), who underwent a two-stage revision arthroplasty using mobile cement prosthesis, were followed for a minimum of 2 years. This series consisted of 16 women and 3 men, having an overall mean age of 71 years. During the first stage of revision, the femoral implant and all the adherent cement was removed, after which it was autoclaved before replacement. The tibial component was removed and a doughy state, antibiotic-impregnated cement was inserted on the tibial side. To achieve joint congruency, intraoperative molding was performed by flexing and extending the knee joint. Each patient was evaluated clinically and radiologically. The clinical assessments included range of motion, and the patients were scored as per the Hospital for Special Surgery (HSS) and Knee Society (KS) criteria. RESULTS: The mean range of knee joint motion was 70degrees prior to the first stage operation and 72degrees prior to the second stage revision arthroplasty; following revision arthroplasty, it was 113degrees at the final follow-up. The mean HSS score and KS knee and function scores were 86, 82, and 54, respectively, at the final follow-up. The success rate in terms of infection eradication was 95% (19/20 knees). No patient experienced soft tissue contracture requiring a quadriceps snip. CONCLUSIONS: This novel technique provides excellent radiological and clinical outcomes. It offers a high surface area of antibiotic-impregnated cement, a good range of motion between first and second stage revision surgery for the treatment of chronic infection after total knee arthroplasty, and is of a reasonable cost.

Revision of Infected Total Knee Arthroplasty: Two-Stage Reimplantation Using an Antibiotic-Impregnated Static Spacer

BACKGROUND: A two-stage revision remains as the "gold standard" treatment for chronically infected total knee arthroplasties. METHODS: Forty-five septic knee prostheses were revised with a minimum follow-up of 5 years. Static antibiotic-impregnated cement spacers were used in all cases. Intravenous antibiotics according to sensitivity test of the culture were applied during patients' hospital stay. Oral antibiotics were given for another 5 weeks. Second-stage surgery was undertaken after control of infection with normal erythrocyte sedimentation rate and C-reactive protein values. Extensile techniques were used if needed and metallic augments were employed for bone loss in 32 femoral and 29 tibial revisions. RESULTS: The average interval between the first-stage resection and reimplantation was 4.4 months. Significant improvement was obtained with respect to visual analog scale pain and clinical and functional scores, and infection was eradicated in 95.6% of cases following a two-stage revision total knee arthroplasty. Radiographic evaluation showed suitable alignment without signs of mechanical loosening. CONCLUSIONS: This technique is a reasonable procedure to eradicate chronic infection in knee arthroplasty and provides proper functional and clinical results. However, it sometimes requires extensile surgical approaches that could imply arduous surgeries. Metallic augments with cementless stems available in most of the knee revision systems are a suitable alternative to handle bone deficiencies, avoiding the use of bone allografts with its complications.

Retrospective analysis of second-stage revision in treating infcction after artificial total hip arthroplasty / 中国医师进修杂志

ObjectiveTo explore the effect of second-stage revision in treating infection after artificial total hip arthroplasty.MethodsThe clinical data of 11 cases with infection after artificial total hip arthroplasty who got second-stage revision from April 2007 to October 2009 were analyzed retrospectively.All patients were treated with first-stage complete debridement,antibiotic-loaded bone cement prosthesis implantation and second-stage revision after controlling infection.The therapeutic effect was assessed by Harris hip score,laboratory examination and imaging study.ResultsThe average interval of first-stage debridement and second-stage revision was 5.6 (4-11) months.The average time of follow-up was 34 (24-48) months.None of 11 patients had reinfection and complications.Harris hip score before operation [17-43 (30.71±13.52) scores] and during follow-up after operation [72-96 (84.38±12.85) scores] had statistical significance (P＜ 0.05).Six cases had good effect,4 cases were moderate and 1 case was acceptable.The rate of good and moderate effect was 90.91％( 10/1 1 ).ConclusionsSecond-stage revision can reserve the function of hip joint effectively and has high infection eradicating rate.Therefore,it is an effective treatment for postoperative infection of artificial total hip arthroplasty.

Treatment of Infected Hip Arthroplasty with Antibiotic-Loaded Cement Spacers

PURPOSE: This study evaluated the effect of antibiotic-loaded cement spacers on the treatment of infected hip arthroplasty. MATERIALS AND METHODS: Twenty-one patients, twenty-one cases that experienced infection after total hip arthroplasty, were treated with two-stage arthroplasty using antibiotic-loaded cement spacers between July 1995 and March 2005. The average age was 56.3 years (range, 36~84 years). The follow-up period was 7.2 years (range, 3~11.4 years). The period from the first operation to diagnosis of infection was 28 months (range, 1~49 months). Preoperative culture, Tc 99m scan or Gallium scan, intraoperative culture and biopsy were performed for the evaluation of infection. We postoperatively evaluated clinical and radiological outcomes, blood analysis including serologic study, complete blood cell count, differential count, erythrocyte sedimentation rate and C-reactive protein. RESULTS: Of a total of 21cases, acetabular cup, femoral head and femoral stem were substituted in 10 cases (48%). Acetabular cup and femoral head were substituted in 11 cases (52%). Revision arthroplasty was performed in 19 cases, on average 11.9 months (range 2~31 months) after insertion of antibiotic-loaded cement spacers. Infection recurred in 1 case. In 18 cases, excluding the reinfected one, the average Harris hip score, 46.8 points (range, 35~72 points) preoperatively, improved to 89.5 points (range, 78~100 points) at last follow-up in the revision group. In 2 cases in which revision total hip arthroplasty was not performed, the Harris hip score was 53 points (range, 36~70 points) preoperatively, and 86 points (range,72~100 points) at last follow-up. CONCLUSION: The use of antibiotic-loaded cement spacers in two-stage arthroplasty is an effective method for management of infection, preserving joint function until performing revision arthroplasty. Preservation of the femoral stem should be considered in cases in which were fixed firmly and in cases which show no evidence of the spreading of infection to the distal part of the stem on Tc 99m scan or Gallium scan performed preoperatively.

Treatment of Infected Total Hip Arthroplasty

PURPOSE: To analyze the effectiveness of a two-stage revision surgery for an infected total hip arthroplasty. MATERIALS AND METHODS: Between 1988 and 2005, twenty-four patients (24 hips, 18 males, 6 females) with documented infection of total hip arthroplasty were reviewed and followed for at least two years postoperatively. The preoperative and postoperative clinical and radiologic findings and blood laboratory work were compared. Eight arthroplasty cases were performed through retention of the femoral stem and removal of the acetabular cup with cementing by impregnated antibiotics in the first stage of the operation, and subsequent acetabular cup revision in the second stage of the operation. RESULTS: After the first stage of the operation, infectious organisms were cultured in 19 patients, and isolated Staphylococcus aureus was cultured in 14 patients. The mean follow-up period was 8.2 years, and the average Harris hip score improved to 88.4 points at last follow-up. Radiologic osteolysis was noted in 5 cases, and possible loosening was demonstrated in 1 case. The erythrocyte sediment rate (mm/hr) and C-reactive protein (mg/L) were 43.8/14.2 preoperatively and 17.9/8.3 postoperatively. There were 2 recurrences of infection, for an eradication rate of 91.7% (22 of 24). CONCLUSION: Two-stage revision for an infected total hip arthroplasty proved to be an excellent method with a high eradication rate.

Two-stage revision of infected total knee arthroplasty

PURPOSE: To evaluate the result of treatment of the infected total knee arthroplasty by two-stage revision using antibiotics-impregnated cement. MATERIALS AND METHODS: We observed 2 staged revision cases of 11 infected total knee arthroplasty from March 1988 and March 2001. Average follow-up was 39.4 (28-60) months. At the time of infection management, the average age was 64.0 years. Local inflammatory finding, WBC with differential count, erythrocyte sedimentation ratio, C-reactive protein, joint aspiration and intraoperative frozen section (x400) were used to diagnose infection. We assessed knee function according to the knee rating system of the Hospital for Special Surgery (HSS). RESULTS: Prior to revision, the average HSS score was 50.8 points, and the average range of motion was 73.4 degrees. At. final follow-up, the average HSS score was 79.1 points, and the average range of motion was 90.2 degrees. At the last follow up, there were no sign of recurrence of infection clinically and radiologically. CONCLUSION: At least 2 year follow up, the results of two-stage revision using antibiotics-impregnated cement were good.