Dataset Information

2-stage revision recommended for treatment of fungal hip and knee prosthetic joint infections.

ABSTRACT:

Background and purpose

Fungal prosthetic joint infections are rare and difficult to treat. This systematic review was conducted to determine outcome and to give treatment recommendations.

Patients and methods

After an extensive search of the literature, 164 patients treated for fungal hip or knee prosthetic joint infection (PJI) were reviewed. This included 8 patients from our own institutions.

Results

Most patients presented with pain (78%) and swelling (65%). In 68% of the patients, 1 or more risk factors for fungal PJI were found. In 51% of the patients, radiographs showed signs of loosening of the arthroplasty. Candida species were cultured from most patients (88%). In 21% of all patients, fungal culture results were first considered to be contamination. There was co-infection with bacteria in 33% of the patients. For outcome analysis, 119 patients had an adequate follow-up of at least 2 years. Staged revision was the treatment performed most often, with the highest success rate (85%).

Interpretation

Fungal PJI resembles chronic bacterial PJI. For diagnosis, multiple samples and prolonged culturing are essential. Fungal species should be considered to be pathogens. Co-infection with bacteria should be treated with additional antibacterial agents. We found no evidence that 1-stage revision, debridement, antibiotics, irrigation, and retention (DAIR) or antifungal therapy without surgical treatment adequately controls fungal PJI. Thus, staged revision should be the standard treatment for fungal PJI. After resection of the prosthesis, we recommend systemic antifungal treatment for at least 6 weeks-and until there are no clinical signs of infection and blood infection markers have normalized. Then reimplantation can be performed.

SUBMITTER: Kuiper JW

PROVIDER: S-EPMC3851663 | biostudies-literature | 2013 Dec

REPOSITORIES: biostudies-literature

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Publications

2-stage revision recommended for treatment of fungal hip and knee prosthetic joint infections.

Kuiper Jesse W P JW van den Bekerom Michel P J MP van der Stappen Jurgen J Nolte Peter A PA Colen Sascha S

Acta orthopaedica 20131031 6

<h4>Background and purpose</h4>Fungal prosthetic joint infections are rare and difficult to treat. This systematic review was conducted to determine outcome and to give treatment recommendations.<h4>Patients and methods</h4>After an extensive search of the literature, 164 patients treated for fungal hip or knee prosthetic joint infection (PJI) were reviewed. This included 8 patients from our own institutions.<h4>Results</h4>Most patients presented with pain (78%) and swelling (65%). In 68% of th ...[more]

PMID: 24171675

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Project description:Background:Prosthetic joint infection (PJI) is the most serious total joint arthroplasty (TJA) complication despite several aseptic and antiseptic preventive measures. There is no clear evidence or even consensus, whether antibiotic-loaded bone cement (ALBC) should be used, in addition to systemic short-term routine antibiotic prophylaxis, to reduce the risk of PJI in primary TJA. We aimed to analyze the efficacy of ALBC for prevention of PJI in patients undergoing primary TJA. Methods:We searched systematically for randomized controlled trials (RCTs) in PubMed, Scopus, Embase, Web of Science and Cochrane library. Two reviewers independently screened potentially eligible studies according to predefined selection criteria and assessed the risk of bias using a modified version of the Cochrane risk of bias tool. PJI was prespecified as the primary outcome of interest. The meta-analyses were based on risk ratios using random-effects model per default. For the purpose of sensitivity, the corresponding fixed effects model odds ratios were calculated with the use of the Peto method as well. To evaluate a potential difference in effect sizes using different types (subgroups) of antibiotics used in bone cement, and at different follow-up periods, we performed stratified meta-analyses. Results:Thirty-seven studies were eligible for the systematic review and qualitative synthesis, and 9 trials (6507 total joint arthroplasties) were included in this meta-analysis. Overall ALBC significantly reduced the risk of PJI following primary TJAs (RRs, 0.36; 95% CIs, 0.16 to 0.80; P = 0.01) with a moderate degree of inconsistency (I2 = 47%). Based on stratified meta-analyses the use of gentamicin appeared to have a better effect (P = 0.0005) in the total hip arthroplasty. Pooled data of different antibiotics used in knee arthroplasties showed a significant association of cefuroxime (RRs, 0.08; 95% CIs, 0.01 to 0.63; P = 0.02). Further, ALBCs significantly reduced the PJI at one and two years of follow-up (P = 0.03 and P = 0.005 respectively). Conclusions:The evidence suggests that ALBCs are effective in reducing the PJI following primary TJA; i.e. between 20 and 84% reduced risk. However, the clear limitations of the available trial evidence highlight the need for joint-specific confirmatory trials, that will need to be designed as cluster-randomized trials of clinics in countries with well-functioning arthroplasty registries.The translational potential of this article: This meta-analysis highlights the prophylactic potential of ALBCs in lowering the risk of infection following primary hip or knee arthroplasties but emphasizes the need for more recent confirmatory trials.

Project description:BackgroundHip and knee arthroplasties are common and successful procedures, however, success and durability are not guaranteed. The revision burden, defined as the ratio of implant revisions to the total number of arthroplasties in a specific period, is a measure of the steady state of arthroplasty success in a given registry. This study examines the hypothesis that revision burden would be similar among contemporary joint replacement registries and improving over time compared with historic controls.MethodsWe evaluated the national joint registries of 5 health systems (Australian Orthopaedic Association National Joint Replacement Registry [AOANJRR]; National Joint Registry of England, Wales, Northern Ireland, and the Isle of Man; New Zealand Joint Registry [NZJR]; Swedish Hip Arthroplasty Register [SHAR] and Swedish Knee Arthroplasty Register [SKAR]; and the American Joint Replacement Registry [AJRR]) for hip and knee revision burden over the past 4 years or since registry inception. Historic controls were obtained from previously published reports.ResultsThe 2014 hip revision burden varied from 9.7 percent (NJR) to 11.9 percent (NZJR), and the unweighted average was 10.4 percent. The 2011, 2012, and 2013 mean hip revision burden was 11.9, 11.9, and 11.4 percent. The 2014 knee revision burden varied from to 6.0 percent (NJR) to 8.1 percent (AJRR), and the unweighted average for the 5 registries studied was 7.0 percent. The 2011, 2012, and 2013 mean knee revision burden was 6.9, 7.0, and 7.0 percent. Historically, the observed hip revision burden was 15.8 percent and the knee revision burden 8.0 percent.ConclusionsRevision burden has gradually decreased for hip replacements and has remained relatively constant for knee replacements both for the last 4 years and compared to historic controls. Knee revision burden was lower than hip revision burden for each period examined. Revision burden is one measure that may be helpful in following the effect of changes in surgical technique and implant design over time in registry populations and may be a helpful way to compare overall results between registries.

Project description:ObjectivesTo determine whether patient reported outcomes improve after single stage versus two stage revision surgery for prosthetic joint infection of the hip, and to determine the cost effectiveness of these procedures.DesignPragmatic, parallel group, open label, randomised controlled trial.SettingHigh volume tertiary referral centres or orthopaedic units in the UK (n=12) and in Sweden (n=3), recruiting from 1 March 2015 to 19 December 2018.Participants140 adults (aged ≥18 years) with a prosthetic joint infection of the hip who required revision (65 randomly assigned to single stage and 75 to two stage revision).InterventionsA computer generated 1:1 randomisation list stratified by hospital was used to allocate participants with prosthetic joint infection of the hip to a single stage or a two stage revision procedure.Main outcome measuresThe primary intention-to-treat outcome was pain, stiffness, and functional limitations 18 months after randomisation, measured by the Western Ontario and McMasters Universities Osteoarthritis Index (WOMAC) score. Secondary outcomes included surgical complications and joint infection. The economic evaluation (only assessed in UK participants) compared quality adjusted life years and costs between the randomised groups.ResultsThe mean age of participants was 71 years (standard deviation 9) and 51 (36%) were women. WOMAC scores did not differ between groups at 18 months (mean difference 0.13 (95% confidence interval -8.20 to 8.46), P=0.98); however, the single stage procedure was better at three months (11.53 (3.89 to 19.17), P=0.003), but not from six months onwards. Intraoperative events occurred in five (8%) participants in the single stage group and 20 (27%) in the two stage group (P=0.01). At 18 months, nine (14%) participants in the single stage group and eight (11%) in the two stage group had at least one marker of possible ongoing infection (P=0.62). From the perspective of healthcare providers and personal social services, single stage revision was cost effective with an incremental net monetary benefit of £11 167 (95% confidence interval £638 to £21 696) at a £20 000 per quality adjusted life years threshold (£1.0; $1.1; €1.4).ConclusionsAt 18 months, single stage revision compared with two stage revision for prosthetic joint infection of the hip showed no superiority by patient reported outcome. Single stage revision had a better outcome at three months, fewer intraoperative complications, and was cost effective. Patients prefer early restoration of function, therefore, when deciding treatment, surgeons should consider patient preferences and the cost effectiveness of single stage surgery.Trial registrationISRCTN registry ISRCTN10956306.

Dataset Information

2-stage revision recommended for treatment of fungal hip and knee prosthetic joint infections.

Background and purpose

Patients and methods

Results

Interpretation

Publications

2-stage revision recommended for treatment of fungal hip and knee prosthetic joint infections.

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