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Poor Prognosis of Patients Treated for Periprosthetic Joint Infection.

ABSTRACT: The study by Gomez et al., "The Fate of Spacers in the Treatment of Periprosthetic Joint Infection," evaluates the clinical course and success rate of treatment of periprosthetic joint infection with two-stage revision with spacer placement in the interim period. The current review critically analyzes the findings of this study and examines how these findings may influence patient care in the field of hip and knee replacement. Gomez et al. report sobering results of two-stage revision with spacer placement for periprosthetic joint infection. Nearly 20% of patients in their study who had a spacer placed never went on to get a new prosthesis and nearly 20% of those who did get a new prosthesis ultimately failed treatment. The authors reported a 7.5% mortality rate in the interstage period after resection arthroplasty. This study provides valuable information for counseling patients about the outcomes of treatment using spacers for infection after total joint arthroplasty. The results of this study also highlight the need for future investigation into better treatments for periprosthetic joint infections.

SUBMITTER: Kahlenberg CA

PROVIDER: S-EPMC5264567 | biostudies-literature | 2017 Feb

REPOSITORIES: biostudies-literature

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Poor Prognosis of Patients Treated for Periprosthetic Joint Infection.

Kahlenberg Cynthia A CA Hernandez-Soria Alexia A Cross Michael B MB

HSS journal : the musculoskeletal journal of Hospital for Special Surgery 20160601 1

The study by Gomez et al., "The Fate of Spacers in the Treatment of Periprosthetic Joint Infection," evaluates the clinical course and success rate of treatment of periprosthetic joint infection with two-stage revision with spacer placement in the interim period. The current review critically analyzes the findings of this study and examines how these findings may influence patient care in the field of hip and knee replacement. Gomez et al. report sobering results of two-stage revision with space ...[more]

PMID: 28167881

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Project description:The volume of joint replacement surgery has risen steadily in recent years, because the population is aging and increasingly wishes to reserve a high functional status onward into old age. Infection is among the more common complications of joint replacement surgery, arising in 0.2% to 2% of patients, or as many as 9% in special situations such as the implantation of megaprostheses. The associated morbidity and mortality are high. It is thus very important to minimize risk factors for infection and to optimize the relevant diagnostic and therapeutic strategies.This review is based on pertinent publications retrieved by a selective search in PubMed, including current guidelines and expert recommendations.The crucial diagnostic step is joint biopsy for the identification of the pathogenic organism, which succeeds with over 90% sensitivity and specificity. If the prosthesis is firmly anchored in bone, the pathogen is of a type that responds well to treatment, and symptomatic infection has been present only for a short time, then rapidly initiated treatment can save the prosthesis in 35-90% of cases. The pillars of treatment are thorough surgical care (radical débridement) and targeted antibiotic therapy. On the other hand, if the prosthesis is loose or the pathogen is of a poorly treatable type, the infection can generally only be cured by a change of the prosthesis. This can be performed in either one or two procedures, always in conjunction with systemic antibiotic therapy tailored to the specific sensitivity and resistance pattern of the pathogen.The risk of infection of an artificial joint is low, but the overall prevalence of such infections is significant, as the number of implanted joints is steadily rising. Artificial joint infections should be treated by a standardized algorithm oriented toward the recommendations of current guidelines. Many of these recommendations, however, are based only on expert opinion, as informative studies providing high-grade evidence are lacking. Thus, for any particular clinical situation, there may now be multiple therapeutic approaches with apparently comparable efficacy. Randomized trials are urgently needed.

Project description:Periprosthetic joint infection (PJI), a devastating complication of total joint replacement, is of incompletely understood pathogenesis and may sometimes be challenging to clinically distinguish from other causes of arthroplasty failure. We characterized human gene expression in 93 specimens derived from surfaces of resected arthroplasties, comparing transcriptomes of subjects with infection- versus non-infection-associated arthroplasty failure. Differential gene expression analysis confirmed 28 previously reported potential biomarkers of PJI, including bactericidal/permeability increasing protein (BPI), cathelicidin antimicrobial peptide (CAMP), C-C-motif chemokine ligand 3 (CCL3), 4(CCL4), and C-X-C-motif chemokine ligand 2 (CXCL2), colony stimulating factor 2 receptor beta (CSF2RB), colony stimulating factor 3 (CSF3), alpha-defensin (DEFA4), Fc fragment of IgG receptor 1B (CD64B), intercellular adhesion molecule 1 (ICAM1), interferon gamma (IFNG), interleukin 13 receptor subunit alpha 2 (IL13RA2), interleukin 17D (IL17D), interleukin 1 (IL1A, IL1B, IL1RN), interleukin 2 receptors (IL2RA, IL2RG), interleukin 5 receptor (IL5RA), interleukin 6 (IL6), interleukin 8 (IL8), lipopolysaccharide binding protein (LBP), lipocalin (LCN2), lactate dehydrogenase C (LDHC), lactotransferrin (LTF), matrix metallopeptidase 3 (MMP3), peptidase inhibitor 3 (PI3), and vascular endothelial growth factor A (VEGFA), and identified three novel molecules of potential diagnostic use for detection of PJI, namely C-C-motif chemokine ligand CCL20, coagulation factor VII (F7), and B cell receptor FCRL4. Comparative analysis of infections caused by staphylococci versus bacteria other than staphylococci and Staphylococcus aureus versus Staphylococcus epidermidis showed elevated expression of interleukin 13 (IL13), IL17D, and MMP3 in staphylococcal infections, and of IL1B, IL8, and platelet factor PF4V1 in S. aureus compared to S. epidermidis infections. Pathway analysis of over-represented genes suggested activation of host immune response and cellular maintenance and repair functions in response to invasion of infectious agents. The data presented provides new potential targets for diagnosis of PJI and for differentiation of PJI caused by different infectious agents.

Project description:IntroductionLimited information is available regarding the treatment strategy and prognosis of non-selected patients treated for chronic periprosthetic hip joint infection. Such information is important as no head-to-head studies on treatment strategies are available. The purpose of this study is to report on the treatment strategy and prognosis of a non-selected, consecutive patient population.MethodsWe identified 130 patients in the National Patient Registry, consecutively treated for a chronic periprosthetic hip joint infection between 2003-2008 at 11 departments of orthopaedic surgery. We extracted information regarding patient demographics, treatment and outcome. 82 patients were re-implanted in a two-stage revision (national standard), the remaining 48 were not re-implanted in a two-stage revision. We were able to collect up-to-date information on all patients to date of death or medical chart review with a minimum of 5 years follow-up by the nationwide electronic patient record system.ResultsAfter primary revision surgery, 53 patients (41%) had a spacer in situ, 64 (50%) had a resection arthroplasty and 13 (9%) did not have the infected implant removed. 63% were re-implanted in a two-stage revision. Re-implantation was performed after an interim period of 14 weeks (IQR 10-18). Patients re-implanted were younger (p-value 0.0006), had a lower CCS score (p-value 0.005), a lower ASA score (p-value 0.0001) and a 68% lower mortality risk in the follow-up period (p-value <0.00001). After adjusting for selected confounders, the mortality risk was no longer significantly different. The 5-year re-infection rate after re-implantation was 14.6% (95%CI 8.0-23.1). Re-infections occurred mainly within 3 years of follow-up. The overall 1-year survival rate was 92% (95%CI 86-96) and the overall 5-year survival rate was 68% (95%CI 59-75). The 5-year survival rate after a two-stage revision was 82% (95%CI 71-89) and in those not re-implanted 45% (95%CI 30-58).ConclusionWe found that patients who receive a two-stage revision after a chronic periprosthetic hip joint infection are younger and healthier when compared to those who do not receive a two-stage revision in a non-selected patient population, indicating a clear selection of patients into this treatment strategy. Re-infection rates following two-stage revision were comparable to international results. We found a high mortality rate in our study population, but the causality of death and chronic periprosthetic hip joint infection cannot be established in this study and this needs further attention.

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Poor Prognosis of Patients Treated for Periprosthetic Joint Infection.

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Poor Prognosis of Patients Treated for Periprosthetic Joint Infection.

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