Spacer prostheses in two-stage revision of infected knee arthroplasty.
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ABSTRACT:
SUBMITTER: Jamsen E
PROVIDER: S-EPMC2532134 | biostudies-other | 2006 Aug
REPOSITORIES: biostudies-other
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Project description:BACKGROUND:Prosthetic joint infections (PJI) of hip and knee arthroplasties are becoming increasingly common with an aging population and an increasing demand for these procedures. Despite attempts at standardization, medical and surgical approaches vary widely among practitioners. QUESTIONS/PURPOSES:We first sought to determine if there were specific factors associated with choice of one- versus two-stage revision. Then we investigated whether the type of revision approach influenced clinical treatment success. Finally, among two-stage revisions, we assessed if an antibiotic holiday prior to the second procedure affected clinical treatment success. METHODS:We retrospectively reviewed patients who had revision surgery for infection of a hip or knee arthroplasty between January 1, 2000, and December 31, 2013, at the Sunnybrook Health Sciences Centre and the Holland Orthopedic and Arthritic Centre. PJI cases were identified using the Ontario Joint Replacement Registry. Infection was defined by gross intraoperative evidence of infection, positive intraoperative culture(s), and/or sinus tract prior to operation. The primary outcome was treatment failure at 1 year after revision surgery based on requirement for further surgery, ongoing infection, and/or continuous suppressive antibiotics. RESULTS:Of 110 eligible patients identified, 35 patients had a one-stage and 75 patients had a two-stage revision. Choice of a one-stage approach was most influenced by particular surgeon preference and was more likely for hip revision versus knee revision (OR 3.39 (95%CI 1.85-6.23). There was no statistical difference in clinical treatment success rate between one-stage (33/35; 94.2% success) and two-stage revision (63/75; 84%; p = 0.13). Enterococcus spp. (21 versus 3%; p = 0.027) and Peptostreptococcus spp. (14 versus 1%; p = 0.042) were more common among clinical treatment failures than successes, with a trend towards the same for Staphylococcus aureus (29 versus 9%; p = 0.06). Additionally, treatment success was not influenced by whether the patient had an antibiotic holiday with a two-stage revision. CONCLUSION:Our findings confirm the uncertainty of surgical strategy for treatment of PJI in hip and knee arthroplasty. Superiority of one- versus two-stage revision and the value of antibiotic-free periods prior to definitive revision remain unclear. Large prospective studies or randomized controlled trials are needed to inform best practice for treatment of these complex clinical problems.
| S-EPMC5617816 | biostudies-other
Project description:Two-stage revision total knee arthroplasty remains the gold standard for management of chronic periprosthetic joint infection in North America. Static cement antibiotic spacers used after knee resection to deliver high-dose antibiotics lack primary stability, potentially leading to spacer migration or dislocation, additional bone loss, extensor mechanism erosion, and even knee subluxation or frank dislocation. A custom brace or cast is often required to augment knee stability, which is time-consuming, costly, and prevents monitoring or wound care of the soft tissues. An external fixator arthrodesis antibiotic spacer can provide primary stability without a brace or cast, allowing for soft-tissue monitoring and care, and minimizes potential spacer complications. We present the technique for implanting and removing this specific external fixator arthrodesis antibiotic spacer.
| S-EPMC6728769 | biostudies-literature
Project description:Periprosthetic joint infection (PJI) is a catastrophic complication of shoulder arthroplasty. Commonly used surgical treatments include one- or two-stage revision, but their effectiveness in controlling infection is uncertain. We aimed to compare re-infection (recurrent and new infections) rates; clinical measures of function and pain; and noninfection complication rates of one- and two-stage revision surgery for shoulder PJI using a systematic review and meta-analysis. We searched MEDLINE, Embase, Web of Science, and The Cochrane Library to February 2018. Longitudinal studies conducted in patients with shoulder PJI treated exclusively by one- or two-stage revision were eligible. No clinical trials were identified. Re-infection rates were meta-analysed using random-effect models after arcsine transformation. The re-infection rate (95% CI) in pooled analysis of eight one-stage studies (147 participants) was 5.3% (1.4-10.6). The corresponding rate for 27 two-stage studies (351 participants) was 11.5% (6.0-18.1). Postoperative clinical measures of function and pain were not significantly different between the two revision strategies. The pooled noninfection complication rate (95% CI) for one-stage and two-stage revision was 12.1% (6.1-19.5) and 18.9% (8.4-31.9) respectively. New evidence suggests one-stage revision is at least equally as effective as the two-stage in controlling infection, maintaining joint function, and improving complications in shoulder PJI.
| S-EPMC6338765 | biostudies-literature
Project description:BackgroundA two-stage prosthesis exchange procedure has been the gold standard in surgical treatment of the chronically infected knee arthroplasty so far. This includes 2 surgeries/hospitalizations and an interim period of 2-3 months between surgeries with impaired health, functional status and quality of life of the patients. A one-stage exchange procedure holds many obvious advantages compared to the two-stage approach, but outcomes of a one-stage versus two-stage procedures have never been investigated in a randomized clinical trial. The purpose of this study is primarily to investigate time-adjusted differences in functional status of patients after one-stage versus two-stage revision. Secondary, to report time-adjusted differences in quality of life, complications (including re-revisions due to infection) and mortality.MethodsThis study is a pragmatic, multi-center, randomized, non-inferiority trial comparing one-stage versus two-stage revision of the infected knee arthroplasty. Seven Danish hospitals are currently participating in the study, but additional hospitals can enter the study if adhering to protocol. Ninety-six patients will be included prospectively. Follow-up will be with PROM-questionnaires and clinical controls up to 10 years. The patients who are not able to participate in the randomized trial are followed in a parallel cohort study.Prom'sOxford Knee Score and EQ5D + EQ5D VAS questionnaires are completed preoperatively and sent out to the study participants at 6 weeks, 3, 6, 9, 12, 18 and 24 months as well as 5 and 10 years postoperatively. In addition a tailor made cost questionnaire on the non-treating hospital resource use, community health and social service use, travel costs, time off work and informal care are sent out.DiscussionIf one of the two treatment alternatives is found superior in both domains of quality of life (both knee-specific and generic) and health economics, that treatment should be promoted. Other outcomes will open informed discussions about treatment strategies for periprosthetic knee infections.Trial registrationThe randomized trial is registered on ClinicalTrials.gov with ID NCT03435679 , initial release date January 31, 2018 and the cohort study is registered with ID NCT04427943 , submitted January 8, 2020 and posted June 11, 2020.
| S-EPMC7881574 | biostudies-literature
Project description:Periprosthetic joint infection in total knee arthroplasty is a significant complication that is a common reason for revision surgery. The current standard of care is two-stage revision surgery. There is however increasing evidence to support the use of single-stage revision surgery. We conducted a PRISMA systematic review of the current evidence on the use of single-stage revision for infected total knee arthroplasty. Four databases (PubMed, Embase, Science Direct, and Cochrane Library) were systematically screened for eligible studies. The risk bias of each study was identified using ROBINS-I tool, and the quality of evidence was assessed using the GRADE criteria. Sixteen articles were retained after applying the inclusion and exclusion criteria that evaluated 3645 knee single-stage revision surgeries. Our review reveals satisfactory outcomes for single-stage revision in the management of infected total knee arthroplasty. The reinfection rates in the studies included in our review varied however the majority reported low reinfection rates and good functional outcomes. Although strict patient selection criteria have yielded successful results, good results were also reported when these criteria were not applied. The greater use of risk factors in identifying patients likely to have a successful outcome needs to be balanced with the practical benefits of performing a single stage procedure in higher risk patients. Future large clinical randomized control trials are required to confirm our results.
| S-EPMC6406500 | biostudies-literature
Project description:Septic loosening of total hip and knee endoprostheses gains an increasing proportion of revision arthroplasties. Operative revisions of infected endoprostheses are mentally and physically wearing for the patient, challenging for the surgeon and a significant economic burden for healthcare systems. In cases of early infection within the first three weeks after implantation a one-stage revision with leaving the implant in place is widely accepted. The recommendations for the management of late infections vary by far. One-stage revisions as well as two-stage or multiple revision schedules have been reported to be successful in over 90% of all cases for certain patient collectives. But implant associated infection still remains a severe complication. Moreover, the management of late endoprosthetic infection requires specific logistics, sufficient and standardized treatment protocol, qualified manpower as well as an efficient quality management. With regard to the literature and experience of specialized orthopaedic surgeons from several university and regional hospitals we modified a commonly used treatment protocol for two-stage revision of infected total hip and knee endoprostheses. In addition to the achievement of maximum survival rate of the revision implants an optimisation of the functional outcome of the affected artificial joint is aimed for.
| S-EPMC3252662 | biostudies-other
Project description:BackgroundProsthetic joint infection (PJI) is a challenging complication of total elbow replacement (TER). Potential surgical treatments include one- or two-stage revision; however, the best treatment for elbow PJI is not clearly defined. We conducted a systematic review in accordance with PRISMA guidelines to compare the clinical effectiveness of one- and two-stage revision surgery for elbow PJI using re-infection (recurrent and new infections) rates; mortality; clinical measures of function, pain, and satisfaction; and non-infection related adverse events.MethodsMEDLINE, Embase, Web of Science, and The Cochrane Library were searched up to June 2019 to identify observational cohort studies and randomised controlled trials (RCTs) that had recruited patients with elbow PJI following TER and treated with one- or two-stage revision. Of 96 retrieved articles, 2 one-stage and 6 two-stage revision studies were eligible. No RCT was identified. Arcsine transformation was used in estimating rates with 95% confidence intervals (CIs).ResultsStaphylococcus aureus was the most common causative organism for PJI of the elbow (24 of 71 elbow PJIs). The re-infection rate (95% CI) for one-stage (7 elbows) ranged from 0.0% (0.0-79.3) to 16.7% (3.0-56.4) and that for two-stage revision (87 elbows) from 0.0% (0.0-49.0) to 20.0% (3.6-62.4). Non-infection related adverse event rate for one-stage (based on a single study) was 16.7% (3.0-56.4) and that for two-stage ranged from 11.8% (4.7-26.6) to 20.0% (3.6-62.4). There were no mortality events recorded following one- or two-stage revision surgery and postoperative clinical measures of function, pain, and satisfaction could not be effectively compared because of limited data.ConclusionsNo strong conclusions can be drawn because of limited data. The one-stage revision may be potentially at least as clinically effective as two-stage revision, but further data is needed. There are clear gaps in the existing literature and studies are urgently warranted to assess the clinical effectiveness of one- and two-stage revision strategies for PJI following TER.Systematic review registrationPROSPERO 2018: CRD42018118002 .
| S-EPMC6806568 | biostudies-literature
Project description:BackgroundLarge femoral defects in late periprosthetic infection (PPI) after total hip arthroplasty (THA) often require the use of large, individual metal endoskeleton-reinforced cement spacers (iMECS).ObjectivesThe aim was to record the clinical, radiological and functional results (Harris Hip Score HHS) up to the 2 years after treatment of a PPI using an iMECS. Major patient-specific parameters were to be evaluated with regard to the treatment outcome.Materials and methodsThe collective of this single-center retrospective cohort study comprised 29 patients. The mean follow-up was 24.4 months (range: 23.0 to 27.6 months). The absence of infection after endoprosthetic hip joint reconstruction was rated as successful treatment. The two patient groups (successful (S)/not successful (nS)) were compared with regard to gender distribution, the Charlson comorbidity index (CCI), the number of previous septic changes, and the rate of polymicrobial and difficult-to-treat infections.ResultsThe average CCI in the total collective was 6.4 points. Joint reconstruction was possible in 23 of 29 patients (79%); 2 years after PPI treatment 4 patients were not available for a follow-up examination (2 deceased, 2 unable to participate). At the time of the follow-up, 17 of the 29 patients had received a joint reconstruction and were free of infection, with an average HHS of 75 points. There were no iMECS-associated complications requiring revision. Only the initial CCI (S: 4.1 points; nS: 9.7 points) differed significantly between the patient groups (p < 0.05).ConclusionsIn the case of large femoral defects, iMECS provide secure temporary stabilization. The chance of a successful joint reconstruction is closely related to the individual comorbidities profile.
| S-EPMC8556826 | biostudies-literature
Project description:BackgroundThe gold standard treatment for infected total knee arthroplasty (TKA) is two-stage revision. The first stage involves a temporary antibiotic spacer, which can be static or articulating; it remains unclear which is best. We aimed to compare 5-year outcomes between static and dynamic spacers.MethodsOne hundred and seventy-six patients with infected TKA requiring two-stage revision were enrolled. Patients were organized based on the type of spacer used during the first-stage revision. One hundred and four patients received articulating spacers, and 72 received static spacers. At 5 years, postoperative range of motion (ROM), Short Form 12 (SF-12), Knee Society Score (KSS), and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores were recorded. Reinfection and revisions were also tracked.ResultsEradication of infection was similar in both groups, with 83.7% in the articulating group and 86.1% in the nonarticulating spacer group (P = .234). Articulating spacers resulted in significantly improved ROM (111 vs 82 degrees, P < .001), SF-12 physical component score (35.2 vs 31.0, P = .01), KSS (145.2 vs 113.7, P < .001), and WOMAC function scores (60.1 vs 51.1, P = .03) as compared to the static spacer group.ConclusionsTreatment with an articulating spacer as opposed to a static spacer resulted in improved ROM, SF-12 physical component score, KSS, and WOMAC function scores at the final follow-up visit. There was no significant difference in reinfection rates. Patients requiring staged revision for infected TKA may benefit from an articulating spacer.
| S-EPMC8783104 | biostudies-literature
Project description:Introduction A devastating complication after total hip arthroplasty (THA) is chronic periprosthetic joint infection (PJI). Most frequently spacers (Sp) with or without antibiotics are implanted in a two-stage procedure even though not always indicated due to unknown pathogen, femoral and acetabular defects or muscular insufficiency.Materials and methods A retrospective analysis of a prospectively collected database was conducted, analyzing the treatment of 44 consecutive cases with chronic PJI undergoing two-stage revision using a Girdlestone situation (GS) in the interim period between 01/2015 and 12/2018. Diagnostics included intraoperative microbiological cultures, histological analysis, sonication of the initial implant, analysis of hip aspiration, as well as laboratory diagnostics and blood cultures. We analyzed the general and age-group-specific success rate of treatment using GS. Furthermore, we compared our data with the current literature on spacer implantation regarding common complications.ResultsIn total, 21 female and 23 male patients at a mean age of 59.3 ± 9.6 years were included. Age groups were divided into young, mid-age, and elderly. In most patients, microbiology revealed Staphylococcus epidermidis in 39.1% of cases, following Staphylococcus lugdunensis and Staphylococcus aureus in 10.9% after THA explantation. For histology, Krenn and Morawietz type 2 (infectious type) was diagnosed in 40.9%, type 3 (infectious and abrade-induced type) in 25.0%. With GS, the total cure rate was 84.1% compared to 90.1% (range 61-100%) using Sp as described in the literature. Among age-groups, cure rate varied between 77.8 and 100%. Other complications, which only occurred in the mid-age and elderly group, included the necessity of transfusion in 31.1%, and in total, one periprosthetic fracture was identified (2.3%).ConclusionGS shows an acceptable cure rate at a minimum of 2 years when compared to the cure rate reported in the literature for Sp without major complications. For patients with increased risks for treatment failure using spacer, GS seems to be an alternative for chronic PJI when looking at the success rate of treatment.Level of evidenceIII, Retrospective trial.
| S-EPMC10030410 | biostudies-literature