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Palacios C, Salingaros S, Lakhlani D, Silverstein M, Riaz T, Kamperman K, Thornton B, Reid CM, Nazerali R. Use of antibiotic-impregnated discs in breast reconstruction among the obese population: A retrospective propensity score-matched analysis. J Plast Reconstr Aesthet Surg 2025; 106:246-253. [PMID: 40449321 DOI: 10.1016/j.bjps.2025.05.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2025] [Revised: 04/25/2025] [Accepted: 05/12/2025] [Indexed: 06/03/2025]
Abstract
Two-stage breast reconstruction is a well-established post-mastectomy surgical technique. Unfortunately, periprosthetic infections in tissue expanders remain a prevalent concern. Antibiotic-impregnated polymethylmethacrylate (PMMA) plates for infection prophylaxis in TE-based reconstruction have been shown to lower infection rates. With the growing obesity epidemic in the US, this propensity-score matched retrospective study aimed to evaluate the impact of PMMA plates on the obese population. A retrospective chart review was performed for patients with a BMI of 30 and above to record patient demographics, complications, operative details, and post-operative details. One-to-one propensity score matching was used to match the intervention and control group on age, diabetes status, smoking status, neoadjuvant chemotherapy, prior radiation history, and laterality of breast reconstruction, resulting in 48 patients in each group. Chi-squared analysis, and Barnard exact tests assessed significant differences between groups and infection rates. T-tests compared the normally distributed continuous variables. Logistic regression controlled for confounders that have been reported in previously published literature. Chi-square analysis revealed a significant association between PMMA plate usage and infection rate (4.2% compared to 16.7%; p = 0.045). Logistic regression analysis found that the PMMA antibiotic plate group had a statistically significant decrease in infection rate (OR: 0.18 [0.033-0.962]; p = 0.045). Though antibiotic-impregnated PMMA plates have demonstrated effective infection prophylaxis in the general population, this study is the first to explore their use in the obese population. Within our cohort, placing an antibiotic plate resulted in a reduced infection rate.
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Affiliation(s)
- Christian Palacios
- Dr. Kiran C. Patel School of Allopathic Medicine, Nova Southeastern University, Ft. Lauderdale, FL, USA
| | - Sophia Salingaros
- Division of Plastic and Reconstructive Surgery, Weill Cornell Medicine, New York, NY, USA
| | - Devi Lakhlani
- Division of Plastic & Reconstructive Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Max Silverstein
- Division of Plastic & Reconstructive Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Tooba Riaz
- Division of Plastic & Reconstructive Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Kathryn Kamperman
- Division of Plastic & Reconstructive Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | | | - Chris M Reid
- Division of Plastic Surgery, University of California San Diego, La Jolla, CA, USA
| | - Rahim Nazerali
- Division of Plastic & Reconstructive Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, CA, USA.
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Buchholz T, Siverino C, Moriarty TF, Sheehy EJ, O'Brien FJ, Nehrbass D, Arveladze S, Constant C, Elsayed SH, Yan M, Awad HA, Zeiter S, Allen MJ. Antibiotic-Loaded Polymer-Calcium Phosphate Scaffold for Treating Orthopedic Device-Related Infection in a Rabbit Segmental Bone Defect Model. J Biomed Mater Res A 2025; 113:e37917. [PMID: 40296342 DOI: 10.1002/jbm.a.37917] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2024] [Revised: 03/07/2025] [Accepted: 04/10/2025] [Indexed: 04/30/2025]
Abstract
Treatment of orthopedic device-related infection (ORDI) generally requires a combination of medical and surgical interventions for successful treatment outcomes. Many cases are treated with a two-stage revision, whereby contaminated implants and necrotic tissues are removed, and dead space is managed with a temporary, non-resorbable polymethyl methacrylate (PMMA) spacer loaded with antibiotics. Weeks later, this is replaced with a bone graft or similar material to aid bone healing. However, this two-stage approach is quite a burden for the patient, and infection may still recur. The use of a 3D-printed, absorbable, antibiotic-releasing material that also promotes bone healing would be a promising alternative that produces the exact geometry of the missing bone and eliminates the need for a second surgery. In this study, we investigated whether a novel 3D-printed, antibiotic-loaded, osteoconductive calcium phosphate scaffold (CPS) is effective in the single-stage revision of an infected segmental bone defect model in rabbits. A 5-mm segmental defect of the radius of female New Zealand White rabbits (n = 64), stabilized with cerclage wire, was inoculated with Staphylococcus aureus. After 4 weeks, the infected bone fragment was removed, the site debrided, and the bone defect was either left empty (Control group) or filled with a PMMA spacer with gentamicin, CPS loaded with rifampicin or non-loaded CPS. The animals were also managed with systemic cefazolin for 4 weeks. An additional group received vancomycin-loaded CPS without adjunctive systemic antibiotic therapy. All animals were euthanized 8 weeks after revision and assessed by quantitative bacteriology or semiquantitative histopathology. The antibiotic-loaded scaffolds (PMMA-Genta and CPS-Rif) in the animals receiving systemic antibiotic treatment resulted in a reduction in bacterial count at euthanasia compared to controls (rabbits receiving systemic antibiotic alone and in which the defect was left empty). The PMMA-Genta induced a significant CFU reduction (p = 0.0486) compared to controls. The infection rate was also reduced from 80% in the control group to 50% for the groups receiving local and systemic antibiotics. The CPS-Vanco group for local delivery without adjunctive systemic antibiotic therapy resulted in a lower infection rate, but the CFUs in these samples at euthanasia were comparable with those of the control group. The findings show that treating an ODRI with PMMA-Genta yields the best results for infection eradication; however, it does not provide the reconstruction opportunity that the antibiotic-loaded CPS does. Even though it is not comparable to the PMMA-Genta, the antibiotic-loaded CPS showed a reduction in infection rates. The use of local antibiotics alone is insufficient to eradicate the infection.
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Affiliation(s)
- T Buchholz
- AO Research Institute Davos, Davos, Switzerland
| | - C Siverino
- AO Research Institute Davos, Davos, Switzerland
| | | | - E J Sheehy
- AO Research Institute Davos, Davos, Switzerland
- Tissue Engineering Research Group, Department of Anatomy and Regenerative Medicine, Royal College of Surgeons in Ireland, Dublin, Ireland
- Trinity Centre for Biomedical Engineering, Trinity Biomedical Sciences Institute, Trinity College Dublin, Dublin, Ireland
- Advanced Materials and Bioengineering Research (AMBER) Centre, Royal College of Surgeons in Ireland & Trinity College Dublin, Dublin, Ireland
| | - F J O'Brien
- Tissue Engineering Research Group, Department of Anatomy and Regenerative Medicine, Royal College of Surgeons in Ireland, Dublin, Ireland
- Trinity Centre for Biomedical Engineering, Trinity Biomedical Sciences Institute, Trinity College Dublin, Dublin, Ireland
- Advanced Materials and Bioengineering Research (AMBER) Centre, Royal College of Surgeons in Ireland & Trinity College Dublin, Dublin, Ireland
| | - D Nehrbass
- AO Research Institute Davos, Davos, Switzerland
| | - S Arveladze
- AO Research Institute Davos, Davos, Switzerland
| | - C Constant
- AO Research Institute Davos, Davos, Switzerland
| | - S Hassouna Elsayed
- Surgical Discovery Centre, Department of Veterinary Medicine, University of Cambridge, Cambridge, UK
- Department of Veterinary Medicine, College of Agriculture and Veterinary Medicine (CAVM), United Arab Emirates University (UAEU), Al Ain, Abu Dhabi, UAE
- Faculty of Veterinary Medicine, Alexandria University, Alexandria, Egypt
| | - M Yan
- Center for Musculoskeletal Research, University of Rochester Medical Center, Rochester, New York, USA
| | - H A Awad
- Center for Musculoskeletal Research, University of Rochester Medical Center, Rochester, New York, USA
| | - S Zeiter
- AO Research Institute Davos, Davos, Switzerland
| | - M J Allen
- Surgical Discovery Centre, Department of Veterinary Medicine, University of Cambridge, Cambridge, UK
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Finger E, Giniyani L, Korshunov YA, Rosenstock JL. A Case of Severe Acute Kidney Injury Due to an Antibiotic-Loaded Cement Spacer for Infected Knee Arthroplasty. Am J Kidney Dis 2025; 85:389-392. [PMID: 39362394 DOI: 10.1053/j.ajkd.2024.07.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2024] [Revised: 07/07/2024] [Accepted: 07/21/2024] [Indexed: 10/05/2024]
Abstract
The treatment for periprosthetic joint infection frequently involves the placement of a high-dose antibiotic-loaded bone cement spacer (ALCS) into the debrided joint. Typical antibiotics in the spacer include aminoglycosides and vancomycin. It has been believed that systemic absorption of intraarticular antibiotics would be low, and early experience suggested that the risk of acute kidney injury (AKI) from ALCS was minimal. However, recent case reports and case series have suggested a risk of AKI owing to antibiotic absorption, though confounding factors are common. We report a case of severe AKI requiring hemodialysis with extremely high systemic tobramycin levels after the placement of an ALCS with increased dosing of antibiotics after previous failure to resolve a periprosthetic joint infection with a prior ALCS. There was no concomitant use of intravenous nephrotoxic antibiotics, nor were there other confounding factors. Despite dialysis, the patient needed urgent removal of the ALCS to control tobramycin levels, with subsequent resolution of the AKI. This case highlights the potentially serious nephrotoxicity of ALCSs, the importance of antibiotic type and dosing, and the value of close monitoring after ALCS placement, especially in a patient with chronic kidney disease.
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Affiliation(s)
- Evan Finger
- Department of Medicine, Lenox Hill Hospital, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New York, New York
| | - Larab Giniyani
- Division of Nephrology, Lenox Hill Hospital, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New York, New York
| | - Yevgeniy A Korshunov
- Department of Orthopedics, Lenox Hill Hospital, Northwell Health, New York, New York
| | - Jordan L Rosenstock
- Division of Nephrology, Lenox Hill Hospital, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New York, New York.
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Frank FA, Krampitz B, Steiner J, Strathausen R, Morgenstern M, Clauss M, Kühn KD. Evaluation and testing of polymethylmetacrylic (PMMA) bone cements with admixed Amphotericin B. J Orthop Surg Res 2025; 20:151. [PMID: 39920816 PMCID: PMC11806800 DOI: 10.1186/s13018-025-05565-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2024] [Accepted: 02/04/2025] [Indexed: 02/09/2025] Open
Abstract
BACKGROUND Amphotericin is admixed to Polymethylmethacrylic (PMMA) spacers for fungal periprosthetic joint infections (PJI) during two-stage exchanges. We aimed to analyse the mechanical properties of PMMA cement with admixed Amphotericin B. MATERIALS AND METHODS We tested Amphotericin in PMMA cement mechanically, its elution properties in vitro and present two cases of fungal PJI treated with Amphotericin B powder in Copal cement in vivo. RESULTS Sterile Amphotericin B is not available as a pure substance but only as powder for infusions. PMMA mixed with such pharmaceutical Amphotericin B formulations colored the cement orange. Compression strength was slightly decreased, bending and impact strength significantly decreased whereas bending modulus was increased. Drug elution was high within the first 24 h and decreased over time until day 5. Amphotericin B in combination with Copal was successfully used in two cases with Candida ssp. INFECTIONS No negative side effects, especially no nephrotoxic effects, were observed. Sterile Amphotericin B powder for preparing an infusion solution contains only small amounts of pure drug. In vivo polymicrobial Candida-infections with bacterial co-infection were successfully treated using the combination of Copal cements with added Amphotericin B without systemic nephrotoxic impact. CONCLUSIONS The addition of Amphotericin B to PMMA cement affects the cement's properties in vitro whereas in vivo the combination with Copal is clinically successful in treating complex cases of fungal PJI. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Florian A Frank
- Centre for Musculoskeletal Infections (ZMSI), University Hospital of Basel, Basel, 4031, Switzerland.
- Department of Orthopaedics and Traumatology, University Hospital of Basel, Basel, 4031, Switzerland.
| | - Barbara Krampitz
- Heraeus Medical, Philipp-Reis-Strasse 8-13, 61273, Wehrheim, Germany
| | - Julia Steiner
- Department of Orthopaedics and Traumatology, Medical University of Graz, Graz, 8036, Austria
| | | | - Mario Morgenstern
- Centre for Musculoskeletal Infections (ZMSI), University Hospital of Basel, Basel, 4031, Switzerland
- Department of Orthopaedics and Traumatology, University Hospital of Basel, Basel, 4031, Switzerland
| | - Martin Clauss
- Centre for Musculoskeletal Infections (ZMSI), University Hospital of Basel, Basel, 4031, Switzerland
- Department of Orthopaedics and Traumatology, University Hospital of Basel, Basel, 4031, Switzerland
| | - Klaus-Dieter Kühn
- Department of Orthopaedics and Traumatology, Medical University of Graz, Graz, 8036, Austria
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Chalasani S, Mannam H, Alomari AK, Rahnama-Moghadam S. Drug Reaction With Eosinophilia and Systemic Symptoms to Vancomycin-Laden Cement Space: A Case Report. Cureus 2025; 17:e76860. [PMID: 39897205 PMCID: PMC11787809 DOI: 10.7759/cureus.76860] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/03/2025] [Indexed: 02/04/2025] Open
Abstract
Drug reaction with eosinophilia and systemic symptoms (DRESS) is a severe cutaneous adverse drug reaction mediated by a complex immune response. Vancomycin is a known cause of DRESS, and cases are often attributed to intravenous exposure. Vancomycin-laden bone cements deliver high concentrations of the drug locally with low to undetectable systemic levels. Despite trace systemic concentrations, cement spacers have been reported to cause systemic reactions ranging from organ failure to diffuse cutaneous eruptions. A patient receiving intravenous (IV) and local vancomycin, via bone cement, experienced symptom resolution only after the vancomycin-eluting bone cement was removed, which was done after the IV vancomycin had been stopped. This suggests that the vancomycin eluted from the local bone cement may be sufficient to maintain the immune response mediating DRESS syndrome. In patients who experience persistent symptoms despite discontinuing systemic drug exposure, clinicians should consider eliminating all sources of the causative drug.
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Affiliation(s)
- Sai Chalasani
- Dermatology, Indiana University School of Medicine, Indianapolis, USA
| | - Harshita Mannam
- Dermatology, Indiana University School of Medicine, Indianapolis, USA
| | - Ahmed K Alomari
- Dermatology/Pathology, Indiana University School of Medicine, Indianapolis, USA
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Li D, Li J, Xu Y, Ling C, Qiu Y, Zhu Z, Liu Z. Topical vancomycin powder for the prevention of surgical site infections in spinal deformity surgery: a systematic review and meta-analysis. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2024; 33:4653-4663. [PMID: 39269667 DOI: 10.1007/s00586-024-08494-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/01/2024] [Revised: 09/05/2024] [Accepted: 09/10/2024] [Indexed: 09/15/2024]
Abstract
PURPOSE To assess the effectiveness and safety of topical vancomycin powder (VP) in preventing surgical site infections (SSIs) in spinal deformity surgeries. METHODS A literature search was conducted on Web of Science, PubMed, and Cochrane Library databases for comparative studies of VP in spinal deformity surgeries published before February 2024. Two reviewers independently screened eligible articles based on the inclusion and exclusion criteria, assessed study quality, and extracted data. Data analysis was performed using Review Manager 5.4 software. RESULTS Of all 143 papers screened, a meta-analysis was conducted on 10 articles, which included a total of 8,166 surgeries. The results of the meta-analysis indicated that the incidence of deep SSI in VP group was 0.28 times that in non-VP group (p < 0.001). In the subgroup analysis, VP treatment significantly reduced the risk of deep SSI in both adult spinal deformity (ASD) (RR 0.40, 95% CI 0.21-0.77, p = 0.006) and pediatric scoliosis (PS) (RR 0.25, 95% CI 0.16-0.38, p < 0.001) surgeries. However, this effect was not observed in neuromuscular scoliosis (NMS) patients (RR 0.66, 95% CI 0.26-1.66, p = 0.38). Bacterial culture results indicated that VP treatment significantly reduced polymicrobial infections (p = 0.007) and gram-positive infections (p = 0.001). CONCLUSION From the literature available at present, VP was associated with reduced deep SSIs rates in spinal deformity patients. However, particular attention should be paid to the lack of the effectiveness of VP in NMS patients. The current literature did not report local cytotoxicity or renal toxicity related to VP in spinal deformity patients.
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Affiliation(s)
- Dong Li
- Division of Spine Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing University, Zhongshan Road 321, Nanjing, 210008, China
| | - Jie Li
- Division of Spine Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing University, Zhongshan Road 321, Nanjing, 210008, China
| | - Yanjie Xu
- Division of Spine Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing University, Zhongshan Road 321, Nanjing, 210008, China
| | - Chen Ling
- Division of Spine Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital, Clinical College of Jiangsu University, Nanjing, 210008, China
| | - Yong Qiu
- Division of Spine Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing University, Zhongshan Road 321, Nanjing, 210008, China
| | - Zezhang Zhu
- Division of Spine Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing University, Zhongshan Road 321, Nanjing, 210008, China
| | - Zhen Liu
- Division of Spine Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing University, Zhongshan Road 321, Nanjing, 210008, China.
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Kwong JW, Abramowicz M, Kühn KD, Foelsch C, Hansen EN. High and Low Dosage of Vancomycin in Polymethylmethacrylate Cements: Efficacy and Mechanical Properties. Antibiotics (Basel) 2024; 13:818. [PMID: 39334991 PMCID: PMC11428212 DOI: 10.3390/antibiotics13090818] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2024] [Revised: 08/14/2024] [Accepted: 08/21/2024] [Indexed: 09/30/2024] Open
Abstract
INTRODUCTION Prosthetic joint infections (PJIs) are difficult to treat and represent a significant burden to the healthcare system. Two-stage revision surgery with placement of an antibiotic-loaded cement spacer is currently the gold standard for treatment in the United States for late-onset infections. We evaluate the efficacy of varying doses of vancomycin added to antibiotic-containing acrylic cement spacers and discuss the biomechanical and antimicrobial properties of using high versus low doses of vancomycin in cement spacers in the hip and knee. MATERIALS AND METHODS Commercially available Copal cement containing either gentamicin and clindamycin (G + C) or gentamicin and vancomycin (G + V) was prepared with the manual addition of low (2 g) and high (6 g) doses of vancomycin. In vitro mechanical testing was then carried out according to ISO 5833 and DIN 53435, as well as inhibition zone assays against common PJI pathogens. Additionally, inhibition zone assays were conducted on two commercially available prefabricated spacers containing gentamicin: Copal Exchange G and Cemex Spacer-K. RESULTS In biomechanical testing, Copal G + V with the addition of 6 g of vancomycin failed to meet the ISO standard. Copal G + C and Copal G + V with low and high dosages of vancomycin were all effective against the tested pathogens and displayed constant efficacy for a duration of 42 days. High doses of vancomycin showed significantly lower mechanical stability. Moreover, Copal Exchange G showed significantly larger inhibition zones across 42 days. DISCUSSION While higher concentrations of vancomycin appear to improve the antimicrobial efficacy of cement, they also reduce its mechanical stability. Despite its smoother surface, the Copal Exchange G spacer exhibits large inhibition zones after 1 day and maintains consistently large inhibition zones over 6 weeks. Thus, it may be preferred for use in two-stage revision surgery. CONCLUSION Copal Exchange G is more effective than Cemex Spacer K against S. aureus and E. coli. The manual addition of vancomycin to cement containing double antibiotics is very effective. The influence on ISO compression is low, the ISO bending modulus is increased, and ISO bending, DIN bending, and DIN impact, are reduced.
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Affiliation(s)
- Jeffrey W. Kwong
- Department of Orthopaedic Surgery, University of California San Francisco, San Francisco, CA 94143, USA; (J.W.K.); (E.N.H.)
| | | | - Klaus Dieter Kühn
- Department of Orthopaedics and Trauma, Medical University of Graz, 8036 Graz, Austria
| | - Christian Foelsch
- Department of Orthopaedics and Orthopaedic Surgery, University Hospital Gießen and Marburg (UKGM), Justus-Liebig-University, Klinikstraße 33, 35392 Gießen, Germany;
| | - Erik N. Hansen
- Department of Orthopaedic Surgery, University of California San Francisco, San Francisco, CA 94143, USA; (J.W.K.); (E.N.H.)
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Savas MJ, Gray KF, Blackburn BE, Pelt CE, Gililland JM, Certain LK. Association of Acute Kidney Injury With Antibiotic Loaded Cement Used for Treatment of Periprosthetic Joint Infection. J Arthroplasty 2023; 38:2704-2709.e1. [PMID: 37279850 PMCID: PMC10694335 DOI: 10.1016/j.arth.2023.05.061] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Revised: 05/20/2023] [Accepted: 05/24/2023] [Indexed: 06/08/2023] Open
Abstract
BACKGROUND Antibiotic-loaded bone cement (ALBC) is commonly used in the treatment of periprosthetic joint infections (PJIs) to increase the local concentration of antibiotic at the site of infection. Use of ALBC has been associated with rare instances of acute kidney injury (AKI) despite low systemic absorption of the nephrotoxic antibiotics; however, the incidence of AKI is unknown. The purpose of this study was to determine the incidence of and risk factors for AKI associated with ALBC. METHODS This single-site, retrospective cohort study compared 162 PJI patients who underwent Stage 1 revision to a spacer with ALBC to 115 PJI patients who underwent debridement, antibiotics, and implant retention (DAIR) without the use of ALBC. Both groups received similar systemic antibiotics postoperatively. Descriptive statistics and multivariable logistic regressions were used to analyze risk factors for AKI. RESULTS There was no statistically significant difference in the rate of AKI: 29 patients (17.9%) in the ALBC group and 17 (14.7%) in DAIR group developed AKI (odds ratio 1.43; 95% CI 0.70 to 2.93). There was a trend toward increased severity of AKI in the ALBC group. Chronic kidney disease, systemic vancomycin, and diuretic use were independent factors associated with the risk of AKI. CONCLUSION An AKI occurred in 17% of PJI patients receiving either a spacer with ALBC or a DAIR. The use of ALBC was not associated with a significant increased risk of AKI. However, the use of systemic vancomycin and diuretic use were independent predictors of AKI in this patient population.
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Affiliation(s)
- Matthew J Savas
- College of Pharmacy, University of Utah, Salt Lake City, Utah
| | - Kristine F Gray
- College of Pharmacy, University of Utah, Salt Lake City, Utah
| | - Brenna E Blackburn
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, Utah
| | - Christopher E Pelt
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, Utah
| | - Jeremy M Gililland
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, Utah
| | - Laura K Certain
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, Utah; Division of Infectious Diseases, Department of Internal Medicine, University of Utah, Salt Lake City, Utah
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Zulkefli N, Che Zahari CNM, Sayuti NH, Kamarudin AA, Saad N, Hamezah HS, Bunawan H, Baharum SN, Mediani A, Ahmed QU, Ismail AFH, Sarian MN. Flavonoids as Potential Wound-Healing Molecules: Emphasis on Pathways Perspective. Int J Mol Sci 2023; 24:ijms24054607. [PMID: 36902038 PMCID: PMC10003005 DOI: 10.3390/ijms24054607] [Citation(s) in RCA: 29] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 01/21/2023] [Accepted: 01/25/2023] [Indexed: 03/02/2023] Open
Abstract
Wounds are considered to be a serious problem that affects the healthcare sector in many countries, primarily due to diabetes and obesity. Wounds become worse because of unhealthy lifestyles and habits. Wound healing is a complicated physiological process that is essential for restoring the epithelial barrier after an injury. Numerous studies have reported that flavonoids possess wound-healing properties due to their well-acclaimed anti-inflammatory, angiogenesis, re-epithelialization, and antioxidant effects. They have been shown to be able to act on the wound-healing process via expression of biomarkers respective to the pathways that mainly include Wnt/β-catenin, Hippo, Transforming Growth Factor-beta (TGF-β), Hedgehog, c-Jun N-Terminal Kinase (JNK), NF-E2-related factor 2/antioxidant responsive element (Nrf2/ARE), Nuclear Factor Kappa B (NF-κB), MAPK/ERK, Ras/Raf/MEK/ERK, phosphatidylinositol 3-kinase (PI3K)/Akt, Nitric oxide (NO) pathways, etc. Hence, we have compiled existing evidence on the manipulation of flavonoids towards achieving skin wound healing, together with current limitations and future perspectives in support of these polyphenolic compounds as safe wound-healing agents, in this review.
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Affiliation(s)
- Nabilah Zulkefli
- Institute of Systems Biology (INBIOSIS), Universiti Kebangsaan Malaysia, Bangi 43600, Selangor, Malaysia
| | | | - Nor Hafiza Sayuti
- Institute of Systems Biology (INBIOSIS), Universiti Kebangsaan Malaysia, Bangi 43600, Selangor, Malaysia
| | - Ammar Akram Kamarudin
- UKM Molecular Biology Institute (UMBI), UKM Medical Center, Kuala Lumpur 56000, Selangor, Malaysia
| | - Norazalina Saad
- Laboratory of Cancer Research UPM-MAKNA (CANRES), Institute of Bioscience, Universiti Putra Malaysia, Serdang 43400, Selangor, Malaysia
| | - Hamizah Shahirah Hamezah
- Institute of Systems Biology (INBIOSIS), Universiti Kebangsaan Malaysia, Bangi 43600, Selangor, Malaysia
| | - Hamidun Bunawan
- Institute of Systems Biology (INBIOSIS), Universiti Kebangsaan Malaysia, Bangi 43600, Selangor, Malaysia
| | - Syarul Nataqain Baharum
- Institute of Systems Biology (INBIOSIS), Universiti Kebangsaan Malaysia, Bangi 43600, Selangor, Malaysia
| | - Ahmed Mediani
- Institute of Systems Biology (INBIOSIS), Universiti Kebangsaan Malaysia, Bangi 43600, Selangor, Malaysia
| | - Qamar Uddin Ahmed
- Drug Discovery and Synthetic Chemistry Research Group, Department of Pharmaceutical Chemistry, Kulliyyah of Pharmacy, International Islamic University Malaysia, Kuantan 25200, Pahang, Malaysia
| | - Ahmad Fahmi Harun Ismail
- Kulliyyah of Allied Health Sciences, International Islamic University Malaysia, Kuantan 25200, Pahang, Malaysia
- Correspondence: (A.F.H.I.); (M.N.S.)
| | - Murni Nazira Sarian
- Institute of Systems Biology (INBIOSIS), Universiti Kebangsaan Malaysia, Bangi 43600, Selangor, Malaysia
- Correspondence: (A.F.H.I.); (M.N.S.)
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Use of Antibiotic-impregnated Polymethylmethacrylate (PMMA) Plates for Prevention of Periprosthetic Infection in Breast Reconstruction. Plast Reconstr Surg Glob Open 2023; 11:e4764. [PMID: 36776590 PMCID: PMC9911200 DOI: 10.1097/gox.0000000000004764] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Accepted: 11/18/2022] [Indexed: 01/19/2023]
Abstract
Periprosthetic infections remain a major challenge for breast reconstruction. Local antibiotic delivery systems, such as antibiotic beads and spacers, have been widely used within other surgical fields, but their use within plastic surgery remains scarce. In this study, we demonstrate the use of antibiotic-impregnated polymethylmethacrylate (PMMA) plates for infection prophylaxis in tissue expander (TE)-based breast reconstruction. Methods A retrospective review of patients who underwent immediate breast reconstruction with prepectoral TEs over the span of 5 years performed by two surgeons was completed, revealing a total of 447 patients. Data pertaining to patient demographics, operative details, and postoperative outcomes were recorded. Fifty patients underwent TE reconstruction with the addition of a PMMA plate (Stryker, Kalamazoo, Michigan) impregnated with tobramycin and vancomycin. Antibiotic plates were removed at the time of TE-to-implant exchange. Patient-matching analysis was performed using the 397 patients without PMMA plates to generate a 50-patient nonintervention cohort for statistical analysis. Results The intervention cohort (n = 50) and 1:1 patient-matched nonintervention cohort (n = 50) demonstrated no statistically significant differences in patient demographics or operative characteristics other than PMMA plate placement. The rate of operative periprosthetic infection was 4% in the intervention group and 14% in the nonintervention group (P = 0.047). The rate of TE explantation was also reduced in the intervention group (6% versus 18%; P = 0.036). Follow-up averaged 9.1 and 8.9 months for the intervention and nonintervention groups, respectively (P = 0.255). Conclusion Local antibiotic delivery using antibiotic-impregnated PMMA plates can be safely and effectively used for infection prevention with TE-based breast reconstruction.
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11
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Borick JJ, Balan S, Lichtenberger P, Bjork L. Timely explantation of tobramycin-impregnated beads and bone cement to avoid haemodialysis in a patient with worsening renal failure. BMJ Case Rep 2022; 15:e242760. [PMID: 35131767 PMCID: PMC8823038 DOI: 10.1136/bcr-2021-242760] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/31/2021] [Indexed: 11/03/2022] Open
Abstract
A male patient with right total knee arthroplasty complicated by prosthetic joint infection on intravenous antimicrobials developed an acute kidney injury (AKI) with creatinine up to 7.3 mg/dL ('normal' range (0.5-1.2 mg/dL)) after hardware removal and tobramycin loaded polymethylmethacrylate beads and spacer placement. The AKI was initially attributed to intravenous vancomycin. Despite discontinuing vancomycin, the AKI worsened. A tobramycin level was collected and resulted at 5.5 µg/mL. Due to high suspicion for aminoglycoside-induced renal toxicity and to prevent haemodialysis, the antibiotic cement spacer with tobramycin-impregnated beads was removed. After the removal, tobramycin level rapidly decreased and renal functions improved. AKI is an increasingly recognised complication related to antibiotic-loaded bone cement (ALBC) due to the systemic absorption of antibiotics. With this case we highlight the early recognition of ALBC-induced renal toxicity necessitating explantation of ALBC and beads in order to prevent haemodialysis and emphasise monitoring aminoglycoside levels in the early postoperative period.
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Affiliation(s)
- Joseph Jeffry Borick
- Infectious Disease, University of Miami Miller School of Medicine, Miami, Florida, USA
- Infectious Disease, Jackson Memorial Hospital, Miami, Florida, USA
- Infectious Disease, VA Medical Center, Miami, Florida, USA
| | - Shuba Balan
- Infectious Disease, University of Miami Miller School of Medicine, Miami, Florida, USA
- Infectious Disease, Jackson Memorial Hospital, Miami, Florida, USA
- Infectious Disease, VA Medical Center, Miami, Florida, USA
| | - Paola Lichtenberger
- Infectious Disease, University of Miami Miller School of Medicine, Miami, Florida, USA
- Infectious Disease, VA Medical Center, Miami, Florida, USA
| | - Lauren Bjork
- Clinical Pharmacy, VA Medical Center Miami, Miami, Florida, USA
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12
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Monika P, Chandraprabha MN, Rangarajan A, Waiker PV, Chidambara Murthy KN. Challenges in Healing Wound: Role of Complementary and Alternative Medicine. Front Nutr 2022; 8:791899. [PMID: 35127787 PMCID: PMC8811258 DOI: 10.3389/fnut.2021.791899] [Citation(s) in RCA: 100] [Impact Index Per Article: 33.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2021] [Accepted: 12/08/2021] [Indexed: 12/26/2022] Open
Abstract
Although the word wound sounds like a simple injury to tissue, individual's health status and other inherent factors may make it very complicated. Hence, wound healing has gained major attention in the healthcare. The biology wound healing is precise and highly programmed, through phases of hemostasis, inflammation, proliferation and remodeling. Current options for wound healing which includes, use of anti-microbial agents, healing promoters along with application of herbal and natural products. However, there is no efficient evidence-based therapy available for specific chronic wounds that can result in definitive clinical outcomes. Under co-morbid conditions, chronic would poses numerous challenges. Use of Complementary and Alternative Medicines (CAMs) in health care sector is increasing and its applications in wound management remains like to "separate the diamonds from ore." Attempts have been made to understand the wound at the molecular level, mainly through the analysis of signature genes and the influence of several synthetic and natural molecules on these. We have outlined a review of challenges in chronic wound healing and the role of CAMs in chronic wound management. The main focus is on the applications and limitations of currently available treatment options for a non-healing wound and the best possible alternates to consider. This information generates broader knowledge on challenges in chronic wound healing, which can be further addressed using multidisciplinary approach and combination therapies.
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Affiliation(s)
- Prakash Monika
- Department of Biotechnology, M.S. Ramaiah Institute of Technology, Bangalore, India
| | | | - Annapoorni Rangarajan
- Department of Molecular Reproduction, Development and Genetics, Indian Institute of Science, Bangalore, India
| | - P. Veena Waiker
- Department of Plastic Surgery, Ramaiah Medical College and Hospitals, Bangalore, India
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13
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Vasiliadis ES, Vlachos C, Antoniades A, Papagrigorakis E, Bakalakos M, Pneumaticos SG. Two stage surgical treatment of cuboid osteomyelitis. A case report and review of the literature. Foot (Edinb) 2021; 47:101796. [PMID: 33957530 DOI: 10.1016/j.foot.2021.101796] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2020] [Revised: 01/25/2021] [Accepted: 02/23/2021] [Indexed: 02/04/2023]
Abstract
Isolated osteomyelitis of the cuboid bone is an extremely rare condition. A 32 year old man was evaluated for a painful and swollen right foot after a penetrating trauma and the presence of a sinus in the lateral aspect the midfoot. MRI findings were consistent with the presence of cuboid osteomyelitis. The patient underwent a two stage procedure which included partial excision of the cuboid bone, the use of a cemented spacer for lateral column length preservation, followed by arthrodesis of the calcaneocuboid joint with a tricortical autologous bone graft harvested from the ilium and preservation of the cuboid-metatarsal joints. At 4 years follow up, the patient is asymptomatic. Diagnosis of isolated cuboid osteomyelitis requires high clinical suspicion and a two stage procedure is an effective approach for symptomatic patients who do not respond to conservative treatment. LEVEL OF CLINICAL EVIDENCE: IV.
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Affiliation(s)
- Elias S Vasiliadis
- Third Department of Orthopaedic Surgery, University of Athens Medical School, KAT Hospital, Nikis Avenue 2, Kifisia, 14651, Athens, Greece
| | - Christos Vlachos
- Third Department of Orthopaedic Surgery, University of Athens Medical School, KAT Hospital, Nikis Avenue 2, Kifisia, 14651, Athens, Greece.
| | - Angelos Antoniades
- Third Department of Orthopaedic Surgery, University of Athens Medical School, KAT Hospital, Nikis Avenue 2, Kifisia, 14651, Athens, Greece
| | - Eftychios Papagrigorakis
- Third Department of Orthopaedic Surgery, University of Athens Medical School, KAT Hospital, Nikis Avenue 2, Kifisia, 14651, Athens, Greece
| | - Matthaios Bakalakos
- Third Department of Orthopaedic Surgery, University of Athens Medical School, KAT Hospital, Nikis Avenue 2, Kifisia, 14651, Athens, Greece
| | - Spyros G Pneumaticos
- Third Department of Orthopaedic Surgery, University of Athens Medical School, KAT Hospital, Nikis Avenue 2, Kifisia, 14651, Athens, Greece
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Touzopoulos P, Arvanitidis K, Filidou E, Tilkeridis K, Karanikas M, Kolios G, Ververidis A. Is serum gentamicin concentration modified with autologous cell-saved blood transfusion after total knee arthroplasty using tranexamic acid? A randomised control trial. Orthop Traumatol Surg Res 2021; 107:102794. [PMID: 33333277 DOI: 10.1016/j.otsr.2020.102794] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 08/08/2020] [Accepted: 08/17/2020] [Indexed: 02/03/2023]
Abstract
BACKGROUND Self-transfusion has been proven as an effective management of blood loss after total knee arthroplasty (TKA). Considering that the high local concentration of antibiotic from bone cement is delivered intravenously through the self-transfusion process, systematic toxicity has never been evaluated. In addition, the effectiveness of self-transfusion with the routine concomitant use of other modern blood-salvage strategies, like tranexamic acid, should also be assessed. Therefore, we performed a randomised study to assess: 1) the safety of self-transfusion in TKA by comparing the gentamicin concentrations resulting from the use or not of autologous blood transfusion; 2) the efficacy of self-transfusion in TKA, with the concomitant administration of tranexamic acid. HYPOTHESIS Self-transfusion in TKA elevates the serum gentamicin concentration and the potential risk of nephrotoxicity. METHODS The serum concentration of aminoglycosides was measured in two groups of 20 patients each, after TKA, according to the use of self-transfusion. Hemoglobin, renal function and calculated blood loss were compared at several points in time between groups. RESULTS The only time where there was a statistically significant difference in serum gentamicin, was at 48h postoperatively between groups [0.3 ug/mL±0.21, range: 0.15 to 0.72 vs. 0.14ug/mL±0.1, range: 0 to 0.35 (p=0.02)]. There were no significant differences in total blood loss [1341mL±501, range: 830 to 2230 vs. 1263mL±459 range: 840 to 2480 (p=0.67)] and need of allogeneic blood transfusion [3 units vs. 2 units] between groups. CONCLUSION The use of autologous blood transfusion was found to be safe, in terms of nephrotoxicity of aminoglycosides after TKA, but it seemed to be ineffective as a blood salvage strategy, when used concomitantly with the administration of tranexamic acid. LEVEL OF EVIDENCE II; low-powered randomised study. CLINICALTRIALS. GOV REGISTRATION NUMBER NCT04505748.
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Affiliation(s)
- Panagiotis Touzopoulos
- Department of Orthopaedics, General University Hospital of Alexandroupolis, Alexandroupolis, Greece.
| | - Konstantinos Arvanitidis
- Laboratory of Pharmacology, Medical School, Democritus University of Thrace, Alexandroupolis, Greece
| | - Eirini Filidou
- Laboratory of Pharmacology, Medical School, Democritus University of Thrace, Alexandroupolis, Greece
| | - Konstantinos Tilkeridis
- Department of Orthopaedics, Medical School, Democritus University of Thrace, Alexandroupolis, Greece
| | - Michael Karanikas
- Department of Surgery, Medical School, Democritus University of Thrace, Alexandroupolis, Greece
| | - George Kolios
- Laboratory of Pharmacology, Medical School, Democritus University of Thrace, Alexandroupolis, Greece
| | - Athanasios Ververidis
- Department of Orthopaedics, Medical School, Democritus University of Thrace, Alexandroupolis, Greece
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Maale GE, Eager JJ, Mohammadi DK, Calderon FA. Elution Profiles of Synthetic CaSO 4 Hemihydrate Beads Loaded with Vancomycin and Tobramycin. Eur J Drug Metab Pharmacokinet 2021; 45:547-555. [PMID: 32328932 PMCID: PMC7359161 DOI: 10.1007/s13318-020-00622-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Backgrounds and Objectives The use of local antibiotic delivery vehicles is common in the management of biofilm-related infections as they provide high concentrations of local antibiotics while simultaneously avoiding complications from systemic toxicity. We present a 100% pure synthetic calcium sulfate hemi-hydrate mixed with 240 mg tobramycin and 500 mg vancomycin per 10 cc mixture for use in revision surgeries of periprosthetic joint infections (PJIs). The purified carrier demonstrates bioabsorbablity, promotion of bone growth, a physiologically favorable pH, and hydrophilicity. These unique properties may alleviate persistent postoperative wound drainage seen in patients with PJI. Our questions consist of two parts: (1) does the novel calcium sulfate carrier provide therapeutic concentrations of antibiotic locally that can kill biofilm related infections? (2) Are serum concentrations of antibiotic significant to cause concern for systemic toxicity? Methods To address these questions, we assayed the elution of antibiotic concentrations obtained from surgical drains and serum among 50 patients in the first 5 postoperative days. Results The elution of vancomycin and tobramycin was greatest on day 1 compared with those concentrations obtained on days 2, 3, 4, and 5; serum concentrations were largely undetectable. Our findings demonstrate that this calcium sulfate preparation provides therapeutic delivery of vancomycin and tobramycin locally at log 2–3 above the minimum inhibitory concentration (MIC), while avoiding toxic serum concentrations. Conclusions When used in one-stage revision arthroplasties, the bioabsorbable, purified carrier delivers high concentrations of antibiotic while avoiding systemic toxicity.
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Affiliation(s)
- Gerhard E Maale
- Orthopaedic Oncology, Dallas Fort Worth Sarcoma Group, 4708 Alliance Blvd Ste 710., Plano, TX, 75093, USA.
| | - John J Eager
- University of Texas Medical School At Houston, 6431 Fannin Street, Box 20708, Houston, TX, 77225, USA
| | - Daniel K Mohammadi
- Orthopaedic Oncology, Dallas Fort Worth Sarcoma Group, 4708 Alliance Blvd Ste 710., Plano, TX, 75093, USA
| | - Flavio A Calderon
- Orthopaedic Oncology, Dallas Fort Worth Sarcoma Group, 4708 Alliance Blvd Ste 710., Plano, TX, 75093, USA
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16
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Leta TH, Gjertsen JE, Dale H, Hallan G, Lygre SHL, Fenstad AM, Dyrhovden GS, Westberg M, Wik TS, Jakobsen RB, Aamodt A, Röhrl SM, Gøthesen ØJ, Lindalen E, Heir S, Ludvigsen J, Bruun T, Hansen AK, Aune KEM, Warholm M, Skjetne JP, Badawy M, Høvding P, Husby OS, Karlsen ØE, Furnes O. Antibiotic-Loaded Bone Cement in Prevention of Periprosthetic Joint Infections in Primary Total Knee Arthroplasty: A Register-based Multicentre Randomised Controlled Non-inferiority Trial (ALBA trial). BMJ Open 2021; 11:e041096. [PMID: 33509845 PMCID: PMC7845702 DOI: 10.1136/bmjopen-2020-041096] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
INTRODUCTION The current evidence on the efficacy of antibiotic-loaded bone cement (ALBC) in reducing the risk of periprosthetic joint infections (PJI) after primary joint reconstruction is insufficient. In several European countries, the use of ALBC is routine practice unlike in the USA where ALBC use is not approved in low-risk patients. Therefore, we designed a double-blinded pragmatic multicentre register-based randomised controlled non-inferiority trial to investigate the effects of ALBC compared with plain bone cement in primary total knee arthroplasty (TKA). METHODS AND ANALYSIS A minimum of 9,172 patients undergoing full-cemented primary TKA will be recruited and equally randomised into the ALBC group and the plain bone cement group. This trial will be conducted in Norwegian hospitals that routinely perform cemented primary TKA. The primary outcome will be risk of revision surgery due to PJI at 1-year of follow-up. Secondary outcomes will be: risk of revision due to any reason including aseptic loosening at 1, 6, 10 and 20 years of follow-up; patient-related outcome measures like function, pain, satisfaction and health-related quality of life at 1, 6 and 10 years of follow-up; risk of changes in the microbial pattern and resistance profiles of organisms cultured in subsequent revisions at 1, 6, 10 and 20 years of follow-up; cost-effectiveness of routine ALBC versus plain bone cement use in primary TKA. We will use 1:1 randomisation with random permuted blocks and stratify by participating hospitals to randomise patients to receive ALBC or plain bone cement. Inclusion, randomisation and follow-up will be through the Norwegian Arthroplasty Register. ETHICS AND DISSEMINATION The trial was approved by the Western Norway Regional Committees on Medical and Health Research Ethics (reference number: 2019/751/REK vest) on 21 June 2019. The findings of this trial will be disseminated through peer-reviewed publications and conference presentations. TRIAL REGISTRATION NUMBER NCT04135170.
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Affiliation(s)
- Tesfaye H Leta
- Faculty of Health Science, VID Specialized University, Bergen, Norway
- The Norwegian Arthroplasty Register, Department of Orthopedic Surgery, Haukeland University Hospital, Bergen, Norway
| | - Jan-Erik Gjertsen
- The Norwegian Arthroplasty Register, Department of Orthopedic Surgery, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, Faculty of Medicine, University of Bergen, Bergen, Norway
| | - Håvard Dale
- The Norwegian Arthroplasty Register, Department of Orthopedic Surgery, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, Faculty of Medicine, University of Bergen, Bergen, Norway
| | - Geir Hallan
- The Norwegian Arthroplasty Register, Department of Orthopedic Surgery, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, Faculty of Medicine, University of Bergen, Bergen, Norway
| | - Stein Håkon Låstad Lygre
- The Norwegian Arthroplasty Register, Department of Orthopedic Surgery, Haukeland University Hospital, Bergen, Norway
- Department of Occupational Medicine, Haukeland University Hospital, Bergen, Norway
| | - Anne Marie Fenstad
- The Norwegian Arthroplasty Register, Department of Orthopedic Surgery, Haukeland University Hospital, Bergen, Norway
| | - Gro Sævik Dyrhovden
- Department of Clinical Medicine, Faculty of Medicine, University of Bergen, Bergen, Norway
| | - Marianne Westberg
- Division of Orthopedic Surgery, Oslo University Hospital, Oslo, Norway
| | - Tina Stromdal Wik
- Department of Orthopedic Surgery, St. Olavs Hospital, Trondheim, Norway
- Department of Neuromedicine and Movement Science, Faculty of Medicine and Health Science, The Norwegian University of Science and Technology, Bergen, Norway
| | - Rune Bruhn Jakobsen
- Department of Health Management and Health Economics, University of Oslo, Oslo, Norway
- Department of Orthopedic Surgery, Akershus Universitetssykehus HF, Oslo, Norway
| | - Arild Aamodt
- Department of Orthopaedic Surgery, Lovisenberg Diakonal Hospital, Oslo, Norway
| | | | - Øystein Johannes Gøthesen
- Department of Clinical Medicine, Faculty of Medicine, University of Bergen, Bergen, Norway
- Department of Orthopaedic, Haugesund Hospital for Rheumatic Diseases, Haugesund, Norway
| | - Einar Lindalen
- Department of Orthopaedic Surgery, Lovisenberg Diakonal Hospital, Oslo, Norway
| | - Stig Heir
- Department of Orthopedic Surgery, Martina Hansens Hospital, Sandvika, Norway
| | - Jarle Ludvigsen
- Department of Orthopedic Surgery, Stavanger University Hospital, Stavanger, Norway
| | - Trond Bruun
- Department of Medicine, Haukeland University Hospital, Bergen, Norway
| | - Ann Kristin Hansen
- Department of Orthopedic Surgery, University Hospital of North Norway, Tromsø, Norway
- Department of Clinical Medicine, UiT-The Arctic University of Norway, Tromsø, Norway
| | | | - Marianne Warholm
- Department of Information and Communication Technology, Western Norway Regional Health Authority, Bergen, Norway
| | - John Petter Skjetne
- Department of Information and Technology, Central Norway Regional Health Authority, Trondheim, Norway
| | - Mona Badawy
- Coastal Hospital in Hagavik, Department of Orthopaedic Surgery, Haukeland University Hospital, Bergen, Norway
| | - Pål Høvding
- The Norwegian Arthroplasty Register, Department of Orthopedic Surgery, Haukeland University Hospital, Bergen, Norway
| | | | | | - Ove Furnes
- The Norwegian Arthroplasty Register, Department of Orthopedic Surgery, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, Faculty of Medicine, University of Bergen, Bergen, Norway
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17
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Abstract
We conducted a systematic review about antibiotic-loaded bone cement (ALBC) with a focus on clinical evidence about ALBC in general, concerns about ALBC and ALBC cost.
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Affiliation(s)
- Antonio V Pellegrini
- Centre of Reconstructive Surgery and Osteo-Articular Infections (C.R.I.O), IRCCS Galeazzi Orthopaedic Institute, Milan, Italy
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Mazza D, Calderaro C, Iorio R, Drogo P, Andreozzi V, Ferretti A. Acute kidney failure after total knee arthroplasty revision with antibiotic-impregnated cement spacer. Orthop Rev (Pavia) 2020; 12:8540. [PMID: 32922700 PMCID: PMC7461639 DOI: 10.4081/or.2020.8540] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2020] [Accepted: 05/01/2020] [Indexed: 11/23/2022] Open
Abstract
Gentamicin-impregnated cement beads and spacers are frequently used in case of infective complications after Total Knee Arthroplasty (TKA). A great number of studies in the literature demonstrated that the local administration of gentamicin produces high local antibiotic levels but low serum and urine gentamicin concentrations. Gentamicin-impregnated cement spacer can induce nephrotoxicity in patients presenting major renal impairment susceptibility. We report a case of acute renal failure using a gentamicin-impregnated block spacer. An 83-year-old woman underwent a gentamicinimpregnated bone-cement spacer implant because of an infected TKA removal. Three days later patient clinical status got worse reporting a decreased urine output and increasing C-reactive protein (CRP), Serum Creatinine (SCr) and Blood Urea Nitrogen (BUN). Because the symptoms could be related to the knee spacer lead us to the decision of gentamicin-impregnated cement spacer removal. The day following the removal procedure showed progressive improvement of general condition with evidence of SCr and BUN normalization. Gentamicin-impregnated cement spacer can induce nephrotoxicity in patients presenting major renal impairment susceptibility.
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Affiliation(s)
- Daniele Mazza
- Department of Orthopedic and Traumatology, S. Andrea Hospital, "La Sapienza" University of Rome, Italy
| | - Cosma Calderaro
- Department of Orthopedic and Traumatology, S. Andrea Hospital, "La Sapienza" University of Rome, Italy
| | - Raffaele Iorio
- Department of Orthopedic and Traumatology, S. Andrea Hospital, "La Sapienza" University of Rome, Italy
| | - Piergiorgio Drogo
- Department of Orthopedic and Traumatology, S. Andrea Hospital, "La Sapienza" University of Rome, Italy
| | - Valerio Andreozzi
- Department of Orthopedic and Traumatology, S. Andrea Hospital, "La Sapienza" University of Rome, Italy
| | - Andrea Ferretti
- Department of Orthopedic and Traumatology, S. Andrea Hospital, "La Sapienza" University of Rome, Italy
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Hoskins T, Shah JK, Patel J, Mazzei C, Goyette D, Poletick E, Colella T, Wittig J. The cost-effectiveness of antibiotic-loaded bone cement versus plain bone cement following total and partial knee and hip arthroplasty. J Orthop 2020; 20:217-220. [PMID: 32051672 DOI: 10.1016/j.jor.2020.01.029] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Accepted: 01/24/2020] [Indexed: 12/31/2022] Open
Abstract
Background Postoperative infection is one of the most prevalent complications following total joint arthroplasty (TJA). As such procedures become more prevalent, it is imperative that we develop new prophylactic methods to prevent the need for revision procedures. In recent years, surgeons have opted to use antibiotic-loaded bone cement (ALBC) rather than plain bone cement (PBC) in primary hip and knee replacements due to its theoretical potential of lowering infection rates. However, the cost-effectiveness of this intervention remains in question.Questions/Purposes: To determine the rate of infection and cost-effectiveness of antibiotic-loaded bone cement as compared to plain bone cement in hip and knee arthroplasty. Patients and methods We reviewed 4116 primary hip and knee arthroplasty cases performed between 2016 and 2018 at Morristown Medical Center in New Jersey. Data regarding demographics, complications, and any readmissions due to deep infection were collected retrospectively. During that time period there were a total of 4016 knee cases (423 ALBC, 3593 PBC) and 123 hip cases (63 ALBC, 60 PBC). The average cost for one bag of antibiotic-loaded bone cement and plain bone cement for hip and knee arthroplasty was $336.42 and $72.14, respectively. A statistical analysis was performed using Fisher's exact test; the National Healthcare Safety Network (NHSN) surgical site infection guidelines were used to distinguish between superficial and deep infections. Results Ten patients were readmitted due to deep infection, all of whom had undergone total knee arthroplasty. Of those cases, plain bone cement was used for the index procedure in seven instances and antibiotic-loaded cement was used in three. This resulted in an infection rate of 0.19% and 0.62%, respectively, p = 0.103. There was no statistically significant difference in infection rates between the two groups. A total of 778 bags of ALBC were used in 423 knee surgeries, and 98 bags of ALBC were used in 63 hip cases. The total cost for ALBC in TKA and THA procedures was $261,734.76 (778*336.42) and $32,969.16 (98*336.42), respectively. If PBC had been used during all index procedures, it would have resulted in a total savings of $231,509.28. Conclusions Antibiotic-loaded cement did not significantly reduce the rate of infection for either knee or hip arthroplasty. Thus, the routine use of antibiotic-loaded cement in primary hip and knee arthroplasty may be an unnecessary financial burden to the healthcare system. A larger sample size and a randomized controlled trial would help confirm our findings and would provide further information on the cost-effectiveness of ALBC cement versus PBC.Significance/Clinical Relevance: In this review of cases performed from 2016 to 2018 there was no statistically significant difference between the rate of infection and the need for revision surgeries for patients treated with ALBC versus PBC. As hospital systems continue to transition towards a bundled payment model, it becomes imperative for providers to reduce any unnecessary costs in order to increase quality and efficiency. We estimate that our hospital system could save nearly $120,000/year by using plain bone cement instead of antibiotic-loaded cement.
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Affiliation(s)
- Tyler Hoskins
- Department of Orthopaedic Surgery, Morristown Medical Center - Atlantic Health System, Morristown, NJ, USA
| | - Jay K Shah
- Department of Orthopaedic Surgery, Morristown Medical Center - Atlantic Health System, Morristown, NJ, USA.,Department of Orthopaedic Surgery, Jersey City Medical Center - RWJBarnabas Health, Jersey City, NJ, USA
| | - Jay Patel
- Department of Orthopaedic Surgery, Morristown Medical Center - Atlantic Health System, Morristown, NJ, USA
| | - Chris Mazzei
- Department of Orthopaedic Surgery, Morristown Medical Center - Atlantic Health System, Morristown, NJ, USA
| | - David Goyette
- Department of Orthopaedic Surgery, Morristown Medical Center - Atlantic Health System, Morristown, NJ, USA
| | - Eileen Poletick
- Department of Orthopaedic Surgery, Morristown Medical Center - Atlantic Health System, Morristown, NJ, USA
| | - Thomas Colella
- Department of Orthopaedic Surgery, Morristown Medical Center - Atlantic Health System, Morristown, NJ, USA
| | - James Wittig
- Department of Orthopaedic Surgery, Morristown Medical Center - Atlantic Health System, Morristown, NJ, USA
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20
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Abstract
Fracture-related infection (FRI) remains a challenging complication that imposes a heavy burden on orthopaedic trauma patients. The surgical management eradicates the local infectious focus and if necessary facilitates bone healing. Treatment success is associated with debridement of all dead and poorly vascularized tissue. However, debridement is often associated with the formation of a dead space, which provides an ideal environment for bacteria and is a potential site for recurrent infection. Dead space management is therefore of critical importance. For this reason, the use of locally delivered antimicrobials has gained attention not only for local antimicrobial activity but also for dead space management. Local antimicrobial therapy has been widely studied in periprosthetic joint infection, without addressing the specific problems of FRI. Furthermore, the literature presents a wide array of methods and guidelines with respect to the use of local antimicrobials. The present review describes the scientific evidence related to dead space management with a focus on the currently available local antimicrobial strategies in the management of FRI. LEVEL OF EVIDENCE:: Therapeutic Level V. See Instructions for Authors for a complete description of levels of evidence.
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Corró S, Vicente M, Rodríguez-Pardo D, Pigrau C, Lung M, Corona PS. Vancomycin-Gentamicin Prefabricated Spacers in 2-Stage Revision Arthroplasty for Chronic Hip and Knee Periprosthetic Joint Infection: Insights Into Reimplantation Microbiology and Outcomes. J Arthroplasty 2020; 35:247-254. [PMID: 31530462 DOI: 10.1016/j.arth.2019.07.043] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Revised: 06/28/2019] [Accepted: 07/30/2019] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Second-stage positive cultures in 2-stage revision arthroplasty are a matter of concern, as their influence in outcomes is not clearly defined. We sought to study reimplantation microbiology when using vancomycin-gentamicin prefabricated cement spacers in hip and knee periprosthetic joint infection. The associations of second-stage positive cultures with treatment failures and patient-associated factors were analyzed. METHODS We conducted a retrospective cohort study, examining patients managed with 2-stage revision arthroplasty due to knee or hip chronic periprosthetic joint infection between 2010 and 2017. Prefabricated vancomycin-gentamicin cement spacers were used during the spacer stage. Intraoperative microbiological culture results after the first and second stages were evaluated. The primary end point was infection eradication or relapse. RESULTS A total of 108 cases were included (61 hips and 47 knees). And 22.2% of patients had ≥1 second-stage positive culture, while 9.3% had ≥2 positive samples. Overall success, at an average follow-up of 46.4 months, was 77.8%. Treatment failure was higher among cases with positive cultures (15.5% vs 45.8%, P < .01) regardless of the number of positive samples. Diabetes was identified as a risk factor for second-stage positive cultures (P = .03); use of cement loaded with extra antibiotics for spacer fixation showed a protective effect (P < .01). CONCLUSION Second-stage positive cultures were related to a higher failure rate when using vancomycin-gentamicin cement spacers. Diabetes increased the likelihood of second-stage positive cultures. The use of extra-antibiotic-loaded cement for spacer fixation during the first stage showed a protective effect.
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Affiliation(s)
- Sebastián Corró
- Orthopaedic Surgery Department, Vall d'Hebron University Hospital, Universitat Autonoma de Barcelona, Barcelona, Spain
| | - Matías Vicente
- Orthopaedic Surgery Department, Vall d'Hebron University Hospital, Universitat Autonoma de Barcelona, Barcelona, Spain
| | - Dolors Rodríguez-Pardo
- Infectious Diseases Department, Vall d'Hebron University Hospital, Universitat Autonoma de Barcelona, Barcelona, Spain
| | - Carles Pigrau
- Infectious Diseases Department, Vall d'Hebron University Hospital, Universitat Autonoma de Barcelona, Barcelona, Spain
| | - Mayli Lung
- Microbology Department, Vall d'Hebron University Hospital, Universitat Autonoma de Barcelona, Barcelona, Spain
| | - Pablo S Corona
- Septic and Reconstructive Surgery Unit, Orthopaedic Surgery Department, Vall d'Hebron University Hospital, Universitat Autonoma de Barcelona, Barcelona, Spain
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22
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Rava A, Bruzzone M, Cottino U, Enrietti E, Rossi R. Hip Spacers in Two-Stage Revision for Periprosthetic Joint Infection: A Review of Literature. JOINTS 2019; 7:56-63. [PMID: 31879732 PMCID: PMC6930843 DOI: 10.1055/s-0039-1697608] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/18/2018] [Accepted: 08/06/2019] [Indexed: 02/06/2023]
Abstract
Infection after total hip arthroplasty (THA) is a devastating complication with significant consequences for patients. In literature, single and two-stage revision, irrigation and debridement, Girdlestone resection arthroplasty, and arthrodesis and amputation are reported as possible treatments. Recently, two-stage revision has become popular as the gold standard treatment for chronic hip joint infections after THA. In this review, we evaluate the current literature about microbiology of periprosthetic joint infections and the use of antibiotic-loaded cement spacers. We aim to give an overview about indications, clinical results, and mechanical complications for spacers implantation, evaluating also selection criteria, pharmacokinetic properties, and systemic safety of the most frequently used antibiotics.
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Affiliation(s)
- Alessandro Rava
- Scuola di Specializzazione in Ortopedia e Traumatologia, Università degli Studi di Torino, Torino, Italy
| | - Matteo Bruzzone
- SC Ortopedia e Traumatologia, AO Ospedale Mauriziano Umberto I, Torino, Italy
| | - Umberto Cottino
- SC Ortopedia e Traumatologia, AO Ospedale Mauriziano Umberto I, Torino, Italy
| | - Emilio Enrietti
- Scuola di Specializzazione in Ortopedia e Traumatologia, Università degli Studi di Torino, Torino, Italy
| | - Roberto Rossi
- SC Ortopedia e Traumatologia, AO Ospedale Mauriziano Umberto I, Torino, Italy
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Abstract
Infection after fracture fixation is a feared complication in orthopaedic surgery leading to poor bone healing and loss of function.Early detection is essential and interdisciplinary care is mandatory.Eradication of infection is only possible through combined surgical and antibiotic treatment.Intraoperative tissue samples must be taken and are effective for guidance of the antibiotic regimen.Infection after fracture fixation is different from prosthetic joint infection (PJI) and needs a specific strategy.In this review, we define infection after fracture fixation, and outline the clinical, radiological and laboratory signs of these infections, as well as a treatment algorithm for optimal patient care. Cite this article: EFORT Open Rev 2019;4:468-475. DOI: 10.1302/2058-5241.4.180093.
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Affiliation(s)
- Sylvain Steinmetz
- Service of Orthopaedics and Traumatology, Lausanne University Hospital, Lausanne, Switzerland
| | - Diane Wernly
- Service of Orthopaedics and Traumatology, Lausanne University Hospital, Lausanne, Switzerland
| | - Kevin Moerenhout
- Service of Orthopaedics and Traumatology, Lausanne University Hospital, Lausanne, Switzerland
| | - Andrej Trampuz
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Center for Musculoskeletal Surgery (CMSC), Berlin, Germany
| | - Olivier Borens
- Service of Orthopaedics and Traumatology, Lausanne University Hospital, Lausanne, Switzerland
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24
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Baranes‐Zeevi M, Goder D, Zilberman M. Novel drug‐eluting soy‐protein structures for wound healing applications. POLYM ADVAN TECHNOL 2019. [DOI: 10.1002/pat.4673] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
- Maya Baranes‐Zeevi
- Department of Biomedical Engineering, Faculty of EngineeringTel‐Aviv University Tel‐Aviv Israel
| | - Daniella Goder
- Department of Materials Science and Engineering, Faculty of EngineeringTel‐Aviv University Tel‐Aviv Israel
| | - Meital Zilberman
- Department of Biomedical Engineering, Faculty of EngineeringTel‐Aviv University Tel‐Aviv Israel
- Department of Materials Science and Engineering, Faculty of EngineeringTel‐Aviv University Tel‐Aviv Israel
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25
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Haseeb A, Ajit Singh V, Teh CSJ, Loke MF. Addition of ceftaroline fosamil or vancomycin to PMMA: An in vitro comparison of biomechanical properties and anti-MRSA efficacy. J Orthop Surg (Hong Kong) 2019; 27:2309499019850324. [PMID: 31138005 DOI: 10.1177/2309499019850324] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Ceftaroline is a cephalosporin that is effective against methicillin-resistant Staphylococcus aureus (MRSA) infections. The objective of this study was to determine the feasibility of using ceftaroline-loaded Polymethyl methacrylate (PMMA) as antibiotic cement against MRSA versus vancomycin-loaded PMMA in an in vitro setting. METHODS PMMA pellets were prepared with three separate concentrations of each of the two antibiotics tested. They were tested to determine the effect of increasing concentration of antibiotics on the biomechanical properties of PMMA and antibiotic activity by measuring the zone of inhibition and broth elution assay. RESULTS Ceftaroline PMMA at 3 wt%, three-point bending was 37.17 ± 0.51 N ( p < 0.001) and axial loading was 41.95 N ± 0.51 ( p < 0.001). At 5-wt% vancomycin-PMMA, three-point bending was 41.65 ± 0.79 N ( p = 0.02) and axial loading was 49.49 ± 2.21 N ( p = 0.01). Stiffness of ceftroline-loaded PMMA in low and medium concentration was significantly higher than the vancomycin. The zone of inhibition for ceftaroline was higher than vancomycin. Ceftaroline at 3 wt% eluted up to 6 weeks (0.3 ± 0.1 μg/ml) above the minimum inhibitory concentration (MIC) and vancomycin at 2.5 wt% eluted up to 3 weeks, same as MIC, that is, 0.5 ± 0.0 μg/ml. CONCLUSIONS Ceftaroline, loaded at similar concentrations as vancomycin into PMMA, is a more potent alternative based on its more favourable bioactivity and elution properties, while having a lesser effect on the mechanical properties of the cement. The use of 3-wt% ceftaroline as antibiotic laden PMMA against MRSA is recommended. It should be noted that this was an in vitro study and to determine the clinical efficacy would need prospective, controlled and randomized studies.
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Affiliation(s)
- Amber Haseeb
- 1 Department of Orthopaedic Surgery, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Vivek Ajit Singh
- 1 Department of Orthopaedic Surgery, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Cindy Shuan Ju Teh
- 2 Department of Medical Microbiology, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Mun Fai Loke
- 2 Department of Medical Microbiology, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
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26
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Abdel MP, Barreira P, Battenberg A, Berry DJ, Blevins K, Font-Vizcarra L, Frommelt L, Goswami K, Greiner J, Janz V, Kendoff DO, Limberg AK, Manrique J, Moretti B, Murylev V, O'Byrne J, Petrie MJ, Porteous A, Saleri S, Sandiford NA, Sharma V, Shubnyakov I, Sporer S, Squire MW, Stockley I, Tibbo ME, Turgeon T, Varshneya A, Wellman S, Zahar A. Hip and Knee Section, Treatment, Two-Stage Exchange Spacer-Related: Proceedings of International Consensus on Orthopedic Infections. J Arthroplasty 2019; 34:S427-S438. [PMID: 30348562 DOI: 10.1016/j.arth.2018.09.027] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
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UV light assisted antibiotics for eradication of in vitro biofilms. Sci Rep 2018; 8:16360. [PMID: 30397224 PMCID: PMC6218519 DOI: 10.1038/s41598-018-34340-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Accepted: 10/09/2018] [Indexed: 11/08/2022] Open
Abstract
The overuse of antibiotics is accelerating the bacterial resistance, and therefore there is a need to reduce the amount of antibiotics used for treatment. Here, we demonstrate in vitro that specific wavelengths in a narrow range around 296 nm are able to eradicate bacteria in the biofilm state (grown for 24 hours) more effectively, than antibiotics and the combination of irradiation and antibiotics is even better, introducing a novel concept light assisted antibiotics. The investigated wavelength range was 249 nm to 338 nm with an approximate step of 5 nm. The novel concept that consists of a UV irradiation treatment followed by a tobramycin treatment can significantly reduce the amount of antibiotics needed for eradicating mature bacterial biofilms. The efficiency of the proposed light assisted antibiotics method was compared to combinatory antibiotic treatment and highly concentrated antibiotic monotherapy. The eradication efficacies, on mature biofilms, achieved by light assisted antibiotic and by the antibiotic monotherapy at approximately 10-fold higher concentration, were equivalent. The present achievement could motivate the development of light assisted antibiotic treatments for treating infections.
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Yadav A, Alijanipour P, Ackerman CT, Karanth S, Hozack WJ, Filippone EJ. Acute Kidney Injury Following Failed Total Hip and Knee Arthroplasty. J Arthroplasty 2018; 33:3297-3303. [PMID: 30006109 DOI: 10.1016/j.arth.2018.06.019] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2018] [Revised: 06/01/2018] [Accepted: 06/12/2018] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Acute kidney injury (AKI) can complicate primary total joint arthroplasty (TJA) of the hip and knee, although the incidence of AKI following revision TJA including prosthetic joint infection (PJI) is poorly defined. We assessed the incidence and risk factors for AKI following revision TJA including surgical treatment of PJI with placement of an antibiotic-loaded cement (ALC) spacer. METHODS We retrospectively reviewed 3218 consecutive failed TJAs. Patients with aseptic failure were compared to those with PJI. AKI was determined by RIFLE creatinine criteria. PJIs treated with placement of ALC were compared to PJIs without. Risk factors for AKI were determined by multivariable analysis within the whole group and within those with PJI. RESULTS AKI developed in 3.4% of 2147 patients revised for aseptic reasons and in 45% of 281 with PJI, including 29% of 197 receiving an ALC and 82% of 84 patients treated with other procedures. By multivariable analysis, age, surgery for PJI, total number of surgeries, and estimated GFR 60-90 compared to >90 cc/min/1.73 m2 were significantly associated with AKI in the whole cohort. Among PJI patients, age, Charlson comorbidity index, and reimplantation surgery were associated with AKI by multivariable analysis. No differences were found between patients with PJI treated with or without ALC. No modifiable factors were found. CONCLUSION AKI develops following aseptic revision TJA at a rate similar to primary TJA, but at a significantly higher rate following surgery for PJI with or without placement of ALC.
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Affiliation(s)
- Anju Yadav
- Division of Nephrology, Department of Medicine, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Pouya Alijanipour
- Department of Orthopedics, Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Colin T Ackerman
- Department of Orthopedics, Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Siddharth Karanth
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal medicine, University of Texas Health Science, Center at Houston McGovern Medical School, Houston, Texas
| | - William J Hozack
- Department of Orthopedics, Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Edward J Filippone
- Division of Nephrology, Department of Medicine, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania
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Acute Kidney Injury Due to Systemic Absorption of Antibiotics Impregnated in a Bone Cement Spacer. INFECTIOUS DISEASES IN CLINICAL PRACTICE 2018. [DOI: 10.1097/ipc.0000000000000575] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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30
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Acute Renal Failure due to a Tobramycin and Vancomycin Spacer in Revision Two-Staged Knee Arthroplasty. Case Rep Nephrol 2018; 2018:6579894. [PMID: 30057836 PMCID: PMC6051127 DOI: 10.1155/2018/6579894] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2018] [Accepted: 06/19/2018] [Indexed: 01/25/2023] Open
Abstract
Two-stage revision total knee arthroplasty (TKA) is the standard of care for prosthetic joint infections. The first stage involves removal of the infected prosthesis and placement of an antibiotic impregnated cement spacer; following a period ranging from 4 weeks to 6 months, the spacer is then removed and replaced with a permanent prosthesis. The advantage to this approach is that antibiotic impregnated spacers provide supratherapeutic levels in the joint without toxic accumulation in serum. However, it remains important for physicians and pharmacists to be aware of antibiotic associated complications in knee revisions. We present a case of a two-stage revision total knee arthroplasty in which a cement antibiotic spacer caused acute renal failure and ultimately resulted in persistent chronic kidney disease without hemodialysis at 2 months' follow-up. Our case reports the third highest serum tobramycin (13.7 mcg/ml) and second highest serum creatinine (8.62 mg/dl) for patients experiencing ARF due to an antibiotic spacer in two-stage revision TKA.
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31
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In-Hospital Acute Kidney Injury After TKA Revision With Placement of an Antibiotic Cement Spacer. J Arthroplasty 2018; 33:S209-S212. [PMID: 29275114 DOI: 10.1016/j.arth.2017.11.050] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2017] [Revised: 11/22/2017] [Accepted: 11/24/2017] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND There is mounting evidence that treatment of periprosthetic joint infection of the knee with an antibiotic cement spacer (ACS) may increase risk for acute kidney injury (AKI). We sought to determine the incidence, as well as potential risk factors, of in-hospital AKI in this cohort. METHODS We retrospectively identified 75 patients that received either a static or articulating ACS at a single institution. In-hospital AKI was defined by a more than 50% rise in serum creatinine from preoperative baseline to at least 1.4 mg/dL. Our secondary outcome was percent change in creatinine from preoperative to peak postoperative value. Variables were analyzed for the outcome of AKI with univariate logistic regression. A final multivariate model for percent change in creatinine was formed while controlling for age, gender, body mass index, and baseline creatinine. RESULTS The incidence of AKI was 14.6%, occurring at a mean of 6.3 days (2-8 days). A lower preoperative hemoglobin (odds ratio = 1.82, P = .015) significantly increased risk for AKI on univariate analysis. Diagnosis of either hypertension or diabetes also showed a strong statistical trend (P = .056). On multivariate regression, lower preoperative hemoglobin significantly correlated with a greater percent rise in creatinine postoperatively (β = 0.30, P = .015). CONCLUSION The incidence of AKI in patients who receive ACS is relatively high, raising clinical concern in the care of periprosthetic joint infection patients. Our results suggest that a lower baseline hemoglobin may be involved in the etiology of AKI in this population. Therefore, it may be clinically appropriate to monitor anemic patients for AKI when implanting an ACS.
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32
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Naseri-Nosar M, Ziora ZM. Wound dressings from naturally-occurring polymers: A review on homopolysaccharide-based composites. Carbohydr Polym 2018; 189:379-398. [DOI: 10.1016/j.carbpol.2018.02.003] [Citation(s) in RCA: 198] [Impact Index Per Article: 28.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2017] [Revised: 01/21/2018] [Accepted: 02/01/2018] [Indexed: 12/18/2022]
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Metsemakers WJ, Kuehl R, Moriarty TF, Richards RG, Verhofstad MHJ, Borens O, Kates S, Morgenstern M. Infection after fracture fixation: Current surgical and microbiological concepts. Injury 2018; 49:511-522. [PMID: 27639601 DOI: 10.1016/j.injury.2016.09.019] [Citation(s) in RCA: 334] [Impact Index Per Article: 47.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2016] [Accepted: 09/08/2016] [Indexed: 02/02/2023]
Abstract
One of the most challenging complications in trauma surgery is infection after fracture fixation (IAFF). IAFF may result in permanent functional loss or even amputation of the affected limb in patients who may otherwise be expected to achieve complete, uneventful healing. Over the past decades, the problem of implant related bone infections has garnered increasing attention both in the clinical as well as preclinical arenas; however this has primarily been focused upon prosthetic joint infection (PJI), rather than on IAFF. Although IAFF shares many similarities with PJI, there are numerous critical differences in many facets including prevention, diagnosis and treatment. Admittedly, extrapolating data from PJI research to IAFF has been of value to the trauma surgeon, but we should also be aware of the unique challenges posed by IAFF that may not be accounted for in the PJI literature. This review summarizes the clinical approaches towards the diagnosis and treatment of IAFF with an emphasis on the unique aspects of fracture care that distinguish IAFF from PJI. Finally, recent developments in anti-infective technologies that may be particularly suitable or applicable for trauma patients in the future will be briefly discussed.
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Affiliation(s)
- W J Metsemakers
- Department of Trauma Surgery, University Hospitals Leuven, Belgium.
| | - R Kuehl
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital of Basel, Switzerland
| | | | | | - M H J Verhofstad
- Department of Trauma Surgery, Erasmus University Medical Centre, Rotterdam, The Netherlands, The Netherlands
| | - O Borens
- Orthopedic Septic Surgical Unit, Department of the Locomotor Apparatus and Department of Surgery and Anaesthesiology, Lausanne University Hospital, Lausanne, Switzerland
| | - S Kates
- Department of Orthopaedic Surgery, Virginia Commonwealth University, USA
| | - M Morgenstern
- Department of Orthopaedic and Trauma Surgery, University Hospital of Basel, Switzerland
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Geller JA, Cunn G, Herschmiller T, Murtaugh T, Chen A. Acute Kidney Injury After First-Stage Joint Revision for Infection: Risk Factors and the Impact of Antibiotic Dosing. J Arthroplasty 2017; 32:3120-3125. [PMID: 28578840 DOI: 10.1016/j.arth.2017.04.054] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2016] [Revised: 04/13/2017] [Accepted: 04/24/2017] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Scarce literature exists regarding risk factors associated with postoperative acute kidney injury (AKI) after first-stage revision procedures. The purpose of this study was to determine risk factors for AKI and the efficacy of intra-articular antibiotics in infection eradication. METHODS We retrospectively identified 247 patients who underwent a 2-stage revision procedure for the treatment of hip or knee periprosthetic joint infection. We applied previously published diagnostic criteria for AKI to determine its incidence and risk factors for its development. RESULTS A 26% incidence of AKI was found after first-stage joint revision for infection. Higher body mass index (odds ratio [OR], 1.07; 95% confidence interval [CI], 1.01-1.13; P = .02), lower baseline hemoglobin level (OR, 0.70; 95% CI, 0.51-0.96; P = .03), and existence of a comorbid condition (OR, 2.67; 95% CI, 1.26-5.64; P = .01) were significant risk factors for AKI. Neither a higher dose of vancomycin (OR, 0.99; 95% CI, 0.88-1.11; P = .83) nor tobramycin (OR, 0.89; 95% CI, 0.77-1.04; P = .15) used in the cement spacer increased the risk of AKI. Each unit increase in vancomycin dose in the cement spacer decreased the odds of failing to clear the infection at 1 and 2 years by a factor of 0.82 (95% CI, 0.70-0.95; P = .01). CONCLUSION AKI after first-stage revision procedures for periprosthetic joint infection occurs more commonly than previously reported. Patients with identified risk factors should be managed carefully with attention paid to hemoglobin levels, to avoid AKI after this procedure. Further research is needed to determine the optimal local antibiotic type and dosing to maximize infection clearance and minimize potential side effects.
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Affiliation(s)
- Jeffrey A Geller
- Department of Orthopedic Surgery, Center for Hip and Knee Replacement, Columbia University Medical Center at New York Presbyterian Hospital, New York, New York
| | - Gregory Cunn
- Department of Orthopedic Surgery, Center for Hip and Knee Replacement, Columbia University Medical Center at New York Presbyterian Hospital, New York, New York
| | - Thomas Herschmiller
- Department of Orthopedic Surgery, Center for Hip and Knee Replacement, Columbia University Medical Center at New York Presbyterian Hospital, New York, New York
| | - Taylor Murtaugh
- Department of Orthopedic Surgery, Center for Hip and Knee Replacement, Columbia University Medical Center at New York Presbyterian Hospital, New York, New York
| | - Antonia Chen
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
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35
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Jämsä P, Jämsen E, Lyytikäinen LP, Kalliovalkama J, Eskelinen A, Oksala N. Risk factors associated with acute kidney injury in a cohort of 20,575 arthroplasty patients. Acta Orthop 2017; 88:370-376. [PMID: 28296531 PMCID: PMC5499326 DOI: 10.1080/17453674.2017.1301743] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Background and purpose - Patients developing postoperative acute kidney injury (AKI) are at risk of higher morbidity and mortality. In arthroplasty patients, many pre- and perioperative factors are associated with AKI but some of the risk factors are unclear. We report the incidence of postoperative AKI, the conditions associated with it, and survival rates in AKI patients. Patients and methods - We obtained data from 20,575 consecutive hip or knee arthroplasties. Postoperative AKI, occurring within 7 days after the operation, was defined using the risk, injury, failure, loss, and end-stage (RIFLE) criteria. We analyzed independent risk factors for AKI using binary logistic regression. In addition, we reviewed the records of AKI patients and performed a survival analysis. Results - The AKI incidence was 3.3 per 1,000 operations. We found preoperative estimated glomerular filtration rate, ASA classification, body mass index, and duration of operation to be independent risk factors for AKI. Infections, paralytic ileus, and cardiac causes were the predominant underlying conditions, whereas half of all AKI cases occurred without any clear underlying condition. Survival rates were lower in AKI patients. Interpretation - Supporting earlier results, existing renal insufficiency and patient-related characteristics were found to be associated with an increased risk of postoperative AKI. Furthermore, duration of operation was identified as an independent risk factor. We suggest careful renal monitoring postoperatively for patients with these risk factors.
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Affiliation(s)
- Pyry Jämsä
- Coxa Hospital for Joint Replacement;,Correspondence:
| | - Esa Jämsen
- Coxa Hospital for Joint Replacement;,School of Medicine, University of Tampere
| | - Leo-Pekka Lyytikäinen
- School of Medicine, University of Tampere;,Department of Clinical Chemistry, University of Tampere;,Fimlab Laboratories
| | | | | | - Niku Oksala
- School of Medicine, University of Tampere;,Department of Surgery, Faculty of Medicine and life sciences, Tampere University Hospital, Tampere, Finland
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Salim SA, Everitt J, Schwartz A, Agarwal M, Castenada J, Fülöp T, Juncos LA. Aminoglycoside impregnated cement spacer precipitating acute kidney injury requiring hemodialysis. Semin Dial 2017; 31:88-93. [DOI: 10.1111/sdi.12639] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Sohail Abdul Salim
- Division of Nephrology; Department of Internal Medicine; University of Mississippi Medical Center; Jackson MS USA
| | - Jessica Everitt
- Division of Nephrology; Department of Internal Medicine; University of Mississippi Medical Center; Jackson MS USA
| | - Aaron Schwartz
- School of Medicine; University of Mississippi Medical Center; Jackson MS USA
| | - Mohit Agarwal
- Division of Nephrology; Department of Internal Medicine; University of Mississippi Medical Center; Jackson MS USA
| | - Jorge Castenada
- Division of Nephrology; Department of Internal Medicine; University of Mississippi Medical Center; Jackson MS USA
| | - Tibor Fülöp
- Division of Nephrology; Department of Medicine; University of Debrecen; Debrecen Hungary
- FMC Extracorporeal Life Support Center - Fresenius Medical Care Hungary; Medical and Health Science Center; University of Debrecen; Debrecen Hungary
| | - Luis A. Juncos
- Division of Nephrology; Department of Internal Medicine; University of Mississippi Medical Center; Jackson MS USA
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Runner RP, Mener A, Bradbury TL. Renal failure after placement of an articulating, antibiotic impregnated polymethylmethacrlyate hip spacer. Arthroplast Today 2017; 4:51-57. [PMID: 29560396 PMCID: PMC5859207 DOI: 10.1016/j.artd.2017.02.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2017] [Revised: 02/10/2017] [Accepted: 02/10/2017] [Indexed: 11/25/2022] Open
Abstract
A 58-year-old male presented with native joint septic arthritis of the hip and osteomyelitis. After treatment with an articulating antibiotic spacer, he developed acute renal failure requiring dialysis. He continued to have elevated serum tobramycin levels exclusively from the antibiotic spacer elution as no intravenous tobramycin was used. Subsequent explantation was required to correct his renal failure. Although renal failure after antibiotic impregnated cement placement is rare, the risk of this potential complication should be considered preoperatively and in the postoperative management of these patients.
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Affiliation(s)
- Robert P. Runner
- Corresponding author. 59 Executive Park South, Atlanta, GA 30329, USA. Tel.: +1 404 778 1567.59 Executive Park SouthAtlantaGA30329USA
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Whiteside LA, Roy ME. One-stage Revision With Catheter Infusion of Intraarticular Antibiotics Successfully Treats Infected THA. Clin Orthop Relat Res 2017; 475:419-429. [PMID: 27511201 PMCID: PMC5213931 DOI: 10.1007/s11999-016-4977-y] [Citation(s) in RCA: 58] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Two-stage revision surgery for infected total hip arthroplasty (THA) is commonly advocated, but substantial morbidity and expense are associated with this technique. In certain cases of infected THA, treatment with one-stage revision surgery and intraarticular infusion of antibiotics may offer a reasonable alternative with the distinct advantage of providing a means of delivering the drug in high concentrations. QUESTIONS/PURPOSES We describe a protocol for intraarticular delivery of antibiotics to the hip through an indwelling catheter combined with one-stage revision surgery and examine (1) the success as judged by eradication of infection at 1 year when treating chronically infected cemented stems; (2) success in treating late-onset acute infections in well-ingrown cementless stems; and (3) what complications were associated with this approach in a small case series. METHODS Between January 2002 and July 2013, 30 patients (30 hips) presented to the senior author for treatment of infected THA. Of those, 21 patients (21 hips) with infected cemented THAs underwent débridement and single-stage revision to cementless total hip implants followed by catheter infusion of intraarticular antibiotics. Nine patients (nine hips) with late-onset acute infections in cementless THA had bone-ingrown implants. These patients were all more than 2 years from their original surgery and had acute symptoms of infection for 4 to 9 days. Seven had their original THA elsewhere, and two were the author's patients. All were symptom-free until the onset of their infection, and none had postoperative wound complications, fever, or prolonged pain suggestive of a more chronic process. They were treated with débridement and head and liner exchange, again followed by catheter infusion of intraarticular antibiotics. During this time period, this represented all infected THAs treated by the senior author, and all were treated with this protocol; no patient underwent two-stage exchange during this time, and no patients were lost to followup. At the time of the surgery, two Hickman catheters were placed in each hip to begin intraarticular delivery of antibiotics in the early postoperative period. Antibiotics were infused daily into the hip for 6 weeks with the tubes used for infusion only. Eleven of the single-stage revisions and four of the hips treated with débridement had methicillin-resistant Staphylococcus aureus. Patients were considered free of infection if they had no clinical signs of infection and had a normal C-reactive protein and erythrocyte sedimentation rate at 1 year. Complications were ascertained by chart review. RESULTS Twenty of 21 (95%) infections in patients who had single-stage revision for chronically infected cemented THA were apparently free from infection and remained so at a mean followup of 63 months (range, 25-157 months). One case grew Candida albicans in the operative cultures and remained free of signs of infection after rerevision followed by infusion of fluconazole. The nine cementless THAs treated with débridement and head/liner exchange all remained free of signs of infection at a mean followup of 74 months (range, 62-121 months). Few complications were associated with the technique. Four patients had elevated serum levels of vancomycin without renal function changes and two patients had transient blood urea nitrogen/creatinine elevations with normal vancomycin levels that resolved with dosage adjustments. No patient had evidence of permanent renal damage. None of the patients in this study developed a chronic fistula or had significant drainage from the catheter site. CONCLUSIONS Single-stage revision for chronically infected cemented THA and débridement of bone-ingrown cementless THA with late-onset acute infection followed with indwelling catheter antibiotic infusion can result in infection eradication even when resistant organisms are involved. Larger study groups would better assess this technique and prospective comparisons to more traditional one- and two-stage revision techniques for infected THA will likely require multi-institutional approaches. LEVEL OF EVIDENCE Level IV, therapeutic study.
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Affiliation(s)
- Leo A. Whiteside
- Missouri Bone and Joint Research Foundation, Missouri Bone and Joint Center, 1000 Des Peres Road, Suite 150, St Louis, MO 63131 USA
| | - M. E. Roy
- Missouri Bone and Joint Research Foundation, Missouri Bone and Joint Center, 1000 Des Peres Road, Suite 150, St Louis, MO 63131 USA
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Anagnostakos K. Therapeutic Use of Antibiotic-loaded Bone Cement in the Treatment of Hip and Knee Joint Infections. J Bone Jt Infect 2017; 2:29-37. [PMID: 28529862 PMCID: PMC5423576 DOI: 10.7150/jbji.16067] [Citation(s) in RCA: 76] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
The use of antibiotic-loaded cement spacers is an established method in the management of periprosthetic hip and knee joint infections. Despite inconsistencies among published studies, data shows that infection control rates exceed 90% with two-stage exchange arthroplasty. The present work reviews the current literature about antibiotic-loaded cement spacers and concentrates on the indications for spacer implantation, spacer production details, antibiotic impregnation, pharmacokinetic properties, clinical success, mechanical complications, and systemic safety.
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Vorrasi J, Zinberg G. Concomitant Suppurative Parotitis and Condylar Osteomyelitis. J Oral Maxillofac Surg 2016; 75:543-549. [PMID: 27717819 DOI: 10.1016/j.joms.2016.08.043] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2016] [Revised: 08/30/2016] [Accepted: 08/31/2016] [Indexed: 11/19/2022]
Abstract
Parotitis is a common occurrence in the immunocompromised, dehydrated, and malnourished patient as a result of dysfunctional ductal and parotid cells. Inflammation can be acute or chronic based on clinical history, and it can be suppurative based on the presence of micro or macro abscess formation within the substance of the gland. This report presents a case of concomitant condylar osteomyelitis and chronic suppurative parotitis in the setting of previous methicillin-susceptible Staphylococcus aureus foot infection. Ultimately, resection of osteomyelitis, drainage of parotid infection, and intravenous antibiotic therapy led to full resolution of the infection and symptoms. The final pathology of osteomyelitis of the temporomandibular joint and methicillin-resistant S aureus infection is an unusual consequence of chronic parotitis. The patient was restored with a total joint replacement approximately 3 months after resection with no recurrence of infection after 24 months.
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Affiliation(s)
- John Vorrasi
- Former Program Director, Department of Oral and Maxillofacial Surgery, Christiana Care Health System, Wilmington, DE; Assistant Professor, Department of Oral and Maxillofacial Surgery, University of Rochester, Eastman Institute of Oral Health, Strong Memorial Hospital, Rochester, NY.
| | - Geoffrey Zinberg
- Former Chief Resident, Department of Oral and Maxillofacial Surgery, Christiana Care Health System, Wilmington, DE
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Drexler M, Dwyer T, Kuzyk PRT, Kosashvilli Y, Abolghasemian M, Regev GJ, Kadar A, Rutenberg TF, Backstein D. The results of two-stage revision TKA using Ceftazidime-Vancomycin-impregnated cement articulating spacers in Tsukayama Type II periprosthetic joint infections. Knee Surg Sports Traumatol Arthrosc 2016; 24:3122-3130. [PMID: 26272061 DOI: 10.1007/s00167-015-3753-y] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2014] [Accepted: 08/07/2015] [Indexed: 11/24/2022]
Abstract
PURPOSE This study examined the success and factors associated with failure, of using cement spacers impregnated with high-dose Ceftazidime and Vancomycin when performing two-stage revision for infected total knee arthroplasty (TKA). METHODS A retrospective analysis was performed using a prospectively collected database of 82 patients (median age 68 years, range 39-87) with a confirmed deep TKA infection treated with a two-stage revision. All cement spacers were impregnated with high-dose Ceftazidime and Vancomycin. The rate of success was recorded-an association between failure of treatment, and patient factors, previous surgical treatment, and microbial characteristics was sought. RESULTS The mean time to infection from index arthroplasty was 45 months (range 3-240). The initial two-stage revision was successful in 70/82 patients (85.4 %), who remained free of infection at average follow-up of 36.2 months (range 24-85). A second two-stage revision for infection was required in 12/82 patients (14.6 %), which was successful in 4/12 (33 %). A third two-stage revision was performed in three patients, all of whom had a polymicrobial infection of which only one patient had successful eradication of infection. Recurrent infection was correlated with irrigation and debridement with implant retention prior to initial two-stage revision (p < 0.01), polymicrobial infections (p = 0.035), and infections presenting <6 months after index surgery (p = 0.031). No correlation was seen with age, BMI, type of organism, diabetes mellitus, or Charlson Comorbidity Index. CONCLUSION The findings of this study suggest that the combination of Ceftazidime and Vancomycin in cement spacers is as efficacious as other published single or combined antibiotic mixtures, which is clinically relevant to clinicians treating this difficult problem in the setting of patients with compromised renal function.
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Affiliation(s)
- Michael Drexler
- Mount Sinai Hospital, 600 University Avenue, Toronto, ON, M5G 1X5, Canada.
| | - Tim Dwyer
- Mount Sinai Hospital, 600 University Avenue, Toronto, ON, M5G 1X5, Canada
| | - Paul R T Kuzyk
- Mount Sinai Hospital, 600 University Avenue, Toronto, ON, M5G 1X5, Canada
| | - Yona Kosashvilli
- Mount Sinai Hospital, 600 University Avenue, Toronto, ON, M5G 1X5, Canada
| | | | - Gilad J Regev
- Tel-Aviv Sourasky Medical Center, Tel Aviv University, Waitzman 6 St, 6423906, Tel Aviv, Israel
| | - Assaf Kadar
- Tel-Aviv Sourasky Medical Center, Tel Aviv University, Waitzman 6 St, 6423906, Tel Aviv, Israel
| | - Tal Frenkel Rutenberg
- Tel-Aviv Sourasky Medical Center, Tel Aviv University, Waitzman 6 St, 6423906, Tel Aviv, Israel
| | - David Backstein
- Mount Sinai Hospital, 600 University Avenue, Toronto, ON, M5G 1X5, Canada
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One-Step Salvage of Infected Prosthetic Breast Reconstructions Using Antibiotic-Impregnated Polymethylmethacrylate Plates and Concurrent Tissue Expander Exchange. Ann Plast Surg 2016; 77:280-5. [DOI: 10.1097/sap.0000000000000409] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Drug eruption secondary to vancomycin-laden spacer in the shoulder: a case report. J Shoulder Elbow Surg 2016; 25:e236-40. [PMID: 27422463 DOI: 10.1016/j.jse.2016.04.033] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2016] [Accepted: 04/18/2016] [Indexed: 02/01/2023]
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Abstract
There is currently no consensus on the optimal management of the infected total hip arthroplasty. Multiple management techniques have been described in contemporary literature.This paper focuses on 2-stage revision for the infected total hip arthroplasty. We discuss the rationale and examine the current evidence for the use of this technique.
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Xue AS, Kania KE, Brown RH, Bullocks JM, Hollier LH, Izaddoost SA. Salvage of Infected Prosthetic Breast Reconstructions. Semin Plast Surg 2016; 30:55-9. [PMID: 27152096 DOI: 10.1055/s-0036-1580729] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Periprosthetic infection is a major complication in breast reconstruction, leading to implant loss and delayed and sometimes abandoned reconstruction. Traditional management of persistent infections requires explantation followed by secondary reconstruction after 6 months of delay. Although effective in treating the infection, this approach often leads to distortion and/or loss of tissue envelope, making secondary reconstruction very difficult. As a result, there is significant interest in salvaging infected prosthetic breast reconstructions. Recent studies reported variable success through systemic antibiotic therapy and surgical interventions. The aim of this article is to review the management of periprosthetic infection and to provide a potential salvage algorithm.
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Affiliation(s)
- Amy S Xue
- Division of Plastic and Reconstructive Surgery, Baylor College of Medicine, Houston, Texas
| | - Katarzyna E Kania
- Division of Plastic and Reconstructive Surgery, Baylor College of Medicine, Houston, Texas
| | - Rodger H Brown
- Division of Plastic and Reconstructive Surgery, Baylor College of Medicine, Houston, Texas
| | - Jamal M Bullocks
- Division of Plastic and Reconstructive Surgery, Baylor College of Medicine, Houston, Texas
| | - Larry H Hollier
- Division of Plastic and Reconstructive Surgery, Baylor College of Medicine, Houston, Texas
| | - Shayan A Izaddoost
- Division of Plastic and Reconstructive Surgery, Baylor College of Medicine, Houston, Texas
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Hinarejos P, Guirro P, Puig-Verdie L, Torres-Claramunt R, Leal-Blanquet J, Sanchez-Soler J, Monllau JC. Use of antibiotic-loaded cement in total knee arthroplasty. World J Orthop 2015; 6:877-885. [PMID: 26716084 PMCID: PMC4686435 DOI: 10.5312/wjo.v6.i11.877] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2015] [Revised: 08/22/2015] [Accepted: 10/19/2015] [Indexed: 02/06/2023] Open
Abstract
Bone cement has the capacity to release antibiotic molecules if any antibiotic is included in it, and these elution properties are improved as cement porosity is increased. In vitro studies have shown high local antibiotic concentration for many hours or few days after its use. Antibiotic loaded bone cement (ALBC) is helpful when treating an infection in total knee arthroplasty (TKA) revision surgery. The purpose of this paper was to review the evidence for the routine use of ALBC in TKA in the literature, its pros and cons. Many authors have recommended the use of ALBC also in primary TKA for infection prophylaxis, but the evidence based on data from National Registries, randomized clinical trials and meta-analysis suggest a protective effect of ALBC against infection when used in hips, but not (or only mild) in knees. A possible explanation to this finding is that the duration and quantity of locally elevated antibiotic levels after surgery are smaller in TKA, due to the smaller amount of cement used for fixation in TKA-only a layer in the bone surface. There are some concerns about the routine use of ALBC in primary TKA as prophylaxis against infection: Firstly, there is a risk of hypersensivity or toxicity even when the chance is highly improbable. Secondly, there is a reduction in the mechanical properties of the cement, but this can be probably neglected if the antibiotic is used in low doses, not more than 1 g per 40 g cement package. Another significant concern is the increased economic cost, which could be overlooked if there were enough savings in treating fewer prosthetic infections. Finally, there is also a risk of selection of antibiotic-resistant strains of bacteria and this could be the main concern. If used, the choice of the antibiotic mixed in ALBC should consider microbiological aspects (broad antimicrobial spectrum and low rate of resistant bacteria), physical and chemical aspects (thermal stability, high water solubility), pharmacological characteristics (low risk to allergic reactions or toxicity) and economic aspects (not too expensive). The most commonly used antibiotics in ALBC are gentamicin, tobramycin and vancomycin. In conclusion, there is a paucity of randomized clinical trials in the use of ALBC in primary TKAs and the actual evidence of the effect of ALBC in reducing the risk of infection is insufficient. This, in addition to concerns about patient safety, risks of increase in the antibiotic resistance of microorganisms and the increase in costs in the procedure, lead us to recommend a cautious use of ALBC, perhaps only in high-risk patients (immunocompromised, morbidly obese, diabetic and patients with previous history of fracture or infection around the knee) unless the benefits of ALBC use were fully proven. Meanwhile, the rigorous use of peri-operative prophylactic systemic antibiotics and adoption of efficient antiseptic procedures and improved surgical techniques must be considered the gold standard in infection prevention in TKA surgery.
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Koul V, Bhowmick S, Thanusha A. Hydrogels for Pharmaceutical Applications. HANDBOOK OF POLYMERS FOR PHARMACEUTICAL TECHNOLOGIES 2015:125-144. [DOI: 10.1002/9781119041559.ch5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/06/2025]
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Dubrovskaya Y, Tejada R, Bosco J, Stachel A, Chen D, Feng M, Rosenberg A, Phillips M. Single high dose gentamicin for perioperative prophylaxis in orthopedic surgery: Evaluation of nephrotoxicity. SAGE Open Med 2015; 3:2050312115612803. [PMID: 26770808 PMCID: PMC4679329 DOI: 10.1177/2050312115612803] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2015] [Accepted: 09/17/2015] [Indexed: 11/16/2022] Open
Abstract
Background: Recent studies described an increase in acute kidney injury when high dose gentamicin was included in perioperative prophylaxis for orthopedic surgeries. To this effect, we compared the rate of nephrotoxicity for selected orthopedic surgeries where gentamicin was included (Gentamicin Group) to those where it was not included (Control Group) for perioperative prophylaxis and evaluated risk factors for nephrotoxicity. Methods: Spine, hip and knee surgeries performed between April 2011 and December 2013 were reviewed retrospectively. Gentamicin was given to eligible patients based on age, weight and Creatinine Clearance. Nephrotoxicity was assessed using Risk, Injury, Failure, Loss, End-stage kidney disease (RIFLE) criteria. Results: Among selected surgeries (N = 1590 in Gentamicin Group: hip = 926, spine = 600, knee = 64; N = 2587 in Control Group: hip = 980, spine = 902, knee = 705), patients’ body weight, serum creatinine, comorbidities and surgery duration were similar in Gentamicin Group and Control Group. Gentamicin median dose was 4.5 mg/kg of dosing weight. Nephrotoxicity rate was 2.5% in Gentamicin Group and 1.8% in Control Group, p = 0.17. Most cases of nephrotoxicity were Risk category by RIFLE criteria (67% in Gentamicin Group and 72% in Control Group, p = 0.49). In logistic regression, risk factors for nephrotoxicity were hospital stay >1 day prior to surgery (odds ratio = 8.1; 95% confidence interval = 2.25–28.97, p = 0.001), knee or hip surgery (odds ratio = 4.7; 95% confidence interval = 2.9–9.48, p = 0.0005) and diabetes (odds ratio = 1.95; 95% confidence interval = 1.13–3.35, p = 0.016). Receipt of gentamicin was not an independent predictor of nephrotoxicity (odds ratio = 1.5; 95% confidence interval = 0.97–2.35, p = 0.07). Conclusion: In this cohort, rate of nephrotoxicity was similar between Gentamicin Group and Control Group. Single high dose gentamicin is a safe and acceptable option for perioperative prophylaxis in eligible patients undergoing orthopedic surgeries.
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Affiliation(s)
| | - Rainer Tejada
- Department of Infection Prevention and Control, NYU Langone Medical Center, New York, NY, USA
| | - Joseph Bosco
- Department of Orthopedic Surgery, Hospital for Joint Diseases and Orthopedic Surgery, New York, NY, USA
| | - Anna Stachel
- Department of Infection Prevention and Control, NYU Langone Medical Center, New York, NY, USA
| | - Donald Chen
- Department of Infection Prevention and Control, NYU Langone Medical Center, New York, NY, USA
| | - Melinda Feng
- Department of Infection Prevention and Control, NYU Langone Medical Center, New York, NY, USA
| | - Andrew Rosenberg
- Department of Anesthesiology, Hospital for Joint Diseases and Orthopedic Surgery, New York, NY, USA
| | - Michael Phillips
- Department of Infection Prevention and Control, NYU Langone Medical Center, New York, NY, USA; Department of Infectious Diseases & Immunology, NYU Langone Medical Center, New York, NY, USA
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Custom-Made Antibiotic Cement Nails in Orthopaedic Trauma: Review of Outcomes, New Approaches, and Perspectives. BIOMED RESEARCH INTERNATIONAL 2015; 2015:387186. [PMID: 26509153 PMCID: PMC4609780 DOI: 10.1155/2015/387186] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/20/2015] [Revised: 05/18/2015] [Accepted: 05/20/2015] [Indexed: 01/26/2023]
Abstract
Since the first description in 2002 by Paley and Herzenberg, antibiotic bone cement nails (ACNs) have become an effective tool in the orthopaedic trauma surgeons' hands. They simultaneously elute high amounts of antibiotics into medullary canal dead space and provide limited stability to the debrided long bone. In this paper, we perform a systematic review of current evidence on ACNs in orthopaedic trauma and provide an up-to-date review of the indications, operative technique, failure mechanisms, complications, outcomes, and outlooks for the ACNs use in long bone infection.
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