|
1
|
Perez‐Prieto D, Koetter K, Fontanellas‐Fes A, Martínez‐Cruz O, the RACat working group. Total knee arthroplasty revision risks depending on the bone cement used-Data from 50,545 knee replacements of the Catalan Arthroplasty Registry. J Exp Orthop 2025; 12:e70271. [PMID: 40421410 PMCID: PMC12104820 DOI: 10.1002/jeo2.70271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2025] [Revised: 02/20/2025] [Accepted: 02/22/2025] [Indexed: 05/28/2025] Open
Abstract
Purpose Clinical data on individual bone cement brands and viscosities in cemented total knee arthroplasty (TKA) is scarce. The Catalan arthroplasty registry (RACat) documents usage of cement brands including viscosities and the inclusion of antibiotics. The objective was to compare the clinical performance of the widely used bone cement brand PALACOS® to other blinded bone cement brands in TKA using data from the RACat. Methods Patient data on 50,545 primary TKA between 2007 and 2017 in the RACat were analysed retrospectively. Implant survival of PALACOS bone cement was compared to other blinded bone cement brand groups using the all-cause revision risk as primary study endpoint. Results Comparing implant survival, it was found that (1) PALACOS® (with or without gentamicin) was associated with a significantly lower revision risk compared to other cement brands (with or without antibiotics) (p = 0.001): RR PALACOS 2.03% versus RR other brands 3.88%, and RR PALACOS+G 1.84% versus RR other antibiotic-loaded bone cements (ALBC) 3.85%; (2) ALBC (all brands) did not reduce the risk of revisions (p = n.s) compared to plain bone cements (PBC); and (3) the medium viscosity PALACOS MV+G showed the lowest reoperation risk versus other ALBC (all viscosities): RR 1.12% versus RR 3.85%. Competing-risk regression models confirmed reduction in revision risk for all PALACOS compared with other brands (p = 0.001) and for PALACOS+G compared with other ALBC (p < 0.001) but showed no difference when comparing all ALBC with all PBC (p = 0.403). Comparing PALACOS MV+G with all other ALBC showed reduction of revision risk (p < 0.001) and no difference when comparing PALACOS medium viscosity (MV) with all other PBC (p = 0.108). Conclusions Type of cement brand, viscosity and the addition of antibiotics have an impact on revision risk of TKA. Medium viscosity cement with gentamicin (PALACOS MV+G), for which no clinical data were previously available, was associated with the lowest revision risk in TKA. Level of Evidence Level III, retrospective comparative study.
Collapse
Affiliation(s)
- Daniel Perez‐Prieto
- Ortophedic Surgery, Hospital del MarUniversitat Autònoma de BarcelonaBarcelonaSpain
| | - Katharina Koetter
- Department of Health Economics & Outcome ResearchHeraeus Medical GmbHWehrheimGermany
| | | | - Olga Martínez‐Cruz
- Departament de SalutData Analytics Program for Research and Innovation in Health (PADRIS) Agència de Qualitat i Avaluació Sanitàries de Catalunya (AQuAS)BarcelonaSpain
| | | |
Collapse
|
|
2
|
Dietz MJ, McGowan BM, Thomas DD, Hunt ER, Stewart E, Squire MW. Does Cement Viscosity Impact Antibiotic Elution and In Vitro Efficacy Against Common Prosthetic Joint Infection Pathogens? Clin Orthop Relat Res 2025; 483:488-497. [PMID: 39724555 PMCID: PMC11828028 DOI: 10.1097/corr.0000000000003272] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Accepted: 09/16/2024] [Indexed: 12/28/2024]
Abstract
BACKGROUND Polymethylmethacrylate (PMMA) antibiotic-laden bone cement (ALBC) is commonly used in total joint arthroplasty to treat and potentially prevent prosthetic joint infection (PJI). Multiple properties impact the elution characteristics of antibiotics from PMMA-based ALBC, including viscosity. What is not known is how medium-viscosity cement formulations affect antibiotic elution and how different cement products from different manufacturers compare regarding reaching the minimum inhibitory concentration (MIC) of antibiotics for common PJI-causing organisms in an in vitro setting. QUESTIONS/PURPOSES (1) Does cement viscosity impact in vitro antibiotic elution characteristics when comparing medium-viscosity ALBC and high-viscosity ALBC formulations from the same manufacturer against four common PJI pathogens? (2) Does the manufacturer of the PMMA-based ALBC product and the type of aminoglycoside (gentamicin versus tobramycin) impact the in vitro antibiotic elution against four common PJI pathogens? METHODS Three different PMMA-based ALBC products, including Palacos® R (high viscosity) plus gentamicin (PR+G), Palacos (medium viscosity) plus gentamicin (PMV+G), and Simplex™ P (low viscosity) plus tobramycin (SP+T), and controls for each cement type, including Palacos R, Palacos medium viscosity, and Simplex P, were evaluated. These cements were tested against four common PJI pathogens: methicillin-sensitive Staphylococcus aureus , methicillin-resistant S. aureus (MRSA), methicillin-sensitive S. epidermidis (MSSE), and methicillin-resistant S. epidermidis . A 5-day elution protocol was observed using uniform cylindrical cement samples of each cement product. Each analysis was run with three separate lots of cement, with four samples created per lot and each sample run in duplicate. Standard curves with known antibiotic concentrations were created. Kirby-Bauer assays were then used to determine the zone of inhibition for each cement product against the four common PJI pathogens. The eluted antibiotic concentration was extrapolated for each product over 5 days to determine the interpolated antibiotic concentration for each of the 5 days. Area under the curve (AUC) was calculated as a surrogate for total antibiotics eluted over the 5-day period. RESULTS Cement viscosity does not impact antibiotic elution characteristics when comparing a medium-viscosity ALBC and a high-viscosity ALBC from the same manufacturer. The cement products from two manufacturers containing different types of aminoglycosides differ in their in vitro activity over a 5-day period against four common PJI pathogens. There was no difference in interpolated antibiotic concentration against MSSE on Day 1 between PMV+G cement and PR+G (high-viscosity) (mean ± SD medium-viscosity cement gentamicin concentration 73.6 ± 14.0 µg/mL versus high-viscosity gentamicin concentration 80.3 ± 15.5 µg/mL, mean difference -6.8 [95% confidence interval (CI) -27 to 40]; p = 0.9); there was, however, greater interpolated effective antibiotic in PR+G when compared with tobramycin concentration of SP+T (80.3 ± 15.5 µg/mL versus 199.9 ± 81 µg/mL, mean difference -120 [95% CI -153 to -86]; p < 0.001). All antibiotic cement products had zones of inhibition that corresponded to an interpolated concentration above the MIC (> 32 mg/L) for all organisms on Day 1. Concentrations were maintained above the MIC even at Day 2 for only MRSA and MSSE for PMV+G and PR+G. Concentrations dropped below the MIC after Day 1 for all organisms for SP+T. Similar results were seen in the AUC, which was used as a surrogate for total antibiotics eluted over 5 days, where PMV+G and PR+G both had greater antibiotics eluted over 5 days than SP+T except for MSSE, which demonstrated no difference in the AUC. CONCLUSION In this study, medium-viscosity ALBC demonstrated similar elution properties compared with high-viscosity ALBC from the same manufacturer. Both the medium- and high-viscosity ALBC cement products from Palacos demonstrated superior in vitro antibiotic elution properties and activity against four common PJI pathogens compared with low-viscosity ALBC from Simplex over a 5-day period. CLINICAL RELEVANCE This in vitro study suggests that a surgeon may choose to use Palacos medium-viscosity ALBC (PMV+G) in total joint applications without impacting the in vitro antibiotic elution properties compared with Palacos high-viscosity ALBC (PR+G), and that both the medium- and high-viscosity formulations of ALBC from Palacos may have improved activity against three of four common PJI pathogens compared with Simplex low-viscosity ALBC (SP+T). However, more related research is needed to determine the in vivo activity of these ALBC products and the overall efficacy of routine use of ALBC in general.
Collapse
Affiliation(s)
- Matthew J. Dietz
- Department of Orthopaedics, West Virginia University, Morgantown, WV, USA
| | - Brian M. McGowan
- Department of Orthopaedics, West Virginia University, Morgantown, WV, USA
| | - Dylan D. Thomas
- Department of Orthopaedics, West Virginia University, Morgantown, WV, USA
| | | | - Elizabeth Stewart
- Department of Orthopaedics, West Virginia University, Morgantown, WV, USA
| | | |
Collapse
|
|
3
|
Guo H, Xue Z, Mei S, Li T, Yu H, Ning T, Fu Y. Clinical efficacy of antibiotic-loaded bone cement and negative pressure wound therapy in multidrug-resistant organisms diabetic foot ulcers: a retrospective analysis. Front Cell Infect Microbiol 2025; 14:1521199. [PMID: 39831106 PMCID: PMC11739815 DOI: 10.3389/fcimb.2024.1521199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2024] [Accepted: 12/10/2024] [Indexed: 01/22/2025] Open
Abstract
Objective The purpose of this study was to investigate the clinical efficacy of antibiotic-loaded bone cement (ALBC) combined with Negative pressure wound therapy (NPWT) aspiration technique in the treatment of multidrug-resistant diabetic foot ulcers (MDRO-DFUs). Methods A retrospective analysis of the clinical data of 80 patients with MDROs-DFU who were used Vacuum sealing drainage (VSD) as NPWT excipient and met the inclusion criteria from January 2019 to January 2024 at our hospital. Patients were divided into an experimental group and a control group, with 40 cases in each. The control group received conventional treatment, routine debridement, and NPWT treatment, while the experimental group received ALBC treatment in addition to the treatment plan of the control group. Measurements of blood inflammatory indicators, foot hemodynamic indicators, wound bacterial clearance time, wound healing time, and hospital stay were taken before and after treatment for both groups. Results Inflammatory indexes, Vascular endothelial growth factor(VEGF), and internal diameter of dorsalis pedis arteriosus of both groups after treatment were significantly better than those before treatment, and the improvement of the experimental group was more obvious than that of the control group; the experimental group had a significantly shorter time of trauma bacterial turnover, healing time of trauma, and hospitalization time compared with that of the control group (P<0.05).
Collapse
Affiliation(s)
| | | | | | | | | | - Tao Ning
- Department of Orthopedics, Fuyang City People’s Hospital, Fuyang, China
| | - Yongbin Fu
- Department of Orthopedics, Fuyang City People’s Hospital, Fuyang, China
| |
Collapse
|
|
4
|
Doxey SA, Urdahl TH, Solaiman RH, Wegner MN, Parikh H, Cunningham BP, Horst PK. Intrawound vancomycin powder in primary total knee arthroplasty: Does it reduce early postoperative infection? Knee 2024; 51:312-319. [PMID: 39476511 DOI: 10.1016/j.knee.2024.10.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2024] [Revised: 09/12/2024] [Accepted: 10/16/2024] [Indexed: 12/07/2024]
Abstract
BACKGROUND The purpose of this retrospective analysis of a prospective quality control project was to determine whether the use of intrawound vancomycin powder (IVP) decreases the rate prosthetic joint infection (PJI) within 90-days following primary total knee arthroplasty (TKA). METHODS From October 2021-September 2022, a prospective quality control project was undertaken in which 10 high-volume arthroplasty surgeons alternated between using IVP and not using IVP each month. Patients who received IVP were compared to those who did not. The primary outcome was culture positive PJI within 90-days following primary total knee arthroplasty. Secondary outcomes included overall reoperation rate, wound complications, and readmission within 90-days post-operatively. RESULTS A total of 1,317 primary TKA patients were identified for analysis. Fifty-six and seven tenths percent (n = 747) of patients were included in the IVP group and 43.3% (n = 570) patients were included in the non-IVP group. The overall PJI rate was 0.5%. There was no difference in 90-day culture positive PJI rates between the groups (0.7% vs. 0.2%, p = 0.24). The overall reoperation rate did not differ between the IVP and non-IVP group (6.4% vs. 4.6%, p = 0.15). Reoperation for suspected infection was not statistically different by IVP administration (1.2% vs. 0.5%, p = 0.25). Additionally, there were no differences in the incidence of wound complications (p = 0.80) or readmissions (p = 0.15). CONCLUSIONS The overall infection rate for this cohort was low. IVP was not associated with decreased culture positive PJI, wound complications, reoperation or readmission rates. Further analysis of IVP use in TKA should be undertaken to fully determine its efficacy and safety profile.
Collapse
Affiliation(s)
- Stephen A Doxey
- Department of Orthopaedic Surgery, TRIA Orthopaedic Institute, Bloomington, MN, USA; Department of Orthopaedic Surgery, Park Nicollet Methodist Hospital, St. Louis Park, MN, USA.
| | - Torben H Urdahl
- Department of Orthopaedic Surgery, University of Minnesota, Minneapolis, MN, USA.
| | - Rafat H Solaiman
- Department of Orthopaedic Surgery, University of Minnesota, Minneapolis, MN, USA.
| | - Mariah N Wegner
- Department of Orthopaedic Surgery, University of Minnesota, Minneapolis, MN, USA.
| | - Harsh Parikh
- Department of Orthopaedic Surgery, TRIA Orthopaedic Institute, Bloomington, MN, USA; Department of Orthopaedic Surgery, Park Nicollet Methodist Hospital, St. Louis Park, MN, USA.
| | - Brian P Cunningham
- Department of Orthopaedic Surgery, TRIA Orthopaedic Institute, Bloomington, MN, USA; Department of Orthopaedic Surgery, Park Nicollet Methodist Hospital, St. Louis Park, MN, USA; Department of Orthopaedic Surgery, University of Minnesota, Minneapolis, MN, USA.
| | - Patrick K Horst
- Department of Orthopaedic Surgery, TRIA Orthopaedic Institute, Bloomington, MN, USA; Department of Orthopaedic Surgery, Park Nicollet Methodist Hospital, St. Louis Park, MN, USA; Department of Orthopaedic Surgery, University of Minnesota, Minneapolis, MN, USA.
| |
Collapse
|
|
5
|
Fraval A, Zhou Y, Parvizi J. Antibiotic-loaded cement in total joint arthroplasty: a comprehensive review. Arch Orthop Trauma Surg 2024; 144:5165-5175. [PMID: 38687383 DOI: 10.1007/s00402-024-05328-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2024] [Accepted: 04/14/2024] [Indexed: 05/02/2024]
Abstract
This review evaluates the decision-making framework for using antibiotic-loaded cement (ALC) in the management of prosthetic joint infection (PJI). Drawing on available literature, we offer orthopaedic surgeons a guided discussion on several critical considerations. First, we explore the impact of antibiotic-loading on the mechanical properties of polymethylmethacrylate (PMMA) cement, assessing both strength and durability. We then explore the optimal antibiotic dosage to load into cement, aiming to achieve effective local concentrations for infection control without compromising mechanical stability. Furthermore, we explore how cement and antibiotic properties affect the overall antibiotic elution characteristics of ALC. Finally, we discuss risks of systemic toxicity, particularly acute kidney injury, when using ALC. The principal goal in this review is to provide a balanced approach based on best available evidence that optimises antibiotic elution from ALC whilst minimising potential harms associated with its use.
Collapse
Affiliation(s)
- Andrew Fraval
- Department of Orthopaedic Surgery, St. Vincent's Hospital Melbourne, 41 Victoria Parade, Fitzroy, VIC, 3065, Australia.
- Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, PA, USA.
| | - Yushy Zhou
- Department of Orthopaedic Surgery, St. Vincent's Hospital Melbourne, 41 Victoria Parade, Fitzroy, VIC, 3065, Australia
| | - Javad Parvizi
- Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, PA, USA
- International Joint Center, Acibadem University Hospital, Istanbul, Turkey
| |
Collapse
|
|
6
|
Leta TH, Chang RN, Fenstad AM, Lie SA, Lygre SHL, Lindberg-Larsen M, Pedersen AB, Lutro O, Willis J, Frampton C, Wyatt M, Dragosloveanu S, Vorovenci AE, Dragomirescu D, Dale H, Hallan G, Gjertsen JE, Prentice HA, Furnes O, Sedrakyan A, Paxton EW. Number of Doses of Systemic Antibiotic Prophylaxis May Be Reduced in Cemented Primary Knee Arthroplasty Irrespective of Use of Antibiotic in the Cement: A Multiregistry-Based Meta-Analysis. JB JS Open Access 2024; 9:e24.00140. [PMID: 39664766 PMCID: PMC11623873 DOI: 10.2106/jbjs.oa.24.00140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2024] Open
Abstract
Background The use of systemic antibiotic prophylaxis (SAP) and antibiotic-loaded bone cement (ALBC) is the accepted practice to reduce the risk of periprosthetic joint infection (PJI) in primary total knee arthroplasty (pTKA). However, practice varies internationally. This study's primary aim was to compare the risk of PJI revision after pTKA with ALBC + SAP vs. plain bone cement (PBC) + SAP, and the secondary aim was to assess whether the risk of PJI revision varies with the number of SAP doses. Methods Cohort of 289,926 pTKAs for osteoarthritis from arthroplasty registries in Denmark, New Zealand, Norway, Romania, and United States registered from 2010 to 2020. One-year revision for PJI following pTKA with ALBC + SAP vs. PBC + SAP, and single vs. multiple SAP doses was compared. We computed cumulative percent revision (1 minus Kaplan-Meier) using distributed analysis method and adjusted hazard rate ratios (HRRs) using Cox regression analyses within each registry. Advanced distributed meta-analysis was performed to summarize HRRs from all countries. Results Among all pTKAs, 64.4% were performed with ALBC + SAP. Each registry reported a 1-year cumulative percent revision for PJI of <1.00% for both pTKAs with ALBC + SAP (0.34%-0.80%) and with PBC + SAP (0.54%-0.69%). The distributed meta-analysis showed HRR = 1.21; (95% confidence interval [CI], 0.79-1.87) for ALBC + SAP compared with PBC + SAP. Similar risk of PJI revision was observed between pTKAs with ALBC + single vs. multiple doses of SAP: 2 doses (0.95; 95% CI, 0.68-1.33), 3 doses (1.09; 95% CI, 0.64-1.87), and 4 doses (1.23; 95% CI, 0.69-2.21). Comparable results were found for the PBC + SAP group except for higher risk of PJI revision with 4 doses of SAP (2.74; 95% CI, 1.11-6.75). Conclusions ALBC and PBC entailed similar risk of PJI revision when patients received SAP in pTKA, regardless of number of SAP doses. ALBC or PBC used in combination with SAP in pTKAs, with one single preoperative dose of SAP may be sufficient without compromising the patient safety. Level of evidence Level III. See Instructions for Authors for a complete description of levels of evidence.
Collapse
Affiliation(s)
- Tesfaye H. Leta
- The Norwegian Arthroplasty Register, Department of Orthopedic Surgery, Haukeland University Hospital, Bergen, Norway
- Faculty of Health Science, VID Specialized University, Bergen, Norway
- Department of Population Health Science, Weill Medical College of Cornell University, New York
- Medical Device Surveillance & Assessment, Kaiser Permanente, San Diego
| | - Richard N. Chang
- Medical Device Surveillance & Assessment, Kaiser Permanente, San Diego
| | - Anne Marie Fenstad
- The Norwegian Arthroplasty Register, Department of Orthopedic Surgery, Haukeland University Hospital, Bergen, Norway
| | - Stein Atle Lie
- The Norwegian Arthroplasty Register, Department of Orthopedic Surgery, Haukeland University Hospital, Bergen, Norway
- Center for Translational Oral Research (TOR), Department of Dentistry, University of Bergen, Bergen, Norway
| | - Stein Håkon L. Lygre
- The Norwegian Arthroplasty Register, Department of Orthopedic Surgery, Haukeland University Hospital, Bergen, Norway
- Department of Occupational Medicine, Haukeland University Hospital, Bergen, Norway
| | - Martin Lindberg-Larsen
- The Danish Knee Arthroplasty Register, Odense, Denmark
- Department of Orthopaedic Surgery and Traumatology, Odense University Hospital, Odense, Denmark
| | - Alma B. Pedersen
- The Danish Knee Arthroplasty Register, Odense, Denmark
- Department of Clinical Epidemiology, Aarhus University Hospital and Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Olav Lutro
- Department of Medicine, Stavanger University Hospital, Stavanger, Norway
| | - Jinny Willis
- The New Zealand Joint Registry, Christchurch, New Zealand
| | - Chris Frampton
- The New Zealand Joint Registry, Christchurch, New Zealand
| | - Michael Wyatt
- The New Zealand Joint Registry, Christchurch, New Zealand
| | - Serban Dragosloveanu
- Romanian Arthroplasty Registry, Bucharest, Romania
- University of Medicine and Pharmacy–Carol Davila–Bucharest–UMFCD Bucharest, Romania
- Foisor Orthopaedic Hospital, Bucharest, Romania
| | - Andreea E. Vorovenci
- Romanian Arthroplasty Registry, Bucharest, Romania
- Economic Cybernetics and Statistics Doctoral School, Bucharest University of Economic Studies, Bucharest, Romania
| | - Dan Dragomirescu
- Romanian Arthroplasty Registry, Bucharest, Romania
- Economic Cybernetics and Statistics Doctoral School, Bucharest University of Economic Studies, Bucharest, Romania
| | - 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
| | - 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
| | | | - 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
| | - Art Sedrakyan
- Department of Population Health Science, Weill Medical College of Cornell University, New York
| | | |
Collapse
|
|
7
|
Chen P, Chen B, Liu N, Lin X, Wei X, Yu B, Teng X, Lin F. Global research trends of antibiotic-loaded bone cement: A bibliometric and visualized study. Heliyon 2024; 10:e36720. [PMID: 39263064 PMCID: PMC11387344 DOI: 10.1016/j.heliyon.2024.e36720] [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: 04/03/2024] [Revised: 08/20/2024] [Accepted: 08/21/2024] [Indexed: 09/13/2024] Open
Abstract
Objective Antibiotic-loaded bone cement (ALBC) plays an indispensable role in the treatment of infectious diseases of bone and joint. Here, we intended to analyze the research status, hot spots and frontiers in the field of ALBC, and to provide reference for future research ideas. Methods The related English literature in the field of ALBC in the Web of Science Core Collection database was retrieved from January 1, 2009 to July 11, 2023. VOSviewer was used to extract the information of research constituents or bibliometric items such as authors, institutions, countries, and journals. CiteSpace was used to perform cluster analysis and frontier analysis of key words in ALBC research field. Results A total of 1091 literatures related to ALBC research were retrieved, and the annual number of publications showed a steady upward trend in the past 15 years. The high-yield countries and regions are mainly represented by the United States, China (including Taiwan, China) and several European countries, such as Germany, England, Spain, Italy, the Netherlands, etc. The top three institutions with the highest number of publications were Shanghai Jiao Tong University, Chang Gung University and Chang Gung Memorial Hospital in China. Four of the top 10 influential scholars come from Germany, namely Konstantinos Anagnostakos, Volker Alt, Andrej Trampuz, and Bernd Fink. The top 10 high-yield journals had an average of 25 articles per journal and an average of 618.9 citations. The top 3 high-yield journals were Journal of Arthroplasty (57 articles, 1213 citations), Clinical Orthopaedics and Related Research (35 articles, 1119 times cited), and Journal of Orthopaedic Research (29 papers, 488 times cited). The keywords with high frequency were infection (266 times), vancomycin (239 times), bone-cement (219 times), gentamicin (216 times), antibiotics (168 times), osteomyelitis (163 times), etc. The clustering knowledge map of high-frequency keywords could be divided into 4 categories: (1) elution, release, mechanical and antibacterial properties of ALBC; (2) Application of ALBC in revision of prosthetic joint infections (PJIs); (3) Antibiotic types and application forms of ALBC; (4) Application of ALBC in the treatment of osteomyelitis. The keywords with the strongest citation bursts analysis revealed a core ("replacement/arthroplasty") and two stages of development in the field of ALBC research. The first stage (2009-2018) focused more on ALBC drug delivery, release, and infection prevention, while the second stage (2018-2023) mainly focused on ALBC drug elution, mechanical properties, and PJIs revision. Starting from 2018, the keyword with the strongest citation bursts had shifted from "acrylic bone cement" to "periprosthetic joint infection". Conclusion ALBC research is steadily on the rise. Arthroplasty related applications continue to be the core of ALBC research. The research hotspot and trend are mainly the application in the prevention and treatment of bone and joint infectious diseases and the elution, release, mechanical and antibacterial properties of ALBC.
Collapse
Affiliation(s)
- Peisheng Chen
- Department of Orthopedics, Fuzhou Second General Hospital, School of Clinical Medicine, Fujian Medical University, Fujian Provincial Clinical Medical Research Center for First Aid and Rehabilitation in Orthopedic Trauma, Fuzhou, 350007, Fujian, People's Republic of China
| | - Bin Chen
- Department of Orthopedics, Fuzhou Second General Hospital, School of Clinical Medicine, Fujian Medical University, Fujian Provincial Clinical Medical Research Center for First Aid and Rehabilitation in Orthopedic Trauma, Fuzhou, 350007, Fujian, People's Republic of China
| | - Nannan Liu
- Department of Orthopedics Institute, Fuzhou Second General Hospital, Fuzhou, 350007, Fujian, People's Republic of China
| | - Xiaofeng Lin
- Department of Orthopedics, Fuzhou Second General Hospital, School of Clinical Medicine, Fujian Medical University, Fujian Provincial Clinical Medical Research Center for First Aid and Rehabilitation in Orthopedic Trauma, Fuzhou, 350007, Fujian, People's Republic of China
| | - Xiaojuan Wei
- Department of Pharmacy, Fuzhou Second General Hospital, Fuzhou, 350007, Fujian, People's Republic of China
| | - Bin Yu
- Division of Orthopedics & Traumatology, Department of Orthopedics, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, Guangdong, People's Republic of China
| | - Xing Teng
- Department of Orthopedic Trauma, Beijing Jishuitan Hospital, Capital Medical University, Beijing, 100035, People's Republic of China
| | - Fengfei Lin
- Department of Orthopedics, Fuzhou Second General Hospital, School of Clinical Medicine, Fujian Medical University, Fujian Provincial Clinical Medical Research Center for First Aid and Rehabilitation in Orthopedic Trauma, Fuzhou, 350007, Fujian, People's Republic of China
| |
Collapse
|
|
8
|
Leta TH, Lie SA, Fenstad AM, Lygre SHL, Lindberg-Larsen M, Pedersen AB, W-Dahl A, Rolfson O, Bülow E, van Steenbergen LN, Nelissen RGHH, Harries D, de Steiger R, Lutro O, Mäkelä K, Venäläinen MS, Willis J, Wyatt M, Frampton C, Grimberg A, Steinbrück A, Wu Y, Armaroli C, Gentilini MA, Picus R, Bonetti M, Dragosloveanu S, Vorovenci AE, Dragomirescu D, Dale H, Brand C, Christen B, Shapiro J, Wilkinson JM, Armstrong R, Wooster K, Hallan G, Gjertsen JE, Chang RN, Prentice HA, Sedrakyan A, Paxton EW, Furnes O. Periprosthetic Joint Infection After Total Knee Arthroplasty With or Without Antibiotic Bone Cement. JAMA Netw Open 2024; 7:e2412898. [PMID: 38780939 PMCID: PMC11117087 DOI: 10.1001/jamanetworkopen.2024.12898] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Accepted: 03/20/2024] [Indexed: 05/25/2024] Open
Abstract
Importance Despite increased use of antibiotic-loaded bone cement (ALBC) in joint arthroplasty over recent decades, current evidence for prophylactic use of ALBC to reduce risk of periprosthetic joint infection (PJI) is insufficient. Objective To compare the rate of revision attributed to PJI following primary total knee arthroplasty (TKA) using ALBC vs plain bone cement. Design, Setting, and Participants This international cohort study used data from 14 national or regional joint arthroplasty registries in Australia, Denmark, Finland, Germany, Italy, New Zealand, Norway, Romania, Sweden, Switzerland, the Netherlands, the UK, and the US. The study included primary TKAs for osteoarthritis registered from January 1, 2010, to December 31, 2020, and followed-up until December 31, 2021. Data analysis was performed from April to September 2023. Exposure Primary TKA with ALBC vs plain bone cement. Main Outcomes and Measures The primary outcome was risk of 1-year revision for PJI. Using a distributed data network analysis method, data were harmonized, and a cumulative revision rate was calculated (1 - Kaplan-Meier), and Cox regression analyses were performed within the 10 registries using both cement types. A meta-analysis was then performed to combine all aggregated data and evaluate the risk of 1-year revision for PJI and all causes. Results Among 2 168 924 TKAs included, 93% were performed with ALBC. Most TKAs were performed in female patients (59.5%) and patients aged 65 to 74 years (39.9%), fully cemented (92.2%), and in the 2015 to 2020 period (62.5%). All participating registries reported a cumulative 1-year revision rate for PJI of less than 1% following primary TKA with ALBC (range, 0.21%-0.80%) and with plain bone cement (range, 0.23%-0.70%). The meta-analyses based on adjusted Cox regression for 1 917 190 TKAs showed no statistically significant difference at 1 year in risk of revision for PJI (hazard rate ratio, 1.16; 95% CI, 0.89-1.52) or for all causes (hazard rate ratio, 1.12; 95% CI, 0.89-1.40) among TKAs performed with ALBC vs plain bone cement. Conclusions and Relevance In this study, the risk of revision for PJI was similar between ALBC and plain bone cement following primary TKA. Any additional costs of ALBC and its relative value in reducing revision risk should be considered in the context of the overall health care delivery system.
Collapse
Affiliation(s)
- Tesfaye H. Leta
- The Norwegian Arthroplasty Register, Department of Orthopedic Surgery, Haukeland University Hospital, Bergen, Norway
- Faculty of Health Science, VID Specialized University, Oslo, Norway
- Department of Population Health Sciences, Weill Medical College of Cornell University, New York, New York
- Medical Device Surveillance and Assessment, Kaiser Permanente, San Diego, California
| | - Stein Atle Lie
- The Norwegian Arthroplasty Register, Department of Orthopedic Surgery, Haukeland University Hospital, Bergen, Norway
- Center for Translational Oral Research, Department of Dentistry, University of Bergen, Bergen, Norway
| | - Anne Marie Fenstad
- The Norwegian Arthroplasty Register, Department of Orthopedic Surgery, Haukeland University Hospital, Bergen, Norway
| | - Stein Håkon L. Lygre
- The Norwegian Arthroplasty Register, Department of Orthopedic Surgery, Haukeland University Hospital, Bergen, Norway
- Department of Occupational Medicine, Haukeland University Hospital, Bergen, Norway
| | - Martin Lindberg-Larsen
- The Danish Knee Arthroplasty Register, Odense, Denmark
- Department of Orthopaedic Surgery and Traumatology, Odense University Hospital, Odense, Denmark
| | - Alma B. Pedersen
- The Danish Knee Arthroplasty Register, Odense, Denmark
- Department of Clinical Epidemiology, Aarhus University Hospital and Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Annette W-Dahl
- The Swedish Arthroplasty Register, Gothenburg, Sweden
- Department of Clinical Sciences Lund, Orthopedics, Lund University, Lund, Sweden
| | - Ola Rolfson
- The Swedish Arthroplasty Register, Gothenburg, Sweden
- Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Erik Bülow
- Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Centre of Registers Västra Götaland, Gothenburg, Sweden
| | | | - Rob G. H. H. Nelissen
- The Dutch Arthroplasty Register, ‘s-Hertogenbosch, the Netherlands
- Department Orthopaedics, Leiden University Medical Center, Leiden, the Netherlands
| | - Dylan Harries
- South Australian Health and Medical Research Institute, Adelaide, Australia
| | - Richard de Steiger
- The Australian Orthopaedic Association National Joint Replacement Registry, Adelaide, Australia
| | - Olav Lutro
- Department of Medicine, Stavanger University Hospital, Stavanger, Norway
| | - Keijo Mäkelä
- The Finnish Arthroplasty Register, Helsinki, Finland
- Turku University Hospital and University of Turku, Turku, Finland
| | | | - Jinny Willis
- The New Zealand Joint Registry, Christchurch, New Zealand
| | - Michael Wyatt
- The New Zealand Joint Registry, Christchurch, New Zealand
| | - Chris Frampton
- The New Zealand Joint Registry, Christchurch, New Zealand
| | | | | | - Yinan Wu
- German Arthroplasty Registry, Berlin, Germany
| | - Cristiana Armaroli
- Arthroplasty Registry of the Autonomous Province of Trento, Clinical Epidemiology Service, Provincial Agency for Health Services of Trento, Trento, Italy
| | - Maria Adalgisa Gentilini
- Arthroplasty Registry of the Autonomous Province of Trento, Clinical Epidemiology Service, Provincial Agency for Health Services of Trento, Trento, Italy
| | - Roberto Picus
- Arthroplasty Register of Autonomous Province of Bolzano, Observatory of Health, Health Department AP of Bolzano, Bolzano, Italy
| | - Mirko Bonetti
- Arthroplasty Register of Autonomous Province of Bolzano, Observatory of Health, Health Department AP of Bolzano, Bolzano, Italy
| | - Serban Dragosloveanu
- Romanian Arthroplasty Registry, Bucharest, Romania
- University of Medicine and Pharmacy–Carol Davila, Bucharest, Romania
- Foisor Orthopaedic Hospital, Bucharest, Romania
| | - Andreea E. Vorovenci
- Romanian Arthroplasty Registry, Bucharest, Romania
- Economic Cybernetics and Statistics Doctoral School, Bucharest University of Economic Studies, Bucharest, Romania
| | - Dan Dragomirescu
- Romanian Arthroplasty Registry, Bucharest, Romania
- Economic Cybernetics and Statistics Doctoral School, Bucharest University of Economic Studies, Bucharest, Romania
| | - 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
| | - Christian Brand
- Swiss National Hip and Knee Joint Registry, Bern, Switzerland
- Institute of Social and Preventive Medicine, SwissRDL, University of Bern, Bern, Switzerland
| | - Bernhard Christen
- Swiss National Hip and Knee Joint Registry, Bern, Switzerland
- Articon, Bern, Switzerland
| | - Joanne Shapiro
- The National Joint Registry for England, Wales, Northern Ireland, The Isle of Man and Guernsey, London, United Kingdom
- NEC Software Solutions, Hemel Hempstead, United Kingdom
| | - J. Mark Wilkinson
- The National Joint Registry for England, Wales, Northern Ireland, The Isle of Man and Guernsey, London, United Kingdom
- Division of Clinical Medicine, School of Medicine and Population Health, University of Sheffield, Sheffield, United Kingdom
| | - Richard Armstrong
- The National Joint Registry for England, Wales, Northern Ireland, The Isle of Man and Guernsey, London, United Kingdom
- NEC Software Solutions, Hemel Hempstead, United Kingdom
| | - Kate Wooster
- The National Joint Registry for England, Wales, Northern Ireland, The Isle of Man and Guernsey, London, United Kingdom
- NEC Software Solutions, Hemel Hempstead, United Kingdom
| | - 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
| | - 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
| | - Richard N. Chang
- Medical Device Surveillance and Assessment, Kaiser Permanente, San Diego, California
| | - Heather A. Prentice
- Medical Device Surveillance and Assessment, Kaiser Permanente, San Diego, California
| | - Art Sedrakyan
- Department of Population Health Sciences, Weill Medical College of Cornell University, New York, New York
| | - Elizabeth W. Paxton
- Medical Device Surveillance and Assessment, Kaiser Permanente, San Diego, California
| | - 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
| |
Collapse
|
|
9
|
Ricciardi BF, Porter KR, Myers TG, Ginnetti JG, Kaplan N, Thirukumaran CP. Demographics and Early Outcomes of Commercial Antibiotic Cement Usage for Infection Prophylaxis During Primary Total Knee Arthroplasty in Patients Older Than 65 Years: An American Joint Replacement Registry Study. J Am Acad Orthop Surg 2024; 32:59-67. [PMID: 37678883 DOI: 10.5435/jaaos-d-23-00434] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Accepted: 07/24/2023] [Indexed: 09/09/2023] Open
Abstract
INTRODUCTION The use of antibiotic-laden bone cement (ALBC) for infection prophylaxis in the setting of primary total knee arthroplasty (TKA) remains controversial. Using data from the American Joint Replacement Registry (AJRR), (1) we examined the demographics of ALBC usage in the United States and (2) identified the effect of prophylactic commercially available ALBC on early revision and readmission for prosthetic joint infection (PJI) after primary TKA. METHODS This is a retrospective cohort study of the AJRR from 2017 to 2020. Patients older than 65 years undergoing primary cemented TKA with or without the use of commercially available antibiotic cement were eligible for inclusion (N = 251,506 patients). Data were linked to available Medicare claims to maximize revision outcomes. Demographics including age, sex, race/ethnicity, Charlson Comorbidity Index (CCI), preoperative inflammatory arthritis, region, and body mass index (BMI) class were recorded. Cox proportional hazards regression analysis was used to evaluate the association between the two outcome measures and ALBC usage. RESULTS Patients undergoing cemented TKA with ALBC were more likely to be Non-Hispanic Black ( P < 0.001), have a CCI of 2 or 3 ( P < 0.001), reside in the South ( P < 0.001), and had a higher mean BMI ( P < 0.001). In the regression models, ALBC usage was associated with increased risk of 90-day revision for PJI (hazards ratio 2.175 [95% confidence interval] 1.698 to 2.787) ( P < 0.001) and was not associated with 90-day all-cause readmissions. Male sex, higher CCI, and BMI >35 were all independently associated with 90-day revision for PJI. DISCUSSION The use of commercial ALBC in patients older than 65 years for primary TKA in the AJRR was not closely associated with underlying comorbidities suggesting that hospital-level and surgeon-level factors influence its use. In addition, ALBC use did not decrease the risk of 90-day revision for PJI and was not associated with 90-day readmission rates.
Collapse
Affiliation(s)
- Benjamin F Ricciardi
- From the Department of Orthopedic Surgery, University of Rochester School of Medicine (Ricciardi, Myers, Ginnetti, Kaplan, and Thirukumaran), the Center for Musculoskeletal Research, Department of Orthopedic Surgery, University of Rochester School of Medicine (Ricciardi, and Thirukumaran), and the American Academy of Orthopaedic Surgery (Porter)
| | | | | | | | | | | |
Collapse
|
|
10
|
Bos PK, Spekenbrink-Spooren A, Croughs P, Bierma-Zeinstra SMA, Reijman M, Van Oldenrijk J. Risk for re-revision and type of antibiotic-loaded bone cement in hip or knee arthroplasty revisions: report of the Dutch Arthroplasty Register. Acta Orthop 2023; 94:471-476. [PMID: 37728200 PMCID: PMC10510150 DOI: 10.2340/17453674.2023.18645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2023] [Accepted: 08/17/2023] [Indexed: 09/21/2023] Open
Abstract
BACKGROUND AND PURPOSE High-dose dual antibiotic-loaded bone cement (ALBC) may reduce the risk of revision after total hip and knee replacements. The aim of our study therefore was to determine the risk of re-revision following first time aseptic hip or knee revision using single versus dual ALBC. PATIENTS AND METHODS Patients from the Dutch Arthroplasty Register treated from 2007 to 2018 with first time cemented aseptic hip (n = 2,529) or knee revisions (n = 7,124) were incorporated into 2 datasets. The primary endpoint of this observational cohort study was subsequent all-cause re-revision. Multivariable Cox proportional hazard and competing risk was analyzed for both groups. RESULTS There was no difference in re-revision rate (any reason) with single versus dual ALBC (hazard ratio 1.06, 95% confidence interval [CI] 0.83-1.35 for hip and 0.93, CI 0.80-1.07 for knee revisions). The 10-year crude cumulative re-revision rate also showed no differences for single versus dual ALBC use. The crude cumulative 7-year THA re-revision and 9-year TKA re-revision rates did not show any difference in implant survival for common cement types used. CONCLUSION We could not confirm the potential benefit of using dual ALBC compared with single ALBC for aseptic hip and knee revisions.
Collapse
Affiliation(s)
- Pieter K Bos
- Department of Orthopedics and Sports Medicine, Erasmus MC University Medical Center, Rotterdam.
| | | | - Peter Croughs
- Department of Medical Microbiology and Infectious Diseases, Erasmus MC University Medical Center, Rotterdam
| | - Sita M A Bierma-Zeinstra
- Department of Orthopedics and Sports Medicine, Erasmus MC University Medical Center, Rotterdam; Department of General Practice, Erasmus MC University Center Rotterdam, Rotterdam, the Netherlands
| | - Max Reijman
- Department of Orthopedics and Sports Medicine, Erasmus MC University Medical Center, Rotterdam
| | - Jakob Van Oldenrijk
- Department of Orthopedics and Sports Medicine, Erasmus MC University Medical Center, Rotterdam
| |
Collapse
|
|
11
|
Abdel Khalik H, Wood TJ, Tushinski DM, Gazendam A, Petruccelli DT, Bali K, Winemaker M, Avram V, de Beer J, Williams D, Puri L, Piccirillo L. Routine use of antibiotic-laden bone cement in total knee arthroplasty is a cost-effective practice in the single-payer healthcare system. Knee Surg Sports Traumatol Arthrosc 2023; 31:3847-3853. [PMID: 36905414 DOI: 10.1007/s00167-023-07364-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2022] [Accepted: 02/21/2023] [Indexed: 03/12/2023]
Abstract
PURPOSE The purpose of this study was to determine the cost-effectiveness of antibiotic-laden bone cement (ALBC) in primary total knee arthroplasty (TKA) from the perspective of a single-payer healthcare system. METHODS A cost-utility analysis (CUA) was performed over a 2-year time horizon comparing primary TKA with either ALBC or regular bone cement (RBC) from the perspective of the single-payer Canadian healthcare system. All costs were in 2020 Canadian dollars. Health utilities were in the form of quality-adjusted life years (QALYs). Model inputs for cost, utilities and probabilities were derived from the literature as well as regional and national databases. One-way deterministic sensitivity analysis was performed. RESULTS Primary TKA with ALBC was found to be more cost-effective compared to primary TKA with RBC with an incremental cost-effectiveness ratio (ICER) of -3,637.79 CAD/QALY. The use of routine ALBC remained cost-effective even with cost increases of up to 50% per bag of ALBC. TKA with ALBC was no longer cost-effective if the rate of PJI following this practice increased 52%, or the rate of PJI following the use of RBC decreased 27%. CONCLUSIONS The routine use of ALBC in TKA is a cost-effective practice in the single-payer Canadian healthcare system. This remains to be the case even with a 50% increase in the cost of ALBC. Policy makers and hospital administrators of single-payer healthcare systems can leverage this model to inform their local funding policies. Future prospective reviews and randomized controlled trials from the perspective of various healthcare models can further shed light on this issue. LEVEL OF EVIDENCE III.
Collapse
Affiliation(s)
- Hassaan Abdel Khalik
- Division of Orthopaedic Surgery, McMaster University, 1280 Main Street West, Hamilton, ON, L8N 3Z5, Canada.
| | - Thomas J Wood
- Division of Orthopaedic Surgery, McMaster University, 1280 Main Street West, Hamilton, ON, L8N 3Z5, Canada
- Complex Care and Orthopaedics Program, Hamilton Health Sciences Juravinski Hospital, 711 Concession St, Hamilton, ON, L8V 1C3, Canada
| | - Daniel M Tushinski
- Division of Orthopaedic Surgery, McMaster University, 1280 Main Street West, Hamilton, ON, L8N 3Z5, Canada
- Complex Care and Orthopaedics Program, Hamilton Health Sciences Juravinski Hospital, 711 Concession St, Hamilton, ON, L8V 1C3, Canada
| | - Aaron Gazendam
- Division of Orthopaedic Surgery, McMaster University, 1280 Main Street West, Hamilton, ON, L8N 3Z5, Canada
| | - Danielle T Petruccelli
- Division of Orthopaedic Surgery, McMaster University, 1280 Main Street West, Hamilton, ON, L8N 3Z5, Canada
- Complex Care and Orthopaedics Program, Hamilton Health Sciences Juravinski Hospital, 711 Concession St, Hamilton, ON, L8V 1C3, Canada
| | - Kamal Bali
- Division of Orthopaedic Surgery, McMaster University, 1280 Main Street West, Hamilton, ON, L8N 3Z5, Canada
- Complex Care and Orthopaedics Program, Hamilton Health Sciences Juravinski Hospital, 711 Concession St, Hamilton, ON, L8V 1C3, Canada
| | | | | | | | | | | | | |
Collapse
|
|
12
|
Tranexamic acid is not associated with decreased infection risk after primary shoulder arthroplasty: a cohort study of 9276 patients. J Shoulder Elbow Surg 2023; 32:581-588. [PMID: 36208673 DOI: 10.1016/j.jse.2022.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Revised: 08/30/2022] [Accepted: 09/05/2022] [Indexed: 02/01/2023]
Abstract
BACKGROUND The use of tranexamic acid (TXA) is associated with less blood loss and reduced transfusion risk after shoulder arthroplasty surgery. Recent studies have shown lower odds of postoperative infection after hip or knee arthroplasty with its use. The purpose of this study was to determine whether TXA use reduces the risk of infection after primary elective shoulder arthroplasty. METHODS A retrospective cohort study was conducted using data from a US integrated health care system's shoulder arthroplasty registry. Patients aged 18 years who underwent primary elective anatomic total shoulder arthroplasty for osteoarthritis or primary reverse shoulder arthroplasty for rotator cuff arthropathy were included (2013-2020). We compared patients who received preoperative intravenous TXA to those who did not receive TXA by assessing the risk for revision due to deep infection within 5 years' follow-up using multivariable Cox proportional hazard regression. Interaction between TXA and diabetes status was analyzed separately. RESULTS The study sample included 9276 shoulder arthroplasties performed by 153 surgeons at 43 hospitals. The mean age was 70.0 years and 48% were male. The 5-year probability of revision for deep infection was 0.8% and 0.7% for patients with and without TXA, respectively. We failed to observe a difference in infection risk after adjustment for confounders and surgeon differences (hazard ratio [HR] 1.00, 95% confidence interval [CI] 0.56-1.80, P = .998). Further, no differences were observed in patients with (HR 1.64, 95% CI 0.42-6.44, P = .481) or without diabetes (HR 0.79, 95% CI 0.40-1.55, P = .488). CONCLUSION In a multicenter cohort of more than 9000 primary shoulder arthroplasty procedures, the use of preoperative TXA was not associated with a decrease in the 5-year probability of revision for deep infection.
Collapse
|
|
13
|
Li HQ, Li PC, Wei XC, Shi JJ. Effectiveness of antibiotics loaded bone cement in primary total knee arthroplasty: A systematic review and meta-analysis. Orthop Traumatol Surg Res 2022; 108:103295. [PMID: 35552043 DOI: 10.1016/j.otsr.2022.103295] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Revised: 06/10/2021] [Accepted: 06/14/2021] [Indexed: 02/03/2023]
Abstract
INTRODUCTION The application of antibiotics loaded bone cement (ALBC) in the revision of failed total knee arthroplasty (TKA) has been widely accepted to reduce risk of peri-prosthetic infection. However, the prophylactic use of ALBC in primary TKA remains controversial. This study was aimed to identify the prophylactic effect on peri-prosthetic infection and safety of ALBC in primary TKA. HYPOTHESIS The application of ALBC could reduce the risk of peri-prosthetic infection in primary TKA. MATERIALS AND METHODS Electronic platforms including PubMed, EMBASE, and CENTRAL were retrieved to identify studies comparing outcomes of prophylactic ALBC and plain cement in primary TKA. For outcomes reported as dichotomous variable and continuous variable, risk ratio (RR) and weighted mean difference (WMD) as well as their 95% confidence intervals (95% CI) were selected as the effect sizes for pooling. While for those outcomes reported the adjusted effect sizes such as odds ratio (OR, derived from multivariate logistic regression), and hazard ratio (HR, derived from multivariate COX proportional hazard model), the reported effect sizes were selected for pooling. RESULTS A total of 17 studies with 2,074,844 patients (1,093,920 in ALBC group and 980,924 in plain cement group) were eligible for final inclusion. No significant difference was found between ALBC and plain cement groups both for the unadjusted (RR=1.02, 95% CI: 0.86∼1.21, p=0.832) and adjusted (OR=0.94, 95% CI: 0.76∼1.17, p=0.596) peri-prosthetic infection rate. ALBC application was related to significantly increased length of hospital stay (WMD=0.13, 95% CI: 0.10∼0.17, p<0.001). There was no significance on the difference of operation related adverse events between two groups (RR=1.31, 95% CI: 0.68∼2.52, p=0.420). Significantly increased risks of acute renal failure and readmission, and temporarily increased ototoxicity in ALBC group were reported in one of the primary study. DISCUSSION There is no sufficient evidence supporting decreased peri-prosthetic infection rate with ALBC application in primary TKA. What's more, it must be taken into consideration about the safety and added cost of additional impregnated antibiotics. LEVEL OF EVIDENCE III; meta-analysis.
Collapse
Affiliation(s)
- Hao-Qian Li
- Department of Orthopaedics, The Second Hospital of Shanxi Medical University, Shanxi Key Laboratory of Bone and Soft Tissue Injury Repair, Taiyuan, 030000 Shanxi, China
| | - Peng-Cui Li
- Department of Orthopaedics, The Second Hospital of Shanxi Medical University, Shanxi Key Laboratory of Bone and Soft Tissue Injury Repair, Taiyuan, 030000 Shanxi, China
| | - Xiao-Chun Wei
- Department of Orthopaedics, The Second Hospital of Shanxi Medical University, Shanxi Key Laboratory of Bone and Soft Tissue Injury Repair, Taiyuan, 030000 Shanxi, China.
| | - Jun-Jun Shi
- Department of Orthopaedics, The Second Hospital of Shanxi Medical University, Shanxi Key Laboratory of Bone and Soft Tissue Injury Repair, Taiyuan, 030000 Shanxi, China
| |
Collapse
|
|
14
|
Zhang S, Qu X, Jiao J, Tang H, Wang M, Wang Y, Yang H, Yuan W, Yue B. Felodipine enhances aminoglycosides efficacy against implant infections caused by methicillin-resistant Staphylococcus aureus, persisters and biofilms. Bioact Mater 2022; 14:272-289. [PMID: 35310349 PMCID: PMC8897655 DOI: 10.1016/j.bioactmat.2021.11.019] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Revised: 11/11/2021] [Accepted: 11/12/2021] [Indexed: 12/11/2022] Open
Abstract
Methicillin-resistant Staphylococcus aureus (MRSA), biofilms, and persisters are three major factors leading to recurrent and recalcitrant implant infections. Although antibiotics are still the primary treatment for chronic implant infections in clinical, only few drugs are effective in clearing persisters and formed biofilms. Here, felodipine, a dihydropyridine calcium channel blocker, was reported for the first time to have antibacterial effects against MRSA, biofilm, and persisters. Even after continuous exposure to sub-lethal concentrations of felodipine, bacteria are less likely to develop resistance. Besides, low doses of felodipine enhances the antibacterial activity of gentamicin by inhibiting the expression of protein associated with aminoglycoside resistance (aacA-aphD). Next, biofilm eradication test and persisters killing assay suggested felodipine has an excellent bactericidal effect against formed biofilms and persisters. Furthermore, the result of protein profiling, and quantitative metabonomics analysis indicated felodipine reduce MRSA virulence (agrABC), biofilm formation and TCA cycle. Then, molecular docking showed felodipine inhibit the growth of persisters by binding to the H pocket of ClpP protease, which could lead to substantial protein degradation. Furthermore, murine infection models suggested felodipine in combination with gentamicin alleviate bacterial burden and inflammatory response. In conclusion, low dose of felodipine might be a promising agent for biomaterial delivery to enhance aminoglycosides efficacy against implant infections caused by MRSA, biofilm, and persisters.
Felodipine inhibits MRSA gene expression associated with aminoglycoside resistance and biofilm formation. Felodipine eradicates formed biofilm and persisters on the surface of implants. Felodipine induces proteolysis of MRSA and decreases energy metabolism. Felodipine in combination with gentamicin alleviates murine periprosthetic joint infection.
Collapse
|
|
15
|
von Hertzberg-Boelch SP, Luedemann M, Rudert M, Steinert AF. PMMA Bone Cement: Antibiotic Elution and Mechanical Properties in the Context of Clinical Use. Biomedicines 2022; 10:biomedicines10081830. [PMID: 36009376 PMCID: PMC9404960 DOI: 10.3390/biomedicines10081830] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Revised: 06/15/2022] [Accepted: 06/22/2022] [Indexed: 12/04/2022] Open
Abstract
This literature review discusses the use of antibiotic loaded polymethylmethacrylate bone cements in arthroplasty. The clinically relevant differences that have to be considered when antibiotic loaded bone cements (ALBC) are used either for long-term implant fixation or as spacers for the treatment of periprosthetic joint infections are outlined. In this context, in vitro findings for antibiotic elution and material properties are summarized and transferred to clinical use.
Collapse
Affiliation(s)
- Sebastian Philipp von Hertzberg-Boelch
- Department of Orthopaedic Surgery, University of Wuerzburg, Koenig-Ludwig-Haus, 11 Brettreichstrasse, 97074 Würzburg, Germany; (M.L.); (M.R.); (A.F.S.)
- Correspondence:
| | - Martin Luedemann
- Department of Orthopaedic Surgery, University of Wuerzburg, Koenig-Ludwig-Haus, 11 Brettreichstrasse, 97074 Würzburg, Germany; (M.L.); (M.R.); (A.F.S.)
| | - Maximilian Rudert
- Department of Orthopaedic Surgery, University of Wuerzburg, Koenig-Ludwig-Haus, 11 Brettreichstrasse, 97074 Würzburg, Germany; (M.L.); (M.R.); (A.F.S.)
| | - Andre F. Steinert
- Department of Orthopaedic Surgery, University of Wuerzburg, Koenig-Ludwig-Haus, 11 Brettreichstrasse, 97074 Würzburg, Germany; (M.L.); (M.R.); (A.F.S.)
- Rhön Klinikum, Campus Bad Neustadt, EndoRhoen Center for Joint Replacement, Teaching Hospital of the Phillipps University Marburg, Von Guttenberg Str. 11, 97616 Bad Neustadt, Germany
| |
Collapse
|
|
16
|
Lewis G. Antibiotic-free antimicrobial poly (methyl methacrylate) bone cements: A state-of-the-art review. World J Orthop 2022; 13:339-353. [PMID: 35582158 PMCID: PMC9048499 DOI: 10.5312/wjo.v13.i4.339] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Revised: 11/30/2021] [Accepted: 03/04/2022] [Indexed: 02/06/2023] Open
Abstract
Prosthetic joint infection (PJI) is the most serious complication following total joint arthroplasty, this being because it is associated with, among other things, high morbidity and low quality of life, is difficult to prevent, and is very challenging to treat/manage. The many shortcomings of antibiotic-loaded poly (methyl methacrylate) (PMMA) bone cement (ALBC) as an agent for preventing and treating/managing PJI are well-known. One is that microorganisms responsible for most PJI cases, such as methicillin-resistant S. aureus, have developed or are developing resistance to gentamicin sulfate, which is the antibiotic in the vast majority of approved ALBC brands. This has led to many research efforts to develop cements that do not contain gentamicin (or, for that matter, any antibiotic) but demonstrate excellent antimicrobial efficacy. There is a sizeable body of literature on these so-called "antibiotic-free antimicrobial" PMMA bone cements (AFAMBCs). The present work is a comprehensive and critical review of this body. In addition to summaries of key trends in results of characterization studies of AFAMBCs, the attractive features and shortcomings of the literature are highlighted. Shortcomings provide motivation for future work, with some ideas being formulation of a new generation of AFAMBCs by, example, adding a nanostructured material and/or an extract from a natural product to the powder and/or liquid of the basis cement, respectively.
Collapse
Affiliation(s)
- Gladius Lewis
- Department of Mechanical Engineering, University of Memphis, Memphis, TN 38152, United States
| |
Collapse
|
|
17
|
Cemented Versus Noncemented Total Knee Arthroplasty Outcomes. J Am Acad Orthop Surg 2022; 30:273-280. [PMID: 35167508 DOI: 10.5435/jaaos-d-21-00353] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Accepted: 12/23/2021] [Indexed: 02/01/2023] Open
Abstract
INTRODUCTION Aseptic loosening remains one of the most common indications for revision total knee arthroplasty (TKA). Given the demographic shift to a younger and more active TKA patient population, some surgeons have revisited noncemented fixation given its potential for lower rates of long-term aseptic loosening. The purpose of this study was to compare the demographics and complications between patients undergoing noncemented and cemented TKA. METHODS Using the MKnee subset of the PearlDiver database, diagnosis and procedure codes were used to identify patients who had undergone cemented or noncemented TKA for osteoarthritis with a minimum 2-year follow-up. Propensity score matching was done to compare risk-adjusted medical and surgical complication profiles at 90 days, 1 year, and 2 years. RESULTS Of 203,574 patients identified, 3.2% underwent noncemented TKA and 96.8% underwent cemented TKA. Using propensity-matched analysis, there was no difference in 90-day medical complications. Noncemented TKA was associated with a greater risk of periprosthetic joint infection throughout the study (90-day odds ratio [OR] 1.34, 1-year OR 1.27, 2-year OR 1.27, P < 0.05). Noncemented TKA was associated with a greater risk of periprosthetic fracture at 1 year and 2 years (1 year OR 2.19, 2 years OR 1.89, P < 0.05). No notable difference was observed in risk of aseptic loosening between the two groups. DISCUSSION Noncemented TKA is associated with a higher rate of periprosthetic joint infection and periprosthetic fracture. Additional studies are needed to compare long-term rates of aseptic loosening between noncemented and cemented TKA. LEVEL OF EVIDENCE Level III.
Collapse
|
|
18
|
Villa JM, Pannu TS, Higuera-Rueda CA. What's New in Adult Reconstructive Knee Surgery. J Bone Joint Surg Am 2022; 104:97-106. [PMID: 34780387 DOI: 10.2106/jbjs.21.01080] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- Jesus M Villa
- Levitetz Department of Orthopaedic Surgery, Cleveland Clinic Florida, Weston, Florida
| | | | | |
Collapse
|
|
19
|
García-Rey E. CORR Insights®: Intraosseous Regional Prophylactic Antibiotics Decrease the Risk of Prosthetic Joint Infection in Primary TKA: A Multicenter Study. Clin Orthop Relat Res 2021; 479:2513-2515. [PMID: 34460441 PMCID: PMC8509909 DOI: 10.1097/corr.0000000000001963] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Accepted: 08/11/2021] [Indexed: 01/31/2023]
|
|
20
|
Khalifa AA, Farouk OA. Total hip arthroplasty periprosthetic infection management, the dilemma remains. JOURNAL OF MUSCULOSKELETAL SURGERY AND RESEARCH 2021; 5:139-141. [DOI: 10.25259/jmsr_85_2021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
Affiliation(s)
- Ahmed A. Khalifa
- Department of Orthopedics, Qena Faculty of Medicine and University Hospital, South Valley University, Qena,
| | - Osama A. Farouk
- Department of Orthopedics and Traumatology, Assiut University Hospitals, Assiut, Egypt,
| |
Collapse
|
|
21
|
Fehring TK, Fehring KA, Hewlett A, Higuera CA, Otero JE, Tande AJ. What's New in Musculoskeletal Infection. J Bone Joint Surg Am 2021; 103:1251-1258. [PMID: 34048412 DOI: 10.2106/jbjs.21.00311] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- Thomas K Fehring
- OrthoCarolina Hip & Knee Center, Charlotte, North Carolina.,Atrium Musculoskeletal Institute, Charlotte, North Carolina
| | | | | | | | - Jesse E Otero
- OrthoCarolina Hip & Knee Center, Charlotte, North Carolina.,Atrium Musculoskeletal Institute, Charlotte, North Carolina
| | | |
Collapse
|
|
22
|
Hinman AD, Prentice HA, Paxton EW, Kelly MP. Modular Tibial Stem Use and Risk of Revision for Aseptic Loosening in Cemented Primary Total Knee Arthroplasty. J Arthroplasty 2021; 36:1577-1583. [PMID: 33349500 DOI: 10.1016/j.arth.2020.11.003] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Revised: 10/27/2020] [Accepted: 11/02/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Modular tibial stem extensions in total knee arthroplasty (TKA) are designed to reduce the risk of aseptic loosening of the tibial base plate. However, these implants add significant cost and an evaluation of their effectiveness in reducing this risk of loosening has not been studied in a large cohort. We sought to evaluate modular tibial stem utilization in primary TKA. METHODS We conducted a cohort study using our integrated healthcare system's Total Joint Replacement Registry. Patients who underwent cemented primary TKA were identified (2009-2019). Propensity scores were used to 1:1 match patients without to those with a stem extension. Cox proportional-hazards regression was used to evaluate the risk for revision due to aseptic loosening. RESULTS Ten thousand four hundred seventy six TKA with a modular tibial stem were matched to 10,476 TKA without a tibial stem. Stem utilization associated with a lower risk of revision for loosening across all postoperative follow-up (hazard ratio = 0.38, 95% confidence interval = 0.17-0.85). CONCLUSION In a matched cohort study, we observed presence of a stem extension was associated with a lower risk of revision for aseptic loosening. Further study to identify specific risk factors for aseptic loosening and confirm the findings presented here are warranted. LEVEL OF EVIDENCE Level III.
Collapse
Affiliation(s)
- Adrian D Hinman
- Department of Orthopaedics, The Permanente Medical Group, San Leandro, California
| | - Heather A Prentice
- Surgical Outcomes and Analysis, Kaiser Permanente, San Diego, California
| | - Elizabeth W Paxton
- Surgical Outcomes and Analysis, Kaiser Permanente, San Diego, California
| | - Matthew P Kelly
- Department of Orthopaedics, Southern California Permanente Medical Group, Harbor City, California
| |
Collapse
|
|
23
|
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.
Collapse
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
| |
Collapse
|