Introduction:. Deep infection after total joint arthroplasty is a devastating complication with reported incidence of 1–3% with projection to increase to 6.8% by 2030. The direct costs of revision surgery due to septic failure are estimated at over $55,000 per case. Antibiotic-Loaded Bone Cement (ALBC) has been proposed as a preventive measure to decrease post-operative infection rates. Its efficacy has been compared with plain bone cement (PBC) in multiple studies. There has been no study to our knowledge examining its efficacy in “high risk” patients. The purpose of this study is to compare infection rates in three cohorts of patients: (1) all patients receiving only PBC, (2) all patients receiving only ALBC, and (3) only “high risk” patients receiving ALBC. Methods:. A standard cement protocol was instituted at our hospital for primary total knee arthroplasties (pTKA). From January 2000 to 2005 all pTKAs were performed with PBC. From February 2005 to May 2010, all pTKAs were performed with ALBC. From June 2010 to March 2012, all patients received regular bone cement unless they had previous diagnoses of rheumatoid arthritis, obesity, and/or diabetes mellitus. Our institutional joint registry was queried and the three cohorts' individual charts were retrospectively reviewed. Infection rates amongst cohorts were compared at 30 days, 6 months, and 1 year from index surgery date utilizing two sided proportion tests. Results:. A total of 3,292 consecutive primary TKAs with full follow up were included. Overall infection rate at one year for the entire study was 0.76%. There were 1,025 patients who received PBC, 1486 ALBC, and 781 in the risk stratified cohort. The 30-day infection rates for cohorts 1, 2, 3 were .0.29%, 0.20%, and 0.13% respectively. The 6-month infection rates for cohorts 1, 2, 3 were 0.39%, 0.54% and 0.38% respectively. The 1-year infection rate for cohorts 1, 2, 3 were 0.78%, 0.61%, and 0.64% respectively. The differences in infection rates between each cohort at all three time intervals were not statistically significant. Conclusions:.
The objective of this study was to compare the elution characteristics,
antimicrobial activity and mechanical properties of antibiotic-loaded
bone cement (ALBC) loaded with powdered antibiotic, powdered antibiotic
with inert filler (xylitol), or liquid antibiotic, particularly focusing
on vancomycin and amphotericin B. Cement specimens loaded with 2 g of vancomycin or amphotericin
B powder (powder group), 2 g of antibiotic powder and 2 g of xylitol
(xylitol group) or 12 ml of antibiotic solution containing 2 g of
antibiotic (liquid group) were tested.Objectives
Methods
Total joint replacement (TJR), such as hip and knee replacement, is commonly used for the treatment of end stage arthritis. The use of Poly (methylmethacrylate) bone cement is a gold standard in such replacement, where it fixes the implant in place and transfer stresses between bone and implant, and frequently used for local delivery of drugs such as antibiotics. The use of
Orthopedic device-related bone infection is one of the most distressing complications of the surgical fixation of fractures. Despite best practice in medical and surgical interventions, the rate of infection remains stubbornly persistent, and current estimates indicate that treatment failure rates are also significant. As we approach the limit of the effectiveness of current anti-infective preventative and therapeutic strategies, novel approaches to infection management assume great importance. This presentation will describe our efforts to develop and test various hydrogels to serve as customized antibiotic delivery vehicles for infection prevention and treatment. Hydrogels offer solutions for many of the challenges faced by complex trauma wounds as they are not restricted spatially within a poorly defined surgical field, they often degrade rapidly with no compatibility issues, and releases 100% of the loaded antibiotic. The preliminary data set proving efficacy in preventing and treating infection in both rabbit and sheep studies will be described, including local antibiotic concentrations in the intramedullary canal over time, compared to that of the more conventional
Aims. Patients receiving cemented hemiarthroplasties after hip fracture have a significant risk of deep surgical site infection (SSI). Standard UK practice to minimize the risk of SSI includes the use of antibiotic-loaded bone cement with no consensus regarding type, dose, or antibiotic content of the cement. This is the protocol for a randomized clinical trial to investigate the clinical and cost-effectiveness of high dose dual antibiotic-loaded cement in comparison to low dose single antibiotic-loaded cement in patients 60 years and over receiving a cemented hemiarthroplasty for an intracapsular hip fracture. Methods. The WHiTE 8 Copal Or Palacos
Aims. A fracture of the hip is the most common serious orthopaedic
injury, and surgical site infection (SSI) is one of the most significant
complications, resulting in increased mortality, prolonged hospital
stay and often the need for further surgery. Our aim was to determine
whether high dose dual antibiotic impregnated bone cement decreases the
rate of infection. Patients and Methods. A quasi-randomised study of 848 patients with an intracapsular
fracture of the hip was conducted in one large teaching hospital
on two sites. All were treated with a hemiarthroplasty. A total
of 448 patients received low dose single-antibiotic impregnated
cement (control group) and 400 patients received high dose dual-antibiotic impregnated
cement (intervention group). The primary outcome measure was deep
SSI at one year after surgery. Results. The rate of deep SSI was 3.5% in the control group and 1.1% in
the intervention group
(p = 0.041; logistic regression adjusting for age and gender). The
overall rate of non-infective surgical complications did not differ
between the two groups (unadjusted chi-squared test; p >
0.999). Conclusion. The use of high dose dual-antibiotic impregnated cement in these
patients significantly reduces the rate of SSI compared with standard
low dose single
Background. Tigecycline, the first member of glycylcycline family, has effective antimicrobial activity against resistant and implant associated infectious organisms. The objectives of this study are to assess the compressive and tensile mechanical strength characteristics of tigecycline loaded bone cement and to compare them with vancomycin and daptomycin loaded bone cements which are used in prosthetic joint infections with resistant microorganisms. Methods. A control group without antibiotics and three
Introduction and Objective. The continued effectiveness of
Background.
Objectives. Investigate the incorporation of an antibiotic in bone cement using liposomes (a drug delivery system) with the potential to promote osseointegration at the bone cement interface whilst maintaining antibiotic elution, anti-microbiological efficacy and cement mechanical properties. Prosthetic joint infection and aseptic loosening are associated with significant morbidity.
Infection prevention in shoulder arthroplasty is an evolving challenge as further understanding of the pathogens becomes available. Infection rates for reverse TSA is higher than anatomic TSA. Standard decolonization protocols from our hip and knee colleagues has decreased the acute post-operative infection risk to less than 1%. By identifying at risk populations anti-MRSA precautions including intranasal antibiotics and anti-bacterial soaps for pre-surgical skin preparation have reduced the incidence of staphylococcus infections. The emerging understanding of propionibacterium acnes (P. acnes) as a primary pathogen in late shoulder periprosthetic joint infection (PJI) has led to new recommendations including pre-operative skin cleansing with 5% benzoyl peroxide to reduce infection risk. Pre-operative IV antibiotic is recommended and chlorhexidine skin prep for surgery. In the operating room, the concern is the surgeon's exposure to skin and sebaceous glands where P. acnes is prevalent. After skin incision the surgeon should use a new blade for deep incision. Application of vancomycin powder to the subcutaneous tissue may be beneficial after incision to treat potential contamination from the incision through skin. Glove change prior to handling implants and thorough irrigation before implantation is prudent. The role of
Background.
Introduction: Infection is a challenging problem in orthopaedic surgery. In oncologic and revision surgery large prosthesis are placed during long procedures, even in patients with immunocompromised status. Infection rates here are reported up to 10%. Infections may necessitate large segmental resections thereby creating large defects. This defect can be filled with antibiotics loaded beads that release the substances locally to sterilise the defect. In recent years solid
In oncological resections there is a higher risk of infection around the foot and ankle. An infection here can be difficult to treat and easily lead to an amputation due to the limited amount of soft tissue coverage of the region. In three patients an infection developed after resection of a bone tumour in the foot and ankle. In the first case, female 34 years, an epitheloid hemangioepithelioma was excised from the anterior part of the calcaneus, cuboid and lateral os cuneiform. An iliac crest graft was initially used to fill the defect, but got infected. The
Copal bone cement loaded with gentamicin and clindamicin was developed recently as a response to the emerging occurrence of gentamicin-resistant strains in periprothetic infections. The objective of this study was to compare the in vitro antibiotic release and antimicrobial efficacy of gentamicin/clindamicin-loaded Copal bone cement and gentamicin-loaded Palacos R-G bone cement, as well as biofilm formation on these cements. In order to determine antibiotic release, cement blocks were placed in phosphate buffer and aliquots were taken at designated times for measurement of antibiotic release. In addition, the bone cement discs were pressed on agar to study the effects of antibiotic release on bacterial growth. Biofilm formation on the different bone cements was also investigated after 1 and 7 days using plate counting and confocal laser scanning microscopy (CLSM). Experiments were done with a gentamicin-sensitive S. aureus and a gentamicin-resistant CNS. Antibiotic release after 672 h from Copal bone cement was more extensive (65% of the clindamycin and 41% of the gentamicin incorporated) than from Palacos R-G (4% of the gentamicin incorporated). The higher antibiotic release from Copal resulted in a stronger and more prolonged inhibition of bacterial growth on agar. Plate counting and CLSM of biofilms grown on the bone cements showed that antibiotic release reduced bacterial viability, most notably close to the cement surface. Moreover, the gentamicin-sensitive S. aureus formed gentamicin-resistant small colony variants on Palacos R-G, and therefore, Copal was much more effective in decreasing biofilm formation than Palacos R-G. Biofilm formation on bone cement could be more effectively reduced by incorporation of a second antibiotic, next to gentamicin. Antibiotic release from the cements had a stronger effect on bacteria close to the cement than on bacteria at the outer surface of the bio-film. Clinically, bone cement with two antibiotics may be more effective than cement loaded with only gentamicin. The clinical efficacy of
INTRODUCTION. Surgical site infections (SSI) in orthopaedics are a major source of postoperative morbidity. Although perioperative antibiotic prophylaxis is a common practice, orthopaedic infections are still high in numbers, due to the increasing use of osteosynthesis material and implants. Implants are avascular and can be easily colonized with biofilm-producing germs. For both, effective prophylaxis and treatment of orthopaedic infections, the right choice of the antibiotics used, the mode of application (only systemic or systemic & local), the timing, dosage and the duration of antibiotics are of extremely high importance. Their inappropriate use does not only lead to failures in prevention or treatment of infections, but may also promote microbial resistance development and may cause serious side effects for the patients. SELECTION & USE OF ANTIBIOTICS. Prophylaxis. Broad-spectrum prophylactic antibiotics should help to eliminate the germs before they start to colonize the implant. For prophylactic purposes the recently published AAOS guidelines [1] recommend the use of cephalosporins, such as cefazolin or cefuroxim, administered within one hour prior to surgery. In cases of suspected beta-lactam allergy, clindamycin or vancomycin can be used. The latter one is also recommended in cases of MRSA colonisation. Due to extended infusion times, vancomycin should be started within two hours prior to incision. In cases of blood loss or long op duration, antibiotic administration must be repeated (e.g. cefazolin, every 2–5 hrs; vancomycin, every 6–12 hrs). There is no evidence of a benefit of continued antibiotic administration past 24 hrs of end of surgery [2]. Treatment. In cases of established infections, use of antibiotics is only considered as an adjuvant to surgical debridement. Typically, the choice of the appropriate antibiotic depends on the bacteria, its antibiotic sensitivity profile and the health state of the patient. A combination of rifampicin & a quinolone (or rifampicin & vancomycin in cases of MRSA) for at least 2 wks up to several months has shown good results [3]. In chronic infections with biofilm involvement, all foreign material must be removed and locally delivered antibiotics via e.g. PMMA as carrier (spacers, PMMA-chains) are of additional clinical benefit. ROLE OF LOCAL ANTIBIOTICS. There is general consensus that PMMA chains or PMMA spacers loaded with specific antibiotics support the eradication of bone and joint infections, because of the high local concentrations achieved. The exact treatment time is, however, variable, ranging from few weeks up to several months. Only small amounts of these local antibiotics are systemically detectable and do not represent a major risk for side effects. Still a matter of debate is the benefit of antibiotic impregnated PMMA for infection prophylaxis. Although common practice in Europe, its routine use in e.g. primary arthroplasty is still discussed in other world regions. Meanwhile, evidence accumulates that joint infection rates are, indeed, lower, if
The static properties of bone cements have been widely reported in the literature (Lewis, 1997, Khun, 2000, Armstrong 2002). Commercial bone cements are expected to perform above the minimum values in static tests specified by ISO 5833: 2002. It has been suggested that the viscoelastic properties of bone cement, such as creep and stress relaxation, might bear more relevance to the in-vivo behaviour of the cement-implant construct (Lee 2002). This study aimed to compare numerous properties of Simplex P, Simplex Antibiotic and Simplex Tobramycin and identify those properties most sensitive to subtle changes in cement composition. The three cements were chosen on the basis that they are characterised by the same liquid and powder compositions, the only difference being represented by the type and amount of added antibiotics. In Simplex Antibiotic the additives are 0.5g Erythromycin and 3 million I.U. Colistin, while in Antibiotic Simplex with Tobramycin the only additive is 0.5g of Tobramycin. The static properties of the cements were assessed following protocols described in ISO 5833: 2002, while the viscoelastic properties of the cement were measured with in-house developed apparatus in quasi-static conditions. Creep and stress relaxation tests were performed in four point bending configuration. Porosity was measured on the mid cross section of the creep samples using a digital image technique. All cements exhibited properties compatible with the ISO standard, but in plain Simplex the ISO minimum for bending and compressive strength was within the variation of the batches tested. Bending strength measurements were the least sensitive to differences in the cements. Plain Simplex displayed lower bending and compressive strength but higher bending modulus than the antibiotic laden options. The bending modulus could only discriminate between Simplex P and Simplex Antibiotic (p=0.02). Differences in the compressive strength of the three cements were significant, with the plain option being the weakest. Stress relaxation only discriminated between plain and Tobramycin loaded cement (p=0.028), while creep was more sensitive to differences and allowed distinction between plain and
Periprosthetic hip-joint infection is a multifaceted and highly detrimental outcome for patients and clinicians. The incidence of prosthetic joint infection reported within two years of primary hip arthroplasty ranges from 0.8% to 2.1%. Costs of treatment are over five-times greater in people with periprosthetic hip joint infection than in those with no infection. Currently, there are no national evidence-based guidelines for treatment and management of this condition to guide clinical practice or to inform clinical study design. The aim of this study is to develop guidelines based on evidence from the six-year INFection and ORthopaedic Management (INFORM) research programme. We used a consensus process consisting of an evidence review to generate items for the guidelines and online consensus questionnaire and virtual face-to-face consensus meeting to draft the guidelines.Aims
Methods
Infection of a total joint replacement (TJR) is considered a devastating complication, necessitating its complete removal and thorough debridement of the site. Usually at least two surgical interventions and antibiotic treatment within a period of several months are estimated being required for a favourable outcome. It is undoubted that one stage exchange, if successful, would provide the best benefit both for the patient and the society. Still the fear of re-infection dominates the surgeons’ decisions and directs them to multiple stage protocols. However, there is no scientifically based argument for that practice. Successful eradication of infection with two stage procedures is reported to average 80% to 98%, whereas there are no significant differences between revisions with or without antibiotic loaded cement, with short or long term antibiotic therapy, with or without the use of spacers and other differences. On the other hand a literature review of Jackson and Schmalzried (CORR 200) summarizing the results of 1,299 infected hip replacements treated with direct exchange (almost exclusively using antibiotic loaded cement), reports of 1,077 (83%) having been successful. For total knee replacement Jaemson et al. (Acta 2009) could show that the overall success rate in eradication of infection was 73–100% after one-stage revisions. It may be calculated, that adding a second one stage procedure for treating the failed cases the overall result with two operations may improve to >
95%, an outcome which is at least as good as the best results after two stage revisions, while requiring only one surgical intervention for the majority of cases. Spacers have been proven to be useful for improving final functional results compared to temporary resection; however, concerning infection control no benefit could be shown. Dead space management is performed comparably effective by a new prosthesis as with a spacer. In addition a definitive prosthesis is providing increased stability, which a spacer does not. As long as protection against colonization is granted by high local antibiotic concentrations a prostheses is likely to provide better functional results than a spacer. These results suggest, that the major factor for a successful outcome with traditional approaches may be found in the quality of the surgical debridement and dead space management. Failures in all protocols seem to be caused by small fragments of bacterial colonies remaining after debridement, whereas neither systemic antibiotics nor
