Table 6 - available via license: Creative Commons Attribution-NonCommercial 4.0 International
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AIM
To undertook a systematic review to determine factors that increase a patient’s risk of developing lower limb periprosthetic joint infections (PJI).
METHODS
This systematic review included full-text studies that reviewed risk factors of developing either a hip or knee PJI following a primary arthroplasty published from January 1998 to November...
Context in source publication
Context 1
... further categorised the resultant risk factors into whether or not they were modifiable, reflecting the opportunity of the surgeon to optimise their patient pre operatively and to reduce the risk of developing a PJI (Table 6) postoperative infection following lower limb arthroplasty. Multiple prospective and retrospective studies have reviewed the risks associated with their patient cohort developing such infections. ...
Citations
... Periprosthetic joint infections (PJIs) represent significant complications following total hip and knee arthroplasty, occurring at a rate of 1-2% [1][2][3]. The genesis of periprosthetic infections is multifactorial: risk factors for periprosthetic infections include an increased body mass index (BMI) [4][5][6][7], increased age [8], female gender [9], diabetes mellitus [5,6,8,9], rheumatoid arthritis [6,9], previous joint surgery [6,8], previous PJI [7,8], hypothyroidism [9], preoperative high-dose steroids [5,6], chronic alcohol use [7,9], tobacco use [5,7], coronary artery disease [5], HIV infection at an advanced stage [8], depression [6], and the presence of distant infectious foci [8]. In cases of late-onset PJIs (occurring more than 4 weeks post operation), the complete removal of all foreign materials in a septic oneor two-stage revision procedure is necessary. ...
... Periprosthetic joint infections (PJIs) represent significant complications following total hip and knee arthroplasty, occurring at a rate of 1-2% [1][2][3]. The genesis of periprosthetic infections is multifactorial: risk factors for periprosthetic infections include an increased body mass index (BMI) [4][5][6][7], increased age [8], female gender [9], diabetes mellitus [5,6,8,9], rheumatoid arthritis [6,9], previous joint surgery [6,8], previous PJI [7,8], hypothyroidism [9], preoperative high-dose steroids [5,6], chronic alcohol use [7,9], tobacco use [5,7], coronary artery disease [5], HIV infection at an advanced stage [8], depression [6], and the presence of distant infectious foci [8]. In cases of late-onset PJIs (occurring more than 4 weeks post operation), the complete removal of all foreign materials in a septic oneor two-stage revision procedure is necessary. ...
... Periprosthetic joint infections (PJIs) represent significant complications following total hip and knee arthroplasty, occurring at a rate of 1-2% [1][2][3]. The genesis of periprosthetic infections is multifactorial: risk factors for periprosthetic infections include an increased body mass index (BMI) [4][5][6][7], increased age [8], female gender [9], diabetes mellitus [5,6,8,9], rheumatoid arthritis [6,9], previous joint surgery [6,8], previous PJI [7,8], hypothyroidism [9], preoperative high-dose steroids [5,6], chronic alcohol use [7,9], tobacco use [5,7], coronary artery disease [5], HIV infection at an advanced stage [8], depression [6], and the presence of distant infectious foci [8]. In cases of late-onset PJIs (occurring more than 4 weeks post operation), the complete removal of all foreign materials in a septic oneor two-stage revision procedure is necessary. ...
Background: Two-stage septic revision is the prevailing method for addressing late periprosthetic infections. Using at least dual-antibiotic-impregnated bone cement leads to synergistic effects with a more efficient elution of individual antibiotics. Recent data on the success rates of multiantibiotic cement spacers in two-stage revisions are rare. Methods: We conducted a retrospective follow-up single-center study involving 250 patients with late periprosthetic hip infections and 95 patients with prosthetic knee infections who underwent septic two-stage prosthesis revision surgery between 2017 and 2021. In accordance with the antibiotic susceptibility profile of the microorganisms, a specific mixture of antibiotics within the cement spacer was used, complemented by systemic antibiotic treatment. All patients underwent preoperative assessments and subsequent evaluations at 3, 6, 9, 12, 18, and 24 months post operation and at the most recent follow-up. Results: During the observation period, the survival rate after two-step septic revision was 90.7%. Although survival rates tended to be slightly lower for difficult-to-treat (DTT) microorganism, there was no difference between the pathogen groups (easy-to-treat (ETT) pathogens, methicillin-resistant staphylococci (MRS), and difficult-to-treat (DTT) pathogens). Furthermore, there were no differences between monomicrobial and polymicrobial infections. No difference in the survival rate was observed between patients with dual-antibiotic-loaded bone cement without an additional admixture (Copal® G+C and Copal® G+V) and patients with an additional admixture of antibiotics to proprietary cement. Conclusion: Employing multiple antibiotics within spacer cement, tailored to pathogen susceptibility, appears to provide reproducibly favorable success rates, even in instances of infections with DTT pathogens and polymicrobial infections.
... There are factors that can hinder this process: soft tissue damage, location of the injury, age of the patient, osteoporosis, and use of particular drugs. In orthopaedic and joint/prosthetic surgery, infections are a not uncommon complication [104,105]. Johnson et al. [106] designed injectable hydrogels to treat infections caused by Staphylococcus aureus in orthopaedic implants used for fracture repair. A mouse model of femoral fracture infection was used to evaluate the therapeutic potential of lysostaphin therapy incorporated into a formulation consisting essentially of a PEG hydrogel. ...
... There are factors that can hinder this process: soft tissue damage, location of the injury, age of the patient, osteoporosis, and use of particular drugs. In orthopaedic and joint/prosthetic surgery, infections are a not uncommon complication [104,105]. ...
The development of biomedical applications is a transdisciplinary field that in recent years has involved researchers from chemistry, pharmacy, medicine, biology, biophysics, and biomechanical engineering. The fabrication of biomedical devices requires the use of biocompatible materials that do not damage living tissues and have some biomechanical characteristics. The use of polymeric membranes, as materials meeting the above-mentioned requirements, has become increasingly popular in recent years, with outstanding results in tissue engineering, for regeneration and replenishment of tissues constituting internal organs, in wound healing dressings, and in the realization of systems for diagnosis and therapy, through the controlled release of active substances. The biomedical application of hydrogel membranes has had little uptake in the past due to the toxicity of cross-linking agents and to the existing limitations regarding gelation under physiological conditions, but now it is proving to be a very promising field This review presents the important technological innovations that the use of membrane hydrogels has promoted, enabling the resolution of recurrent clinical problems, such as post-transplant rejection crises, haemorrhagic crises due to the adhesion of proteins, bacteria, and platelets on biomedical devices in contact with blood, and poor compliance of patients undergoing long-term drug therapies.
... The SSI is largely preventable if some of the information in the local settings such as risk factors, common causative organisms and their susceptibility patterns are known. Among modifiable risk factors that has been published in previous reports are pre-operative anaemia 5,6 , obesity 5,7-9 , renal disease 5 , diabetes 5,10,11 , tobacco use 10,12 , long operative time 13 and coronary artery disease 10 . ...
... The SSI is largely preventable if some of the information in the local settings such as risk factors, common causative organisms and their susceptibility patterns are known. Among modifiable risk factors that has been published in previous reports are pre-operative anaemia 5,6 , obesity 5,7-9 , renal disease 5 , diabetes 5,10,11 , tobacco use 10,12 , long operative time 13 and coronary artery disease 10 . ...
... The SSI is largely preventable if some of the information in the local settings such as risk factors, common causative organisms and their susceptibility patterns are known. Among modifiable risk factors that has been published in previous reports are pre-operative anaemia 5,6 , obesity 5,7-9 , renal disease 5 , diabetes 5,10,11 , tobacco use 10,12 , long operative time 13 and coronary artery disease 10 . ...
INTRODUCTION: The devastating outcome of orthopaedic surgical site infections (SSI) are largely preventable if its risk factors, causative organisms and antimicrobial susceptibility patterns in the regional area are known.
MATERIALS AND METHODS: We conducted a retrospective study to address the lack of epidemiological and microbiological data on orthopaedic SSI in Malaysia. All the 80 patients diagnosed and treated for microbiologically proven orthopaedic SSIs in a tertiary hospital in Malaysia from April 2015 to March 2019 were included in a 1:2 case control study.
RESULTS: The prevalence of SSI in clean and clean- contaminated surgeries was 1.243%, which is consistent with most of the studies worldwide, but is low compared to other studies done in Malaysia. The most common type of orthopaedics SSI were internal fixation infections (46.25%), superficial SSIs (25.2%) and Prosthetic joint infections (18.75%). Obesity and tobacco use were found to be significant risk factors of orthopaedic SSI. The most common perioperative prophylaxis used was IV cefuroxime. Majority of the cases (86.5%) received prolonged prophylactic antibiotics. The most common causative agent was Staphylococcus aureus (31.25%), followed by Pseudomonas aeruginosa (26.25%) and Enterobacter spp (7.5%). Methicillin-resistant Staphylococcus aureus (MRSA) accounted for 20% of the S. aureus infections. Up to 19.4% of the Gram-negative organisms are multidrug resistant. The higher rate of isolation of organisms resistant to the prophylactic antibiotics being used may be related to the prolonged use of prophylactic antibiotics, which exerted selective pressure for the acquisition of resistant organisms.
CONCLUSION: Despite its relatively low prevalence in our local institution and worldwide, the prevention of SSI in orthopaedic practice is crucial to avoid morbidity, mortality and high healthcare cost. This may be achieved by control of modifiable risk factors such as obesity and tobacco use, appropriate use of prophylactic antibiotics and implementation of good surgical and infection control practices.
... Evidence appears to suggest that the risk of infection increases further above a threshold BMI of 40 kg/m 2 [12], perhaps due to a compounding of the effects of the aforementioned contributing factors, although this trend has not been investigated within the present study. Diabetes mellitus is also associated with post-operative wound infection [6,33]. However, the details surrounding this association remain unclear. ...
Introduction
Although the independent effects of diabetes mellitus and obesity on total hip replacement (THR) outcomes have been widely studied, their combined effect remains uncharacterised. This study aimed to assess the influence of diabesity on primary THR operative outcomes.
Materials and methods
A retrospective study was performed comparing the outcomes of patients with diabesity (diabetes mellitus and obesity [BMI ≥ 30]) with a control cohort after primary THR using an established arthroplasty database. Data were collected pre-operatively and 12 months post-operatively, including Oxford Hip Score (OHS), EuroQol 5-dimensions (EQ5D), post-operative satisfaction and complication rates.
Results
2323 THRs were analysed, of which 94 (4%) had diabesity. Diabesity was independently associated with significantly worse OHS improvement post-operatively (− 1.85 points, 95% CI − 2.93 to − 0.76, p = 0.001). This reduction in addition to the independent effect of obesity (− 0.69 points, 95% CI − 1.18 to − 0.21, p = 0.005) resulted in an overall 2.54 point OHS reduction for patients with diabesity. Diabesity was not associated with EQ5D score change or post-operative satisfaction. Diabesity was independently associated with a worse pre-operative EQ5D score (−0.08 points, 95% CI −0.12 to −0.03, p = 0.002). When combining the associated risk of obesity (Odds Ratio (OR) 1.71, 95% CI 1.15–2.54, p = 0.008) with the superadded effect of diabesity (OR 2.37, 95% CI 1.19–4.71, p = 0.014) the rate of superficial wound infection post-operatively was significantly increased (OR 4.05, 95% CI 1.38–11.95). Obesity was associated with a significantly increased risk of deep infection (OR 3.67, 95% CI 1.55–8.68, p = 0.003), but no additive effect of diabetes was found.
Conclusions
Diabesity confers a superadded effect over established associations between THR outcomes and obesity and diabetes individually. Patients with diabesity experience worse improvement in hip-specific functional outcome, worse post-operative quality of life, and an increased risk of superficial and deep wound infection following THR.
... The first is infection itself, whose eradication is difficult because of biofilm formation, especially in case of "difficult-to-treat" pathogens [7]. The second is the wide spectrum of systemic diseases affecting the patients, who are often also immunocompromised [8,9]. This leads to a more complex recovery and may Logoluso et al. ...
Background
Periprosthetic hip infections with severe proximal femoral bone loss may require the use of limb salvage techniques, but no agreement exists in literature regarding the most effective treatment. Aim of this study is to analyze the infection eradication rate and implant survival at medium-term follow-up in patients treated with megaprostheses for periprosthetic hip infections with severe bone loss.
Methods
Twenty-one consecutive patients were retrospectively reviewed at a mean 64-month follow-up (24–120). Functional and pain scores, microbiological, radiological and intraoperative findings were registered. Kaplan Meier survival analysis and log rank test were used for infection free survival and implant survival analyses.
Results
The infection eradication rate was 90.5%, with an infection free survival of 95.2% at 2 years (95%CI 70.7–99.3) and 89.6%(95%CI 64.3–97.3) at 5 years. Only two patients required major implant revisions for aseptic implant loosening. The most frequent complication was dislocation (38.1%). The major revision-free survival of implants was 95.2% (95%CI 70.7–99.3) at 2 years and 89.6% (95%CI 64.3–97.3) at 5 years. The overall implant survival was 83.35% (CI95% 50.7–93.94) at 2 and 5 years. Subgroup analyses (cemented versus cementless MPs, coated versus uncoated MPs) revealed no significant differences at log rank test, but its reliability was limited by the small number of patients included.
Conclusions
Proximal femoral arthroplasty is useful to treat periprosthetic hip infections with severe bone loss, providing good functional results with high infection eradication rates and rare major revisions at medium-term follow-up. No conclusions can be drawn on the role of cement and coatings.
... In der Review-Studie von George et al. (2017) Nach der Zuordnung veränderten sich die prozentualen Anteile auf 0,7 % für die Keramik-Keramik-Gleitpaarung und 0,9 % für die Keramik-PE-Gleitpaarung (Renner et al. 2021 ...
Zusammenfassung Hintergrund und Ziele Seit 1938 Philipp Wiles die erste klinisch relevante Implantation einer Hüfttotalendoprothese (HTEP) gelang, nimmt die Anzahl der jährlich durchgeführten Primärimplantationen stetig zu. Analog dazu werden auch Revisionseingriffe – aktuell mit einem Anteil von 8 % der Hüft-TEP-Eingriffe – häufiger durchgeführt (Bobzin 2021, Wiles 1958). Aufgrund des mittlerweile exzellenten klinischen Outcomes werden HTEPs mittlerweile zunehmend auch schon bei jüngeren Patienten implantiert. Deshalb rückt die Hüft-Revisionsendoprothetik bzw. die Vermeidung von Problemen und Risiken, welche zu Revisionseingriffen führen könnten, immer mehr in den Mittelpunkt des klinischen Interesses. Methoden (Patienten, Material und Untersuchungsmethoden) Durchgeführt wurde eine retrospektive Studie aller Hüft-TEP-Revisionsoperationen, die vom 31.08.2011 bis 07.02.2018 in der Orthopädischen Universitätsklinik der Friedrich-Alexander-Universität Erlangen-Nürnberg am Malteser Waldkrankenhaus St. Marien in Erlangen durchgeführt wurden. Insgesamt wurden die Hüft-TEP-Revisionsoperationen von 134 Patienten untersucht und neben der Primärimplantation die ersten beiden Revisionseingriffe genauer betrachtet und im Rahmen der deskriptiven Statistik mit Statistical Package for the Social Sciences (SPSS) ausgewertet. Ergebnisse und Beobachtungen Einzelne Risikofaktoren bzw. protektive Faktoren zur Vermeidung von Revisionsoperationen konnten ermittelt werden. Hierbei ergab sich ein erhöhtes Risiko für aseptische Lockerungen bei Verwendung von Polyethylen (PE) in der Gleitpaarung. Infektionen traten seltener bei Verwendung der Keramik-Keramik-Gleitpaarung auf. Ein größerer Kopfdurchmesser und jüngeres Patientenalter scheint das Luxationsrisiko, wie auch schon in der Literatur beschrieben (Herman et al. 2019, Wetters et al. 2013), zu verringern. Und, während höheres Alter und das weibliche Geschlecht das Risiko für periprothetische Frakturen erhöhen, treten bei jungen Männern häufiger Materialbrüche des einliegenden Implantates auf. (Praktische) Schlussfolgerungen Im eigenen Patientengut konnten Tendenzen und in der Literatur signifikante Ergebnisse für einzelne Risikofaktoren, für das Auftreten von revisionsbedürftigen HTEPs, isoliert werden. Generell zeigte sich allerdings, dass allen Indikationen für eine Revision ein multifaktorielles Geschehen zugrunde liegt. Keine Gleitpaarung, kein Prothesendesign und keine Operationstechnik können generell empfohlen werden. Hingegen unterliegt die Therapieplanung einer individuellen Entscheidungsfindung bei der das Alter, die Aktivität und Mobilität des Patienten, die Indikation, Knochenstruktur, Vorerkrankungen, Voroperationen sowie die Erfahrung und Erfahrungswerte des Operateurs mit einfließen. In den kommenden Jahren werden frühere Operationen, höhere Lebenserwartung und BMI sowie eine größere Aktivität der Patienten und damit einhergehend ein insgesamt höherer Anspruch der Patienten, die Operationstechnik und das Prothesendesign der HTEP vor weitere Herausforderungen stellen, wobei hier zweifellos Kompromisse in Abhängigkeit von der individuell vorliegenden Pathologie sowohl vom Patienten als auch vom Operateur akzeptiert werden müssen.
... Like many other surgical procedures, the implantation of knee, hip, or shoulder joint prostheses can result in bacterial infections to the prosthesis itself, and possibly to the adjacent bone tissues. Because the number of prosthesis implants is continuously increasing, especially due to the increase in the age of the population in developed countries, and to the increase in traumatism, numerous epidemiological studies are available to help define the risk of prosthetic infection [8,9]. ...
Highlights Prosthetic joint infections (PJI) represent one of the major problems in orthopedic prosthetic surgery. The diagnosis of prosthetic infections requires a multispecialist approach, from accurate anamnestic collection, to clinical evaluation and biomarkers of inflammation, to the use of imaging techniques. The identification of the bacteria responsible for the infection is essential for the timely diagnostic setting and the correct antibiotic treatment. Risk management procedures, adherence to guidelines and good care practices, to prevent errors and complications.
... Like many other surgical procedures, the implantation of knee, hip, or shoulder joint prostheses can result in bacterial infections to the prosthesis itself, and possibly to the adjacent bone tissues. Because the number of prosthesis implants is continuously increasing, especially due to the increase in the age of the population in developed countries, and to the increase in traumatism, numerous epidemiological studies are available to help define the risk of prosthetic infection [8,9]. ...
Fractures of the pelvic ring and acetabulum generally result after high energy trauma.
Pelvic fractures, especially, are considered complex injuries from a therapeutic point of view, in relation to the frequent coexistence of skeletal and / or parenchymal lesions affecting other areas, and the abundant bleeding invariably associated with the latter. The systematic study of these injuries, starting from the 1950s, has led to a significant prognostic improvement, while generally remaining a non-negligible degree of disability. The knowledge of the characteristics of the lesions and of the classification systems, as well as an accurate assessment of the anatomo-functional repercussions, represent therefore the fundamental prerequisites for the correct assessment of physical damage.
Herein, we aim to examine whether the medico-legal assessment parameters of physical damage being used in Italy and Europe are appropriate and consistent with the complexity of similar injuries.
... Revision surgery is another important option to treat PJI, but this is burdened by an infection rate over 10% [8], which is not without clinical impact. Indeed, it may raise the risk of prolonged hospitalization and duration of antibiotic therapy at home, increasing costs and causing relevant social and economic problems. ...
Prosthetic joint infection (PJI) is a possible complication occurring after prosthesis implantation. We describe the case of a patient with early postoperative multidrug-resistant polymicrobial PJI and mixed infection of the surgical wound. Despite the removal of the prosthesis, the positioning of double-stage exchange, and dehiscence debridement of the surgical wound, the infection continued. Positioning of an external fixator, plastic reconstruction with a skin graft, and continuous (two years) multiple antimicrobial therapy led to the resolution of the knee infection; a knee prosthesis was implanted, but a new infection of the extensus apparatus by multidrug-resistant Klebsiella pnumoniae followed. It was complicated by surgical wound dehiscence, forcing us to remove the prosthesis, put a new external fixator, and continue with the antibiotic treatment, with no results, and, finally, proceed to a leg amputation. Fourteen days after, the patient was discharged in good clinical condition but, fifteen days later, during rehabilitation in another hospital, the patient developed a severe Clostridium difficilis infection with profuse, intense diarrhea, toxic megacolon, and septic shock; despite colectomy and treatment in an intensive care unit, he died four months later. Patients affected by polymicrobial PJI are at high risk of treatment failure and, therefore, should be given a warning, in good time and appropriate form, of the likelihood of leg amputation.
... Sex differences we could not account for may be responsible for this disparity. For example, men are more susceptible to peripheral arterial disease [79e84], which is commonly manifested in the lower extremities and is associated with infection risk [77,85,86]. The risk for infection is potentially higher in knees than in hips given the more distal aspect of the limb, and thus, peripheral vascular disease would be more impactful. ...
Introduction: Surgical and host factors predispose patients to periprosthetic joint infection (PJI) following primary total hip (THA) and knee (TKA) arthroplasty. While surgical factors are modifiable, host factors can be challenging and there are limited data demonstrating that preoperative patient optimization decreases risk of PJI. The goal of this study was to evaluate whether extended oral antibiotic prophylaxis reduces the one-year infection rate in high-risk patients.
Methods: 3,855 consecutive primary THAs and TKAs performed between 2011 and 2019 at a suburban academic hospital with modern perioperative and infection-prevention protocols were retrospectively reviewed. Beginning in January 2015, a 7-day oral antibiotic prophylaxis protocol was implemented after discharge for patients at high risk for PJI. The percentage of high-risk patients diagnosed with PJI within 1 year were compared between groups that did and did not receive extended antibiotic prophylaxis. Univariate and logistic regression analyses were performed, with p ≤ 0.05 denoting statistical significance.
Results: Overall 1-year infection rates were 2.26% and 0.85% after THA and TKA, respectively. High-risk patients with extended antibiotic prophylaxis had a significantly lower rate of PJI compared to high-risk patients without extended antibiotic prophylaxis (0.89% vs. 2.64%, respectively; p<0.001). There was no difference in the infection rate between high-risk patients who received antibiotics and low-risk patients (0.89% vs. 1.29%, respectively; p=0.348) with numbers available.
Conclusion: Extended postoperative oral antibiotic prophylaxis for 7 days led to a statistically significant and clinically meaningful reduction in 1-year infection rates of patients at high risk for infection. In fact, the PJI rate in high-risk patients who received antibiotics was less than the rate seen in low-risk patients. Thus, extended oral antibiotic prophylaxis may be a simple measure to effectively counteract poor host factors. Moreover, the findings of this study may mitigate the incentive to select healthier patients in outcome-based reimbursement models. Further study with a multi-center randomized control trial is needed to further validate this protocol.
