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Advances in Prosthetic Joint Infection Care

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A special issue of Journal of Clinical Medicine (ISSN 2077-0383). This special issue belongs to the section "Orthopedics".

Deadline for manuscript submissions: closed (31 August 2020) | Viewed by 28479

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Prof. Dr. Jiri Gallo

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Guest Editor

Department of Orthopedics, Faculty of Medicine and Dentistry, Palacký University Olomouc, University Hospital Olomouc, Olomouc, Czech Republic
Interests: prosthetic joint infection; aseptic loosening; periprosthetic osteolysis; osteoarthritis; functional movement diagnostics

Special Issue Information

Dear Colleagues,

Total joint arthroplasty (TJA) delivers highly valuable outcomes to patients with the end-stage joint diseases. The most frequent reason for early failure is prosthetic joint infection (PJI) associated with colonization of the implant by causative agents originating from wounds during the surgery. Some PJIs originate from hematogenous bacterial invasion or “per continuitatem” from infections occurring around the implant at some point after the surgery. PJI is usually linked to the development of biofilm on prosthetic surfaces, inducing the anti-infective inflammatory host response and resulting in premature implant failure. Little is known regarding the regulation mechanisms individualizing a particular PJI phenotype. TJA reoperations increase the morbidity and mortality at the side of patients and burden healthcare systems. Complex preventative measures, including anti-infective implants, could reduce the incidence of biofilm development on the implant surfaces. Implementing a concept targeting early stages of hematogenous/per continuitatem PJIs is more difficult. Advanced diagnostics enable early and more precise identification of patients suffering from PJI. This can lead to interventions and even save the original implant. Together, these advancements could increase the implant survivorship. In this Special Issue, we critically review advances in the field of PJI diagnosis and prevention, and discuss future research directions.

Prof. Dr. Jiri Gallo
Guest Editor

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Keywords

prosthetic joint infection
epidemiology
biofilm
prevention
anti-infective strategies
diagnostics
diagnostic strategy

Published Papers (10 papers)

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Editorial

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4 pages, 163 KiB

Open AccessEditorial

Prosthetic Joint Infection: Updates on Prevention, Diagnosis and Therapy

by Jiri Gallo

J. Clin. Med. 2020, 9(12), 3892; https://doi.org/10.3390/jcm9123892 - 30 Nov 2020

Cited by 1 | Viewed by 1177

Abstract

Total joint arthroplasty (TJA) delivers highly valuable outcomes to patients with end-stage joint diseases [...] Full article

(This article belongs to the Special Issue Advances in Prosthetic Joint Infection Care)

Research

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9 pages, 257 KiB

Open AccessArticle

A Modified Technique for Two-Stage Revision in Knee PJI Treatment

by Raffaele Iorio, Ferdinando Iannotti, Leonardo Previ, Edoardo Viglietta, Yuri Gugliotta, Federico Corsetti, Simone Fenucci, Angelo De Carli, Pier Francesco Indelli and Andrea Redler

J. Clin. Med. 2023, 12(23), 7323; https://doi.org/10.3390/jcm12237323 - 26 Nov 2023

Cited by 1 | Viewed by 775

Abstract

Knee PJIs represent one of the most important complications after joint replacement surgery. If the prerequisites for implant retention do not subsist, the surgical treatment of these conditions is performed using one-stage and two-stage revision techniques. In this study, an implemented two-stage revision technique was performed, adopting antibiotic calcium sulfate beads and tumor-like debridement guided by methylene blue, such as described for the DAPRI technique. The aim of the present study is to compare the implemented two-stage revision technique with the standard technique in order to assess its effectiveness. Methods. Twenty patients affected by knee PJIs were prospectively enrolled in the study and underwent an implemented two-stage revision technique (Group A). Data collected and clinical results were compared with a matched control group treated with a standard two-stage technique (Group B). For each patient, the time of the reimplantation and length of antibiotic systemic therapy were recorded. Each patient underwent routine laboratory tests, including inflammatory markers. Results. In Group A and in Group B, inflammatory markers normalized at 6.5 ± 1.1. weeks and 11.1 ± 2.3 weeks, respectively (p < 0.05). Also, the difference in length of antibiotic therapy and time to reimplantation were significantly shorter in Group A (p < 0.05). No recurrence of infection was found in Group A at the last follow-up. Discussion. The implemented two-stage revision technique demonstrated a faster normalization of inflammatory markers, as well as a decrease in reimplantation time and duration of antibiotic therapy, compared to the traditional technique. The use of calcium sulfate antibiotic beads and tumor-like debridement seems to improve the results and reduce the time of healing. Conclusion. The implemented two-stage revision technique seems to improve the results and reduce the time of healing. This leads to a more rapid and less stressful course for the patient, as well as a reduction in health care costs. Full article

(This article belongs to the Special Issue Advances in Prosthetic Joint Infection Care)

12 pages, 2297 KiB

Open AccessArticle

Increased Diagnostic Certainty of Periprosthetic Joint Infections by Combining Microbiological Results with Histopathological Samples Gained via a Minimally Invasive Punching Technique

by Andreas Enz, Johanna Becker, Philipp Warnke, Friedrich Prall, Christoph Lutter, Wolfram Mittelmeier and Annett Klinder

J. Clin. Med. 2020, 9(10), 3364; https://doi.org/10.3390/jcm9103364 - 20 Oct 2020

Cited by 9 | Viewed by 2169

Abstract

Background: The diagnosis of low-grade infections of endoprostheses is challenging. There are still no unified guidelines for standardised diagnostic approaches, recommendations are categorised into major and minor criteria. Additional histopathological samples might sustain the diagnosis. However, ambulatory preoperative biopsy collection is not widespread. Method: 102 patients with hip or knee endoprosthesis and suspected periprosthetic joint infection (PJI) were examined by arthrocentesis with microbiological sample and histopathological punch biopsy. The data were retrospectively analysed for diagnosis concordance. Results: Preoperative microbiology compared to intraoperative results was positive in 51.9% (sensitivity 51.9%, specificity 97.3%). In comparison of preoperative biopsy to intraoperative diagnostic results 51.9% cases were positive (sensitivity 51.9%, specificity 100.0%). The combination of preoperative biopsy and microbiology in comparison to intraoperative results was positive in 70.4% of the cases (sensitivity 70.4%, specificity 97.3%). Conclusion: The diagnosis of PJI is complex. One single method to reliably detect an infection is currently not available. With the present method histopathological samples might be obtained quickly, easily and safely for the preoperative detection of PJI. A combination of microbiological and histopathological sampling increases the sensitivity up to 18.5% to detect periprosthetic infection. Full article

(This article belongs to the Special Issue Advances in Prosthetic Joint Infection Care)

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12 pages, 680 KiB

Open AccessArticle

Risk Factors of Periprosthetic Infection in Patients with Tumor Prostheses Following Resection for Musculoskeletal Tumor of the Lower Limb

by Toshifumi Fujiwara, Toshihiro Ebihara, Kazuki Kitade, Nokitaka Setsu, Makoto Endo, Keiichiro Iida, Yoshihiro Matsumoto, Tomoya Matsunobu, Yoshinao Oda, Yukihide Iwamoto and Yasuharu Nakashima

J. Clin. Med. 2020, 9(10), 3133; https://doi.org/10.3390/jcm9103133 - 28 Sep 2020

Cited by 11 | Viewed by 1938

Abstract

Tumor prostheses for the lower limb following resection of musculoskeletal tumors is useful limb salvage management; however, as compared with routine total joint replacement, an increased incidence of deep periprosthetic infection of tumor prosthesis has been observed. The risk factors for periprosthetic infection of tumor prosthesis remain unclear. This study examines the risk factors and outcomes of periprosthetic infection. This was a retrospective observational study including 121 patients (67 males and 54 females) who underwent tumor prosthesis of the lower limb after resection of musculoskeletal tumors between 1 January 2000 and 30 November 2018. Among a total of 121 tumor prostheses, 7 were total femurs, 47 were proximal femurs, 47 were distal femurs, and 20 were proximal tibias. The incidence of postoperative infection and its risk factors were analyzed. Forty-five patients (37%) had osteosarcoma, 36 patients (30%) had bone metastasis, and 10 patients (8%) had soft-tissue tumors invading the bone. The mean operating time was 229 min, and the mean follow-up duration was 5.9 years. Deep periprosthetic infection was noted in 14 patients (12%). In the multivariate analysis, the risk factors for postoperative infection were identified as being male (hazard ratio [HR], 11.2316; p = 0.0100), soft-tissue tumor (HR, 52.2443; p = 0.0003), long operation (HR, 1.0056; p = 0.0184), and radiotherapy (HR, 6.5683; p = 0.0476). The incidence of periprosthetic infection in our institution was similar to that of previous reports. Patients undergoing tumor prosthesis of the lower limb who were male, had a soft-tissue tumor, were predicted to have a long operation, and who underwent radiation, had an increased possibility of postoperative infection. Full article

(This article belongs to the Special Issue Advances in Prosthetic Joint Infection Care)

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15 pages, 3206 KiB

Open AccessArticle

Orthopaedic Surgery Elicits a Systemic Anti-Inflammatory Signature

by Cortney E. Heim, Kelsey J. Yamada, Rachel Fallet, Jessica Odvody, Dana M. Schwarz, Elizabeth R. Lyden, Matthew J. Anderson, Roxanne Alter, Debbie Vidlak, Curtis W. Hartman, Beau S. Konigsberg, Chris A. Cornett, Kevin L. Garvin, Naglaa Mohamed, Annaliesa S. Anderson and Tammy Kielian

J. Clin. Med. 2020, 9(7), 2123; https://doi.org/10.3390/jcm9072123 - 6 Jul 2020

Cited by 13 | Viewed by 2456

Abstract

Little information is available on the functional activity of leukocytes after arthroplasty or the expansion of populations with immune suppressive properties during the acute post-operative period. Synovial fluid and matched pre- and post-surgical blood samples were collected from total hip and knee arthroplasty patients (THA and TKA, respectively) to examine the impact of surgery on peripheral blood leukocyte frequency, bactericidal activity, and inflammatory mediator expression. For spinal surgeries, inflammatory mediator production by peripheral blood mononuclear cells (PBMCs) pre- and post-surgery was examined. An expansion of immune suppressive granulocytic myeloid-derived suppressor cells (G-MDSCs) was observed following arthroplasty, which correlated with significantly increased serum interleukin-10 (IL-10) levels. Analysis of synovial fluid from THA and TKAs revealed reduced granulocyte colony-stimulating factor (G-CSF) and soluble CD40 ligand (sCD40L) and increased interleukin-6 (IL-6), monocyte chemoattractant protein 2 (CCL2) and Fms-like tyrosine kinase 3 ligand (Flt-3L) compared to pre- and post-surgical serum. For the spinal surgery cohort, stimulation of PBMCs isolated post-surgery with bacterial antigens produced significantly less pro-inflammatory (IL-1α, IL-1β, interleukin-1 receptor antagonist (IL-1RA), IL-12p40, growth-related oncogene-α/GRO-α (CXCL1) and 6Ckine (CCL21)) and more anti-inflammatory/tissue repair mediators (IL-10, G-CSF and granulocyte-macrophage colony-stimulating factor (GM-CSF)) compared to PBMCs recovered before surgery. The observed bias towards systemic anti-inflammatory changes without concomitant increases in pro-inflammatory responses may influence susceptibility to infection following orthopaedic surgery in the context of underlying co-morbidities or risk factors. Full article

(This article belongs to the Special Issue Advances in Prosthetic Joint Infection Care)

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16 pages, 274 KiB

Open AccessArticle

The W.A.I.O.T. Definition of Peri-Prosthetic Joint Infection: A Multi-center, Retrospective Validation Study

by Svetlana Bozhkova, Virginia Suardi, Hemant K Sharma, Hiroyuki Tsuchiya, Hernán del Sel, Mahmoud A. Hafez, Thami Benzakour, Lorenzo Drago and Carlo Luca Romanò

J. Clin. Med. 2020, 9(6), 1965; https://doi.org/10.3390/jcm9061965 - 23 Jun 2020

Cited by 12 | Viewed by 2617

Abstract

Peri-prosthetic joint infection (PJI) definition plays an important role in diagnostic and therapeutic decisions. However, while several criteria have been proposed by eminent institutions to define a PJI in the last decade, their clinical validation has been rarely performed. Aim of the present multicenter, international, retrospective study was to validate the World Association against Infection in Orthopedics and Trauma (WAIOT) pre/intra-operative PJI definition with post-operative confirmatory tests. A total of 210 patients, undergoing hip (n = 86) or knee (n = 124) revision surgery for any reason in six orthopedic centers in Africa, Asia, Europe and South America, were retrospectively evaluated at a two years minimum follow-up after surgery. All the available pre-, intra- and post-operative findings were collected and analyzed according to the WAIOT criteria, which include a set of tests to confirm (Rule In) or to exclude (Rule Out) a PJI. On average, patients were investigated pre/intra-operatively with 3.1 ± 1.1 rule out and 2.7 ± 0.9 rule in tests; the presence of a fistula or exposed implant was reported in 37 patients (17.6%). According to pre/intraoperative findings, 36.2% of the patients were defined as affected by high-grade PJI (n = 76; average score: 2.3 ± 0.8), 21.9% by low-grade PJI (n = 46; average score: 0.8 ± 0.8), 10.5% by biofilm-related implant malfunction (n = 22; average score: –1.6 ± 0.8), 2.9% as contamination (n = 6; average score: –3.5 ± 1.0), and 28.6% as no infection (n = 60; average score: –3.0 ± 1.4). Pre/intra-operative PJI definitions matched post-operative confirmatory tests, in 97.1% of the patients. This is, to our knowledge, one of the largest study ever conducted to validate a PJI definition The retrospective analysis in different centers was greatly facilitated by the structure of the WAIOT definition, that allows to include different tests on the basis of their sensitivity/specificity, while the comparison between pre/intra-operative and post-operative findings offered the internal validation of the scoring system. Our results authenticate the WAIOT definition as a reliable, simple tool to identify patients affected by PJI prior to joint revision surgery. Full article

(This article belongs to the Special Issue Advances in Prosthetic Joint Infection Care)

11 pages, 1180 KiB

Open AccessArticle

Extracellular Vesicle Isolation and Characterization from Periprosthetic Joint Synovial Fluid in Revision Total Joint Arthroplasty

by Julian M. Rüwald, Thomas M. Randau, Cäcilia Hilgers, Werner Masson, Stephan Irsen, Robin L. Eymael, Hendrik Kohlhof, Sascha Gravius, Christof Burger, Dieter C. Wirtz and Frank A. Schildberg

J. Clin. Med. 2020, 9(2), 516; https://doi.org/10.3390/jcm9020516 - 14 Feb 2020

Cited by 8 | Viewed by 3192

Abstract

Extracellular vesicles (EVs) comprise an as yet insufficiently investigated intercellular communication pathway in the field of revision total joint arthroplasty (RTJA). This study examined whether periprosthetic joint synovial fluid contains EVs, developed a protocol for their isolation and characterized them with respect to quantity, size, surface markers as well as documented their differences between aseptic implant failure (AIF) and periprosthetic joint infection (PJI). EV isolation was accomplished using ultracentrifugation, electron microscopy (EM) and nanoparticle tracking analysis evaluated EV presence as well as particle size and quantity. EV surface markers were studied by a bead-based multiplex analysis. Using our protocol, EM confirmed the presence of EVs in periprosthetic joint synovial fluid. Higher EV particle concentrations and decreased particle sizes were apparent for PJI. Multiplex analysis confirmed EV-typical surface epitopes and revealed upregulated CD44 and HLA-DR/DP/DQ for AIF, as well as increased CD40 and CD105. Our protocol achieved isolation of EVs from periprosthetic joint synovial fluid, confirmed by EM and multiplex analysis. Characterization was documented with respect to size, concentration and epitope surface signature. Our results indicate various differences between PJI and AIF EVs. This pilot study enables new research approaches and rising diagnostic opportunities in the field of RTJA. Full article

(This article belongs to the Special Issue Advances in Prosthetic Joint Infection Care)

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9 pages, 705 KiB

Open AccessArticle

The Right Time to Safely Re-Evaluate Empirical Antimicrobial Treatment of Hip or Knee Prosthetic Joint Infections

by Luc Deroche, Pascale Bémer, Anne-Sophie Valentin, Anne Jolivet-Gougeon, Didier Tandé, Geneviève Héry-Arnaud, Carole Lemarié, Marie Kempf, Laurent Bret, Christophe Burucoa, Stéphane Corvec and Chloé Plouzeau

J. Clin. Med. 2019, 8(12), 2113; https://doi.org/10.3390/jcm8122113 - 2 Dec 2019

Cited by 8 | Viewed by 2444

Abstract

Currently, no guideline provides recommendations on the duration of empirical antimicrobial treatment (EAT) in prosthetic joint infection (PJI). The aim of our study was to describe the time to growth of bacteria involved in PJI, rendering possible decreased duration of EAT. Based on a French multicentre prospective cohort study, culture data from patients with confirmed hip or knee PJI were analysed. For each patient, five samples were processed. Time to positivity was defined as the first positive medium in at least one sample for virulent pathogens and as the first positive medium in at least two samples for commensals. Definitive diagnosis of polymicrobial infections was considered the day the last bacteria were identified. Among the 183 PJIs, including 28 polymicrobial infections, microbiological diagnosis was carried out between Day 1 (D1) and D5 for 96.7% of cases. There was no difference in the average time to positivity between acute and chronic PJI (p = 0.8871). Microbiological diagnosis was given earlier for monomicrobial than for polymicrobial infections (p = 0.0034). When an optimized culture of peroperative samples was carried out, almost all cases of PJI were diagnosed within five days, including polymicrobial infections. EAT can be re-evaluated at D5 according to microbiological documentation. Full article

(This article belongs to the Special Issue Advances in Prosthetic Joint Infection Care)

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Review

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12 pages, 1228 KiB

Open AccessReview

Is There a Role for Spacer Exchange in Two-Stage Exchange Arthroplasty for Periprosthetic Joint Infection?

by Elie Kozaily, Emanuele Chisari and Javad Parvizi

J. Clin. Med. 2020, 9(9), 2901; https://doi.org/10.3390/jcm9092901 - 8 Sep 2020

Cited by 12 | Viewed by 4214

Abstract

Periprosthetic joint infection (PJI) continues to be one of the most serious complications after hip and knee arthroplasty. The choice of surgical treatment depends on a multitude of factors like chronicity of infection, host factors, and institutional or surgeon experience. Two-stage exchange remains one of the most commonly used technique for chronic PJI in the United States of America. The intended two-stage revision may involve an additional interim procedure where the initial antibiotic cement spacer is removed and a new spacer is inserted. Mostly, the rationale behind spacer exchange is an additional load of local antibiotics before proceeding to reimplantation. There is no conclusive evidence whether a spacer exchange confers additional benefits, yet it delays reimplantation and exposes already fragile patients to the risks and morbidity of an additional surgery. Full article

(This article belongs to the Special Issue Advances in Prosthetic Joint Infection Care)

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26 pages, 1494 KiB

Open AccessReview

Prevention of Prosthetic Joint Infection: From Traditional Approaches towards Quality Improvement and Data Mining

by Jiri Gallo and Eva Nieslanikova

J. Clin. Med. 2020, 9(7), 2190; https://doi.org/10.3390/jcm9072190 - 11 Jul 2020

Cited by 20 | Viewed by 6723

Abstract

A projected increased use of total joint arthroplasties will naturally result in a related increase in the number of prosthetic joint infections (PJIs). Suppression of the local peri-implant immune response counters efforts to eradicate bacteria, allowing the formation of biofilms and compromising preventive measures taken in the operating room. For these reasons, the prevention of PJI should focus concurrently on the following targets: (i) identifying at-risk patients; (ii) reducing “bacterial load” perioperatively; (iii) creating an antibacterial/antibiofilm environment at the site of surgery; and (iv) stimulating the local immune response. Despite considerable recent progress made in experimental and clinical research, a large discrepancy persists between proposed and clinically implemented preventative strategies. The ultimate anti-infective strategy lies in an optimal combination of all preventative approaches into a single “clinical pack”, applied rigorously in all settings involving prosthetic joint implantation. In addition, “anti-infective” implants might be a choice in patients who have an increased risk for PJI. However, further progress in the prevention of PJI is not imaginable without a close commitment to using quality improvement tools in combination with continual data mining, reflecting the efficacy of the preventative strategy in a particular clinical setting. Full article

(This article belongs to the Special Issue Advances in Prosthetic Joint Infection Care)

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