Claudio Diaz-Ledezma

Success After Treatment of Periprosthetic Joint Infection: A Delphi-based International Multidisciplinary Consensus

BackgroundThe lack of agreement regarding what constitutes successful treatment for periprosthetic joint infections (PJI) makes it difficult to compare the different strategies of management that are used in clinical practice and in research studies.Questions/purposesThe aims of this study were to create a consensus definition for success after PJI treatment, and to provide a universal, multidimensional framework for reporting of studies regarding PJI treatment.MethodsA two-round basic Delphi method was used to reach a consensus definition. We invited 159 international experts (orthopaedic surgeons, infectious disease specialists, and clinical researchers) from 17 countries to participate; 59 participated in the first round, and 42 participated in the second round. The final definition consisted of all statements that achieved strong agreement (80% or greater of participants considering a criterion relevant for defining success).ResultsThe consensus definition of a successfully treated PJI is: (1) infection eradication, characterized by a healed wound without fistula, drainage, or pain, and no infection recurrence caused by the same organism strain; (2) no subsequent surgical intervention for infection after reimplantation surgery; and (3) no occurrence of PJI-related mortality (by causes such as sepsis, necrotizing fasciitis). The Delphi panel agreed to defining midterm results as those reported 5 or more years after the definitive PJI surgery, and long-term results as those reported 10 or more years after surgery. Although no consensus was reached on the definition of short-term results, 71% of the participants agreed that 2 years after the definitive PJI surgery is acceptable to define it.ConclusionsThis multidimensional definition of success after PJI treatment may be used to report and compare results of treatment of this catastrophic complication.Level of EvidenceLevel V, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Direct anterior approach for total hip arthroplasty: indications, technique, and results.

The direct anterior approach (DAA) to the hip was initially described in the 19th century and has been used sporadically for total hip arthroplasty (THA). In the past decade, enthusiasm for the approach has been renewed because of increased demand for minimally invasive techniques. New surgical instruments and tables designed specifically for use with the DAA for THA have made the approach more accessible to surgeons. Some authors claim that this approach results in less muscle damage and pain as well as rapid recovery, although limited data exist to support these claims. The DAA may be comparable to other THA approaches, but there is no evidence to date that shows improved long-term outcomes for patients. The steep learning curve and complications unique to this approach (fractures and nerve damage) have been well described. However, the incidence of these complications decreases with greater surgeon experience. A question of keen interest to hip surgeons and patients is whether the DAA results in improved early outcomes and long-term results comparable to those of other approaches for THA.

Diagnosis of Periprosthetic Joint Infection in Medicare Patients: Multicriteria Decision Analysis

BackgroundIn the setting of finite healthcare resources, developing cost-efficient strategies for periprosthetic joint infection (PJI) diagnosis is paramount. The current levels of knowledge allow for PJI diagnostic recommendations based on scientific evidence but do not consider the benefits, opportunities, costs, and risks of the different diagnostic alternatives.Questions/purposesWe determined the best diagnostic strategy for knee and hip PJI in the ambulatory setting for Medicare patients, utilizing benefits, opportunities, costs, and risks evaluation through multicriteria decision analysis (MCDA).MethodsThe PJI diagnostic definition supported by the Musculoskeletal Infection Society was employed for the MCDA. Using a preclinical model, we evaluated three diagnostic strategies that can be conducted in a Medicare patient seen in the outpatient clinical setting complaining of a painful TKA or THA. Strategies were (1) screening with serum markers (erythrocyte sedimentation rate [ESR]/C-reactive protein [CRP]) followed by arthrocentesis in positive cases, (2) immediate arthrocentesis, and (3) serum markers requested simultaneously with arthrocentesis. MCDA was conducted through the analytic hierarchy process, comparing the diagnostic strategies in terms of benefits, opportunities, costs, and risks.ResultsStrategy 1 was the best alternative to diagnose knee PJI among Medicare patients (normalized value: 0.490), followed by Strategy 3 (normalized value: 0.403) and then Strategy 2 (normalized value: 0.106). The same ranking of alternatives was observed for the hip PJI model (normalized value: 0.487, 0.405, and 0.107, respectively). The sensitivity analysis found this sequence to be robust with respect to benefits, opportunities, and risks. However, if during the decision-making process, cost savings was given a priority of higher than 54%, the ranking for the preferred diagnostic strategy changed.ConclusionsAfter considering the benefits, opportunities, costs, and risks of the different available alternatives, our preclinical model supports the American Academy of Orthopaedic Surgeons recommendations regarding the use of serum markers (ESR/CRP) before arthrocentesis as the best diagnostic strategy for PJI among Medicare patients.Level of EvidenceLevel II, economic and decision analysis. See Instructions to Authors for a complete description of levels of evidence.

Periprosthetic knee infection: ten strategies that work.

Periprosthetic joint infection (PJI) is one of the most serious complications following total knee arthroplasty (TKA). The demand for TKA is rapidly increasing, resulting in a subsequent increase in infections involving knee prosthesis. Despite the existence of common management practices, the best approach for several aspects in the management of periprosthetic knee infection remains controversial. This review examines the current understanding in the management of the following aspects of PJI: preoperative risk stratification, preoperative antibiotics, preoperative skin preparation, outpatient diagnosis, assessing for infection in revision cases, improving culture utility, irrigation and debridement, one and two-stage revision, and patient prognostic information. Moreover, ten strategies for the management of periprosthetic knee infection based on available literature, and experience of the authors were reviewed.

Mini-Open Femoroacetabular Osteoplasty How Do These Patients Do?

Femoroacetabular impingement, a condition seen in young active patients, is believed to lead to early degeneration of the hip joint if left untreated. We have over the last 5 years utilized a mini-open direct anterior approach to perform femoroacetabular osteoplasty (FAO) for the hip. Between January 2006 and February 2011, 293 hips (265 patients) underwent direct anterior mini-open FAO performed by a single surgeon; 156 hips (149 patients) have reached a minimum 2-year follow-up, with an average follow-up of 2.3 years (range 2.0 to 4.2 years). Preoperative Short Form 36, Western Ontario and McMaster Universities Arthritis Index, University of California Los Angeles, modified Harris Hip, and Super Simple Hip scores improved significantly (P < .001). This study shows promising mid-term results for the mini-open FAO procedure, alleviating pain and allowing return to activity in young patients with femoroacetabular impingement. Further studies need to be performed to determine risk factors for failure of FAO and ideal patient selection.

Extensor Mechanism Reconstruction with Achilles Tendon Allograft in TKA: Results of an Abbreviate Rehabilitation Protocol

Various treatment alternatives address extensor mechanism failure after total knee arthroplasty. We present the results of a protocol utilizing Achilles tendon allograft followed by an abbreviated immobilization program to treat extensor mechanism disruptions after TKA in 29 knees (27 patients). Failed reconstruction was defined as mechanical allograft failure requiring re-intervention, extension lag >30°, recurrent falls, regression to a lower ambulatory status, and revision due to infection. With mean follow-up of 3.5 years, seventeen cases (58.6%) had satisfactory results, eleven cases (37.9%) were considered failures, and one case was lost to follow-up. Among failures, eight (27.5%) underwent reoperation with four (13.8%) due to late infections. Our observational data suggest that 1) a shortened immobilization protocol yields less favorable results than expected, and 2) continuous monitoring of patients who had allograft reconstruction for possible development of late infection is recommended.

Diagnosis of Periprosthetic Joint Infection: The Role of Nuclear Medicine May Be Overestimated.

Although the International Consensus Meeting on Periprosthetic Joint Infections definition of periprosthetic joint infection (PJI) does not include nuclear imaging as part of the diagnostic criteria, many contemporary nuclear imaging studies are reporting exceptional results in PJI diagnosis. We conducted a systematic review of studies published from 2004 to 2012 reporting the accuracy of nuclear imaging for diagnosis of PJI, utilizing a specially designed tool (QUADAS-2) for critical appraisal and investigation of bias. Our results revealed high risk of bias as well as high levels of concern regarding the clinical applicability of these tests in a majority of the studies. On the basis of our findings, we recommend that the use of nuclear imaging for diagnosis of PJI be limited to a few select cases.

Surgical Approaches for Cam Femoroacetabular Impingement: The Use of Multicriteria Decision Analysis

BackgroundCurrently, three surgical approaches are available for the treatment of cam femoroacetabular impingement (FAI), namely surgical hip dislocation (SHD), hip arthroscopy (HA), and the miniopen anterior approach of the hip (MO). Although previous systematic reviews have compared these different approaches, an overall assessment of their performance is not available.Questions/purposesWe therefore executed a multidimensional structured comparison considering the benefits, opportunities, costs, and risk (BOCR) of the different approaches using multicriteria decision analysis (MCDA).MethodsA MCDA using analytic hierarchical process (AHP) was conducted to compare SHD, HA, and MO in terms of BOCR on the basis of available evidence, institutional experience, costs, and our understanding of pathophysiology of FAI. A preclinical decision-making model was created for cam FAI to establish the surgical approach that better accomplishes our objectives regarding the surgical treatment. A total score of an alternative’s utility and sensitivity analysis was established using commercially available AHP software.ResultsThe AHP model based on BOCR showed that MO is the best surgical approach for cam FAI (normalized score: 0.38) followed by HA (normalized score: 0.36) and SHD (normalized score: 0.25). The sensitivity analysis showed that HA would turn into the best alternative if the variable risks account for more than 61.8% of the priority during decision-making. In any other decision-making scenario, MO remains as the best alternative.ConclusionsUsing a recognized method for decision-making, this study provides supportive data for the use of MO approach as our preferred surgical approach for cam FAI. The latter is predominantly derived from the lower cost of this approach. Our data may be considered a proxy performance measurement for surgical approaches in cam FAI.Level of EvidenceLevel II, economic and decision analyses. See the Guidelines for Authors for a complete description of levels of evidence.

Prevention of venous thromboembolic events following femoroacetabular osteoplasty: aspirin is enough for most

Background As hip-preservation surgery is performed in a particularly young and active group of patients, the knowledge accrued in the fields of hip arthroplasty and hip fracture care regarding postoperative thromboprophylaxis cannot be extrapolated to this patient population. Recommendations based on the evidence for each particular surgical procedure and population is desirable. For these reasons, the purpose of our study is to describe the rate of clinically relevant venous thromboembolism (VTE) and anticoagulation-related complications observed in patients undergoing hip-preservation surgery through mini-open femoracetabular osteoplasty (FAO) with a formal postoperative thromboprophylaxis protocol of aspirin dosing. Methods A prospective case series of 407 consecutive FAO procedures in 375 patients of mean age 34.5 ± 11.1 years (range 15–62 years) were followed six weeks postoperatively to document the presence of clinically relevant VTE as well as major bleeding events, as defined by the most recent American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. All patients were given aspirin 325 mg by mouth daily for two to four weeks. Results There was one case of distal DVT in a 31-year-old male with no specific risk factors. No cases of pulmonary embolism were observed. There were no major bleeding events or reoperations due to postsurgical haematoma. There were no deaths. The crude incidence of clinically relevant VTE was 1 per 407 procedures (0.25%). Conclusion Aspirin is a safe and effective modality to provide thromboprophylaxis in patients undergoing hip-preservation surgery. The rate of VTE that we observed is, thus far, the lowest in comparison to other published series of hip preservation surgery that specifically focused on this complication.

Statistics In Brief: Minimum Clinically Important Difference—Availability of Reliable Estimates

To enter the era of value-based orthopaedics (‘‘health outcomes per dollar spent’’) [2, 19], clinical researchers will have to prove that each treatment produces a meaningful clinical improvement using outcomes that are relevant for patients. The American Association of Hip and Knee Surgeons has recommended the use of patient-reported outcome measures to evaluate the results of knee and hip arthroplasties [16]. Studies have focused on statistically detectable (sometimes called statistically significant) differences [35]; however, it can be possible to detect statistical differences between interventions that are so small as not to be discernible to patients. Such small differences may not justify the cost or risk of the intervention. It seems much more important that treatments should result in clinical improvements big enough for patients to consider clinically important. For a given outcome measure, we questioned how much improvement is needed for patients to consider the difference clinically important? Stated otherwise, what is the minimum clinically important differences (MCID) for a specific outcomes measurement tool, such as the SF-36 or the Oswestry Disability Index?