Wilfrid Graff

Infected total hip arthroplasty revision: one- or two-stage procedure?

INTRODUCTION Better outcomes have been reported for two-stage total hip arthroplasty (THA) revision for infection. However, one-stage revision arthroplasty remains an attractive alternative option since it requires only one operation. A decision tree has been developed by the authors in order to determine which type of surgical procedure can be performed safely. The goal of this study was to assess this decision tree for THA replacement in the case of a peri-prosthetic infection. HYPOTHESIS A one-stage procedure may be as successful as a two-stage procedure provided some criteria are fulfilled. METHODS A prospective study included 84 patients, all diagnosed with infected THA who had prosthesis replacement. A one-stage exchange was performed in 38 cases and a two-stage procedure in 46 cases. A two-stage procedure was decided in the case of important bone loss or unidentified germ. Postoperatively, patients received intravenous antibiotics (six weeks), then oral antibiotics (six weeks). The main evaluation criterion was the rate of infection eradication at 2 years minimal follow-up since surgery. If new infection was suspected, a hip aspiration was performed to determine whether it was non-eradication (same germ) or a new re-infection (other germ), which was not considered as a failure. RESULTS The initial infection was cured in 83 out of 84 patients (98.8%), 38 (100%) for the one-stage group and 45 (97.8%) for the two-stage group. Three patients were re-infected with different germs in the two-stage group. Eighty out of 84 (95.2%) patients were infection free, all patients (100%) of the one-stage group and 42 patients (91.3%) of two-stage group. DISCUSSION If some selection criteria were respected, a high success rate in THA replacement for infection may be achieved with a one-stage procedure. It permits to reduce the costs with no loss of chance for the patients. The decision tree was validated. LEVEL OF EVIDENCE Level III; prospective case control study.

One-Stage Exchange Arthroplasty for Chronic Periprosthetic Hip Infection: Results of a Large Prospective Cohort Study

BACKGROUND Exchange arthroplasty of one or two stages is required for the treatment of chronic periprosthetic joint infections. Two-stage exchange is costly and has high morbidity with limited patient mobility between procedures. One-stage exchange has been promoted by several European teams as the preferred alternative. The aim of this study was to prospectively analyze the outcome of patients with a periprosthetic hip infection treated with one-stage exchange arthroplasty. METHODS We performed a prospective cohort study in a French referral center for osteoarticular infections including all periprosthetic hip infections treated with one-stage exchange arthroplasty from November 2002 to March 2010. Direct exchange was performed in chronic periprosthetic hip infection with no or minor bone loss and preoperative identification of a microorganism from joint fluid aspirate. No antibiotic-loaded bone cement was used. Antibiotic therapy was administered for twelve weeks: intravenously for four to six weeks, followed by an oral regimen for six to eight weeks. Follow-up was a minimum of two years. The following events were noted: relapse, new infection, joint revision for mechanical reasons, and periprosthetic hip infection-related and unrelated deaths. RESULTS One hundred and fifty-seven patients with periprosthetic hip infections with a median infection duration of 258 days (interquartile range, 120 to 551 days) prior to our index surgical procedure for infection were included. Periprosthetic hip infection occurred in ninety-nine cases of primary hip arthroplasty, twenty-seven cases of revision arthroplasty, and thirty-one cases in which the periprosthetic hip infection had been treated previously. A difficult-to-treat organism was isolated in fifty-nine cases (38%). After a median follow-up of 41.6 months (interquartile range, 28.1 to 66.9 months), two relapses, six new infections, nine revisions for mechanical reasons, two related deaths, and nineteen unrelated deaths occurred. CONCLUSIONS One-stage exchange arthroplasty is an effective surgical procedure in patients with periprosthetic hip infection who have good bone quality. Precise identification of the microorganism(s) and prolonged administration of appropriate intravenous antibiotic therapy are key factors for successful treatment.

Arthrodesis with Internal Fixation of the Infected Ankle

Arthrodesis may be necessary to avoid amputation when treating an infected tibiotalar joint. In such cases, external or hybrid fixation is usually used. In this retrospective study, we report our experience in treating tibiotalar joint infection by arthrodesis with internal fixation. From March 1992 to October 2005 (13 years, 7 months), 20 patients underwent septic ankle arthrodesis with internal fixation. The mean duration of infection before fusion was 2.5 ± 6.7 years. Arthrodesis was performed with the Méary technique in 9 (45%) cases and with the Crawford-Adams technique in 11 (55%) cases. Internal fixation consisted of screw fixation, staple fixation, or a combination of both. The mean duration of antibiotic treatment was 97.5 ± 37.5 days, and the mean follow-up was 64 ± 36 months, with no patient lost to follow-up. Patients were considered cured if no clinical, biological, or radiologic signs of infection were present at a minimum of 2 years follow-up. The incidence of cure was 85.0% (91.0% with Crawford-Adams and 77.8% with Méary techniques). Radiographic fusion was identified in 89.5% of the cases (91.0% with Crawford-Adams and 87.5% with Méary techniques) at a mean of 4.8 ± 2.4 (range 3 to 11) months postoperative. Tibiotalar arthrodesis in the presence of sepsis can be performed with internal osteosynthesis only under certain conditions. In our experience, this treatment produced satisfactory fusion in 89.5% of patients and eradicated infection in 85.0% of cases.

Monitoring the one year postoperative infection rate after primary total hip replacement

PurposeInfection of a total hip replacement is potentially a devastating complication. Statistical process control methods have been generating interest as a means of improving the quality of healthcare, and we report our experience with the implementation of such a method to monitor the one year infection rate after primary total hip replacement.MethodInfection was defined as the growth of the same organism in cultures of at least two aspirates or intra-operative specimens, or growth of one pathogen in a patient with local signs of infection such as erythema, abscess or draining sinus tract. The cumulative summation test (CUSUM test) was used to continuously monitor the one year postoperative infection rate. The target performance was 0.5% and the test was set to detect twice that rate.ResultsOver the three year study period, 2006 primary total hip replacements were performed. Infection developed within one year after surgery in eight (0.4%) hips. The CUSUM test generated no alarms during the study period, indicating that there was no evidence that the process was out of control.ConclusionThe one year infection rate after primary total hip replacement was in control. The CUSUM test is a useful method to continuously ensure that performance is maintained at an adequate level.

169 Étude prospective du traitement des infections de prothèses totales de hanche. À propos de 100 cas suivis avec un recul minimum de 2 ans

Introduction L’infection sur prothese totale de hanche (PTH) est une complication grave source de morbidite et parfois de mortalite. Son traitement est lourd et couteux. Il reste mal codifie et peu evalue. Le taux de recurrence infectieuse varie entre 6 et 12 % dans la litterature. L’objectif principal de l’etude etait d’evaluer l’efficacite de nos strategies therapeutiques. Methode Cette etude prospective menee de 2002 a 2005, a inclus 100 patients ayant presente une infection documentee sur PTH, âges en moyenne de 67 annees ± 12. Une excision lavage etait realisee en cas d’evolution inferieure a 15 jours (en l’absence de descellement) alors qu’un changement de prothese etait entrepris dans le cas inverse. Le choix de reprise en 1 ou 2 temps dependait de l’importance du defect osseux (classification SOFCOT). Une antibiotherapie postoperatoire etait instauree 6 semaines par voie intraveineuse, puis 6 semaines per-os. Le critere principal de jugement etait le taux de guerison apparente de l’infection initiale a un recul minimum de 2 ans, definie par l’absence de signes cliniques biologiques et radiologiques d’infection et l’absence de deces imputable a l’infection ou au traitement. En cas de suspicion d’infection, la ponction de hanche ou les prelevements peroperatoires confirmaient la rechute (germe identique) ou la reinfection (germe different). Resultats Le traitement chirurgical a consiste en une excision lavage dans 10 cas, un changement en un temps dans 44 cas et en 2 temps dans 41 cas. Une resection tete-col a ete realisee chez 5 patients. La duree moyenne de l’antibiotherapie etait de 99 jours ± 37 dont 45 jours ± 19 par voie intraveineuse. Le taux de guerison avec un recul moyen de 27 mois ± 10 etait de 95 % et de 100 % en cas de un temps. Cinq echecs on ete notes dont 2 deces et 3 rechutes infectieuses, dont 2 apres excision-lavage et 1 apres changement en 2 temps. Cependant, 3 patients ont eu une re-infection avec un germe different moins de 2 ans apres un changement en 2 temps. Le taux de patients indemnes de toute infection au dernier recul etait donc de 92 %. Discussion Trois reinfections sont survenues apres un changement en 2 temps posant la question du mode de contamination. Conclusion Les strategies therapeutiques utilisees ont ete validees avec un taux de guerison de 95 % comparable a ceux rapportes dans la litterature. L’infection sur PTH est une complication grave associee dans cette etude a une mortalite de 2 % et une rechute de 3 %.

Hip arthroplasty infection with heterogeneous vancomycin-resistant Staphylococcus aureus.

We report a case of heterogeneous vancomycin-resistant Staphylococcus aureus hip arthroplasty infection. Apparent cure was obtained by excision of infected tissues and removal of prosthetic material combined with optimal and closely monitored prolonged intravenous antibiotic therapy including continuous high-dose vancomycin.

Concomitant Multiple Joint Arthroplasty Infections: Report on 16 Cases.

BACKGROUND Concomitant infections of several prostheses are very rare, serious events that pose particular medical and surgical therapeutic challenges. This study was undertaken to describe epidemiologic, clinical, and microbiological characteristics of concomitant multiple joint arthroplasty infections, their treatments, and outcomes. METHODS Retrospective (January 2000 and January 2014), single-center, cohort study in a referral center for bone and joint infections. All patients with at least 2 concomitant, microbiologically documented, prosthetic joint infections, that is, during the same septic episode, were included. RESULTS Sixteen patients were included. Median (range) age was 78 years (46-93 years), gender ratio was 1, and median (range) body mass index was 27 (21-42). Multiple joint arthroplasties (bilateral hip in 8 patients; bilateral knee in 3 patients; hip and knee in 1 patient; and 2 knees and 1 hip in 1 patient) were contaminated hematogenously in all patients, 2 after early postoperative infections. Eight Staphylococcus aureus, 1 Staphylococcus epidermidis, 6 Streptococcus, and 1 Escherichia coli strains were isolated. A curative strategy was applied to 11 patients: 3 underwent bilateral synovectomies, 6 had successive 1-stage exchange arthroplasties, and 2 were treated with other strategies. After 37 months (range, 24-132 months) of follow-up, reinfection occurred in 1 patient. The 5 other patients received prolonged suppressive antibiotic therapy. CONCLUSION These complex infections occur during staphylococcal or streptococcal bacteremia. Treatment strategies should be discussed by a multidisciplinary team on a case-by-case basis.

Doctor, What Does my Knee Arthroplasty Weigh?

The aim of this study was to compare the weight of the total knee arthroplasty (TKA) implants and the weight of the natural knee. A prospective study was conducted with two different brands of cemented primary TKA. During the procedure, we collected the removed bone, soft tissues and the post-implantation cement and weighed them all separately at the end. In both groups, the implants plus cement were significantly heavier than the removed bone and soft tissues. The average weight gained was 266.7 ± 35.1 g for group 1 and 279.1 ± 48.7 g for group 2. This significant local weight gained after TKA is a new parameter that should be taken into account for further studies and when creating new implants.