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PubMed2003

Immunoscintigraphy of septic loosening of knee endoprosthesis: a retrospective evaluation of the antigranulocyte antibody BW 250/183.

Immunoscintigraphy with the use of the antigranulocyte antibody BW 250/183 is a reliable method for detecting infection, especially in septic loosening of hip prostheses, for which purpose quantitative interpretation of the time-activity course is employed. Therefore, we retrospectively studied whether similar results could be achieved in knee prostheses. We verified 28 scintigraphic examinations in 26 patients by histology. Scintigraphy was performed during an early (4-6 h post injection) and a late phase (23-25 h post injection). Infection was diagnosed when activity around the knee prosthesis increased by more than 10% compared with bone marrow. We found a sensitivity and a negative predictive value of 100%, a specificity of 80%, a positive predictive value of 81% and an accuracy of 89%. Specificity and accuracy are lower than in the evaluation of hip prostheses; however, in comparison to other scintigraphic modalities, scintigraphy with the antigranulocyte antibody BW 250/183 is superior in excluding infection and has better specificity and accuracy. Therefore, as in the case of hip prostheses, the described methodology appears to be the scintigraphic modality of choice for knee prostheses.

Aged↗
PubMed2006

The value of FDG-PET in patients with painful total knee arthroplasty.

PURPOSE: The purpose of this study was to evaluate 18F-fluorodeoxyglucose (FDG) uptake in patients with painful total knee arthroplasty and to relate FDG uptake to the location of soft tissue pain. METHODS: Twenty-eight patients with painful total knee arthroplasty had a clinical examination, standard radiographs, CT measurement of rotation of the femoral component and FDG-PET (18 PET/CT, 10 PET). The diagnosis of infection was based on microbiological examinations of surgical specimens (n=12) or clinical follow-up for at least 6 months (n=16), 99mTc-labelled monoclonal antibody scintigraphy and joint aspiration. RESULTS: Twenty-seven of 28 patients presented with diffuse synovial FDG uptake. Additional focal extrasynovial FDG uptake was observed in 19 knees. Twenty-four of the 28 patients had a diagnosis of internal femoral malrotation. The remaining four patients showed no rotation (0 degrees) and 3 degrees, 4 degrees and 7 degrees of external rotation, respectively. Three patients presented with the additional diagnosis of an infected total knee replacement. Pain was described as diffuse (n=10) or focal (n=18). In two knees a relationship between pain location and FDG uptake was observed. Of ten patients with a severe internal femoral component rotation (>6 degrees), seven had focal uptake, four in the femoral periosteum and three in the tibial periosteum. The difference between knees with severe malrotation and the remaining knees was not significant (p=1.000, Fisher's Exact Test). CONCLUSION: Diffuse synovial and focal extrasynovial FDG-PET uptake is commonly found in patients with malrotation of the femoral component and is not related to pain location. The information provided by FDG-PET does not contribute to the diagnosis and management of individual patients with persistent pain after total knee replacement.

Aged↗
PubMed2001

Hydroxyapatite coated hip prosthesis followed up for 5 years.

We prospectively studied 250 patients with a proximal hydroxyapatite coated hip prosthesis. The follow-up period was 5 years. All components showed osseointegration except for one deep infection. The morphology of bone remodeling with either endosteal bone formation or periosteal bone formation was dependent on the way the stem filled the medullary canal. No linear or distal osteolysis around the stems was observed.

Adult↗
PubMed2001

Primary total hip arthroplasty in patients with rheumatoid arthritis.

Twenty-eight (11 cemented and 17 noncemented) total hip arthroplasties (THA) were performed in 20 patients with rheumatoid arthritis (RA). The average age at operation was 42.1 years and the average follow-up was 10.8 years. There were two deep infections requiring removal of the prosthesis. Three cemented acetabular cups and one cemented femoral component were revised due to aseptic loosening. One cemented cup was loosened radiologically. One PCA polyethylene liner was revised because of significant wear. Both cemented and noncemented femoral components are capable of providing respectable results in RA patients. The relatively inferior results of THA among RA patients is due not only to the fixation method, but also to the poorer bone quality.

Activities of Daily Living↗
PubMed1998

The Girdlestone pseudarthrosis in the treatment of infected hip replacements.

The results of 78 resections of the head and neck of the femur (Girdlestone pseudarthrosis) in patients with infected hip replacements were studied. The mean follow-up was 5 years. At the time of the resection, gram-positive organisms were found in 53% of the cases, gram-negative in 33%, and in 12% there were mixed flora. The Girdlestone pseudarthrosis controlled the infection in 86% and achieved satisfactory relief of pain in 83%. The mean shortening of the limb was 4.1 cm and every patient needed some type of external walking aid. We found no correlation between the type of organisms and the persistence of infection, nor between shortening and the functional results. The Girdlestone pseudarthrosis is an acceptable method of controlling infection and relieving pain after infection of a total hip replacement.

Adult↗
PubMed1998

A cement spacer for two-stage revision of infected implants of the hip joint.

We report the technical details and clinical results of twelve patients who had deep infections of implants in the hip joint and were treated by two-stage revision, using a gentamicin-loaded, hand-moulded cement spacer inserted for the period between resection and reimplantation arthroplasty. During management with the spacer, usually for 4 months, patients were almost free of pain and mobile with good leg control, spending 2/3 of the treatment period at home. Six of twelve spacers failed locally due to dislocation [5] or cement fracture [1], and more than two further episodes of surgery were required in 3 patients. Problems with dislocation of the spacer were significantly higher when the head to neck offset was lacking (P < 0.05) or when anchorage in the femoral shaft was poor. Nevertheless, infection after reimplantation arthroplasty did not occur by the time of follow-up (2.2 years). Based on these data, we consider that the use of the cement spacer is a promising approach to the treatment of complicated infections of the hip joint.

Aged↗
PubMedDate not supplied

Conversion of non-tunneled to tunneled hemodialysis catheters.

PURPOSE: To determine the safety and efficacy of conversion of non-tunneled (temporary) catheters to tunneled catheters in hemodialysis patients. METHODS: A retrospective review of 112 consecutive conversions in 111 patients was performed over a period of 4 years. Fourteen patients were lost to follow-up. The remaining 97 patients had clinical follow-up. Temporary catheters were converted to tunneled catheters utilizing the same internal jugular venotomy sites and a modified over-the-wire technique with use of a peel-away sheath . Follow-up clinical data were reviewed. RESULTS: Technical success was achieved in all 112 procedures. None of the 97 patients with follow-up suffered early infection within 30 days. The total number of follow-up catheter days was 13,659 (range 2-790). Cases of confirmed and suspected bacteremia requiring catheter removal occurred at a frequency of 0.10 per 100 catheter days. Suspected catheter infection treated with antibiotics but not requiring catheter intervention occurred at a frequency of 0.04 per 100 catheter days. Frequency of all suspected or confirmed infections was 0.14 per 100 catheter days. Catheter interventions as a result of poor blood flow, inadvertent removal, catheter fracture, or kinking occurred at a rate of 0.18 per 100 catheter days. Life table analysis revealed primary patency rates of 86%, 64%, and 39% at 30 days, 90 days, and 180 days, respectively. CONCLUSION: Conversion of temporary catheters to tunneled catheters using the pre-existing venotomy sites is safe and has low rates of infection and malfunction. These rates are comparable to previously published rates for tunneled catheters placed de novo and tunneled catheter exchanges.

Adult↗
PubMed2007

[The treatment of periprosthetic infections].

Periprosthetic infections are severe complications following total joint arthroplasty. The infection rate is estimated to be 0.5-2%. Systemic diseases such as rheumatoid arthritis and previous surgery are considered risk factors for infection. The infection rate in the present patient cohort was low (0.72%). The recurrence rate (23.4%) is due to patients with rheumatoid arthritis and septic total knee arthroplasties. Successful treatment is dependent on various factors, one of which involves accurate preoperative bacterial diagnostics. Joint fluid aspiration is the appropriate procedure. Open biopsy or arthroscopically guided biopsy can be performed in cases of unclear diagnostic results. Early infection can be treated with thorough joint debridement without exchanging fixed implant components; "low-grade" or late infections require revision with implant removal in a one or two stage septic revision according to clearly determined algorithms. Antibiotic therapy is mandatory, and a combination with rifampicin is a very useful basis.

Adult↗
PubMed2003

Posterior dislocation of a cruciate-retaining total knee arthroplasty following an acute bacterial infection.

BACKGROUND: We report a rare complication of posterior dislocation of a cruciate-retaining total knee arthroplasty following an acute bacterial infection. The mechanism of dislocation proved to be septic loosening of the femoral component and a tear of the posterior cruciate ligament near to the femoral insertion site. The tear arose during the treatment of acute septic arthritis following total knee arthroplasty when the patient attempted full weight-bearing with the affected limb in a semiflexion position and twisted the knee. METHODS AND RESULTS: Successful treatment was provided with subsequent surgical debridement, removal of the loosened prosthesis, the application of systemic antibiotics, and a revision total knee arthroplasty utilizing a posteriorly stabilized prosthesis after adequate control of the infection. CONCLUSION: Soft-tissue protection from full weight-bearing of the knee during the treatment of an acute infection following total knee arthroplasty and timely removal of the loosened total knee prosthesis are recommended in order to prevent such a complication.

Arthritis, Infectious↗
PubMed2005

Diagnostic values of positron emission tomography versus triple-phase bone scan in hip arthroplasty loosening.

INTRODUCTION: The most frequent complications of total hip arthroplasty are septic and aseptic wear-induced loosening. A reliable differentiation between septic and aseptic loosening with current diagnostic tools is not possible. Therefore, we examined the diagnostic valency of positron emission tomography (PET) with (18)F-fluorodeoxyglucose (FDG) in cases of septic or aseptic hip arthroplasty loosening compared with conventional triple-phase bone scan (TPBS). MATERIALS AND METHODS: Fifty patients with 70 total hip replacements (symptomatic n=50, asymptomatic n=20) were examined by means of FDG-PET and TPBS to detect septic and aseptic loosening and differentiate between the two. A differentiated algorithm subdivided into categories I-V was developed for FDG-PET. Additionally, standardized uptake values (SUV) were calculated from the lesion with the highest FDG uptake. Interpretations of the TPBS were done according to the criteria described by Wilson. The final diagnosis was based on operative findings including microbiological and histological examinations (n=50), while the remaining asymptomatic arthroplasties (n=20) were integrated into a clinical follow-up (> or =9 months). RESULTS: Sensitivity/specificity of FDG-PET was 91%/92% (accuracy 91%) compared with 78%/70% (accuracy 74%) for TPBS. A high correlation could be proved between FDG-PET investigation and operative histopathological findings (r(Spear)> or =0.9). No significant differences were found regarding cemented and uncemented implanted hip arthroplasties (p> or =0.05). Calculation of the SUV turned out to be inappropriate as a sole criterion for image interpretation. CONCLUSION: FDG-PET is a promising, highly accurate examination method to detect polyethylene and metal wear-induced chronic inflammation followed by periprosthetic osteolysis. In addition, FDG-PET has a significantly higher sensitivity and specificity than TPBS for differentiating between aseptic loosening and infection.

Adult↗
PubMed2000

Histological and microbiological findings in non-infected and infected revision arthroplasty tissues. The OSIRIS Collaborative Study Group. Oxford Skeletal Infection Research and Intervention Service.

An assessment of clinical and laboratory findings is generally required to distinguish between septic and aseptic loosening of a hip implant. In order to evaluate the diagnostic utility of histological and microbiological investigative techniques to differentiate between these two conditions, we analysed their results in 617 patients with hip implant loosening. Histology and microbiology study confirmed the clinical diagnosis of septic loosening in approximately 98% and 89%. respectively. The clinical diagnosis of aseptic loosening was confirmed by histology in 99% of cases. In all but 2 of 81 cases of septic loosening, in which an organism was isolated on microbiological culture, the histological diagnosis of septic loosening was made on the basis of the degree of the acute inflammatory infiltrate (i.e. the presence of 1 or more neutrophil polymorphs per high power field (x 400) on average after examination of at least 10 high power fields) in periprosthetic tissues. In 10 patients for whom there was a strong clinical suspicion of septic loosening but no organisms were isolated on microbiological culture, the histological findings, using the above criteria, were in keeping with the clinical diagnosis of septic loosening. As almost 11% of cases of septic loosening would not have been diagnosed by microbiological investigation alone, our findings indicate that histological examination of periprosthetic tissues should form part of the investigative protocol to distinguish between aseptic and septic loosening.

Adult↗
PubMed2001

Treatment of staphylococcal implant infection with rifampicin-ciprofloxacin in stable implants.

Infection following total joint replacement remains a problem that has not been solved so far. The treatment options include removal of the implant and a delayed reconstruction or a direct exchange operation. Among patients with stable implants and short duration of infection as well as in patients who for certain reasons are inoperable, antibiotic therapy with a combination of rifampicin-ciprofloxacin may be a reasonable treatment option for curing staphyloccocal infection without removal of the implant. A case study of a Staphylococcus epidermidis (coagulase-negative) infection following delayed revision total knee replacement after septic loosening of a knee arthroplasty and its successful conservative treatment with rifampicin-ciprofloxacin is described. Alternative rifampicin combinations are discussed with respect to recently developed pharmacodynamical and pharmacokinetical findings of biofilm active drugs.

Anti-Bacterial Agents↗
PubMed2000

Total hip arthroplasty after arthrodesis of the hip joint.

The results of 15 conversions of a hip arthrodesis into a total hip arthroplasty performed in the years 1980-1995 are reported. Fifteen patients (8 men, 7 women) underwent total hip arthroplasty 30.9 (range 2-61) years after spontaneous or operative fusion of a hip joint. The primary indications of the conversion were low-back pain (n = 10), knee pain (n = 2) and hip problems (n = 3). At follow-up examination 5.4 (range 2-13.3) years postoperatively, the Harris Hip Score averaged 86.0 (range 70.1-99.0). Six patients were pain-free, 7 had less pain, 2 felt no improvement of pain. All patients confirmed that they would undergo the operation again. The Trendelenburg sign was negative or mild in 8 patients and moderate to severe in 7. Aseptic loosening of 2 stems (1 cemented, 1 cementless) and 2 deep infections required revision surgery. We conclude that this operation can lead to satisfactory results even after a long duration of the arthrodesis. However, full function with no pain and a negative Trendelenburg sign could be obtained in only 20% (3/15) of the cases.

Adult↗
PubMed2005

Late hypopharyngo-esophageal perforation after cervical spine surgery: proposal of a therapeutic strategy.

BACKGROUND: Hypopharynx and esophagus are occasionally at risk of perforation after cervical spine surgery. Although relatively rare--compared to the frequency of anterior instrumentation--hypopharyngo-esophageal perforation has to be considered as a late complication. An interdisciplinary surgical strategy is required for treatment. MATERIALS AND METHODS: We herein propose a flow sheet for an interdisciplinary treatment strategy. The concept is based on the authors' personal experiences with this rare complication in a high-volume center for esophageal surgery. RESULTS: Our interdisciplinary surgical strategy is based on three central parameters that determine the course of treatment: (1) The patient's general condition and signs of systemic infection determine the requirement for critical care management. (2) The stability of the spine (to be addressed by the orthopedic surgeon) determines the requirement for dorsal stabilization, prior to the mandatory removal of the anterior osteosynthesis material that is damaging the hypopharyngo-esophageal structures. (3) The surgical strategy for treatment of the gastrointestinal perforation--the decision to undertake either primary repair or resection--is based on its morphological characteristics; whether it is covered or free, whether it is associated with severe local infection or not, whether the defect is small or large. CONCLUSIONS: Hypopharyngo-esophageal perforations after spine surgery are an interdisciplinary challenge, best treated by a concert of specialists (ICU, orthopedic surgeon, and gastrointestinal surgeon).

Adult↗
PubMed2000

Use of cryopreserved arterial homografts for management of infected prosthetic grafts: a multicentric study.

The objective of this study was to evaluate the effectiveness of cryopreserved arterial homografts for management of prosthetic graft infection. Between October 1992 and July 1998, 90 patients (84 men) with a mean age of 64 years from six different hospitals were treated for prosthesis infection by in situ replacement using a cryopreserved arterial homograft (CAH). In 43 patients (47%), the primary procedure had been performed at a nonparticipating center. Prosthetic graft infection occurred early (i.e., within 1 month after the primary procedure) in 15 cases and late in 75 cases. In the late group, the mean interval between the primary procedure and CAH replacement was 34 months (range, 3 to 330 months). In 41 patients, infection was located in the aortic region, including 17 presenting with enteroprosthetic fistula (EPF). In 49 patients, infection was confined to the femoral, popliteal, or subclavian region. Bacteriologic cultures were positive for one or more germs in 75 patients and negative in 15. The surgical procedure consisted of complete or partial removal of the infected prosthetic graft, debridement, and in situ reconstruction using one or more CAH. Our results showed that management of prosthetic graft infection, a grave complication, using a CAH is a promising technique, especially for patients in stable condition prior to reconstruction.

Adult↗
PubMed2005

Inhibition of bacterial adherence on the surface of stents and bacterial growth in bile by bismuth dimercaprol.

Bacterial infection and biofilm formation on the surface of biliary stents is believed to be one of the main factors in stent occlusion. This study explored the role of the new reagent, bismuth dimercaprol, in preventing bacterial adherence and bacterial biofilm formation on the surface of biliary stents. Sterile porcine bile preparations, infected separately with Escherichia coli, Klebsiella pneumoniae, Enterobacter, and Enterococcus, were used as the perfusion media in an in vitro perfusion system. The bacterial growth in the media and the bacterial adherence on the surface of stents were tested when different concentrations of bismuth dimercaprol were used in the perfusion media. BisBAL (5 microM) did not inhibit the growth of any of the tested bacterial species. It did, however, significantly decrease the amount of bacteria adhering to the surface of stents for all bacterial strains except Escherichia coli. Bismuth dimercaprol (20 microM) significantly inhibited the growth of Escherichia coli, Klebsiella pneumoniae, and Enterobacter and, thereby, significantly decreased the amount of these bacteria adhering to the surface of stents. The unique bactericidal and anitbiofilm activities of bismuth thiols might contribute to delaying the process of biliary stent occlusion if the effective concentrations of bismuth thiols could be delivered to the target sites. The feasibility of this application of bismuth thiols deserves further investigation.

Animals↗