Multiple irrigation, debridement, and retention of components in infected total knee arthroplasty

Section: Discussionmentioning

confidence: 99%

Incidence and Reasons for Nonrevision Reoperation After Total Knee Arthroplasty

Zmistowski

Restrepo

Kahl

et al. 2011

“…The high failure rate of irrigation and débridement in periprosthetic joint infection (PJI) suggests that biofilm has a high tolerance to antibiotics [3,4,7,11,14,15,19,20,23,32]. Bacterial persisters are defined as a subpopulation present in bacterial species that have a phenotypically high tolerance to antibiotics secondary to an absence of metabolism after an environmental stress [1].…”

Section: Introductionmentioning

confidence: 99%

Antibiotic-tolerant Staphylococcus aureus Biofilm Persists on Arthroplasty Materials

Urish

DeMuth

Kwan

et al. 2016

Background The continued presence of biofilm may be one cause of the high risk of failure observed with irrigation and débridement with component retention in acute periprosthetic joint infection (PJI). There is a poor understanding of the role of biofilm antibiotic tolerance in PJI. Questions/purposes (1) Do increasing doses of cefazolin result in decreased viable biofilm mass on arthroplasty materials? (2) Is cefazolin resistance phenotypic or genotypic? (3) Is biofilm viability a function of biofilm depth after treatment with cefazolin? (4) Is the toxin-antitoxin system, yoeB expression, associated with antibiotic stress?Methods Methicillin-sensitive Staphylococcus aureus biofilm was cultured on total knee arthroplasty (TKA) materials and exposed to increasing doses of cefazolin (control, 0.5, 1.0, 10.0, 100.0 lg/mL). Quantitative confocal microscopy and quantitative culture were used to measure viable biofilm cell density. To determine if cefazolin resistance was phenotypic or genotypic, we measured minimum inhibitory concentration (MIC) after exposure to different cefazolin concentrations; changes in MIC would suggest genotypic features, whereas unchanged MIC would suggest phenotypic behavior. Finally, quantitative reverse transcription-polymerase chain reaction was used to quantify expression of yoeB levels between biofilm and planktonic bacteria after exposure to 1 lg/mL cefazolin for 3 hours. Results Although live biofilm mass was reduced by exposure to cefazolin when compared with biofilm mass in controls (39.2 9 10 3 ± 26.4 9 10 3 pixels), where the level after 0.5 lg/mL exposure also showed reduced mass (20.3 9 10 3 ± 11.9 9 10 3 pixels), no further reduction was seen after higher doses (mass at 1.0 lg/mL: 5.0 9 10 3 pixels ± 1.1 9 10 3 pixels; at 10.0 lg/mL: 6.4 9 10 3 ± 9.6 9 10 3 pixels; at 100.0 lg/mL: 6.4 9 10 3 ± 3.9 9 10 3 ). At the highest concentration tested (100 lg/ mL), residual viable biofilm was present on all three materials, and there were no differences in percent biofilm survival among cobalt-chromium (18.5% ± 15.1%),The project described was supported by the National Institutes of Health through Grant Number KL2 TR000146 (KLU 123Clin Orthop Relat Res (2016) 474:1649-1656 DOI 10.1007 Clinical Orthopaedics and Related Research ® A Publication of The Association of Bone and Joint Surgeons® polymethylmethacrylate (22.8% ± 20.2%), and polyethylene (14.7% ± 10.4%). We found that tolerance was a phenotypic phenomenon, because increasing cefazolin exposure did not result in changes in MIC as compared with controls (MIC in controls: 0.13 ± 0.02; at 0.5 lg/mL: 0.13 ± 0.001, p = 0.96; at 1.0 lg/m: 0.14 ± 0.04, p = 0.95; at 10.0 lg/m: 0.11 ± 0.016, p = 0.47; at 100.0 lg/m: 0.94 ± 0.047, p = 0.47). Expression of yoeB after 1 lg/mL cefazolin for 3 hours in biofilm cells was greater in biofilm but not in planktonic cells (biofilm: 62.3-fold change, planktonic cells: À78.8-fold change, p \ 0.001). Conclusions Antibiotics are inadequate at complete removal of the biofilm from the surface o...

“…Various methods have been used in the initial treatment of periprosthetic knee infection, including irrigation and debridement [10,11,38], direct exchange arthroplasty [6,16], and two-stage revision TKA with subsequent reimplantation [15,18]. Incision and drainage has been an attractive option, with low cost and relatively low morbidity; however, the failure rate has been high, ranging between 61% and 82% [4,5,7,23,30,35,38,39,41,44]. There has also been evidence suggesting that patients who failed a previous incision and drainage procedure were more likely to have a higher rate of failure with a subsequent two-stage revision arthroplasty [46].…”

Section: Introductionmentioning

confidence: 99%

Assessing the Gold Standard: A Review of 253 Two-Stage Revisions for Infected TKA

Mahmud

Lyons

Naudie

et al. 2012

121

Background Periprosthetic joint infection has been the leading cause of failure following TKA surgery. The gold standard for infection control has been a two-staged revision TKA. There have been few reports on mid-to longterm survivorship, functional outcomes, and fate of patients with a failed two-stage revision TKA. Questions/purposes Therefore, we determined (1) the mid-term survivorship of two-stage revision TKA, (2) the function of patients in whom infection was controlled, and (3) the outcome of patients with a failed two-stage revision due to recurrent infection. Methods We retrospectively reviewed 239 patients who underwent 253 two-stage revision TKAs for periprosthetic infection. There were 239 patients (253 knees), 104 men and 135 women, with a mean age of 70 ± 10 years at the time of two-stage revision and a mean BMI of 31.53 ± 6.74 kg/m 2 . During followup, we obtained WOMAC and The Knee Society Clinical Rating Scores and radiographs.