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Orthopedic Implant-Associated Infections: Unlocking the Secrets of Prevention and Treatment

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A special issue of Healthcare (ISSN 2227-9032).

Deadline for manuscript submissions: 30 June 2024 | Viewed by 5407

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Prof. Dr. Olimpio Galasso

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Orthopedic & Trauma Unit, Department of Medical and Surgical Sciences, University "Magna Græcia", 88100 Catanzaro, Italy
Interests: orthopedic surgery; hip/knee/shoulder arthroplasty; knee/shoulder arthroscopy; hand and foot surgery

Prof. Dr. Biagio Moretti

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Guest Editor

Orthopaedic and Trauma Unit, Department DiBraiN, University of Bari "Aldo Moro ", Bari, Italy
Interests: trauma; orthopedic surgery; arthroplasty; rehabilitation; tendon; physical activity; osteoarthritis; osteoporosis; fragility fractures; biophysical stimulation; gender-related differences; musculoskeletal diseases
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Special Issue Information

Dear Colleagues,

In recent years, orthopedic implants have revolutionized the field of medicine, enabling countless individuals to regain mobility and restore their quality of life. These remarkable devices have played a pivotal role in the successful treatment of various musculoskeletal conditions, ranging from joint replacements to fracture fixations. However, amid these medical breakthroughs, a persistent challenge has emerged—orthopedic implant-associated infections.

Orthopedic implant-associated infections pose a significant threat to patients undergoing orthopedic procedures. Despite the advancements in surgical techniques, sterilization protocols, and antimicrobial strategies, these infections continue to present formidable complications, often leading to prolonged hospital stays, revision surgeries, and sometimes even permanent disability.

Understanding the complexity of orthopedic implant-associated infections necessitates a multidisciplinary approach. Researchers, orthopedic surgeons, microbiologists, and infectious disease specialists must collaborate to unravel the secrets of prevention, early detection, and effective treatment.

As an esteemed scientific society dedicated to orthopedic research, the South Italian Society of Orthopedics and Traumatology, commonly referred to as SOTIMI, promotes this Special Issue in Healthcare to bridge the gap between theory and practice, providing a comprehensive overview of the current knowledge, innovative strategies, and future directions in combating orthopedic implant-associated infections.

The fundamental aspects of orthopedic implants, as well as an exploration of the interactions between the device, the host, and the infecting microorganisms, will be addressed. Through a meticulous analysis of the risk factors and pathogenesis, we will gain valuable insights into the identification and prevention of implant-associated infections.

This Special Issue will also offer a detailed exploration of the diagnostic modalities available, including traditional and advanced laboratory techniques, imaging studies, and molecular testing methods. We will discuss the challenges associated with early detection, as well as the emerging technologies that hold promise for a more accurate and timely diagnosis.

Furthermore, we will highlight the latest advancements in the field of antimicrobial therapies, ranging from prophylactic measures to targeted treatment strategies. We will delve into the intricacies of antibiotic stewardship, the role of implant coatings, and the potential of immunotherapeutic interventions. The different surgical strategies and their outcomes will be the object of this Special Issue. By shedding light on these cutting-edge developments, we hope to equip healthcare professionals with the tools necessary to effectively combat orthopedic implant-associated infections.

Ultimately, this Special Issue will serve as a comprehensive resource for clinicians, researchers, and healthcare professionals involved in the management of orthopedic implant-associated infections. By addressing the multifaceted nature of these infections, we aspire to inspire new perspectives, foster innovative research, and ultimately improve patient outcomes.

Prof. Dr. Olimpio Galasso
Prof. Dr. Biagio Moretti
Guest Editors

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Manuscripts should be submitted online at www.mdpi.com by registering and logging in to this website. Once you are registered, click here to go to the submission form. Manuscripts can be submitted until the deadline. All submissions that pass pre-check are peer-reviewed. Accepted papers will be published continuously in the journal (as soon as accepted) and will be listed together on the special issue website. Research articles, review articles as well as short communications are invited. For planned papers, a title and short abstract (about 100 words) can be sent to the Editorial Office for announcement on this website.

Submitted manuscripts should not have been published previously, nor be under consideration for publication elsewhere (except conference proceedings papers). All manuscripts are thoroughly refereed through a single-blind peer-review process. A guide for authors and other relevant information for submission of manuscripts is available on the Instructions for Authors page. Healthcare is an international peer-reviewed open access semimonthly journal published by MDPI.

Please visit the Instructions for Authors page before submitting a manuscript. The Article Processing Charge (APC) for publication in this open access journal is 2700 CHF (Swiss Francs). Submitted papers should be well formatted and use good English. Authors may use MDPI's English editing service prior to publication or during author revisions.

Keywords

bone infection
arthroplasty
trauma
prevention
surgical treatment
antibiotic
biofilms
biomarkers
organism(s)

Published Papers (9 papers)

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Research

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10 pages, 1235 KiB

Open AccessArticle

Systemic Inflammation Response Index (SIRI) and Monocyte-to-Lymphocyte Ratio (MLR) Are Predictors of Good Outcomes in Surgical Treatment of Periprosthetic Joint Infections of Lower Limbs: A Single-Center Retrospective Analysis

by Raffaele Vitiello, Alessandro Smimmo, Elena Matteini, Giulia Micheli, Massimo Fantoni, Antonio Ziranu, Giulio Maccauro and Francesco Taccari

Healthcare 2024, 12(9), 867; https://doi.org/10.3390/healthcare12090867 - 23 Apr 2024

Viewed by 275

Abstract

Background: Periprosthetic joint infection (PJI) is a devastating complication that develops after total joint arthroplasty (TJA), whose incidence is expected to increase over the years. Traditionally, surgical treatment of PJI has been based on algorithms, where early infections are preferably treated with debridement, antibiotics, and implant retention (DAIR) and late infections with two-stage revision surgery. Two-stage revision is considered the “gold standard” for treatment of chronic prosthetic joint infection (PJI) as it enables local delivery of antibiotics, maintenance of limb-length and mobility, and easier reimplantation. Many studies have attempted to identify potential predicting factors for early diagnosis of PJI, but its management remains challenging. In this observational retrospective study, we investigated the potential role of inflammatory blood markers (neutrophil-to-lymphocyte ratio (NLR), monocyte-to-lymphocyte ratio (MLR), platelet-to-lymphocyte ratio (PLR), systemic inflammatory index (SII), systemic inflammatory response index (SIRI), and aggregate index of systemic inflammation (AISI)) as prognostic factors in two-stage exchange arthroplasty for PJI. Methods: A single-center retrospective analysis was conducted, collecting clinical data and laboratory parameters from patients submitted to prosthetic explantation (EP) for chronic PJI. Laboratory parameters (PCR, NLR, MLR, PLR, SIRI, SII, and AISI) were evaluated at the explantation time; at 4, 6, and 8 weeks after surgery; and at reimplantation time. The correlation between laboratory parameters and surgery success was evaluated and defined as infection absence/resolution at the last follow-up. Results: A total of 57 patients with PJI were evaluated (62% males; average age 70 years, SD 12.14). Fifty-three patients with chronic PJI were included. Nine patients underwent DAIR revision surgery and chronic suppressive therapy; two patients died. Nineteen patients completed the two-stage revision process (prosthetic removal, spacer placement, and subsequent replanting). Among them, none showed signs of reinfection or persistence of infection at the last available follow-up. The other twenty-three patients did not replant due to persistent infection: among them, some (the most) underwent spacer retention; others (fewer in number) were submitted to resection arthroplasty and arthrodesis (Girdlestone technique) or chronic suppressive antibiotic therapy; the remaining were, over time, lost to follow-up. Of the patients who concluded the two-stage revision, the ones with high SIRI values (mean 3.08 SD 1.7 and p-value 0.04) and MLR values (mean 0.4 SD 0.2 and p-value 0.02) at the explantation time were associated with a higher probability of infection resolution. Moreover, higher variation in the SIRI and PCR, also defined, respectively, as delta-SIRI (mean −2.3 SD 1.8 and p-value 0.03) and delta-PCR (mean −46 SD 35.7 and p-value 0.03), were associated with favorable outcomes. Conclusions: The results of our study suggest that, in patients with PJI undergoing EP, the SIRI and MLR values and delta-SIRI and delta-PCR values could be predictive of a favorable outcome. The evaluation of these laboratory indices, especially their determination at 4 weeks after removal, could therefore help to determine which patients could be successfully replanted and to identify the best time to replant. More studies analyzing a wider cohort of patients with chronic PJI are needed to validate the promising results of this study. Full article

(This article belongs to the Special Issue Orthopedic Implant-Associated Infections: Unlocking the Secrets of Prevention and Treatment)

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Review

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11 pages, 251 KiB

Open AccessReview

Infection after Anterior Cruciate Ligament Reconstruction: A Narrative Review of the Literature

by Giuseppe Danilo Cassano, Lorenzo Moretti, Giovanni Vicenti, Claudio Buono, Federica Albano, Teresa Ladogana, Igor Rausa, Angela Notarnicola and Giuseppe Solarino

Healthcare 2024, 12(9), 894; https://doi.org/10.3390/healthcare12090894 - 25 Apr 2024

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Abstract

Infection is an uncommon side effect of arthroscopic surgery, and this percentage is higher in anterior cruciate ligament reconstruction (ACLR) surgery, where graft and fixation devices are used. Infections can not only lead to high re-admission rates and poor functional recovery of the knee but can also have a significant negative impact on the patient’s psychological and economic health, especially in athletes, as it can affect their sports career. It is important to be aware of the many risk factors, especially the manifestation of symptoms. These may sometimes be non-specific to the infectious pathology and common to other situations, such as the presence of a significant intra-articular hematoma. Septic arthritis after ACLR can occur at any time after surgery but typically presents acutely, while late manifestation is relatively rare. Diagnosis of infection is based on patient history, physical examination, laboratory parameters, and analysis of synovial fluid after joint aspiration, which is the gold standard for diagnosing post-operative infection. Once symptoms appear and the diagnosis seems certain, it is necessary to intervene quickly with arthroscopic debridement and long-term antibiotic treatment to try to save the graft and resolve the infectious situation to avoid graft failure and arthrofibrotic sequelae. The aim of this paper is to provide an overview of the epidemiology, pathogenesis, risk factors, clinical presentation, diagnostic evaluation, and current treatment guidelines of septic arthritis after ACLR surgery by analyzing recent literature, in particular meta-analyses and systematic reviews. Full article

(This article belongs to the Special Issue Orthopedic Implant-Associated Infections: Unlocking the Secrets of Prevention and Treatment)

13 pages, 905 KiB

Open AccessReview

Debridement, Antibiotic Pearls, and Retention of the Implant (DAPRI) in the Treatment of Early Periprosthetic Knee Joint Infections: A Literature Review

by Giovanni Vicenti, Elisa Pesare, Giulia Colasuonno, Claudio Buono, Federica Albano, Teresa Ladogana, Anna Claudia Passarelli and Giuseppe Solarino

Healthcare 2024, 12(8), 843; https://doi.org/10.3390/healthcare12080843 - 16 Apr 2024

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Abstract

(1) Background: Periprosthetic joint infections (PJIs) are severe and frightening complications in orthopaedic surgery, and they are generally divided into three categories: early infections (those occurring within the first 4–6 weeks), delayed infections (those occurring between 3 and 24 months), and late infections (those occurring more than 2 years after surgery). PJI treatment comprises “debridement, antibiotics, and implant retention” (DAIR), single-stage revision, and double-stage revision. Nowadays, to improve the chances of retaining an infected implant and to improve the traditional DAIR method, a modified surgical technique has been developed, named DAPRI (debridement, antibiotic pearls, and retention of the implant). Our study aims to present an up-to-date concept evaluation of the DAPRI technique and its success rate. (2) Methods: Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) standards were followed, applying a protocol defined by the authors: a total of 765 articles were identified, and at the end of the screening process only 7 studies were included. (3) Results: Currently, the DAPRI procedure can be performed only on patients who have had PJI symptoms for less than 4 weeks, and in order to achieve the highest success rate, indications are quite strict: it is appropriate in patients with acute, superficial infections without sinus tract presence, and well-fixed implants with known sensitive bacteria. The DAPRI surgical method follows a step-by-step process consisting of a first phase of biofilm identification with intra-articular injection of methylene blue, followed by biofilm removal (thermic, mechanical, and chemical aggression), and a last step consisting of prevention of PJI recurrence by using calcium sulphate antibiotic-added beads. (4) Conclusions: The DAPRI approach improves the traditional DAIR technique. It is a correct treatment for acute and early haematogenous PJI, and improves the DAIR success rate. Full article

(This article belongs to the Special Issue Orthopedic Implant-Associated Infections: Unlocking the Secrets of Prevention and Treatment)

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14 pages, 614 KiB

Open AccessReview

The Effect of Spacer Treatment of Infected Hip and Knee Arthroplasties on Patients’ Mental Health: A Narrative Review of the Literature

by Donato Di Gennaro, Giannantonio Coletta, Enrico Festa, Domenico De Mauro, Maria Rizzo, Luca Diana, Giovanni Balato and Massimo Mariconda

Healthcare 2024, 12(7), 790; https://doi.org/10.3390/healthcare12070790 - 06 Apr 2024

Viewed by 504

Abstract

Background: The gold standard treatment for periprosthetic joint infections is the two-stage revision that includes the spacer placement before definitive reimplantation. The management of PJI affects patients’ joint function and, subsequently, their mental health. Even though significant advances have been achieved, little to no attention has been paid to the psychological implications. So, based on standardized patient-reported outcome measures (PROMs), this study aimed to clarify the effect of spacer treatment of infected hip and knee arthroplasties on patients’ mental health. Methods: We performed research on the literature on PJIs in the English language using the MEDLINE database with the search strings “spacer” OR “spacers” AND “hip” OR “knee” AND “SF-12” OR “SF-36” OR “EQ-5” OR “mental” OR “depression” OR “anxiety.” The reference lists of selected articles were also hand-searched for any additional articles. Results: A total of 973 published papers were extracted, and 9 papers were finally included. A total of 384 patients who underwent spacer placement for PJI were identified. Of these 384 patients, 54% were female. The mean age ranged from 62 to 78.2 years. Of the11 papers identified for this review, 4 analyzed only hip spacers, including 119 patients; 4 only knee spacers, evaluating 153 patients; while a single study included 112 patients for both joints. Conclusions: Patients with the spacer are living in a state of mental upset, albeit better than the preoperative state. Clinical improvement with the review is not assured. The alteration of mental state turns out not to be transient for all the patients. Full article

(This article belongs to the Special Issue Orthopedic Implant-Associated Infections: Unlocking the Secrets of Prevention and Treatment)

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21 pages, 2930 KiB

Open AccessReview

Preoperative Risk Factors for Periprosthetic Joint Infection: A Narrative Review of the Literature

by Ludovico Lucenti, Gianluca Testa, Alessia Caldaci, Fabio Sammartino, Calogero Cicio, Martina Ilardo, Marco Sapienza and Vito Pavone

Healthcare 2024, 12(6), 666; https://doi.org/10.3390/healthcare12060666 - 15 Mar 2024

Viewed by 689

Abstract

Periprosthetic joint infection (PJI) poses a challenging complication for many patients undergoing arthroplasty, and the literature identifies numerous risk factors. A comprehensive understanding of the primary risk and protective factors for PJI is valuable for surgeons. This article aims to compile and summarize the key risk factors for PJI documented in the literature. Some risk factors are related to the nutritional status of patients, with obesity, weight loss, hypovitaminosis, and malnutrition being frequently reported. Pathologies affecting patients also contribute to PJI risk, including septic arthritis, hepatitis, diabetes, urinary tract infections, anemia, hypothyroidism, osteoporosis, and dental pathologies. Unhealthy habits, such as tobacco and drug abuse, are significant factors. Previous corticosteroid injections may also play a role in infection development. A few protective factors are also reported in the literature (use of statins, preoperative decolonization, and preadmission skin preparation). The identification of risk factors and the implementation of evidence-based preoperative protocols are essential steps in reducing the incidence of PJI. Full article

(This article belongs to the Special Issue Orthopedic Implant-Associated Infections: Unlocking the Secrets of Prevention and Treatment)

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12 pages, 644 KiB

Open AccessSystematic Review

Knee Arthrodesis for Periprosthetic Knee Infection: Fusion Rate, Complications, and Limb Salvage—A Systematic Review

by Michele Mercurio, Giorgio Gasparini, Erminia Cofano, Andrea Zappia, Filippo Familiari and Olimpio Galasso

Healthcare 2024, 12(7), 804; https://doi.org/10.3390/healthcare12070804 - 07 Apr 2024

Viewed by 493

Abstract

The aim of this systematic review was to investigate the outcomes of knee arthrodesis (KA) after periprosthetic joint infection (PJI) of the knee. Differences in clinical outcomes and complication rates among the intramedullary nailing (IMN), external fixation (EF), and compression plating (CP) procedures were compared. A total of 23 studies were included. Demographics, microbiological data, types of implants, surgical techniques with complications, reoperations, fusion, and amputation rates were reported. A total of 787 patients were evaluated, of whom 601 (76.4%), 166 (21%), and 19 (2.4%) underwent IMN, EF, and CP, respectively. The most common causative pathogen was coagulase-negative Staphylococcus (CNS). Fusion occurred in 71.9%, 78.8%, and 92.3% of the patients after IMN, EF, and CP, respectively, and no statistically significant difference was found. Reinfection rates were 14.6%, 15.1%, and 10.5% after IMN, EF, and CP, respectively, and no statistically significant difference was found. Conversion to amputation occurred in 4.3%, 5%, and 15.8% of patients after IMN, EF, and CP, respectively; there was a higher rate after CP than after EF. The IMN technique is the most common option used for managing PJI with KA. No differences in terms of fusion, reinfection, or conversion-to-amputation rates were reported between IMN and EF. CP is rarely used, and the high amputation rate represents an important limitation of this technique. Full article

(This article belongs to the Special Issue Orthopedic Implant-Associated Infections: Unlocking the Secrets of Prevention and Treatment)

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12 pages, 26277 KiB

Open AccessTechnical Note

Augmented Articulating Spacers in Infected Total Knee Arthroplasty: Surgical Technique

by Domenico De Mauro, Enrico Festa, Donato Di Gennaro, Tiziana Ascione, Giannantonio Coletta, Massimo Mariconda and Giovanni Balato

Healthcare 2024, 12(7), 735; https://doi.org/10.3390/healthcare12070735 - 28 Mar 2024

Viewed by 450

Abstract

Periprosthetic joint infections (PJIs) are a prominent subject of discussion in orthopedics and are frequently debated at conferences and congresses. In the context of PJIs affecting the knee, the decision between following a one-stage or two-stage treatment approach has historically been a pivotal consideration. The first option is limited by indications and potentially devastating complications in case of failure, whereas the second is widely accepted as the gold standard. Initially, the spacer was conceived solely to restore and maintain knee space after removal of the implant. An articulating spacer was introduced to mitigate patient limitations and improve knee function and quality of life. Two main types of articulating spacers are utilized in knee PJI treatment: the mold spacer and the metal-on-poly spacer. This text outlines a technique for metal-on-poly spacer implants. Based on our experience and the existing literature, this approach facilitates early full weight bearing and faster recovery of the knee’s range of motion, ultimately improving the quality of life after surgery, thus allowing the spacer retention for an extended period, as suggested by the 1.5-stage revision. Full article

(This article belongs to the Special Issue Orthopedic Implant-Associated Infections: Unlocking the Secrets of Prevention and Treatment)

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12 pages, 523 KiB

Open AccessSystematic Review

Do Preoperative Corticosteroid Injections Increase the Risk of Infection after Shoulder Arthroscopy or Shoulder Arthroplasty? A Systematic Review

by Ludovico Lucenti, Flora Maria Chiara Panvini, Claudia de Cristo, Damiano Rapisarda, Marco Sapienza, Gianluca Testa and Vito Pavone

Healthcare 2024, 12(5), 543; https://doi.org/10.3390/healthcare12050543 - 24 Feb 2024

Viewed by 940

Abstract

Introduction: Corticosteroid injections have demonstrated short-term benefits for shoulder pain. This symptomatic treatment method is used in various inflammatory conditions that affect the shoulder joint. Corticosteroid joint injections are not without risks and complications. Adverse effects have been documented, including damage to the articular cartilage, tendon rupture, and attenuation of the subject’s immune response. The aim of this study was to examine the timing of preoperative corticosteroid injections on infectious outcomes of shoulder arthroscopies and shoulder arthroplasty. Materials and Methods: In accordance with the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), the PubMed, Cochrane, and Science Direct databases were systematically reviewed by two independent authors in January 2024. After full-text reading and checking the reference lists, 11 article were included. Results: Patients who received a shoulder injection within three months prior to undergoing shoulder arthroplasty exhibited a markedly elevated incidence of infection. In addition, a significantly increased risk of periprosthetic joint infection (PJI) at 90 days postoperatively in patients who received CSIs (corticosteroid injections) within 1 month prior to shoulder arthroplasty was found. Different authors consider CSI injections within the 2 weeks prior to shoulder arthroscopy surgery principally associated with an increased risk of postoperative infection. Discussion: There is still no consensus on the correct timing of preoperative CSIs in both arthroscopic and arthroplasty procedures. The literature does not identify whether the number of preoperative injections could increase the risk of periprosthetic infection. Obesity, sex, and smoking did not have a significant effect on PJIs; alcohol abuse could be considered as a risk factor for PJIs with CSIs. Both in prosthetic surgeries and in arthroscopy procedures, modifiable and unmodifiable factors play secondary roles. The risk of postoperative infection is greater within 3 months, although it is almost comparable at one- and two-year follow-ups. Full article

(This article belongs to the Special Issue Orthopedic Implant-Associated Infections: Unlocking the Secrets of Prevention and Treatment)

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12 pages, 1533 KiB

Open AccessCase Report

Corynebacterium striatum Periprosthetic Hip Joint Infection: An Uncommon Pathogen of Concern?

by Athanasios Galanis, Spyridon Karampitianis, John Vlamis, Panagiotis Karampinas, Michail Vavourakis, Christos Vlachos, Eftychios Papagrigorakis, Dimitrios Zachariou, Evangelos Sakellariou, Iordanis Varsamos, Christos Patilas, Sofia Tsiplakou, Vasiliki Papaioannou and Spyridon Kamariotis

Healthcare 2024, 12(2), 273; https://doi.org/10.3390/healthcare12020273 - 21 Jan 2024

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Abstract

Background: Total hip arthroplasty is indubitably a dominant elective surgery in orthopaedics, contributing to prodigious improvement in the quality of life of patients with osteoarthritis. One of the most potentially devastating complications of this operation is periprosthetic joint infection. Immunocompromised patients might be afflicted by infrequent low-virulence organisms not typically detected with conventional procedures. Consequently, employing advanced identification methods, such as the circumstantial sonication of orthopaedic implants, could be crucial to managing such cases. Case Presentation: We present a peculiar case of a 72-year-old female patient suffering from a chronic periprosthetic hip infection due to Corynebacterium striatum. The pathogen was only identified after rigorous sonication of the extracted implants. The overall management of this case was immensely exacting, primarily because of the patient’s impaired immune system, and was finally treated with two-stage revision in our Institution. Literature Review: Although copious literature exists concerning managing periprosthetic hip infections, no concrete guidelines are available for such infections in multimorbid or immunocompromised patients with rare low-virulence microorganisms. Hence, a diagnostic work-up, antibiotic treatment and appropriate revision timeline must be determined. Sonication of extracted implants could be a powerful tool in the diagnostic arsenal, as it can aid in identifying rare microbes, such as Corynebacterium spp. Pertinent antibiotic treatment based on antibiogram analysis and apposite final revision-surgery timing are the pillars for effective therapy of such infections. Clinical Relevance: Corynebacterium striatum has been increasingly recognized as an emerging cause of periprosthetic hip infection in the last decade. A conspicuous rise in such reports has been observed in multimorbid or immunocompromised patients after the COVID-19 pandemic. This case is the first report of Corynebacterium striatum periprosthetic hip infection diagnosed solely after the sonication of extracted implants. This paper aims to increase awareness surrounding Corynebacterium spp. prosthetic joint infections, while highlighting the fields for further apposite research. Full article

(This article belongs to the Special Issue Orthopedic Implant-Associated Infections: Unlocking the Secrets of Prevention and Treatment)

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