Optimal treatment methods of infectious complications in cases of large joint replacement arthroplasty in modern conditions

Research objective: to choose optimal treatment methods in conditions of Federal Centers of high-technology medical carebased on the analysis of infectious complications in cases of large joint replacement arthroplasty. Materials and methods. In the Federal State Publicly Funded Institution “Federal Center of Traumatology, Orthopedics and Replacement Arthroplasty” in Cheboksary city in the period from 2009 to 2014 there weremade 20761 large joint replacement operations. The incidence rate of deep infectious complicationsamounted to 0.3%. The average age of patients who had infectious complications was 61.2± 12.3 years old, and the male to female ratio was 1:2. Infectious complication risk factors have been evaluated using the continuous method, and the species composition of selected microflora have been studied. Based on the analysis of surgical intervention approaches the optimal method of surgical treatment has been determined. Results. The main predisposing infectious complication risk factors were chronic infection sites, diabetes, obesity, systemic inflammatory diseases, previous intra-articular administration of medicines, blood transfusions, repeated surgical manipulations in the area of the planned surgical intervention, as well as hematomas in the periprosthetic area identified in the postoperative period. The main germ of infectious complications is represented by gram-positive organisms, and the leading role belongs to staphylococci (52%). When identifying infection in the operated jointat the Center, such priority treatment strategiesas a two-stage replacement arthroplasty with long interval" (70.5%), single-stage revision surgery (23.5%), and three-stage revision surgery (6 % ) were used. Two-stage replacement arthroplasty with “long interval” is an efficient treatment, as well as it is economically feasible. It is necessary to take into account the duration of an antibioticrelease from the cement spacer. Reduction of the period between reimplantations significantly reduces the proportion of re-revisions (from 9% to 4.5% , p<0.05), improves long-term results and increases the treatmentmotivation of patients.Цель исследования: на основе анализа инфекционных осложнений при эндопротезировании крупных суставов выбрать оптимальные методы лечения в условиях Федеральных Центров высокотехнологичной медицинской помощи. Материалы и методы. В ФГБУ «Ф Ц ТОЭ » Минздрава России (г. Чебоксары) за период с 2009 по 2014 гг. было проведено 20 761 операций по эндопротезированию крупных суставов. Частота возникновения глубоких инфекционных осложнений составила 0,3%. Средний возраст пациентов с инфекционными осложнениями составил 61,2+12,3 года, соотношение мужчин и женщин 1:2. Сплошным методом проведена оценка факторов риска развития инфекционных осложнений, изучен видовой состав выделенной микрофлоры. На основании анализа тактики оперативного вмешательства определен оптимальный метод хирургического лечения. Результаты. Основными предрасполагающими факторами риска в развитии инфекционных осложнений явились очаги хронической инфекции, сахарный диабет, ожирение, системные воспалительные заболевания, предшествующее внутрисуставное введение лекарственных средств, гематрансфузии, неоднократные хирургические манипуляции области планируемого хирургического вмешательства, а также наличие гематом в перипротезной зоне, выявленные в послеоперационном периоде. Основной возбудитель инфекционных осложнений представлен Грамм положительными микроорганизмами, ведущая роль из которых принадлежит стафилококкам (52%). При выявлении инфекционного процесса в оперированном суставе приоритетная тактика лечения в Центре состояла в двухэтапном эндопротезировании с «длинным интервалом» (70,5%), одноэтапное ревизионное вмешательство составило 23,5%, трехэтапное ревизионное вмешательство - 6%. Двухэтапное эндопротезирование с «длинным интервалом» является эффективным методом лечения, а также экономически целесообразным. При этом необходимо учитывать длительность высвобождения антибиотика из цементного спейсера. Сокращение срока между реимплантациями достоверно снижает долю реревизий (с 9% до 4,5%, р<0,05), улучшает долгосрочные результаты, повышает мотивацию пациентов к лечению

Diagnostically significant differences septic and aseptic instability of endoprosthesis components during arthroplasty of large joints

The purpose of the work is to analyze the results of laboratory, microbiological and instrumental studies to search for screening criteria for the difference between aseptic and septic instability of endoprosthesis components after knee and hip joint arthroplasty. The materials contained 146 cases of revision arthroplasty of the knee and hip joints, performed under the conditions of Federal State Budgetary Institution Federal Center of Traumatology, Orthopedics and endoprosthesis replacement of Ministry of Health of the Russian Federation (Cheboksary) for a 3-year period, including cases of aseptic instability - 69, septic instability-77. By methods for laboratory diagnosis were used to evaluate the blood levels of leukocytes, stab neutrophils, ESR, C-reactive protein (CRP), presepsin, procalcitonin, D-dimer, interleukin-6. Using ultrasound (ultrasonic) examination of the periprosthetic zone, the presence of fluid, granulation tissue in the joint cavity, altered lymph nodes was determined. Before the operation, the level of cytosis and cellular composition were determined in the synovial fluid; tissue bioptates, removed components of implants (after ULTRASONIC treatment) with sowing on the microflora were studied intraoperatively. Intraoperative tissue biopsies were used to make smears-prints on the glass, with gram staining, estimating the number of leukocytes and neutrophils in the field of vision. Results. Determination of indicators of ESR, presepsin and interleukin-6, the level of which goes beyond the generally recognized normal values in the presence of infection, can be recommended as a screening test in the diagnosis of the infectious nature of instability of the components of the endoprosthesis of large joints. The second stage of differential diagnosis of septic and aseptic instability can be the detection of lymphadenopathy. The third (final) stage of determining the infectious nature of instability is an invasive technique to determine the level of cytosis with the calculation of neutrophils in the synovial fluid.Цель работы - анализ результатов лабораторных, микробиологических и инструментальных исследований для поиска скрининг-критериев отличия асептической и септической нестабильности компонентов эндопротеза после артропластики коленных и тазобедренных суставов. Материалами послужили 146 случаев ревизионной артропластики коленных и тазобедренных суставов, выполненной в условиях Федерального государственного бюджетного учреждения «Федеральный центр травматологии, ортопедии и эндопротезирования» Министерства здравоохранения российской Федерации (г. Чебоксары) за 3-летний период, из них случаев асептической нестабильности - 69, септической нестабильности - 77. Методами лабораторной диагностики проводилась оценка содержания в крови лейкоцитов, палочкоядерных нейтрофилов, СОЭ, С-реактивного белка (СРБ), пресепсина, прокальцитонина, Д-димера, интерлейкина-6. С помощью ультразвукового (УЗ) исследования перипротезной зоны определяли наличие жидкости, грануляционной ткани в полости сустава, измененных лимфатических узлов. до операции в синовиальной жидкости определяли уровень цитоза и клеточный состав; интраоперационно исследовались тканевые биоптаты, удаленные компоненты имплантов (после УЗ обработки) с посевом на микрофлору. Из интраоперационных тканевых биоптатов делали мазки-отпечатки на стекле, с окрашиванием по Граму, оценивая количество лейкоцитов и нейтрофилов в поле зрения. результаты. Определение показателей СОЭ, пресепсина и интерлейкина-6, уровень которых выходит за пределы общепризнанных нормальных значений при наличии инфекции, может быть рекомендовано в качестве скрининг-теста при диагностике инфекционной природы нестабильности компонентов эндопротеза крупных суставов. Вторым этапом дифференциальной диагностики септической и асептической нестабильности может служить выявление лимфоаденопатии. третьим (заключительным) этапом определения инфекционной природы нестабильности является инвазивная методика с определением уровня цитоза с подсчетом нейтрофилов в синовиальной жидкости

The role of culture-negative infection among infectious complications after total knee arthroplasty

Introduction Diagnosis of chronic periprosthetic joint infection (PJI) is difficult with the clinical signs of periprosthetic inflammation showing no growth of microorganism in the biomaterial. The frequency of culture-negative infection can reach 42.1 %. The objective of the study was to analyze outcomes of two-stage treatment of chronic PJI of the knee joint depending on the etiology of the infectious process. Material and methods A retrospective analysis of outcomes was produced for 103 patients: group I (n=30) showing no growth of microorganisms and group II (n = 73) demonstrating positive growth of pathogens. Knee PJI was diagnosed according to the 2018 ICM criteria. A favorable outcome suggested absence of recurrence for at least two years after reimplantation of endoprosthesis, arthrodesis, “life with a spacer” without signs of infection. Results Culture-negative infection was detected in 29.1 % (n = 30). Patients in the group were 1.5 times more likely to receive antibiotic therapy prior to admission and had average levels of CRP, ESR and articular leukocyte count being 1.5-2 times less than those in group II. Staphylococci (69.8 %) including MRSE (75 %) was the leading pathogen in group II. Recurrence of infection was 3.4 % in group I and 16.9 % in group II (p = 0.0928), the two-stage treatment was successful in 96.7 % and 74 %, respectively (p = 0.0064). Discussion Causes for the lack of growth of microorganisms in biological materials included previous antibiotic therapy, wound drainage, violations of the rules for sampling of biological material, absence of media for the growth of atypical microorganisms and the ability of microorganisms to form biofilms on implant surfaces. An emergency histological examination of the affected tissues was practical during surgery in doubtful situations for adequate surgical approach. The results of a meta-analysis (2023) showed that the replacement of an infected endoprosthesis was more effective for the treatment of a culture-negative infection compared to debridement and preservation of implant. Conclusion The culture-negative infection group in our series showed better success rate of a two-stage treatment of PJI using implant replacement and broad-spectrum empiric antibiotic therapy at a two-year follow-up period. The negative microbiological result in the group could be caused by antibacterial drugs administered prior to diagnosis of PJI

Evaluation of diagnostic criteria and choice of treatment tactics for patients with infectious spondylodiscitis based on a case series

Objective. To present a brief description of a series of clinical cases of infectious spondylodiscitis with an assessment of the used diagnostic criteria in terms of their influence on the choice of sanifying treatment tactics. Material and Methods. A continuous retrospective study of 39 cases of spondylodiscitis was carried out. Level of evidence is IIIC. The level of ESR, serum C-reactive protein, the results of the study of biopsy materials, and CT and MRI data were evaluated. Criteria of neurological deficit, instability of the spinal motion segment, and recommendations for assessing the clinical and radiological severity of the disease were used to select the treatment tactics. Treatment success was defined as primary wound healing, absence of recurrent infection and/or death, and satisfaction with treatment according to the EQ-5D and EQ-VAS scales at a follow-up period of 22.5 months. Results. The average age of patients was 57.4 years. Primary spondylodiscitis accounted for 82 %, the predominant localization of the pathological focus was the lumbar spine (56.4 %), and staphylococci were predominant etiologic agents (59.1 %). On average, the increase in ESR was 45 mm/h, C-reactive protein – 57 ng/l, and D-dimer – 1235 pg/ml. The level of pain before sanation according to the VAS scale was 6.79 points, after the operation it was 2.3 points (p < 0.05). Instability of the spinal motion segment according to the SINS scale was revealed in 36 cases, paravertebral abscess according to MRI – in 51.3 % of cases, and neurological deficit – in 38.5 % of cases. Severe spondylodiscitis according to the SponDT scale was noted in 53.8 %, moderate – in 43.6 %, and mild – in 2.6 % of patients. According to the clinical and radiological classification of infectious spondylodiscitis severity (SSC), grade I was present in 2 patients, grade II – in 21, and grade III – in 6. Compliance of the chosen treatment tactics with current recommendations was noted in 94,9 % of cases. Recurrence of infection was observed in 7.7 %; lethal outcome – in 5.1 %. Satisfaction with the quality of life according to EQ-5D was 0.74 points, and according to EQ-VAS – 73.88 points. Conclusions. The integrated use of criteria for neurological deficit, instability of spinal motion segments, and severity of the disease according to the SponDT classification with the account of Pola’s recommendations on treatment tactics made it possible to choose the optimal treatment tactics and achieve satisfactory results in the sanation of patients with infectious spondylodiscitis

Linear-Chain Nanostructured Carbon with a Silver Film Plated on Metal Components Has a Promising Effect for the Treatment of Periprosthetic Joint Infection

Background: Due to the aging of the world population, the number of joint diseases, along with the number of arthroplasties, has increased, simultaneously increasing the amount of complications, including periprosthetic joint infection (PPI). In this study, to combat a PPI, we investigated the antimicrobial properties of the new composite cover for titanium implants, silver-doped carbyne-like carbon (S-CLC) film. Methods: The first assay investigated the antimicrobial activity against Pseudomonas aeruginosa and releasing of silver ions from S-CLC films into growth media covered with S-CLC with a thickness of 1, 2, and 4 mm. The second assay determined the direct antibacterial properties of the S-CLC film&rsquo;s surface against Staphylococcus aureus, Enterococcus faecalis, or P. aeruginosa. The third assay studied the formation of microbial biofilms of S. aureus or P. aeruginosa on the S-CLC coating. Silver-doped carbyne-like carbon (S-CLC)-covered or titanium plates alone were used as controls. Results: S-CLC films, compared to controls, prevented P. aeruginosa growth on 1 mm thickness agar; had direct antimicrobial properties against S. aureus, E. faecalis, and P. aeruginosa; and could prevent P. aeruginosa biofilm formation. Conclusions: S-CLC films on the Ti surface could successfully fight the most common infectious agent in PPI, and prevented biofilm formation