Vol 25, No 4 (2019)

Editorial.

The key aspects of the study: 1) what has changed in the structure of revisions in recent years? 2) what is the spectrum of reasons for revision after primary hip arthroplasty and re-revision? 3) what are the demographic features of patients’ population undergoing the revision? Materials and methods. The authors conducted a retrospective evaluation of 2415 hip revision cases during the period of time from 2014 until 2018. Separately the authors assessed revisions after primary surgeries and re-revisions as well as the group of early revisions. Results. In the period from 2014 until 2018 the overall share of revisions was 16,6% from all total hip arthroplasties, at the same time the authors reported the absolute 1.7 times increase in number of revisions as well as increased share of revisions in the total structure of hip arthroplasty from 12,5% to 18,9% without significant variances in the number of primary procedures. The share of early revisions increased from 32.9% in 2013 to 56.7% while the number of early revisions amounted to 37.4% of all primary revisions. Gender composition in primary and revision hip arthroplasty varied insignificantly. Mean age at the moment of hip revision was 59.2% (95% CI from 58.7 to 59.7; Me 60 years) which is slightly less than in primary replacement — 60.2 years (95% CI from 58.9 to 61.1; Me 62 years), but such variances had a high statistical significance, р<0.001. The main reasons for primary revisions were aseptic loosening of prosthesis components (50.3%), infection (27.6%), polyethylene wear and osteolysis (9.0%) as well as dislocations (6,2%). Re-revisions structure featured prevalence of infection (69.0%), aseptic loosening (20.8%) and dislocations (7,8%). Mean period of time after primary hip arthroplasty to revision was 7.9 years (95% CI from 7.7 to 8.2; Me 7.3), to first re-revision — 2.9 (95% CI from 2.6 to 3.2; Me 1.2), to second re-revision — 2.2 (95% CI from 1.8 to 2.7; Me 1.1), to third — 2,2 (95% CI from 1.7 to 2.8; Me 1.1), to fourth — 1.0 (95% CI from 0.6 to 1.3; Me 0.6), remaining cases demonstrated rather high heterogeneity. Conclusion. In the result of the present study the authors observed increased number of all revision hip arthroplasties, especially the share of early revisions within first five years from the moment of previous surgery. The most often reason for revision after primary hip arthroplasty was aseptic loosening of one or both components of prosthesis. Infection was the absolute leader in the group of re-revisions constituting over half of all reasons for secondary intervention.

Relevance. Late deep periprosthetic infection (PJI) of the hip joint is a serious complication after arthroplasty which takes the lead among the world reasons for revision. Accurate diagnostics allows to achieve good results and select a proper treatment tactics. Purpose of the study — to evaluate the efficiency of diagnostics algorithm for late deep PJI and impact of the microbial landscape on the risk of infection recurrence. Materials and methods. The authors evaluated two groups of patients who underwent revision in the period from 2002 to 2014 and from 2015 to 2018. The first (retrospective) group included 144 patients who were not diagnosed for late deep PJI. The second (prospective) group included 157 patients who underwent detailed diagnostics for late deep PJI based on the algorithm including the analysis of x-rays, pelvic CT, triple evaluation of ESR and CRP, puncturing of affected joint and microbiology examination. The authors assessed the microbial landscape in 51 patients with late deep hip PJI. Results. In the first group 12 patients (8.3%) underwent sanation and spacer insertion during first stage of treatment, 46 patients (59.7%) after revision demonstrated positive intraoperative cultures confirming septic etiology of implant loosening, 19 patients (24.67%) had no flora growth, and no intraoperative microbiological examination was done for remaining 67 patients (46.52%). In the second group after detailed diagnostics 51 patients (32.4%) underwent removal of prosthesis and spacer insertion in the first stage, other 13 patients (8.2%) featured flora growth after revision, remaining 93 patients (59.2%) had no flora growth after revision. Recurrent PJI was observed in 21 patients (14.5%) in the first group, and in 10 patients (6.3%) in the second group. In the second group recurrent PJI was reported in 40% of patients due to microbial associations, in 30% — due to MRSA, in 20% — due to culture negative bacteria and in 10% — due to S. aureus. Conclusion. Triple examination allows to obtain an accurate diagnosis and isolate the pathogen for deep PJI. Application of such diagnostics algorithm allows to reduce 2.1 times the risk of recurrent deep PJI and to scale down 4 times the detection of type IV infection by Coventry–Tsukayama classification.

Relevance. Formation of pan-resistance microorganisms, microbial biofilms on implants and recurrent infection rate stimulate the search for optimal prosthesis materials for treatment of periprosthetic infection (PJI). Purpose of the study — to compare the efficiency of two stage PJI treatment with simultaneous implantation of a spacer in combination with implants with silver-doped coatings based on two-dimensionally ordered linear chain carbon (TDOLCC+Ag) during the first stage and the conventional revision with a spacer only. Materials and methods. The study included 72 patients with PJI of the knee (n = 42) and hip (n = 30) joints. Control group (conventional revision) consisted of 35 patients and the main group (TDOLCC+Ag coated implant incorporated in a spacer) — 37 patients. Mean age of the patients was 61 years. Temporary components were replaced by the final components during revision at the second stage. Evaluation methods: clinical, X-ray, laboratory, microbiological and follow up history. Results. Inflammation markers and synovial fluid cytosis in the groups at the first revision stage featured equal high base values. During the second stage leucocyte count and cytosis reached normal values, ESR decreased twofold in both groups, CRP decreased five times in the main group. Throat and nasal swabs demonstrated growth of Staphylococcus aureus at 24,3-32,4% in both groups. The leading inducer of PJI was staphylococcal flora with MRSA share of 7,1% and MRSE — from 62,5 to 66,7%. End-points of evaluating treatment outcomes were revision spacer implantation at the second stage of sanation and recurrent PJI. Control group featured implantation of more revision spacers (5) as compared to the main group (1) after the treatment. Two recurrent PJIs were reported for the control group in 11 months while no recurrent infection was reported for the main group. Conclusion. The study demonstrated statistically significant improvement in the outcomes of PJI treatment by spacers with implants coated by TDOLCC+Ag as compared to the conventional treatment option.

Relevance. There is a limited number of publications reporting outcomes of primary large joint arthroplasty in patients with human immunodeficiency virus (HIV). The authors were unable to find papers on revision arthroplasty in patients with periprosthetic infection. Purpose of the study — to evaluate short term outcomes after revision arthroplasty in HIV-positive patients with periprosthetic infection of the hip and knee joint. Materials and methods. 13 HIV-positive patients with periprosthetic infection of the hip (10 cases) and knee (3 cases) joint underwent treatment in the period from 2015 to 2019. Patients were examined by clinical, laboratory and roentgenological methods. Harris Hip Score and Knee Society Score were used for evaluation prior to and after the surgery. Results. Mean follow up period was 21,4±2,6 months. Successful two-stage treatment was performed in two (15,4%) out of 13 patients with periprosthetic infection. In 5 cases (38,5%) control over infection was achieved by resection arthroplasty, and in one case (7,7%) – by arthrodesis. Five patients (38,5%) refused from interchange of spacer to prosthesis. Mean Harris Hip score demonstrated insignificant increase postoperatively — from 45,3±2,2 to 52,2±4,15 (р = 0,2). Conclusion. Despite following the international protocols for treatment of implant-associated infection the infection recurrence rate in HIV-positive patients in the asymptomatic phase remains very high. Efficiency of twostage treatment using antibacterial spacers in the present group of patients amounted only to 15,4%.

Periprosthetic joint infection (PJI) following total joint arthroplasty (TJA) is a complex disease state that is quite devastating to those affected. Improvement in diagnostic testing modalities and therapeutic techniques have led to significant advances in treatment for patients, but there is still a considerable gap in treatment success across providers and institutions. Where and who should be treating cases of PJI remains a debated topic. Many experts have proposed a new treatment model not dissimilar to that with which has been used to treat other complex disease states such as cancer for decades, and there is now a growing body of evidence to support such a strategy is superior. In this article, we evaluate the current body of literature on the topic and offer recommendations for the ideal treatment model for PJI: the multidisciplinary approach.

Current prophylactic and hygienic measures notwithstanding, implant-related infection remains among leading reasons for failure in orthopaedics and trauma surgery, resulting in extremely high social and economic costs. Various antibacterial coating technologies have been proven safe and effective both in preclinical and in clinical settings and able to reduce post-surgical infections up to 90%, depending on the type of the coating and on the experimental setup. In spite of this findings, the widespread use of these technologies is still limited by several factors. After reviewing the latest evidence on currently available antibacterial coatings, an algorithm is proposed to calculate the impact of the delayed introduction of these technologies in the clinical practice. When applied to joint arthroplasties, our calculator shows that each year of delay to implement an antibacterial coating, able to reduce post-surgical infection by 80% at a final user’s cost price of €600, causes an estimated 35 200 new cases of periprosthetic joint infection in Europe and additional annual hospital costs of approximately €440 million. Faster and more affordable regulatory pathways for antibacterial coating technologies and an adequate reimbursement policy for their clinical use appear a feasible solution to mitigate the impact of implant-related infections and may benefit patients, healthcare systems, and related research.

All patients provided written informed consent.

Competing interests: the authors declare that there are no competing interests.

The rate of periprosthetic infection (PJI) following primary total knee arthroplasty ranges from 0,5 to 6%, while after the revision arthroplasty PJI rate grows up to 13,6%. Despite the fact that PJI is more often caused by gram-positive microorganisms, the treatment of patients induced by gram-negative pathogens and fungi is the most complex and associated with the higher recurrence rate. This paper presents a positive two-stage treatment of a patient with fungal periprosthetic infection with a review of current medical literature. Revision, sanation of infection site and implantation of articulating antibacterial spacer was performed in the first stage of treatment. The second stage, which was the implantation of a revision prosthesis, followed in 6 months after removal of infection nidus. Subsequently the authors obtained good functional outcomes and stopping the infection process.

Nikolai V. Kornilov.