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Treatment Solutions Are Unclear for Perimegaprosthetic Infections

  • Symposium: 2012 Musculoskeletal Infection Society
  • Published:
Clinical Orthopaedics and Related Research®

Abstract

Background

Infection about a megaprosthesis is a dreaded complication. Treatment options vary from débridement alone to staged revisions, arthrodesis, and amputation. Indications for how to treat this complication are unclear.

Questions/purposes

We therefore determined (1) the incidence of perimegaprosthetic infections, (2) the methods of treatment, (3) the number of patients who failed their original treatment plan, and (4) the characteristics of the infection.

Methods

We retrospectively identified 291 patients who had megaprostheses implanted between 2001 and 2011 and identified all those surgically treated for a perimegaprosthetic infection during that time. We defined a treatment failure as any unplanned reoperation or death due to uncontrolled infection. All patients with failure had a minimum followup of 1 year (mean, 3.3 years; range, 1–8 years).

Results

Of the 291 patients, 31 (11%) had subsequent infections. Surgical management varied among irrigation and débridement (n = 15), single-stage revisions (n = 11), two-stage revisions (n = 4), and amputations (n = 1). Sixteen patients failed their original treatment plan: 13 required additional surgery and three died. Infections were mostly chronic and single organism with five being methicillin-resistant Staphylococcus aureus.

Conclusions

An 11% incidence of perimegaprosthetic infections is consistent with the increased risk of infection seen in other studies. A variety of surgical methods were employed at our institution and by those contributing to the literature without clear evidence of superiority of one method over another. Given the complicated medical and surgical histories of these patients, individualization in decision making is necessary.

Level of Evidence

Level III, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.

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References

  1. Bradbury T, Fehring TK, Taunton M, Hanssen A, Azzam K, Parvizi J, Odum S. The fate of acute methicillin-resistant Staphylococcus aureus periprosthetic knee infections treated by open debridement and retention of components. J Arthroplasty. 2009;24:101–104.

    Article  PubMed  Google Scholar 

  2. Capanna R, Morris HG, Campanacci D, Del Ben M, Campanacci M. Modular uncemented prosthetic reconstruction after resection of tumours of the distal femur. J Bone Joint Surg Br. 1994;76:178–186.

    PubMed  CAS  Google Scholar 

  3. Chim H, Tan B, Tan M, Tan K, Song C. Optimizing the use of local muscle flaps for knee megaprosthesis coverage. Ann Plast Surg. 2007;59:398–403.

    Article  PubMed  CAS  Google Scholar 

  4. Cho W, Song W, Jeon D, Kong C, Kim J, Lee S. Cause of infection in proximal tibial endoprosthetic reconstructions. Arch Orthop Trauma Surg. 2012;132:163–169.

    Article  PubMed  Google Scholar 

  5. Deirmengian C, Greenbaum J, Lotke P, Booth R, Lonner J. Limited success with open debridement and retention of components in the treatment of acute staphylococcus aureus infections after total knee arthroplasty. J Arthroplasty. 2003;18:22–26.

    Article  PubMed  Google Scholar 

  6. Donati D, Biscaglia R. The use of antibiotic impregnated cement in infected reconstructions after resection for bone tumors. J Bone Joint Surg Br. 1998;80:1045–1050.

    Article  PubMed  CAS  Google Scholar 

  7. Donati D, D’Arenzo R, Ercolani C, Boriani S. Infection in limb salvage surgery for bone tumors. Eur J Orthop Surg Traumatol. 1995;5:71–74.

    Article  Google Scholar 

  8. Eckardt J, Eilber F, Rosen G, Mirra J, Dorey F, Ward W, Kabo J. Endoprosthetic replacement for stage IIB osteosarcoma. Clin Orthop Relat Res. 1991;270:202–213.

    PubMed  Google Scholar 

  9. Flint M, Griffin AM, Bell R, Wunder J, Ferguson P. Two-stage revision of infected uncemented lower extremity tumor endoprostheses. J Arthroplasty. 2007;22:859–865.

    Article  PubMed  Google Scholar 

  10. Gosheger G, Gebert C, Ahrens H, Streitbuerger A, Winkelmann W, Hardes J. Endoprosthetic reconstruction in 250 patients with sarcoma. Clin Orthop Relat Res. 2006;450:164–171.

    Article  PubMed  Google Scholar 

  11. Gosheger G, Goetze C, Hardes J, Joosten U, Winkelmann W, von Eiff C. The influence of the alloy of megaprostheses on infection rate. J Arthroplasty. 2008;23:916–920.

    Article  PubMed  Google Scholar 

  12. Gosheger G, Hardes J, Ahrens H, Streitburger A, Buerger H, Erren M, Gunsel A, Kemper F, Winkelmann W, von Eiff C. Silver-coated megaendoprostheses in a rabbit model—an analysis of the infection rate and toxicological side effects. Biomaterials. 2004;25:5547–5556.

    Article  PubMed  CAS  Google Scholar 

  13. Grimer R, Belthur M, Chandrasekar C, Carter S, Tillman R. Two-stage revision for infected endoprostheses used in tumor surgery. Clin Orthop Relat Res. 2002;395:193–203.

    Article  PubMed  Google Scholar 

  14. Grimer R, Carter S, Tillman R, Sneath R, Walker P, Unwin P, Shewell P. Endoprosthetic replacement of the proximal tibia. J Bone Joint Surg Br. 1999;81:488–494.

    Article  PubMed  CAS  Google Scholar 

  15. Hardes J, Ahrens H, Gebert C, Streitburger A, Buerger H, Erren M, Gunsel A, Wedemeyer C, Saxler G, Winkelmann W, Gosheger G. Lack of toxicological side-effects in silver-coated megaprostheses in humans. Biomaterials. 2007;28:2869–2875.

    Article  PubMed  CAS  Google Scholar 

  16. Hardes J, Gebert C, Schwappach A, Ahrens H, Streiburger A, Winkelman W, Gosheger G. Characteristics and outcome of infections associated with tumor endoprostheses. Arch Orthop Trauma Surg. 2006;126:289–296.

    Article  PubMed  CAS  Google Scholar 

  17. Hardes J, von Eiff C, Streitbuerger A, Balke M, Budny T, Henrichs M, Hauschild G, Ahrens H. Reduction of periprosthetic infection with silver-coated megaprostheses in patients with bone sarcoma. J Surg Oncol. 2010;101:389–395.

    PubMed  Google Scholar 

  18. Henderson E, Groundland J, Pala E, Dennis J, Wooten R, Cheong D, Windhager R, Kotz R, Mercuri M, Funovics P, Hornicek F, Temple H, Ruggieri P, Letson G. Failure mode classification for tumor endoprostheses: retrospective review of five institutions and a literature review. J Bone Joint Surg Am. 2011;93:418–429.

    Article  PubMed  Google Scholar 

  19. Holzer G, Windhager R, Kotz R. One-stage revision surgery for infected megaprostheses. J Bone Joint Surg Br. 1997;79:31–35.

    Article  PubMed  CAS  Google Scholar 

  20. Jeys L, Kulkarni A, Grimer R, Carter S, Tillman R, Abudu A. Endoprosthetic reconstruction for the treatment of musculoskeletal tumors of the appendicular skeleton and pelvis. J Bone Joint Surg Am. 2008;90;1265–1271.

    Article  PubMed  CAS  Google Scholar 

  21. Kuhne C, Taeger G, Nast-Kolb D, Ruchholtz S. Knee arthrodesis after infected tumor mega prosthesis of the knee using an intramedullary nail for callus distraction. Langenbecks Arch Surg. 2003;388:56–59.

    PubMed  CAS  Google Scholar 

  22. LaPorte D, Waldman B, Mont M, Hungerford D. Infections associated with dental procedures in total hip arthroplasty. J Bone Joint Surg Br. 1999;81:56–59.

    Article  PubMed  CAS  Google Scholar 

  23. Leung F, Richards C, Garbuz D, Masri B, Duncan C. Two-stage total hip arthroplasty: how often does it control methicillin-resistant infection? Clin Orthop Relat Res. 2011;469;1009–1015.

    Article  PubMed  Google Scholar 

  24. McDonald D, Capanna R, Gherlinzoni F, Bacci G, Ferruzzi A, Casadei R, Ferraro A, Cazzola A, Campanacci M. Influence of chemotherapy on perioperative complications in limb salvage surgery for bone tumors. Cancer. 1990;65:1509–1516.

    Article  PubMed  CAS  Google Scholar 

  25. Mittermayer F, Krepler P, Dominkus M, Schwameis E, Sluga M, Heinzl H, Kotz R. Long-term followup of uncemented tumor endoprostheses for the lower extremity. Clin Orthop Relat Res. 2001;388:167–177.

    Article  PubMed  Google Scholar 

  26. Morii T, Yabe H, Morioka H, Beppu Y, Chuman H, Kawai H, Takeda K, Hosaka S, Yazawa Y, Takeuchi K, Anazawa U, Mochizuki K, Satomi K. Postoperative deep infection in tumor endoprosthesis reconstruction around the knee. J Orthop Sci. 2010;15:331–339.

    Article  PubMed  Google Scholar 

  27. Namba R, Inacio M, Paxton E. Risk factors associated with surgical site infection in 30,491 primary total hip replacements. J Bone Joint Surg Br. 2012;94:1330–1338.

    Article  PubMed  CAS  Google Scholar 

  28. Ogose A, Hotta T, Kawashima H, Kawaji Y, Endo N. Ischial weight-bearing brace after the infection of megaprosthesis: a salvage method for resection arthroplasty. J Arthroplasty. 2005;20:954–956.

    Article  PubMed  Google Scholar 

  29. Osmon D, Berbari E, Berendt A, Lew D, Zimmerli W, Steckelberg J, Rao N, Hanssen A, Wilson W. Executive summary: diagnosis and management of prosthetic joint infection: clinical practice guidelines by the infectious disease society of America. Clin Infect Dis. 2013;56:1–10.

    Article  PubMed  Google Scholar 

  30. Patel R, Osmon D, Hanssen, A. The diagnosis of prosthetic joint infection: current techniques and emerging technologies. Clin Orthop Relat Res. 2005;437:55–58.

    Article  PubMed  Google Scholar 

  31. Peel T, Dowsey M, Daffy J, Stanley P, Choong P, Buising K. Risk factors for prosthetic hip and knee infections according to arthroplasty site. J Hosp Infect. 2011;79:129–133.

    Article  PubMed  CAS  Google Scholar 

  32. Rao N, Cannella B, Crossett L, Yates A, McGough R, Hamilton C. Preoperative screening/decolonization for Staphylococcus aureus to prevent orthopedic surgical site infection: prospective cohort study with 2-year follow-up. J Arthroplasty. 2011;26:1501–1507.

    Article  PubMed  Google Scholar 

  33. Roberts P, Chan D, Grimer R, Sneath R, Scales J. Prosthetic replacement of the distal femur for primary bone tumors. J Bone Joint Surg Br. 1991;73:762–769.

    PubMed  CAS  Google Scholar 

  34. Song K, Kim E, Kim Y, Jin H, Jeong S, Kwak Y, Cho Y, Sung J, Lee Y, Oh H, Kim T, Koo K, Kim E, Kim J, Choi T, Kim H, Choi H, Kim H. Differences in the risk factors for surgical site infection between total hip arthroplasty and total knee arthroplasty in the Korean Nosocomial Infections Surveillance System (KONIS). Infect Control Hosp Epidemiol. 2012;33:1086–1093.

    Article  PubMed  Google Scholar 

  35. van Kasteren M, Mannien J, Ott A, Kullberg B, de Boer A, Gyssens I. Antiobiotic prophylaxis and the risk of surgical site infections following total hip arthroplasty: timely administration is the most important factor. Clin Infect Dis. 2007;44:921–927.

    Article  PubMed  Google Scholar 

  36. Wirganowicz P, Eckardt J, Dorey F, Eilber F, Kabo M. Etiology and results of tumor endoprosthesis revision surgery in 64 patients. Clin Orthop Relat Res. 1999;358:64–74.

    Article  PubMed  Google Scholar 

  37. Yoshida S, Yokoyama R, Sakamoto A. Treatment of pelvic defect and infection with endoprosthesis exposure by topical negative pressure and irrigation with myocutaneous flap. Microsurgery. 2011;31:655–658.

    Article  PubMed  Google Scholar 

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Acknowledgments

The authors thank Dr. Mark Goodman for his assistance in developing and bringing the study to completion.

Author information

Authors and Affiliations

  1. Department of Orthopaedics, University of Pittsburgh, 3471 Fifth Avenue, Pittsburgh, PA, 15213, USA

    Lisa B. Ercolano MD, Richard McGough MD & Kurt Weiss MD

  2. University of Pittsburgh School of Medicine, Pittsburgh, PA, USA

    Tyson Christensen BS

Authors
  1. Lisa B. Ercolano MD
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  2. Tyson Christensen BS
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  3. Richard McGough MD
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  4. Kurt Weiss MD
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Corresponding author

Correspondence to Lisa B. Ercolano MD.

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Each author certifies that he or she, or a member of his or her immediate family, has no funding or commercial associations (eg, consultancies, stock ownership, equity interest, patent/licensing arrangements, etc) that might pose a conflict of interest in connection with the submitted article.

All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research editors and board members are on file with the publication and can be viewed on request.

Each author certifies that his or her institution approved the human protocol for this investigation, that all investigations were conducted in conformity with ethical principles of research, and that informed consent for participation in the study was obtained.

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Ercolano, L.B., Christensen, T., McGough, R. et al. Treatment Solutions Are Unclear for Perimegaprosthetic Infections. Clin Orthop Relat Res 471, 3204–3213 (2013). https://doi.org/10.1007/s11999-013-2852-7

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  • DOI: https://doi.org/10.1007/s11999-013-2852-7

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