Long-term results of periprosthetic infection prevention and treatment in oncoorthopedics

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Abstract

BACKGROUND: Endoprosthesis after bone and joint resection is the treatment of choice for patients with malignant bone tumors, especially in case of a favorable oncological prognosis. Endoprosthesis bone site infection and relapse associated with the underlying disease are important complications that are difficult to treat. The development of periprosthetic infection leads to the loss of functional potential after the end of this complication treatment and worsens oncologic prognosis.

AIM: To study and improve the long-term results of treatment in patients with diagnosed periprosthetic infection who underwent oncologic endoprosthesis, to develop a preventive complex of measures aimed at reducing periprosthetic infection.

MATERIAL AND METHODS: The study included 1292 patients with primary bone sarcomas, soft tissue sarcomas, metastatic and benign bone tumors who underwent 1671 primary and recurrent endoprosthetic replacements between January 1992 and January 2020. A total of 677 (52.4%) men and 615 (47.6%) women participated in the study. Patients ranged in age from 10 years to 81 years. Oncologic endoprosthetics were performed in 886 (68.6%) patients with primary malignancies, 144 (11.1%) with metastatic bone lesions, and 262 (20.3%) with benign neoplasms. The mean follow-up period after endoprosthetic replacement with various bone segments was 82.8 months (0-335.7 months).

RESULTS: The incidence of periprosthetic infection during the entire follow-up period in primary endoprosthesis was 7.1%, and in repeat endoprosthesis — 6.2%. The recurrence rate of endoprosthesis infection in primary endoprosthesis during the observation period was 83%, in repeat endoprosthesis — 61.5%. The frequency of periprosthetic infection was reduced by changes in the endoprosthetic strategy. The prevalence of early (type IVA according to ISOLS 2013) infectious complications (15 and 11.9%) over late (type IVB) complications (5 and 4.4%, respectively) in both primary and repeat arthroplasty was higher. Staphylococcus aureus was most frequently identified after primary endoprosthetic replacement (38.1%) and Staphylococcus epidermidis was most commonly verified after repeat endoprosthetic replacement (53%). Two-stage reendoprosthesis was used most often to treat periprosthetic infection: after primary endoprosthesis — in 58.3% of cases, after repeat endoprosthesis — in 65.4%. The preventive measures developed in the study made it possible to reduce the incidence of the endoprosthesis site early infection by 15.3% in primary endoprosthesis and by 7.1% in repeat endoprosthesis.

CONCLUSION: The perioperative antibiotic prevention regimen should provide a steady antibiotic concentration during the entire course of surgery and the time associated with the highest risk of endoprosthesis site early infection (extended antibiotic treatment up to 5 days), which allows to reduce the wound microbial contamination to a safe level. The findings suggest that two-stage reendoprosthetic replacement remains the main treatment option for periprosthetic infection.

About the authors

Anatolii V. Sokolovskii

Blokhin National Medical Research Center of Oncology

Author for correspondence.
Email: avs2006@mail.ru
ORCID iD: 0000-0002-8181-019X
SPIN-code: 8261-4838

MD, Dr. Sci. (Med.)

Russian Federation, Moscow

Vladimir A. Sokolovskii

Blokhin National Medical Research Center of Oncology

Email: arbat.62@mail.ru
ORCID iD: 0000-0003-0558-4466

MD, Dr. Sci. (Med.)

Russian Federation, Moscow

Gennady N. Machak

Priorov National Medical Research Center of Traumatology and Orthopedics

Email: machak.gennady@mail.ru
ORCID iD: 0000-0003-1222-5066
SPIN-code: 4020-1743

MD, Dr. Sci. (Med.)

Russian Federation, Moscow

Irina N. Petukhova

Blokhin National Medical Research Center of Oncology

Email: irinapet@list.ru
ORCID iD: 0000-0003-3077-0447
SPIN-code: 1265-2875

MD, Dr. Sci. (Med.)

Russian Federation, Moscow

Alexander A. Kurilchik

Tsyba Medical Radiological Research Center

Email: aleksandrkurilchik@yandex.ru
ORCID iD: 0000-0003-2615-078X
SPIN-code: 1751-0982

MD, Cand. Sci. (Med.)

Russian Federation, Obninsk

Alexander A. Geravin

Meshalkin National Medical Research Center of Oncology

Email: avs2006@mail.ru
ORCID iD: 0000-0003-3169-0326

MD, Cand. Sci. (Med.)

Russian Federation, Novosibirsk

References

  1. Pala E, Trovarelli G, Calabro T, Angelini A, Abati CN, Ruggieri P. Survival of Modern Knee Tumor Megaprostheses: Failures, Functional Results, and a Comparative Statistical Analysis. Clin Orthop Relat Res. 2015;473(3):891–899. doi: 10.1007/s11999-014-3699-2
  2. Benevenia J, Kirchner R, Patterson F, et al. Outcomes of a modular intercalary endoprosthesis as treatment for segmental defects of the femur, tibia, and humerus. Clin Orthop Relat Res. 2016;474(2):539–548. doi: 10.1007/s11999-015-4588-z
  3. Henderson ER, O’Connor MI, Ruggieri P, Windhager R, Funovics PT, Gibbons CL, Guo W, Hornicek FJ, Temple HT, Letson GD. Classification of failure of limb salvage after reconstructive surgery for bone tumours. Bone Joint J. 2014;96-B(11):1436–1440. doi: 10.1302/0301-620X.96B11.34747
  4. Jeys L, Grimer R. The long-term risks of infection and amputation with limb salvage surgery using endoprostheses. Recent Results Cancer Res. 2009;(179):75–84. doi: 10.1007/978-3-540-77960-5_7
  5. Berbari EF, Marculescu C, Sia I, Lahr BD, Hanssen AD, Steckelberg JM, Gullerud R, Osmon DR. Culture-negative prosthetic joint infection. Clin Infect Dis. 2007;45(9):1113–1119. doi: 10.1086/522184
  6. Tan TL, Kheir MM, Shohat N, Tan DD, Kheir M, Chen C, Parvizi J. Culture-Negative Periprosthetic Joint Infection. JBJS Open Access. 2018;3(3):e0060. doi: 10.2106/JBJS.OA.17.00060
  7. Huang R, Hu CC, Adeli B, Mortazavi J, Parvizi J. Culture-negative periprosthetic joint infection does not preclude infection control. Clin Orthop Relat Res. 2012;470(10):2717–2723. doi: 10.1007/s11999-012-2434-0
  8. Pala E, Henderson ER, Calabro T, Angelini A, Abati CN, Trovarelli G, et al. Survival of current production tumor endoprostheses: Complications, functional results, and a comparative statistical analysis. J Surg Oncol. 2013;108(6):403–408. doi: 10.1002/jso.23414
  9. Holl S, Schlomberg A, Gosheger G, Dieckmann R, Streitbuerger A, Schulz D, Hardes J. Distal femur and proximal tibia replacement with megaprosthesis in revision knee arthroplasty: a limb-saving procedure. Knee Surg Sports Traumatol Arthrosc. 2012;20(12):2513–2518. doi: 10.1007/s00167-012-1945-2
  10. Finstein JL, King JJ, Fox EJ, Ogilvie CM, Lackman RD. Bipolar Proximal Femoral Replacement Prostheses for Musculoskeletal Neoplasms. Clinical orthopaedics and related research. 2007;(459):66–75. doi: 10.1097/BLO.0b013e31804f5474
  11. Myers GJC, Abudu AT, Carter SR, Tillman RM, Grimer RJ. The long-term results of endoprosthetic replacement of the proximal tibia for bone tumours. J Bone Joint Surg [Br]. 2007;89-B(12):1632–1637. doi: 10.1302/0301-620X.89B12.19481
  12. Wang В, Wu Q, Liu J, Yang S, Shao Z. Endoprosthetic reconstruction of the proximal humerus after tumour resection with polypropylene mesh. International Orthopaedics (SICOT). 2015;39(3):501–506. doi: 10.1007/s00264-014-2597-2
  13. Pala E, Trovarelli G, Calabro T, Angelini A, Abati CN, Ruggieri P. High Infection Rate Outcomes in Long-bone Tumor Surgery with Endoprosthetic Reconstruction in Adults: A Systematic Review. Clin Orthop Relat Res. 2013;471(6):2017–2027. doi: 10.1007/s11999-013-2842-9
  14. Gosheger G, Carsten G, Ahrens H, Streitbuerger A, Winkelmann W, Hardes J. Endoprosthetic Reconstruction in 250 Patients with Sarcoma. Clinical Orthopaedics and Related Research. 2006;(450):164–171. doi: 10.1097/01.blo.0000223978.36831.39
  15. Kostuj T, Baums MH, Schaper K, Meurer A. Midterm Outcome after Mega-Prosthesis Implanted in Patients with Bony Defects in Cases of Revision Compared to Patients with Malignant Tumors. The Journal of Arthroplasty. 2015;30(9):1592–1596. doi: 10.1016/j.arth.2015.04.002
  16. Ahlmann ER, Menendez LR, Kermani C, Gotha H. Survivorship and clinical outcome of modular endoprosthetic reconstruction for neoplastic disease of the lower limb. J Bone Joint Surg Br. 2006;88(6):790–795. doi: 10.1302/0301-620X.88B6.17519
  17. Illingworth KD, Mihalko WM, Parvizi J, Sculco T, McArthur B, el Bitar Y, Saleh KJ. How to minimize infection and thereby maximize patient outcomes in total joint arthroplasty: a multicenter approach: AAOS exhibit selection. J Bone Joint Surg Am. 2013;95(8):е50. doi: 10.2106/JBJS.L.00596
  18. Allison DC, Huang E, Ahlmann ER, Carney S, Wang L, Menendez LR. Peri-Prosthetic Infection in the Orthopedic Tumor Patient. JISRF Reconstructive Review. 2014;4(3):13–17. doi: 10.15438/rr.4.3.74
  19. Adeli B, Parvizi J. Strategies for the prevention of periprosthetic joint infection. J Bone Joint Surg Br. 2012;94(11, Suppl A):42–46. doi: 10.1302/0301-620X.94B11.30833
  20. Jämsen E, Huhtala H, Puolakka T, Moilanen T. Risk factors for infection after knee arthroplasty. A register-based analysis of 43,149 cases. J Bone Joint Surg Am. 2009;91(1):38–47. doi: 10.2106/JBJS.G.01686
  21. Ong KL, Kurtz SM, Lau E, Bozic KJ, Berry DJ, Parvizi J. Prosthetic joint infection risk after total hip arthroplasty in the Medicare population. J Arthroplasty. 2009;24(6, Suppl):105–109. doi: 10.1016/j.arth.2009.04.027
  22. Urquhart DM, Hanna FS, Brennan SL, Wluka AE, Leder K, Cameron PA, Graves SE, Cicuttini FM. Incidence and risk factors for deep surgical site infection after primary total hip arthroplasty: a systematic review. J Arthroplasty. 2010;25(8):1216–1222. doi: 10.1016/j.arth.2009.08.011
  23. Matar WY, Jafari SM, Restrepo C, Austin M, Purtill JJ, Parvizi J. Preventing infection in total joint arthroplasty. J Bone Joint Surg Am. 2010;92(Suppl 2):36–46. doi: 10.2106/JBJS.J.01046
  24. Grimer RJ, Aydin BK, Wafa H, Carter SR, Jeys L, Abudu A, Parry M. Very long-term outcomes after endoprosthetic replacement for malignant tumours of bone. Bone Joint J. 2016;98-B(6):857–864. doi: 10.1302/0301-620X.98B6.37417
  25. Sigmund IK, Gamper J, Weber C, Holinka J, Panotopoulos J, Funovics PT, Windhager R. Efficacy of different revision procedures for infected megaprostheses in musculoskeletal tumour surgery of the lower limb. PLoS One. 2018;13(7):e0200304. doi: 10.1371/journal.pone.0200304
  26. Dmitrieva NV, Petukhova IN. Postoperative infectious complications. Moscow: Practical Medicine; 2013. 113–135 р. (In Russ).
  27. Aliyev MD, Sokolovsky VA, Dmitrieva NV. Complications in endoprosthetics of patients with bone tumors. Bulletin of the N.N. Blokhin Russian Research Center of the Russian Academy of Medical Sciences. 2003;14(2–1):35–39. (In Russ).
  28. Schmalzried TP, Amstutz HC, Au MK, Dorey FJ. Etiology of deep sepsis in total hip arthroplasty: the sifnificance of hamatogenous and reccurent infections. Clin. Orthop. 1992;(280):200–207.
  29. Zajonz D, Prietzel T, Moche M. Periprosthetic joint infections in modular endoprostheses of the lower extremities: a retrospective observational study in 101 patients. Patient safety in surgery. 2016;(10):6. doi: 10.1186/s13037-016-0095-8

Supplementary files

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1. JATS XML
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2. Fig. 1. The structure of bacterial microorganisms isolated during primary and repeated arthroplasty.

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3. Fig. 2. Use of various treatment methods of periprosthetic infection.

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4. Fig. 3. The frequency of early periprosthetic infection (IVA type) after primary and repeat endoprosthesis replacement.

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5. Fig. 4. The frequency of late periprosthetic infection (IVB type) after primary and revision endoprosthesis replacement.

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6. Fig. 5. Radiography after primary endoprosthetics in 2015: a — femoral stem of the endoprosthesis, frontal projection; b — femoral stem of the endoprosthesis, lateral projection; c — tibial pedicle of the endoprosthesis, frontal projection; d — tibial pedicle of the endoprosthesis, lateral projection.

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7. Fig. 6. Microbiological examination of the endoprosthesis bed aspirate.

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8. Fig. 7. Manufacturing stages of articulating 3D spacer: a — creating a mold for manufacturing a 3D spacer; b, c — fabricated articulatory 3D spacer of the knee joint; d — defect replacement after removal of the knee endoprosthesis with an articulatory 3D spacer.

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9. Fig. 8. Functional result 6 months after the defect was replaced with an articulatory 3D spacer of the knee joint.

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10. Fig. 9. X-ray after stage II knee revision endoprosthetics (2022): a — femoral stem of the endoprosthesis, frontal projection; b — femoral stem of the endoprosthesis, lateral projection; c — tibial pedicle of the endoprosthesis, frontal projection; d — tibial pedicle of the endoprosthesis, lateral projection.

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