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      Revision of late periprosthetic infections of total hip endoprostheses: pros and cons of different concepts

      review-article

      International Journal of Medical Sciences

      Ivyspring International Publisher

      periprosthetic infections, hip endoprostheses

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          Abstract

          Many concepts have been devised for the treatment of late periprosthetic infections of total hip prostheses. A two-stage revision with a temporary antibiotic-impregnated cement spacer and a cemented prosthesis appears to be the most preferred procedure although, in recent times, there seems to be a trend towards cementless implants and a shorter period of antibiotic treatment. Because of the differences in procedure, not only between studies but also within studies, it cannot be decided which period of parenteral antibiotic treatment and which spacer period is the most suitable. The fact that comparable rates of success can be achieved with different treatment regimens emphasises the importance of surgical removal of all foreign materials and the radical debridement of all infected and ischaemic tissues and the contribution of these crucial procedures to the successful treatment of late periprosthetic infections.

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          Most cited references 57

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          Role of rifampin for treatment of orthopedic implant-related staphylococcal infections: a randomized controlled trial. Foreign-Body Infection (FBI) Study Group.

          Rifampin-containing regimens are able to cure staphylococcal implant-related infections based on in vitro and in vivo observations. However, this evidence has not been proven by a controlled clinical trial. To evaluate the clinical efficacy of a rifampin combination in staphylococcal infections associated with stable orthopedic devices. A randomized, placebo-controlled, double-blind trial conducted from 1992 through 1997. Two infectious disease services in tertiary care centers in collaboration with 5 orthopedic surgeons in Switzerland. A total of 33 patients with culture-proven staphylococcal infection associated with stable orthopedic implants and with a short duration of symptoms of infection (exclusion limit <1 year; actual experience 0-21 days). Initial debridement and 2-week intravenous course of flucloxacillin or vancomycin with rifampin or placebo, followed by either ciprofloxacin-rifampin or ciprofloxacin-placebo long-term therapy. Cure was defined as (1) lack of clinical signs and symptoms of infection, (2) C-reactive protein level less than 5 mg/L, and (3) absence of radiological signs of loosening or infection at the final follow-up visit at 24 months. Failure was defined as (1) persisting clinical and/or laboratory signs of infection or (2) persisting or new isolation of the initial microorganism. A total of 18 patients were allocated to ciprofloxacin-rifampin and 15 patients to the ciprofloxacin-placebo combination. Twenty-four patients fully completed the trial with a follow-up of 35 and 33 months. The cure rate was 12 (100%) of 12 in the ciprofloxacin-rifampin group compared with 7 (58%) of 12 in the ciprofloxacin-placebo group (P=.02). Nine of 33 patients dropped out due to adverse events (n=6), noncompliance (n=1), or protocol violation (n=2). Seven of the 9 patients who dropped out were subsequently treated with rifampin combinations, and 5 of them were cured without removal of the device. Among patients with stable implants, short duration of infection, and initial debridement, patients able to tolerate long-term (3-6 months) therapy with rifampin-ciprofloxacin experienced cure of the infection without removal of the implant.
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            Practical applications of antibiotic-loaded bone cement for treatment of infected joint replacements.

            The use of antibiotic-loaded bone cement is an accepted treatment method for infected joint arthroplasties. It is helpful to separate the use of antibiotic-loaded bone cement as a method of prophylaxis as compared with the treatment of an established infection. A low dose of antibiotic-loaded bone cement ( 1 g antibiotic per batch of cement) is indicated for treatment. The only commercially available antibiotic-loaded bone cement products are low dose, with the use of tobramycin or gentamicin as an antibiotic selection. High-dose antibiotic-loaded bone cement requires hand mixing by the surgeon to facilitate the use of high dosages and choices of multiple antibiotics. Treatment of infected hip and knee arthroplasties with high-dose antibiotic-loaded bone cement is aided by the use of spacers of various shapes and sizes. These spacers, whether they are static or articulating (mobile), are meant to provide local delivery of antibiotics, stabilization of soft tissues, facilitation of an easier reimplantation, and improved clinical outcomes.
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              Long-term elution of antibiotics from bone-cement: an in vivo study using the prosthesis of antibiotic-loaded acrylic cement (PROSTALAC) system.

              A prospective study of 49 patients undergoing a modified 2-stage exchange arthroplasty for infected total hip and knee arthroplasties using the prosthesis of antibiotic-loaded acrylic cement (PROSTALAC) system with a variety of doses of tobramycin and vancomycin was performed. The intra-articular concentrations of tobramycin and vancomycin were measured at the time of removal of the PROSTALAC temporary spacer and reimplantation of a definitive joint arthroplasty prosthesis, at a mean 118 days following initial implantation. The 95% confidence interval of the intra-articular concentration of tobramycin (4.35-123.88 mg/L) was entirely above the breakpoint sensitivity limit for sensitive organisms when at least 3.6 g of tobramycin was used per package of bone-cement but was entirely below it when at most 2.4 g was used. Vancomycin elution was not as good; however, detectable levels were still present in most patients. There was a statistically significant increase in the elution of vancomycin when the dose of tobramycin was increased from at most 2.4 g to at least 3.6 g. The dose of vancomycin in the cement did not influence the elution of either tobramycin or vancomycin. On the basis of these results, the use of at least 3.6 g of tobramycin and 1 g of vancomycin per package of bone-cement is recommended when antibiotic-loaded cement spacers are used in 2-stage exchange arthroplasty for infected total hip and knee arthroplasties.
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                Author and article information

                Journal
                Int J Med Sci
                ijms
                International Journal of Medical Sciences
                Ivyspring International Publisher (Sydney )
                1449-1907
                2009
                4 September 2009
                : 6
                : 5
                : 287-295
                Affiliations
                Department of Joint Replacement, General and Rheumatic Orthopaedics, Orthopaedic Clinic Markgröningen gGmbH, Kurt-Lindemann-Weg 10, 71706 Markgröningen, Germany
                Author notes
                ✉ Correspondence to: Prof. Dr. med. Bernd Fink, M.D., Department of Joint Replacement, General and Rheumatic Orthopaedics, Orthopaedic Clinic Markgröningen gGmbH, Kurt-Lindemann-Weg 10, 71706 Markgröningen gGmbH, Kurt-Lindemann-Weg 10, 71706 Markgröningen, Germany, Phone: ++49-7145-912201, Fax: ++49-7145-912922, E-mail: b.fink@ 123456okm.de

                Conflict of interest: The author has no conflict of interest

                Article
                ijmsv06p0287
                2755126
                19834595
                f7fd105b-f99d-441c-91b1-e441069a48dc
                © Ivyspring International Publisher. This is an open-access article distributed under the terms of the Creative Commons License (http://creativecommons.org/licenses/by-nc-nd/3.0/). Reproduction is permitted for personal, noncommercial use, provided that the article is in whole, unmodified, and properly cited.
                Categories
                Review

                Medicine

                hip endoprostheses, periprosthetic infections

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