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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 references57

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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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            Infection and musculoskeletal conditions: Prosthetic-joint-associated infections.

            In patients with osteoarthritis or arthritis, prosthetic joint replacement is increasingly used to alleviate pain and to improve mobility. The most important risk factors are comorbidity and prior joint replacement (revision surgery). Diagnosis of prosthetic-joint-associated infection is difficult, because the infecting agent may be missed in synovial fluid due to its exclusive presence as a device-associated biofilm. Implant-associated infections are difficult to treat because of their resistance to natural host defence mechanisms and to most antibiotics. In staphylococcal implant-associated infections a rifampin combination should be used, because this drug has an excellent efficacy on surface-adhering microorganisms. Antimicrobial therapy must always be combined with the correct surgical treatment which is chosen according to an algorithm. The use of antibiotics during procedures with potential bacteraemia is controversial because evidence for its need is lacking. In contrast, during sepsis rapid antibiotic therapy is needed to prevent haematogenous seeding on the artificial joint.
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              Infection after total hip arthroplasty. Past, present, and future.

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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
                10.7150/ijms.6.287
                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.
                History
                : 16 April 2009
                : 2 September 2009
                Categories
                Review

                Medicine
                hip endoprostheses,periprosthetic infections
                Medicine
                hip endoprostheses, periprosthetic infections

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