Gram-negative prosthetic joint infection: outcome of a debridement, antibiotics and implant retention approach. A large multicentre study.

We aim to evaluate the epidemiology and outcome of gram-negative prosthetic joint infection (GN-PJI) treated with debridement, antibiotics and implant retention (DAIR), identify factors predictive of failure, and determine the impact of ciprofloxacin use on prognosis. We performed a retrospective, multicentre, observational study of GN-PJI diagnosed from 2003 through to 2010 in 16 Spanish hospitals. We define failure as persistence or reappearance of the inflammatory joint signs during follow-up, leading to unplanned surgery or repeat debridement>30 days from the index surgery related death, or suppressive antimicrobial therapy. Parameters predicting failure were analysed with a Cox regression model. A total of 242 patients (33% men; median age 76 years, interquartile range (IQR) 68-81) with 242 episodes of GN-PJI were studied. The implants included 150 (62%) hip, 85 (35%) knee, five (2%) shoulder and two (1%) elbow prostheses. There were 189 (78%) acute infections. Causative microorganisms were Enterobacteriaceae in 78%, Pseudomonas spp. in 20%, and other gram-negative bacilli in 2%. Overall, 19% of isolates were ciprofloxacin resistant. DAIR was used in 174 (72%) cases, with an overall success rate of 68%, which increased to 79% after a median of 25 months' follow-up in ciprofloxacin-susceptible GN-PJIs treated with ciprofloxacin. Ciprofloxacin treatment exhibited an independent protective effect (adjusted hazard ratio (aHR) 0.23; 95% CI, 0.13-0.40; p<0.001), whereas chronic renal impairment predicted failure (aHR, 2.56; 95% CI, 1.14-5.77; p 0.0232). Our results confirm a 79% success rate in ciprofloxacin-susceptible GN-PJI treated with debridement, ciprofloxacin and implant retention. New therapeutic strategies are needed for ciprofloxacin-resistant PJI.

Cirugía reconstructiva del aparato locomotor, nuevas técnicas y opciones terapéuticas / Reconstructive surgery of the locomotor apparatus: new techniques and therapeutic options

La aplicación de criterios tumorales en el tratamiento quirúrgico secuencial de las osteítis crónicas y seudoartrosis sépticas en forma de resecciones segmentarias origina amplios defectos óseos. Una vez controlado el proceso séptico, en un entorno estable y vascularizado, se procede a la reconstrucción en dichas lesiones mediante transporte óseo basado en la osteogénesis a distracción. A pesar de los buenos resultados obtenidos, los periodos de fijación externa y de curación son muy largos, 2,4 meses por centímetro reconstruido. Estos prolongados tratamientos motivan que haya un elevado número de complicaciones. Los avances en ingeniería tisular y regeneración ósea contribuyen con nuevas técnicas y opciones terapéuticas. La estimulación de la formación de hueso nuevo en la zona de distracción o en el punto de atraque del fragmento transportado puede minimizar las complicaciones asociadas a la larga duración del procedimiento. La utilización de un osteoinductor como BMP-7 origina en la práctica un aumento de la formación ósea y el nuevo hueso puede tener incrementadas sus propiedades biomecánicas (AU)

The application of oncologic criteria in the sequential surgical treatment of chronic osteomyelitis foci and septic pseudarthrosis, through segmental resections, produces extensive bone defects. Once the septic process is under control, in a stable and well vascularized atmosphere, we perform reconstruction of intercalary defects through bone transportation based on distraction osteogenesis. Despite the good results, the healing index and the time on ex-fi x are very long, about 10 weeks per centimeter rebuilt. These prolonged treatments lead to a large number of complications. Advances in tissue engineering and bone regeneration have led to new techniques and therapeutic options. Stimulation of new bone formation in the distraction area or in the “docking-site” can minimize the complications associated with the length of time required by the procedure. The use of an osteoinducer, such as BMP-7, increases new bone formation and may enhance its biomechanical properties (AU)