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Prophylaxis, Diagnosis and Treatment of Prosthetic Joint Infections

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Prophylaxis, Diagnosis and Treatment of Prosthetic Joint Infections RICARDO JORGE GOMES DE SOUSA PROPHYLAXIS, DIAGNOSIS AND TREATMENT OF PROSTHETIC JOINT INFECTIONS Tese de Candidatura ao grau de Doutor em Ciências Médicas submetida ao Instituto de Ciências Biomédicas Abel Salazar da Universidade do Porto. Orientador: Doutor António Fonseca Oliveira Professor Catedrático Convidado Instituto de Ciências Biomédicas Abel Salazar da Universidade do Porto Coorientadores Doutor Alejandro Soriano Viladomiu Professor Associado Faculdade de Medicina da Universidade de Barcelona Doutora Maria Pia de Melo Alvim Ferraz Tavares Professora Associada Faculdade de Ciências da Saúde da Universidade Fernando Pessoa 1 Real knowledge is to know the extent of one’s ignorance Confucius 2 This work was performed in the Orthopedic Department of the Centro Hospitalar do Porto with the cooperation of several other departments within the same institution. 3 Publicações De acordo com o Artigo 34º do Decreto-Lei nº 115/2013, foram utilizados para esta tese resultados contidos nos seguintes trabalhos publicados: • Sousa R, Massada M, Pereira A, Fontes F, Amorim I, Oliveira A. Diagnostic accuracy of combined 99mTc-sulesomab and 99mTc-nanocolloid bone marrow imaging in detecting prosthetic joint infection. Nucl Med Commun 2011;32-9:834-9. • Sousa R, Munoz-Mahamud E, Quayle J, Dias da Costa L, Casals C, Scott P, Leite P, Vilanova P, Garcia S, Ramos MH, Dias J, Soriano A, Guyot A. Is asymptomatic bacteriuria a risk factor for prosthetic joint infection? Clin Infect Dis 2014;59-1:41-7. • Sousa R, Soriano A, Guyot A. Reply to Uckay et al. Clin Infect Dis 2014;59-10:1507-8. • Sousa R, Barreira P, Leite P, Santos AC, Ramos MH, Oliveira A. Preoperative Staphylo- coccus aureus Screening/Decolonization Protocol Before Total Joint Arthroplasty: Results of a Small Prospective Randomized Trial. J Arthroplasty 2016; 31-1:234-9. • Sousa R, Serrano P, Dias J, Oliveira JC, Oliveira A. Improving synovial fluid accuracy for the diagnosis of prosthetic joint infection with simple and inexpensive biomarkers: C-reactive protein and Adenosine deaminase. Bone Joint J. 2017; 99-B:351-7. • Sousa R, Silva M, Sousa A, Esteves J, Neves P, Seabra Lopes, Oliveira A. Prosthetic Joint Infections Treatment with Debridement and Implant Retention: results of prospectively ap- plying a predetermined protocol. Rev Port Ort Traum. in press. • Sousa R, Esteves J, Sousa A, Silva M, Ramos J, Seabra Lopes, Oliveira A. Treatment of Prosthetic Joint Infections with Two-stage Exchange Surgery - results of a prospective study with a management protocol. Rev Port Ort Traum. in press. 4 Preface Those who know me the longest, know that my interest in prosthetic joint infections was born many years ago when I was still taking my first steps as an orthopedic resident. As many things in life, I think it happened by accident… I was confronted with a series of patients suffering with infected total joint replacements and I witnessed my colleagues struggling hard to try and treat them and not often succeeding. Then I operated on D. Natalia, a very nice but extremely obese patient that I followed on the outpatient clinic after her total knee replacement. She presented persistent wound leakage and despite being prescribed antibiotic therapy she progressively worsened. I closely witnessed as she went through a long calvary of surgical debridements and prolonged periods of IV antibiotics followed by removal of the implant, a few more debridements and then ultimately a knee fusion! This patient really opened my eyes to this problem as I witnessed her downfall from being an active working women to a disabled woman struggling to walk with crutches… I started reading and researching and I reached a point where I was able to identify a lot of common mistakes that were being made on a daily basis. In order to systematically address this problem, I retrospectively looked at our institution’s experience in dealing with prosthetic joint infections between 2001 and 2007. Out of 69 cases, only 30 were successfully treated! I undertook an extensive literature review and proposed a number of changes to our practice. I was lucky enough to see my work acknowledged and I continued to make clinical research on this topic throughout the years. When I finished my residency, I had already set the scene for continued clinical research and transforming it into a PhD dissertation was but a natural event. My only condition was that I wanted it to be all about clinical research. At the end of the day, what I am really interested about is what can I do to improve the outcome of patients afflicted by prosthetic joint infections. Now that it ends, I am sure the work must continue. There are still a lot of gray or even black areas in our current knowledge. Much of this needed understanding will certainly be born out of present and future cooperation with basic science researchers. Whereas our diagnostic accuracy and treatment results improved significantly in the past few years, the search for reliable diagnostic and treatment alternatives while providing a more comfortable and less disturbing experience to the patient is the next priority. 5 Acknowledgments Naturally, a work of this span would not have been feasible without the help of many people that I must thank. First and foremost, I would like to thank Professor António Oliveira. Long before I was even considering a PhD he had the vision to acknowledge me. I imagine it was not easy for a Head of Department to have a “kid” point out to an existing problem in such a sturdy way. I always felt encouraged to question the status quo and pursue the search for further know-how even if it meant leaving abroad. If there are conditions in our department to advance scientific research regardless of classic beliefs and traditions, it is greatly thanks to him. I also think I could not have made a better choice for my supervisor. I thank him deeply for helping me keep things in perspective whenever I got lost in the fine print. Lastly, I cannot thank him enough for all the times he proved his belief in me and my work and for all the occasions he helped promote it. I would also like to deeply thank Professor Alex Soriano. We have come a long way since we met in 2010 and I had the chance to learn a lot about PJI management visiting his Bone and Joint Infection Unit. Not only is he a never-ending source of knowledge regarding prosthetic joint infections but he is also always glad to share his love for scientific research in this field. Thank you for greatly contributing for the success of the work we have been performing. To Professor Maria Pia Ferraz I would like to thank her for introducing me to the world of basic science research, especially in the field of infection resistant implant surfaces. I hope we can further improve our cooperation and bring new developments to the clinical setting. I also need to thank all those within my department that have endured me throughout the years. To Dr. Seabra Lopes a special thank you for always believing and trusting me and my work. I know he was fearful of taking on this endeavor within his group, because tradition implied these were difficult to treat cases that one would be better of avoiding. He always knew how to give me just the right amount of autonomy while always being there for support when I needed. To Dr. Costa e Castro for being a most helpful reviewer of all my papers since the beginning. Thank you for your always pertinent comments and insights. To Dr. Joaquim Ramos for being there to help me in more complex hip surgeries whenever I asked him. Results would not have been the same without him. To Dr. Alexandre Pereira, a colleague and a real friend of many battles. 6 To all other colleagues that were kind enough to cooperate and accommodate my requests as well as those who trusted me to treat their cases. Without them I could not have gained much needed experience. To all my junior colleagues that so willingly helped me collect, organize and process data. Without their help, it would not have been possible to perform the same amount of scientific output over the last few years. To all the nurses of the Orthopedic Department, especially those in our outpatient clinic, for gladly embracing the added work load with a smile. Although the main focus of this work was in the Orthopedic Department, it would not have been possible without the cooperation of several others. To Dra. Inês Amorim from the Nuclear Medicine Department who believed and encouraged since early on. To Dra. Maria Helena Ramos, Dra. Ana Paula Casto, Dra. Claudia Santos, Dr. Paulo Pereira, Dra. Virgínia Lopes and all other staff of the Microbiology Department for always seeking to accommodate our relentless and increasing demands. To Dr. José Carlos Oliveira and his staff of Clinical Chemistry in the Clinical Pathology Department for your huge cooperation and help in evaluating synovial fluid biomarkers. I would also like to sincerely thank Dra Joana Dias for all her statistical work over the years. If it wasn’t for her support, know-how, thoroughness, patience, perseverance, and most of all endless hours spend with this research, our findings would certainly not have been as respectable. Last but certainly not least, a few words to my loving family. I could not have made it here without their great sacrifice over the years. Thank you for everything! To my brother, a friend for every occasion. To my mother who never ceases to take care of me even when I am at my worst.
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