Do Positive Cultures at Second Stage Re-Implantation Increase the Risk for Reinfection in Two-Stage Exchange for Periprosthetic Joint Infection?

Abstract Introduction Two-stage revision is a frequently chosen approach to treat chronic periprosthetic joint infection (PJI). However, management of recurrent infection after a two-stage exchange remains debated and the outcome of a repeat two-stage procedure is unclear. This study investigates the success rates of repeat two-stage exchange arthroplasty and analyzes possible risk factors for failure. Materials and methods We retrospectively identified 55 patients (23 hips, 32 knees) who were treated with repeat resection arthroplasty and planned delayed reimplantation for recurrent periprosthetic joint infection between 2010 and 2019 after a prior two-stage revision at the same institution. The minimum follow-up was 12 months with a median follow-up time of 34 months (IQR 22–51). The infection-free survival, associated revision surgeries, and potential risk factors for further revision were analyzed using Kaplan–Meier survival curves and comparative non-parametric testing. Results 78% (43/55) underwent reimplantation after a repeat implant removal. Of those who completed the second-stage surgery, 37% (16/43) underwent additional revision for infection and 14% (6/55) underwent amputation. The reinfection-free implant survivorship amounted to 77% (95% CI 64–89%) after 1 year and 38% (95% CI 18–57%) after 5 years. Patients with a higher comorbidity score were less likely to undergo second-stage reimplantation (median 5 vs. 3, p = 0.034). Furthermore, obese patients (p = 0.026, Fisher’s exact test) and diabetics (p < 0.001, log-rank test) had a higher risk for further infection. Most commonly cultures yielded polymicrobial growth at the repeat two-stage exchange (27%, 15/55) and at re-reinfection (32%, 9/28). Pathogen persistence was observed in 21% (6/28) of re-reinfected patients. Conclusion The success rates after repeat two-stage exchange arthroplasty are low. Patients must be counseled accordingly and different modes of treatment should be considered.

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Elevated ESR and CRP Prior to Second-Stage Reimplantation Knee Revision Surgery for Periprosthetic Joint Infection Are Associated with Increased Reinfection Rates

The Journal of Knee Surgery ◽

10.1055/s-0041-1733902 ◽

2021 ◽

Author(s):

Christian Klemt ◽

Anand Padmanabha ◽

John G. Esposito ◽

Samuel Laurencin ◽

Evan J. Smith ◽

...

Keyword(s):

Revision Surgery ◽

Periprosthetic Joint Infection ◽

Joint Infection ◽

Elevated Serum ◽

Revision Total Knee Arthroplasty ◽

Optimal Timing ◽

Two Stage ◽

Second Stage ◽

Knee Revision Surgery ◽

Knee Revision

Abstract Purpose Although two-stage revision surgery is considered as the most effective treatment for managing chronic periprosthetic joint infection (PJI), there is no current consensus on the predictors of optimal timing to second-stage reimplantation. This study aimed to compare clinical outcomes between patients with elevated erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) prior to second-stage reimplantation and those with normalized ESR and CRP prior to second-stage reimplantation. Methods We retrospectively reviewed 198 patients treated with two-stage revision total knee arthroplasty for chronic PJI. Cohorts included patients with: (1) normal level of serum ESR and CRP (n = 96) and (2) elevated level of serum ESR and CRP prior to second-stage reimplantation (n = 102). Outcomes including reinfection rates and readmission rates were compared between both cohorts. Result At a mean follow-up of 4.4 years (2.8–6.5 years), the elevated ESR and CRP cohort demonstrated significantly higher reinfection rates compared with patients with normalized ESR and CRP prior to second-stage reimplantation (33.3% vs. 14.5%, p < 0.01). Patients with both elevated ESR and CRP demonstrated significantly higher reinfection rates, when compared with patients with elevated ESR and normalized CRP (33.3% vs. 27.6%, p = 0.02) as well as normalized ESR and elevated CRP (33.3% vs. 26.3%, p < 0.01). Conclusion This study demonstrates that elevated serum ESR and/or CRP levels prior to reimplantation in two-stage knee revision surgery for chronic PJI are associated with increased reinfection rate after surgery. Elevation of both ESR and CRP were associated with a higher risk of reinfection compared with elevation of either ESR or CRP, suggesting the potential benefits of normalizing ESR and CRP prior to reimplantation in treatment of chronic PJI.

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The Use of Cell Salvage During Second-stage Reimplantation for the Treatment of Chronic Hip Periprosthetic Joint Infection: a Retrospective Cohort Study

10.21203/rs.3.rs-1012018/v1 ◽

2021 ◽

Author(s):

Zunhan Liu ◽

Xuetao Yang ◽

En-Ze Zhao ◽

Xufeng Wan ◽

Guorui Cao ◽

...

Keyword(s):

Blood Transfusion ◽

Periprosthetic Joint Infection ◽

Joint Infection ◽

Control Group ◽

Published Data ◽

Cell Salvage ◽

Two Stage ◽

Reinfection Rate ◽

Second Stage ◽

Intraoperative Cell Salvage

Abstract Introduction Given the possibility of undetectable infection, the use of cell salvage is relatively contraindicated in cases of reimplantation for chronic hip periprosthetic joint infection (PJI). However, there is no published data supporting this assertion. The purpose of the current study was to compare the reinfection rate and rate of in second-stage reimplantation for PJI with or without intraoperative cell salvage reinfusion.Materials and methods We identified 125 patients who underwent two-stage exchange for chronic hip PJI between November 2012 and April 2019. The groups of patients who had and had not received intraoperative cell salvage reinfusion were compared with respect to the curative infection-free rate and need for postoperative ABT. We identified independent factors associated with ABT using multiple regression analysis.Results The log-rank survival curve with an endpoint of infection eradication failure was not significantly different between the cell salvage group (98.4%, 95% CI 95.3-99.9%) and the control group (95.3%, 95% CI 90.2-99.9%) at one year (log rank, P = .330). Meanwhile, the rates of postoperative ABT in the cell salvage group were significantly lower than those in the control group (11.5% vs 26.6%, P = .041). In multivariable models, patient age, body mass index (BMI), preoperative haemoglobin level, and intraoperative cell salvage were independent predictors of ABT exposure (P < .05).Conclusions The use of cell salvage during reimplantation in two-stage exchange for chronic hip PJI did not appear to increase the reinfection rate, while it significantly reduced the rate of postoperative allogeneic red blood transfusion. Greater age, lower BMI, lower preoperative haemoglobin, and non-intraoperative cell salvage reinfusion were associated with higher rate of allogeneic red blood transfusion.

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The use of augmented antibiotic-loaded cement spacer in periprosthetic joint infection patients with acetabular bone defect

Journal of Orthopaedic Surgery and Research ◽

10.1186/s13018-020-01831-2 ◽

2020 ◽

Vol 15 (1) ◽

Author(s):

Jun Fu ◽

Yi Xiang ◽

Ming Ni ◽

Jiying Chen ◽

Xiang Li ◽

...

Keyword(s):

Clinical Outcomes ◽

Bone Defect ◽

Periprosthetic Joint Infection ◽

Joint Infection ◽

Cement Spacer ◽

Two Stage ◽

Acetabular Bone ◽

Wall Defect ◽

Second Stage ◽

Acetabular Bone Defect

Abstract Background Spacer complications may affect final clinical outcome of the two-stage approach in periprosthetic joint infection (PJI) patients. This study aimed to investigate clinical outcomes and complications of augmented antibiotic-loaded cement spacer in PJI patients with acetabular bone defect. Methods Data on PJI patients with acetabular bone defect receiving two-stage revision from January 2009 to December 2016, in our hospital were retrospectively reviewed. Screw-cement-shell was used to improve the stability of the hip with acetabular wall defect. Handmade acetabular spacer could prevent femoral spacer entering into pelvis in patients with acetabular internal wall defect. A total of 26 patients (11 males and 15 females) were included in the current study. Their mean age was 46.7 ± 15.4 years old. Clinical outcomes and complications were measured. Results Twenty-one of total 26 hips (21/26, 80.8%) showed positive cultures and 15/26 (57.7%) samples were cultured with staphylococcus. Of enrolled patients, 5/26 (19.2%) developed mixed infection. There was one patient (3.8%) with spacer dislocation and two (7.7%) with spacer fracture. One patient developed acute PJI 5 years after the second-stage revision, so overall success rate among these patients was 96.2%. Differences in Paprosky classifications before the first and second stage did not reach significant level (p > 0.05). Hip Harris score was raised from 40.9 ± 14.0 to 81.2 ± 11.2 (p < 0.05). Conclusions Augmented antibiotic-loaded cement spacer could achieve satisfactory clinical outcomes in PJI patients with acetabular bone defect. It provided joint mobility, increased additional joint stability, and decreased iatrogenic bone defect caused by acetabular wear.

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The change in plasma D-dimer does not help to guide the timing of reimplantation in two stage exchange for periprosthetic joint infection

Scientific Reports ◽

10.1038/s41598-021-86890-z ◽

2021 ◽

Vol 11 (1) ◽

Author(s):

Thomas Ackmann ◽

Jan Schwarze ◽

Georg Gosheger ◽

Tom Schmidt-Braekling ◽

Kristian Nikolaus Schneider ◽

...

Keyword(s):

Prosthetic Joint Infection ◽

Periprosthetic Joint Infection ◽

Joint Infection ◽

Two Stage ◽

Musculoskeletal Infection ◽

Second Stage ◽

Prosthetic Joint ◽

The Difference ◽

D Dimer

AbstractD-dimer has been included in the criteria by the Musculoskeletal Infection Society in 2018 as a novel parameter to diagnose prosthetic joint infection (PJI). However, it is unclear how D-dimer levels change in between stages of a two-stage exchange. We prospectively investigated 30 patients who underwent a two-stage exchange using a spacer for PJI. D-Dimer, CRP and IL-6 were collected before first and second stage surgery and the difference (Δ) in between stages was calculated. The levels of plasma D-Dimer did not change from first to second stage surgery (2770 ng/ml (IQR, 1600–3770 ng/ml) versus 2340 ng/ml (IQR, 1270–4100 ng/ml); p = 0.8) while CRP (4.0 mg/dl (IQR, 1.7–5.5 mg/dl) versus 0.6 mg/dl (IQR, 0.5–0.8 mg/dl); p < 0.001) and IL-6 (21 pg/ml (IQR, 10–29 pg/ml) versus 6 pg/ml (4–9 pg/ml); p < 0.001) decreased. The ΔD-dimer between both stages was 300 ng/ml (range: − 2820 to 4280 ng/ml), the median ΔCRP was − 3.4 mg/dl (IQR, − 1.2 to − 4.8 mg/dl) and ΔIL-6 was − 13 pg/ml (IQR, − 4 to − 20 pg/ml). In 15 of 30 cases (50%) the D-dimer level increased between both stages, whereas the level of CRP (93%; 28/30) and IL-6 (96%; 28/29) decreased in most patients. As the level of serum D-dimers varies greatly, lacks a uniform decrease and does not identify persisting infection, surgeons should be cautious when using it at the timing of reimplantation.

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Two-Stage Exchange Arthroplasty Is a Favorable Treatment Option Upon Diagnosis of a Fungal Periprosthetic Joint Infection

The Journal of Arthroplasty ◽

10.1016/j.arth.2018.07.024 ◽

2018 ◽

Vol 33 (11) ◽

pp. 3555-3560 ◽

Cited By ~ 6

Author(s):

Feng-Chih Kuo ◽

Karan Goswami ◽

Noam Shohat ◽

Kier Blevins ◽

Alexander J. Rondon ◽

...

Keyword(s):

Treatment Option ◽

Periprosthetic Joint Infection ◽

Joint Infection ◽

Two Stage ◽

Exchange Arthroplasty

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Two-stage revision arthroplasty for coagulase-negative staphylococcal periprosthetic joint infection of the hip and knee

World Journal of Orthopedics ◽

10.5312/wjo.v10.i10.348 ◽

2019 ◽

Vol 10 (10) ◽

pp. 348-355 ◽

Cited By ~ 2

Author(s):

Ewout S Veltman ◽

Dirk Jan F Moojen ◽

Marc L van Ogtrop ◽

Rudolf W Poolman

Keyword(s):

Periprosthetic Joint Infection ◽

Joint Infection ◽

Revision Arthroplasty ◽

Two Stage

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A Case of Periprosthetic Joint Infection Because of Rothia Mucilaginosa

Military Medicine ◽

10.1093/milmed/usab203 ◽

2021 ◽

Author(s):

Janse T Schermerhorn ◽

Donald F Colantonio ◽

Derek T Larson ◽

Robert J McGill

Keyword(s):

Knee Arthroplasty ◽

Periprosthetic Joint Infection ◽

Joint Infection ◽

Diagnostic Delay ◽

Infectious Agent ◽

Two Stage ◽

Treatment Regimens ◽

History Of ◽

Rothia Mucilaginosa ◽

One Year

ABSTRACT Periprosthetic joint infection (PJI) is a rare but devastating complication of total joint arthroplasty. Identifying the offending infectious agent is essential to appropriate treatment, and uncommon pathogens often lead to a diagnostic delay. This case describes the first known instance of a total knee arthroplasty (TKA) with Rothia mucilaginosa, a typical respiratory tract organism. This report aims to provide insight into the treatment of this atypical PJI, as there are only six previously published cases of Rothia species PJI septic arthritis. The patient is a 64-year-old diabetic male who underwent a right TKA and left TKA ∼6 months later. Approximately 3 weeks status post-left TKA, he showed evidence of left PJI. One year after treatment and recovery from his left PJI, he presented with several months of right knee pain and fatigue. Subsequent labs and imaging revealed right PJI. No recent history of dental disease or work was observed. He then underwent two-stage revision right knee arthroplasty and microbial cultures yielded Rothia mucilaginosa. After initial empiric treatment, antibiotic therapy was narrowed to 6 weeks of vancomycin. Following negative aspiration cultures the patient underwent reimplantation of right TKA components. One year following treatment, the patient was fully recovered with no evidence of infection. This case emphasizes the possibility of microbial persistence despite various antibiotic treatment regimens for the patient’s contralateral knee arthroplasty and PJI. Additionally, this case demonstrates the importance of two-stage revision in patients with PJI, and the viability of treating Rothia species PJIs with vancomycin.

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