The treatment of periprosthetic joint infection: safety and efficacy of two stage versus one stage exchange arthroplasty

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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Two-Stage Exchange Arthroplasty for Periprosthetic Joint Infection Following Total Hip or Knee Arthroplasty Is Associated With High Attrition Rate and Mortality

The Journal of Arthroplasty ◽

10.1016/j.arth.2019.12.005 ◽

2020 ◽

Vol 35 (5) ◽

pp. 1384-1389 ◽

Cited By ~ 3

Author(s):

Cameron B. Barton ◽

David L. Wang ◽

Qiang An ◽

Timothy S. Brown ◽

John J. Callaghan ◽

...

Keyword(s):

Knee Arthroplasty ◽

Periprosthetic Joint Infection ◽

Joint Infection ◽

Attrition Rate ◽

Two Stage ◽

Total Hip ◽

Exchange Arthroplasty ◽

High Attrition Rate

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Trend of serum C-reactive protein is associated with treatment outcome of hip Periprosthetic joint infection undergoing two-stage exchange arthroplasty: a case control study

BMC Musculoskeletal Disorders ◽

10.1186/s12891-021-04893-3 ◽

2021 ◽

Vol 22 (1) ◽

Author(s):

Zhong-Yan Li ◽

Yu-Chih Lin ◽

Chih-Hsiang Chang ◽

Szu-Yuan Chen ◽

Tung-Wu Lu ◽

...

Keyword(s):

Treatment Outcome ◽

Treatment Failure ◽

Periprosthetic Joint Infection ◽

Kidney Diseases ◽

Joint Infection ◽

Multivariate Logistic Regression Analysis ◽

C Reactive Protein ◽

Two Stage ◽

Reactive Protein ◽

Exchange Arthroplasty

Abstract Background Serum C-reactive protein (CRP) trends are critical for monitoring patients’ treatment response following a two-stage exchange arthroplasty for periprosthetic joint infection (PJI) of the hip. However, CRP trends are poorly described in the literature. The primary aim of this study was to identify the relationships between PJI treatment outcomes and our proposed CRP trend definitions, parameters, and microbiological data. The secondary aim was to investigate CRP trends after the occurrence of spacer-related complications. Methods We conducted a retrospective review of 74 patients treated with a two-stage exchange protocol for PJI in a tertiary referral joint center between 2014 and 2016. Patients with factors that may affect CRP levels (inflammatory arthritis, concomitant infections, liver and kidney diseases, and intensive care admissions) were excluded. CRP trends were categorized into five types and PJI treatment outcome was defined as “success” or “failure” according to the Delphi criteria. Results Treatment was successful in 67 patients and failed in 7 patients. Multivariate logistic regression analysis showed that type 5 CRP, defined as serum CRP fluctuation without normalization after first stage surgery (odds ratio [OR]: 17.4; 95% confidence interval [CI]: 2.3–129.7; p = 0.005), and methicillin-resistant Staphylococcus aureus (MRSA; OR: 14.5; 95% CI: 1.6–131.7; p = 0.018) were associated with treatment failure. Spacer-related complications occurred in 18 patients. Of these, 12 had elevated CRP levels at later follow-up, while six had no elevation in CRP levels. Conclusions We found that MRSA infection and type 5 CRP were associated with PJI treatment failure.

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Diagnosis and management of infected arthroplasty

SICOT-J ◽

10.1051/sicotj/2021054 ◽

2021 ◽

Vol 7 ◽

pp. 54

Author(s):

Tejbir S. Pannu ◽

Jesus M. Villa ◽

Carlos A. Higuera

Keyword(s):

Joint Infection ◽

Treatment Options ◽

Clinical Situation ◽

The United States ◽

Sinus Tract ◽

Two Stage ◽

International Consensus ◽

Musculoskeletal Infection ◽

One Stage ◽

Exchange Arthroplasty

Periprosthetic joint infection (PJI) is one of the most dreadful complications after THA and TKA. Though prevention is of utmost importance in PJI management, the last decade has seen many remarkable developments in PJI diagnosis, including the introduction of several standardized PJI diagnostic definitions and biomarkers. Depending on the specific clinical situation, a myriad of treatment options for PJI are offered. Our review aims to summarize the pertinent information on PJI diagnosis and synthesize literature on the different treatment methods currently used in clinical practice. One of the most accepted PJI diagnostic definitions was developed by the Musculoskeletal Infection Society (MSIS) in 2011, later modified in the 2013 International Consensus Meeting (ICM). After promising results from studies, alpha-defensins and D-dimer were recently incorporated into the 2018 ICM PJI definition. The management choices for PJI include irrigation and debridement (DAIR), one-stage exchange arthroplasty, or two-stage exchange arthroplasty, to name a few. While two-stage revision has traditionally been the treatment of choice in the United States, there has been a growing body of evidence framing one-stage revision as a comparable choice. One-stage revision should be offered in patients meeting strict selection criteria: no sinus tract, proper soft tissue available for wound closure, appropriate bone stock, a favorable identifiable organism with encouraging antibiotic sensitivities (for cement and oral suppression later), and robust immunological status. DAIR can be considered in case of early infections with sensitive infecting organisms. Patients with multiple unsuccessful revisions or those who refuse further surgical intervention for PJI can be offered antibiotic suppression. If nothing seems to work, salvage procedures (resection arthroplasty and arthrodesis) are available as a last resort. Further research is encouraged to improve on diagnostic capabilities and develop evidence on the best treatment of choice for PJI.

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