Repeat two‐stage revision for knee prosthetic joint infection results in very high failure rates

Aims The increasing infection burden after total hip arthroplasty (THA) has seen a rise in the use of two-stage exchange arthroplasty and the use of increasingly powerful antibiotics at the time of this procedure. As a result, there has been an increase in the number of failed two-stage revisions during the past decade. The aim of this study was to clarify the outcome of repeat two-stage revision THA following a failed two-stage exchange due to recurrent prosthetic joint infection (PJI). Patients and Methods We identified 42 patients who underwent a two-stage revision THA having already undergone at least one previous two stage procedure for infection, between 2000 and 2015. There were 23 women and 19 men. Their mean age was 69.3 years (48 to 81). The outcome was analyzed at a minimum follow-up of two years. Results A satisfactory control of infection and successful outcome was seen in 26 patients (57%). There therefore remained persistent symptoms that either required further surgery or chronic antibiotic suppression in 16 patients (38%). One-third of patients had died by the time of two years’ follow-up. Conclusion The rate of failure and complication rate of repeat two-stage exchange THA for PJI is high and new methods of treatment including host optimization, immunomodulation, longer periods between stages, and new and more powerful forms of antimicrobial treatment should be investigated. Cite this article: Bone Joint J 2019;101-B(6 Supple B):110–115.

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Post-surgery and recovery experiences following one- and two-stage revision for prosthetic joint infection—A qualitative study of patients’ experiences

PLoS ONE ◽

10.1371/journal.pone.0237047 ◽

2020 ◽

Vol 15 (8) ◽

pp. e0237047 ◽

Cited By ~ 1

Author(s):

Cecily K. Palmer ◽

Rachael Gooberman-Hill ◽

Ashley W. Blom ◽

Michael R. Whitehouse ◽

Andrew J. Moore

Keyword(s):

Qualitative Study ◽

Prosthetic Joint Infection ◽

Joint Infection ◽

Two Stage ◽

Post Surgery ◽

Prosthetic Joint ◽

Recovery Experiences

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257. Outcomes in Fungal Prosthetic Joint Infection

Open Forum Infectious Diseases ◽

10.1093/ofid/ofab466.459 ◽

2021 ◽

Vol 8 (Supplement_1) ◽

pp. S235-S235

Author(s):

Caitlyn M Hollingshead ◽

Joan Duggan ◽

Roberta Redfern ◽

Gregory Georgiadis ◽

Jason Tank

Keyword(s):

Prosthetic Joint Infection ◽

Candida Species ◽

Joint Infection ◽

Two Stage ◽

One Stage ◽

Prosthetic Joint ◽

Hip Replacements ◽

Fungal Organisms ◽

Poor Outcomes ◽

Wbc Count

Abstract Background There is a paucity of data in the literature regarding the most effective treatment and related outcomes of fungal prosthetic joint infection. The majority of reported cases are treated using a two stage revision method in which the initial prosthesis is removed and the patient is treated with systemic antifungal medications and potentially irrigation of the joint cavity with antifungal and antibacterial agents. Alternately, others have suggested a one-stage revision in order to prevent a period of significant functional impairment and potentially improved functional outcomes and lower overall costs. Cases of radical removal of the prosthesis without replacement have been reported. To date, the largest studies of total hip arthroplasty and total knee arthroplasty have included 37 and 45 patients, respectively. Methods A retrospective record review of patients admitted within two health systems between January 1, 2007 and December 31, 2018 with prosthetic joints and a deep culture of the joint positive for fungal organisms was performed. Results Eighteen patients fit criteria. Nine patients had knee replacements and nine patients had hip replacements. The average age at time of infection was 61. Ten patients were female. Average BMI was 32.1. Twelve presented with a painful joint, eight presented with drainage, and one with dehiscence. Average WBC count was 9.3, average ESR was 47, and average CRP was 11.8. All patients were noted with Candida species. Eight patients were treated with two stage revisions, three received one stage revisions as destination therapy. One required amputation. All but one patient was associated with concurrent bacterial infection. Of the twelve patients that had known outcomes, six were noted with cure and six were noted with relapse. All patients that were cured received two stage exchange or girdlestone procedure. Conclusion In our study, fungal prosthetic joint infection was associated with poor outcomes. All of the patients in our study were noted with Candida species, which is in concordance with the known literature. Two stage exchange was associated with better outcomes. Disclosures All Authors: No reported disclosures

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Complications in the treatment of prosthetic joint infection

The Bone & Joint Journal ◽

10.1302/0301-620x.102b6.bjj-2019-1582.r1 ◽

2020 ◽

Vol 102-B (6_Supple_A) ◽

pp. 145-150 ◽

Cited By ~ 1

Author(s):

Molly A. Hartzler ◽

Katherine Li ◽

Michael B. Geary ◽

Susan Marie Odum ◽

Bryan D. Springer

Keyword(s):

Prosthetic Joint Infection ◽

Joint Infection ◽

Definitive Treatment ◽

Two Stage ◽

Musculoskeletal Infection ◽

Exchange Arthroplasty ◽

Prosthetic Joint ◽

Definition Of Success ◽

One Year ◽

Definition Of

Aims Two-stage exchange arthroplasty is the most common definitive treatment for prosthetic joint infection (PJI) in the USA. Complications that occur during treatment are often not considered. The purpose of this study was to analyze complications in patients undergoing two-stage exchange for infected total knee arthroplasty (TKA) and determine when they occur. Methods We analyzed all patients that underwent two-stage exchange arthroplasty for treatment of PJI of the knee from January 2010 to December 2018 at a single institution. We categorized complications as medical versus surgical. The intervals for complications were divided into: interstage; early post-reimplantation (three months); and late post-reimplantation (three months to minimum one year). Minimum follow-up was one year. In total, 134 patients underwent a first stage of a two-stage exchange. There were 69 males and 65 females with an mean age at first stage surgery of 67 years (37 to 89). Success was based on the new Musculoskeletal Infection Society (MSIS) definition of success reporting. Results Overall, 70 (52%) patients experienced a complication during the planned two-stage treatment, 36 patients (27%) experienced a medical complication and 47 (41%) patients experienced a surgical complication. There was an 18% mortality rate (24/134) at a mean of 3.7 years (0.09 to 8.3). During the inter-stage period, 28% (37/134) of patients experienced a total of 50 complications at a median of 47 days (interquartile range (IQR) 18 to 139). Of these 50 complications, 22 were medical and 28 required surgery. During this inter-stage period, four patients died (3%) and an additional five patients (4%) failed to progress to the second stage. While 93% of patients (125/134) were reimplanted, only 56% (77/134) of the patients were successfully treated without antibiotic suppression (36%, 28/77) or with antibiotic suppression (19%, 15/77) at one year. Conclusion Reported rates of success of two stage exchanges for PJI have not traditionally considered complications in the definition of success. In our series, significant numbers of patients experienced complications, more often after reimplantation, highlighting the morbidity of this method of treatment. Cite this article: Bone Joint J 2020;102-B(6 Supple A):145–150.

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Specific microbiology issues relating to prosthetic joint infection

Pathways in Prosthetic Joint Infection ◽

10.1093/med/9780198791881.003.0007 ◽

2018 ◽

pp. 41-50

Author(s):

Umraz Khan ◽

Graeme Perks ◽

Rhidian Morgan-Jones ◽

Peter James ◽

Colin Esler ◽

...

Keyword(s):

Antibiotic Resistance ◽

Antibiotic Therapy ◽

Prosthetic Joint Infection ◽

Joint Infection ◽

Antibiotic Use ◽

Stopping Rules ◽

Two Stage ◽

Infected Case ◽

Prosthetic Joint ◽

Resistance Approach

This chapter discusses specific microbiology issues relating to prosthetic joint infection (PJI) and includes discussion on antibiotic prophylaxis (including elective joint replacement in the uninfected case), choice of ‘prophylaxis/treatment’ in the infected, or presumed, infected case, a suggested framework for a safe practice, antibiotic use in PJI in the age of resistance, background on rising antibiotic resistance, approach to one- and two-stage surgical management, outpatient antibiotic therapy and when to use it, monitoring/stopping rules, the particular problems of Pseudomonas and Candida in PJI, and myths and facts about what ‘immunosuppression’ actually means in practice (including MRSA), and a conclusion.

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Is sonication of antibiotic-loaded cement spacers useful in two-stage revision of prosthetic joint infection?

Journal of Microbiological Methods ◽

10.1016/j.mimet.2018.12.006 ◽

2019 ◽

Vol 156 ◽

pp. 81-84 ◽

Cited By ~ 4

Author(s):

Andrea Sambri ◽

Alessandra Maso ◽

Elisa Storni ◽

Maria Elena Donati ◽

Annalisa Pederzoli ◽

...

Keyword(s):

Prosthetic Joint Infection ◽

Joint Infection ◽

Two Stage ◽

Prosthetic Joint

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One- and two-stage surgical revision of peri-prosthetic joint infection of the hip: a pooled individual participant data analysis of 44 cohort studies

European Journal of Epidemiology ◽

10.1007/s10654-018-0377-9 ◽

2018 ◽

Vol 33 (10) ◽

pp. 933-946 ◽

Cited By ~ 20

Author(s):

Setor K. Kunutsor ◽

◽

Michael R. Whitehouse ◽

Ashley W. Blom ◽

Tim Board ◽

...

Keyword(s):

Data Analysis ◽

Cohort Studies ◽

Prosthetic Joint Infection ◽

Joint Infection ◽

Surgical Revision ◽

Individual Participant Data ◽

Two Stage ◽

Prosthetic Joint ◽

Individual Participant

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Synovial aspiration and serological testing in two-stage revision arthroplasty for prosthetic joint infection: evaluation before reconstruction with a mean follow-up of twenty seven months

International Orthopaedics ◽

10.1007/s00264-017-3700-2 ◽

2017 ◽

Vol 42 (2) ◽

pp. 265-271 ◽

Cited By ~ 18

Author(s):

Heinrich M. L. Mühlhofer ◽

C. Knebel ◽

Florian Pohlig ◽

Susanne Feihl ◽

Norbert Harrasser ◽

...

Keyword(s):

Prosthetic Joint Infection ◽

Joint Infection ◽

Revision Arthroplasty ◽

Serological Testing ◽

Two Stage ◽

Prosthetic Joint

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Prosthetic Joint Infection: Report on the One versus Two-stage Exchange EBJIS Survey

Journal of Bone and Joint Infection ◽

10.7150/jbji.14671 ◽

2016 ◽

Vol 1 (1) ◽

pp. 1-6 ◽

Cited By ~ 6

Author(s):

Pedro Santos Leite ◽

Sérgio Figueiredo ◽

Ricardo Sousa

Keyword(s):

Prosthetic Joint Infection ◽

Revision Surgery ◽

Joint Infection ◽

Clinical Aspects ◽

Online Questionnaire ◽

Two Stage ◽

Significant Group ◽

One Stage ◽

Prosthetic Joint ◽

Multicentre Research

Abstract. Background: Prosthetic Joint Infection (PJI) is one of the most challenging problems in orthopaedic surgery and musculoskeletal infections specifically. Some very important controversies remain and strong evidence-based recommendations are still lacking in many clinical aspects. Therefore, an undisputed methodology of treatment does not exist yet and there are many different valid approaches.Purposes: To draw a picture of the different practice patterns around Europe and understand the motivations of the European Bone & Joint Infection Society (EBJIS) members in choosing between one- or two-stage revision surgery in treating chronic PJI.Methods: The participants of the 34th EBJIS Annual Meeting were surveyed through an online questionnaire. The survey assessed the main philosophy in the treatment of chronic PJI, personal and institutional information as well as the importance of different factors in choosing two-stage or one-stage procedures.Results: One hundred and forty-three participants responded to the survey, including a significant group of skilful orthopaedic surgeons with large experience in treating musculoskeletal infections. Primarily two-stage was the most common philosophy regrading treatment of chronic PJI (60.1%), followed by two-stage or one-stage accordingly (34,8%) and primarily one-stage (5,1%). Significant soft tissue compromise, failure of previous revision surgery attempts, highly resistant or unclear infective microorganism(s) preoperatively and patient presenting with sepsis or immunosuppression, were considered the more relevant factors in choosing two-stage instead one-stage procedures.Interpretation: Treatment of chronic PJI is challenging and demanding. An open dialogue to share the different experiences and a collective effort to plan a major multicentre research in order to establish standardized protocols are essential.

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