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

Abstract Background Coagulation-related biomarkers are drawing new attention in the diagnosis of periprosthetic joint infection (PJI). The thromboelastography (TEG) assay provides a comprehensive assessment of blood coagulation; therefore, it could be a promising test for PJI. This study aims to assess the value of TEG in diagnosing PJI and to determine the clinical significance of TEG in analysing reimplantation timing for second-stage revision. Methods From October 2017 to September 2020, 62 patients who underwent revision arthroplasty were prospectively included. PJI was defined by the 2011 Musculoskeletal Infection Society criteria, in which 23 patients were diagnosed with PJI (Group A), and the remaining 39 patients were included as having aseptic loosening (Group B). In group A, 17 patients completed a two-stage revision in our centre. C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), D-dimer, and TEG parameters (clotting time, α-angle, MA [maximum amplitude], amplitude at 30 min, and thrombodynamic potential index) were measured preoperatively in all included patients. In addition, receiver operating characteristic curves were used to evaluate the diagnostic value of these biomarkers. Results ESR (area under curve [AUC], 0.953; sensitivity, 81.82; specificity, 94.87) performed best for PJI diagnosis, followed by MA (AUC, 0.895; sensitivity, 82.61; specificity, 97.44) and CRP (AUC, 0.893; sensitivity, 82.61; specificity, 94.74). When these biomarkers were combined in pairs, the diagnostic value improved compared with any individual biomarker. The overall success rate of the two-stage revision was 100%. Furthermore, ESR and MA were valuable in determining the time of reimplantation, and their values all decreased below the cut-off values before reimplantation. Conclusion TEG could be a promising test in assisting PJI diagnosis, and a useful tool in judging the proper timing of reimplantation.

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One-stage revision is as effective as two-stage revision for chronic culture-negative periprosthetic joint infection after total hip and knee arthroplasty

The Bone & Joint Journal ◽

10.1302/0301-620x.103b.bjj-2020-1480.r2 ◽

2021 ◽

pp. 1-7

Author(s):

Janna van den Kieboom ◽

Venkatsaiakhil Tirumala ◽

Hayden Box ◽

Ruben Oganesyan ◽

Christian Klemt ◽

...

Keyword(s):

Periprosthetic Joint Infection ◽

Joint Infection ◽

Randomized Study ◽

Treatment Strategies ◽

Revision Arthroplasty ◽

Two Stage ◽

One Stage ◽

Hip And Knee Arthroplasty ◽

Culture Negative

Aims Removal of infected components and culture-directed antibiotics are important for the successful treatment of chronic periprosthetic joint infection (PJI). However, as many as 27% of chronic PJI patients yield negative culture results. Although culture negativity has been thought of as a contraindication to one-stage revision, data supporting this assertion are limited. The aim of our study was to report on the clinical outcomes for one-stage and two-stage exchange arthroplasty performed in patients with chronic culture-negative PJI. Methods A total of 105 consecutive patients who underwent revision arthroplasty for chronic culture-negative PJI were retrospectively evaluated. One-stage revision arthroplasty was performed in 30 patients, while 75 patients underwent two-stage exchange, with a minimum of one year's follow-up. Reinfection, re-revision for septic and aseptic reasons, amputation, readmission, mortality, and length of stay were compared between the two treatment strategies. Results The patient demographic characteristics did not differ significantly between the groups. At a mean follow-up of 4.2 years, the treatment failure for reinfection for one-stage and two-stage revision was five (16.7%) and 15 patients (20.0%) (p = 0.691), and for septic re-revision was four (13.3%) and 11 patients (14.7%) (p = 0.863), respectively. No significant differences were observed between one-stage and two-stage revision for 30- 60- and 90-day readmissions (10.0% vs 8.0%; p = 0.714; 16.7% vs 9.3%; p = 0.325; and 26.7% vs 10.7%; p = 0.074), one-year mortality (3.3% vs 4.0%; p > 0.999), and amputation (3.3% vs 1.3%; p = 0.496). Conclusion In this non-randomized study, one-stage revision arthroplasty demonstrated similar outcomes including reinfection, re-revision, and readmission rates for the treatment of chronic culture-negative PJI after TKA and THA compared to two-stage revision. This suggests culture negativity may not be a contraindication to one-stage revision arthroplasty for chronic culture-negative PJI in selected patients.

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Does serum interleukin-6 guide the diagnosis of persistent infection in two-stage hip revision for periprosthetic joint infection?

Journal of Orthopaedic Surgery and Research ◽

10.1186/s13018-019-1448-7 ◽

2019 ◽

Vol 14 (1) ◽

Cited By ~ 3

Author(s):

Peng-Fei Qu ◽

Chi Xu ◽

Jun Fu ◽

Rui Li ◽

Wei Chai ◽

...

Keyword(s):

Periprosthetic Joint Infection ◽

Interleukin 6 ◽

Persistent Infection ◽

Joint Infection ◽

Revision Arthroplasty ◽

Roc Curves ◽

Two Stage ◽

Predictive Values ◽

Musculoskeletal Infection ◽

Significant Difference

Abstract Purpose The diagnosis of persistent infection at reimplantation of two-stage revision arthroplasty for periprosthetic joint infection (PJI) remains challenging. Several studies have shown the benefit of serum interleukin-6 (IL-6) in diagnosing periprosthetic joint infection (PJI). Recent data indicated serum IL-6 could be promising in differentiating persistent infection. The purpose of this study was to validate the efficacy of serum IL-6 in diagnosing persistent infection at reimplantation. Methods A retrospective review of 86 PJI patients with a two-stage exchanged hip arthroplasty from 2013 to 2017 was conducted. Persistent infection was defined using the modified Musculoskeletal Infection Society (MSIS) criteria combined with follow-up results. Serum IL-6 at reimplantation were collected and compared among patients with or without persistent infection. Receiver operating characteristic (ROC) curves were generated to evaluate the diagnostic performance and optimal cut-off value of serum IL-6 at reimplantation. Results Sixteen cases were diagnosed as persistent infection at reimplantation. There was no significant difference in serum IL-6 levels between cases with persistent infection and controls (7.89 pg/ml vs. 5.56 pg/ml; P = 0.179). The area under the ROC curve (AUC) for serum IL-6 in diagnosing persistent infection at reimplantation was 0.59 (95% confidential interval [CI] 0.40–0.77). With the calculated threshold set at 8.12 pg/ml, the corresponding sensitivity, specificity, positive predictive value, and negative predictive values were 38%, 88%, 38%, and 87%, respectively. Conclusion Serum IL-6 is inadequate in diagnosing persistent infection at reimplantation for two-stage revision arthroplasty. With the serum IL-6 threshold set at 8.12 pg/ml, the specificity to rule out persistent infection is high, but the sensitivity to predict persistent infection is not satisfactory.

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Thromboelastography Performs Well for the Diagnosis of Periprosthetic Joint Infection.

10.21203/rs.3.rs-257605/v1 ◽

2021 ◽

Author(s):

Tao Yuan ◽

Yi Wang ◽

Shui Sun

Keyword(s):

Periprosthetic Joint Infection ◽

Joint Infection ◽

Revision Arthroplasty ◽

Maximum Amplitude ◽

Diagnostic Value ◽

Two Stage ◽

Musculoskeletal Infection ◽

Group A ◽

Group B ◽

Α Angle

Abstract Background: Coagulation-related biomarkers are drawing new attention in diagnosing periprosthetic joint infection (PJI). Thromboelastography (TEG) analysis provides a comprehensive assessment of coagulation and therefore could be a promising test for PJI. This study aims to assess the value of TEG in diagnosing PJI and to determine the clinical significance of TEG in analyzing reimplantation timing for the second-stage revision.Methods: From October 2017 to September 2020, 62 patients who underwent revision arthroplasty were prospectively included, PJI was defined by 2011 Musculoskeletal Infection Society (MSIS) criteria. Twenty-three patients were diagnosed with PJI (Group A) and the other 39 patients were included as aseptic loosen (Group B). Seventeen patients in Group A finished two-stage revision in our center. C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), D-dimer and TEG parameters (K (clotting time), Angle (α-angle), MA (maximum amplitude), A30 (amplitude at 30 min), TPI (thrombodynamic potential index)) were measured preoperatively in all included patients. Receiver operating characteristic curves were applied to evaluate the diagnostic value of these biomarkers.Results: ESR (AUC 0.953, sensitivity 81.82, specificity 94.87) performed best in PJI diagnosis, followed by MA (AUC 0.895, sensitivity 82.61, specificity 97.44) and CRP (AUC 0.893, sensitivity 82.61, specificity 94.74). When these biomarkers combined in pairs, the diagnosis value improved compared with any individual biomarker. The overall success rate of the two-stage revision was 100%. ESR and MA showed valuable in determining the time of reimplantation, with their values all decreased below cut-off values before reimplantation.Conclusion: TEG could be a promising test in assisting PJI diagnosis, and a useful tool in judging the proper timing of reimplantation.

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Current actual success rate of the two-stage exchange arthroplasty strategy in chronic hip and knee periprosthetic joint infection

The Bone & Joint Journal ◽

10.1302/0301-620x.102b12.bjj-2020-0792.r1 ◽

2020 ◽

Vol 102-B (12) ◽

pp. 1682-1688

Author(s):

Pablo S. Corona ◽

Matías Vicente ◽

Lluís Carrera ◽

Dolors Rodríguez-Pardo ◽

Sebastián Corró

Keyword(s):

Risk Factors ◽

Success Rate ◽

Periprosthetic Joint Infection ◽

Joint Infection ◽

Revision Arthroplasty ◽

Success Rates ◽

Two Stage ◽

Medical Issues ◽

American Society

Aims The success rates of two-stage revision arthroplasty for infection have evolved since their early description. The implementation of internationally accepted outcome criteria led to the readjustment of such rates. However, patients who do not undergo reimplantation are usually set aside from these calculations. The aim of this study was to investigate the outcomes of two-stage revision arthroplasty when considering those who do not undergo reimplantation, and to investigate the characteristics of this subgroup. Methods A retrospective cohort study was conducted. Patients with chronic hip or knee periprosthetic joint infection (PJI) treated with two-stage revision between January 2010 and October 2018, with a minimum follow-up of one year, were included. Variables including demography, morbidity, microbiology, and outcome were collected. The primary endpoint was the eradication of infection. Patients who did not undergo reimplantation were analyzed in order to characterize this subgroup better. Results A total of 162 chronic PJIs were included in the study. After a mean follow-up of 57.3 months (12.1 to 115.7), 18 patients (11.1%) did not undergo reimplantation, due either to medical issues (10), the patient’s choice (4), or death (4). When only considering those who underwent reimplantation, the success rate was 80.6%. However, when those who did not undergo reimplantation were included, the success rate dropped to 71.6%. Advanced age, American Society of Anesthesiologists grade ≥ III, McPherson’s C host, and Gram-negative related PJI were independent risk factors for retention of the spacer. The mortality was higher in the non-reimplanted group. Conclusion The real success rate of two-stage revision may not be as high as previously reported. The exclusion of patients who do not undergo reimplantation resulted in a 9% overestimation of the success rate in this series. Many comorbidity-related risk factors for retention of the spacer were identified, as well as higher death rates in this group. Efforts should be made to optimize these patients medically in order to increase reimplantation and success rates, while decreasing mortality. Cite this article: Bone Joint J 2020;102-B(12):1682–1688.

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