One- and two-stage surgical revision of infected elbow prostheses following total joint replacement: a systematic review

Andrew D Beswick,Michael R Whitehouse,Setor K Kunutsor,Ashley W Blom

doi:10.1186/s12891-019-2848-x

Abstract

BackgroundProsthetic joint infection (PJI) is a challenging complication of total elbow replacement (TER). Potential surgical treatments include one- or two-stage revision; however, the best treatment for elbow PJI is not clearly defined. We conducted a systematic review in accordance with PRISMA guidelines to compare the clinical effectiveness of one- and two-stage revision surgery for elbow PJI using re-infection (recurrent and new infections) rates; mortality; clinical measures of function, pain, and satisfaction; and non-infection related adverse events.MethodsMEDLINE, Embase, Web of Science, and The Cochrane Library were searched up to June 2019 to identify observational cohort studies and randomised controlled trials (RCTs) that had recruited patients with elbow PJI following TER and treated with one- or two-stage revision. Of 96 retrieved articles, 2 one-stage and 6 two-stage revision studies were eligible. No RCT was identified. Arcsine transformation was used in estimating rates with 95% confidence intervals (CIs).ResultsStaphylococcus aureus was the most common causative organism for PJI of the elbow (24 of 71 elbow PJIs). The re-infection rate (95% CI) for one-stage (7 elbows) ranged from 0.0% (0.0–79.3) to 16.7% (3.0–56.4) and that for two-stage revision (87 elbows) from 0.0% (0.0–49.0) to 20.0% (3.6–62.4). Non-infection related adverse event rate for one-stage (based on a single study) was 16.7% (3.0–56.4) and that for two-stage ranged from 11.8% (4.7–26.6) to 20.0% (3.6–62.4). There were no mortality events recorded following one- or two-stage revision surgery and postoperative clinical measures of function, pain, and satisfaction could not be effectively compared because of limited data.ConclusionsNo strong conclusions can be drawn because of limited data. The one-stage revision may be potentially at least as clinically effective as two-stage revision, but further data is needed. There are clear gaps in the existing literature and studies are urgently warranted to assess the clinical effectiveness of one- and two-stage revision strategies for PJI following TER.Systematic review registrationPROSPERO 2018: CRD42018118002.

Highlights

Prosthetic joint infection (PJI) is a challenging complication of total elbow replacement (TER)
Of the 8 eligible articles, 6 articles were based on two-stage revision; 1 article evaluated the one-stage revision; and 1 article evaluated both one- and two-stage revision strategies
Studies reported the diagnosis of PJI in a variety of ways, but was mainly based on the presence of one or more of the following criteria: (i) clinical, haematological and radiological assessments suggesting the diagnosis with persistent swelling and inflammation, high blood indices and progressive radiolucent lines; (ii) positive results of microbiological culture from preoperative elbow joint aspirate, intraoperative periprosthetic tissue, or sonication fluid of the removed plant; (iii) visible purulence of a preoperative aspirate or intraoperative periprosthetic tissue; (iv) wound findings such as the presence of a sinus tract communicating with the prosthesis; and (v) pathological findings on tissue sections

Summary

Introduction

Prosthetic joint infection (PJI) is a challenging complication of total elbow replacement (TER). Prosthetic joint infection (PJI) is a potentially devastating complication of TER and compared with hip or knee replacement, TER is associated with a higher incidence of PJI which affects between 1 to 12% of patients [4,5,6]. The best treatment for elbow PJI is not clearly defined as choices of treatment strategy are generally based on the treating surgeon’s experience and evidence derived from studies of PJI treatment in hip and knee replacement [13]. An extensive body of evidence suggests that one- and two-stage revision strategies for hip, knee and shoulder PJI are clinically comparable [14,15,16,17]; the data are sparse and conflicting on the role of these strategies for treating infected elbow prostheses. We are not aware of any randomised controlled trial (RCT) that has compared the clinical effectiveness of the two revision strategies

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Conclusion