One‐stage Versus Two‐stage Exchange

Abstract

Journal of Orthopaedic ResearchVolume 32, Issue S1 p. S141-S146 Research ArticleFree Access One-stage Versus Two-stage Exchange First published: 24 January 2014 https://doi.org/10.1002/jor.22558Citations: 19AboutSectionsPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat Liaison Paul Lichstein MD, MS Leaders Thorsten Gehrke MD (International), Adolph Lombardi MD, FACS (US), Carlo Romano MD (International), Ian Stockley MB, ChB, MD, FRCS (International) Delegates George Babis MD, Jerzy Bialecki MD, László Bucsi MD, Xu Cai MD, Li Cao MD, Brian de Beaubien MD, Johannes Erhardt MD, Stuart Goodman MD, PhD, FRCSC, FACS, FBSE, William Jiranek MD, Peter Keogh, David Lewallen MD, MS, Paul Manner MD, Wojciech Marczynski MD, J. Bohannon Mason MD, Kevin Mulhall MB, MCh, FRCSI, Wayne Paprosky MD, Preetesh Patel MD, Francisco Piccaluga MD, Gregory Polkowski MD, Luis Pulido MD, Ian Stockley MBBS, ChB, FRCS, Juan Suarez MD, Fritz Thorey MD, Rashid Tikhilov MD, Job Diego Velazquez MD, Heinz Winkler MD Exchange arthroplasty for infection, be it a one-stage or two-stage surgery, is not for the occasional operator. The morbidity and mortality associated with such a surgery is not to be ignored. Team work is paramount to the success of the surgery. A multidisciplinary approach with microbiologists, infectious disease physicians, critical care anaesthetists, plastic surgeons, and orthopaedic surgeons with a particular interest in infection are essential. Question 1: What are the indications and contraindications for one-stage exchange arthroplasty? Consensus One stage-exchange arthroplasty is a reasonable option for the treatment of periprosthetic joint infection (PJI) in circumstances where effective antibiotics are available but not in patients with systemic manifestations of infection (sepsis) in whom resection arthroplasty and reduction of bioburden may be necessary. Relative contraindications to performing a one-stage exchange may include lack of identification of an organism preoperatively, the presence of a sinus tract, or severe soft tissue involvement that may lead to the need for flap coverage. Delegate Vote Agree: 78%, Disagree: 17%, Abstain: 5% (Strong Consensus) Justification Currently, there are no randomized clinical trials (RCTs) that provide concrete indications or contraindications for one-stage exchange arthroplasty over two-stage exchange arthroplasty. There are little data supporting the use of one-stage exchange outside of total hip arthroplasty (THA) or without antibiotic-impregnated cement or bone graft.1-10 Systemic infection with sepsis is a definitive contraindication. In clinical scenarios involving an acutely decompensated patient with PJI as the probable source of sepsis, timely administration of appropriate wide spectrum antibiotics and prompt removal of all implants with thorough debridement is essential. Reimplantation of a prosthesis should be delayed until adequate resuscitation and eradication of the offending organism has been completed.4, 7, 10-18 Although there are reports of effectively treating PJI involving resistant organisms and/or a sinus tract with a one-stage exchange procedure, such cases are generally managed with two-stage procedures, as the presence of a sinus tract may contaminate pre-operative cultures and inhibit the prerequisite identification of the offending organism. In the case of culture-negative PJI, one-stage exchange arthroplasty may also be contraindicated.4, 7, 10, 11, 14, 16-33 Viable soft tissues affording adequate coverage for the new prosthesis are essential when undertaking one-stage revision arthroplasty and surgeons able to perform flaps and proper soft tissue coverage need to be available at the time of one-stage arthroplasty. If soft tissue coverage cannot be performed at the time of one-stage exchange arthroplasty, two-stage surgery should be considered.7, 17, 18 Question 2: What are the indications for two-stage exchange arthroplasty? Consensus Two stage-exchange arthroplasty is a reasonable option for the treatment of PJI. Specific conditions where two-stage exchange may be indicated over one-stage exchange include: (1) patients with systemic manifestations of infection (sepsis); (2) a scenario where infection appears ovious but no organism has been identified; (3) preoperative cultures identifying difficult to treat and antibiotic-resistant organisms; (4) presence of a sinus tract; (5) inadequate and non-viable soft tissue coverage. Delegate Vote Agree: 93%, Disagree: 7%, Abstain: 0% (Strong Consensus) Justification Currently, two-stage exchange arthroplasty surgery is the most popular surgical regimen for the surgical management of PJI in North America and elsewhere. However, to date there are no RCTs that provide absolute indications or contraindications for two-stage exchange arthroplasty.4, 7, 17, 18 Although there is variability in the reported rates of success in eradicating infection, a possible increased morbidity and mortality, and variable time periods prior to reimplantation, direct comparisons with one-stage exchange arthroplasty are difficult due to a patient selection bias in the current literature.7, 9, 17, 34 However, in a recent systematic review, Romano et al.35 demonstrated that a two-stage exchange provides, on average, a better outcome with respect to the control of infection in the knee. The same group recently presented similar findings for the hip, although the difference in infection control was less.36 Systemic infection and/or sepsis are indications for two-stage exchange where timely administration of appropriate antibiotics and prompt removal of implants with thorough debridement of the soft tissues are needed to address the life-threatening sequelae of PJI. The immunocompromised patient or the presence of medical comorbidities, including metastatic disease, advanced cardiac disease, and renal and/or liver dysfunction, have been shown to impact the infection eradication success rates and certainly influence morbidity and mortality. It is unknown if the presence of these comorbidities constitute a contraindication for one-stage exchange arthroplasty surgery.7, 14, 17, 18, 32, 34 The presence of compromised soft tissues that may limit adequate implant coverage is an indication for two-stage exchange arthroplasty. The use of tissue expanders, development of musculocutaneous flaps, and possible need for repeat debridement may all be indicated and require further time between initial resection and reimplantation.7, 17, 18, 32 Question 3: What is the optimal interval between two stages? Consensus There is no definitive evidence in the literature as to the optimal time interval between the two stages. Reports vary from 2 weeks to several months. Delegate Vote Agree: 87%, Disagree: 9%, Abstain: 4% (Strong Consensus) Justification There should be ample time to complete antibiotic administration, eradicate infection, repeat the debridement if necessary, and allow for adequate soft tissue preparation in the event of compromised soft tissue coverage. Positive results have been experienced in situations where implantation is conducted within 2–6 weeks of resection, the infecting pathogen is not resistant, and systemic antibiotic administration is ongoing.7, 18 Intravenous (IV) antibiotic therapy lasting 4–6 weeks with subsequent cessation of antibiotics for 2–8 weeks prior to reimplantation is most commonly employed in the United States and has yielded positive results.7, 37-40 Evidence suggests time intervals greater than 6 months result in suboptimal results in restoring patient function and eradicating infection. Patients who underwent two-stage exchange with greater than 6 months between resection and reimplantation experienced no improvement in function when compared to those who were reimplanted within 6 months of resection.41 The need for serologic evaluation, synovial fluid analysis, and culture of joint fluid aspirate prior to reimplantation is unclear. Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) are poorly predictive of persistent PJI and studies were unable to define optimal cutoff values for these values. However, a change in value from those conducted at the time of resection was a helpful indicator.17, 42-45 Question 4: Is there a difference in cost between one-stage and two-stage exchange arthroplasty? Consensus Due to the lack of knowledge about the real costs and the absence of comparative studies, we are not able to give a clear statement. If, however, infection is effectively treated without the need for reoperation, one-stage exchange arthroplasty is less expensive than two-stage exchange. Further studies are required. Delegate Vote Agree: 91%, Disagree: 5%, Abstain: 4% (Strong Consensus) Justification The economic impact of PJI is immense; therefore, developing and utilizing cost-effective and efficient surgical treatment strategies that provide satisfactory restoration of function and resolution of pain and guard against recurrence are essential.46-48 Differences in cost between one-stage and two-stage exchange arthroplasty are not straightforward to analyze. Costs may vary due to factors associated with hospital facilities, patients, surgeons, and the infecting organism. There is no definitive evidence that takes into account all factors contributing to overall expenditures.4, 46, 47, 49-51 The direct monetary cost of PJI treatment utilizing one-stage versus two-stage arthroplasty varies greatly. However, it may generally be accepted that patient morbidity, operative time, operating room utilization, hospital and surgeon fees, and duration of antibiotic administration are less when undergoing one procedure versus a minimum of two major procedures.4, 7, 46, 49-51 A cost analysis by Klouche et al.52 revealed that two-stage revision of septic THA cost 1.7 times more than a one-stage revision. However, if the results of one-stage and two-stage exchange arthroplasty are comparable, one-stage may be preferred due to the advantages of decreased patient morbidity, lower cost, improved mechanical stability of the affected limb, and shorter period of disability.30, 53 Reinfection rates may be higher when employing a one-stage exchange arthroplasty as compared to a two-stage. However, the cost of additional diagnostic tests and clinical evaluation, coupled with possible reoperation and consideration of quality-adjusted life years, highlights the efficacy of a single-stage revision.54 A Markov expected-utility analysis by Wolf et al.54 favored a one-stage exchange over two-stage exchange when taking into account the health endpoints of quality-adjusted life years. Methicillin-resistant Staphylococcus aureus (MRSA)-associated PJI has emerged as difficult and expensive to effectively eradicate, and is associated with greater expense. Some authorities believe that two-stage exchange may be the preferred treatment for PJI caused by highly virulent organisms and may incur lower total costs.31, 55, 56 Question 5: How many exchange arthroplasty should be attempted in patients with PJI? Consensus There is no definitive evidence that supports limiting the number of septic exchanges that should be attempted. Reimplantation is appropriate if the infection is adequately controlled following repeat resection, the patient is able to tolerate additional surgery, and such surgery will allow for a functioning joint with adequate soft tissue coverage. Delegate Vote Agree: 98%, Disagree: 2%, Abstain: 0% (Strong Consensus) Justification Key factors for the consideration of two-stage exchange are the causative organism, duration and extent of infection, patient willingness and medical fitness to undergo such surgery, and adequate bone stock and viable soft tissues capable of facilitating adequate reconstruction. Reimplantation is feasible if the infection is adequately controlled following repeat resection. 17, 31, 55, 57, 58 The success rate of subsequent two-stage exchange is often favorable but may be lower than with the first attempt.3, 7, 17, 57-63 Patients with resistant organisms including MRSA and enterococcal PJI experienced higher rates of salvage surgery (definitive resection, fusion, or amputation) and should be counseled regarding possible outcomes.1, 23, 25 Involvement of the tibial tuberosity may be an indicator of possible functional failure of two-stage exchange in the knee. Arthrodesis in the event of severely compromised extensor musculature may be required.28 Question 6: What are the indications for knee arthrodesis? Consensus The literature is deficient in providing guidance on this issue. Knee arthrodesis may be an appropriate option for patients who have had failed multiple attempts at reconstruction and stand an unacceptably high risk of recurrent infection with repeat arthroplasty procedures and/or have a deficient extensor mechanism. Surgeons making a choice between arthrodesis and amputation need to take into account the clinical situation of the individual and patient preference. Delegate Vote Agree: 96%, Disagree: 1%, Abstain: 3% (Strong Consensus) Justification Pain and instability in a joint that is not amenable to reconstruction, with or without prior failed exchange arthroplasty and carries an unacceptably high risk of recurrent infection with further arthroplasty surgery, will likely require knee arthrodesis.7, 9, 18, 25, 43, 55, 56, 59, 60, 64, 65 Polymicrobial infections or those due to highly-resistant organisms for which there is no effective antimicrobial therapy are more prone to repeatedly failed attempts at exchange arthroplasty and may also benefit from knee arthrodesis.2, 7, 18, 25, 56, 66 Severe immunocompromization inhibits both infection eradication and wound healing and may be prohibitive for staged exchange, thus favoring a salvage procedure.7, 17, 18 Active IV drug abuse may be a contraindication to repeat attempts at staged exchange and may also indicate the need for a salvage procedure.7 Contraindications might apply to non-ambulatory patients or those with extensive medical comorbidity that precludes multiple surgeries.2, 7, 17, 18 Question 7: If knee arthrodesis is planned for a chronically infected joint, should this be performed in a single stage or two stages? Consensus Knee arthrodesis may be performed as one-stage or two-stage, but the decision depends on the individual circumstances and the host factors. Delegate Vote Agree: 94%, Disagree: 3%, Abstain: 3% (Strong Consensus) Justification Surgical debridement of the infected tissues is a critical factor for success of any surgical procedures for treatment of PJI, in particular arthrodesis of the knee. Thus, inability to perform adequate debridement in one operation should prompt the surgeon to consider two-stage arthrodesis of the knee. In considering one-stage versus two-stage arthrodesis of the knee, other factors may also be considered. Extensive bone loss associated with chronic infection has been shown to decrease the rate of successful arthrodesis and a two-stage approach may allow for comprehensive treatment of defects following aggressive debridement.2, 65, 67-70 Reinfection is uncommon following arthrodesis of the knee performed for PJI. However, infections due to polymicrobial or resistant organisms have a higher propensity for recurrence of infection and failure when treated with a one-stage exchange arthroplasty protocol.2, 4, 7, 11-18, 40, 71-74 Eradication of infection prior to arthrodesis provides higher fusion rates and allows an expanded armamentarium for fixation, such as the use of intramedullary and plating devices.2, 73, 75-80 One-stage arthrodesis, using an external fixation device, is successful when conducted in cases of PJI caused by low-virulence organisms and minimal soft tissue compromise.2, 18, 25, 65, 78, 81, 82 Question 8: What are the indications for amputation? Consensus Amputation for treatment of PJI affecting the knee or the hip may be appropriate in selected cases involving a non-ambulatory patient, necrotizing fasciitis resistant to aggressive debridement, severe bone loss that precludes arthrodesis (knee), inadequate soft tissue coverage, and multiple failed attempts at staged exchange and resection arthroplasty, or peripheral vascular disease and neurovascular injury. Delegate Vote Agree: 98%, Disagree: 1%, Abstain: 1% (Strong Consensus) Justification Salvage of a failed total joint arthroplasty in the setting of infection with recalcitrant necrotizing fasciitis, resistant organisms, failed arthrodesis, and bone loss is difficult and may not respond to further attempts at reconstruction.2, 7, 17, 18, 25, 56, 59, 83, 84 Amputation above the knee results in suboptimal functional outcomes and should be reserved for non-ambulatory patients unless other indications are present and all attempts at infection eradication have failed.3, 84, 85 Except in emergency cases, referral to a center with specialist experience in the management of PJI is advised before amputation is carried out, due to high mortality rates.45, 84, 85 Other indications not directly related to PJI include periprosthetic fracture, peripheral vascular disease, pain, or neuropathy.2, 84 Other salvage operations for management of recalcitrant hip infection include excisional arthroplasty that is performed by some surgeons. Although functional outcome in these patients may not be optimal, excision arthroplasty can be very successful in the control of infection and allow for assisted ambulation.86 REFERENCES 1 Casanova D, Hulard O, Zalta R, et al. 2001. Management of wounds of exposed or infected knee prostheses. Scand J Plast Reconstr Surg Hand Surg 35: 71– 77. CrossrefCASPubMedWeb of Science®Google Scholar 2 Conway JD, Mont MA, Bezwada HP. 2004. Arthrodesis of the knee. J Bone Joint Surg Am 86-A: 835– 848. CrossrefPubMedWeb of Science®Google Scholar 3 Hanssen AD, Trousdale RT, Osmon DR. 1995. Patient outcome with reinfection following reimplantation for the infected total knee arthroplasty. Clin Orthop Relat Res 55– 67. CASPubMedWeb of Science®Google Scholar 4 Jackson WO, Schmalzried TP. 2000. Limited role of direct exchange arthroplasty in the treatment of infected total hip replacements. Clin Orthop Relat Res 101– 105. CrossrefCASPubMedWeb of Science®Google Scholar 5 Jamsen E, Sheng P, Halonen P, et al. 2006. Spacer prostheses in two-stage revision of infected knee arthroplasty. Int Orthop 30: 257– 261. CrossrefCASPubMedWeb of Science®Google Scholar 6 Nahabedian MY, Orlando JC, Delanois RE, et al. 1998. Salvage procedures for complex soft tissue defects of the knee. Clin Orthop Relat Res 119– 124. CrossrefCASPubMedWeb of Science®Google Scholar 7 Osmon DR, Berbari EF, Berendt AR, et al. 2013. Executive summary: diagnosis and management of prosthetic joint infection: clinical practice guidelines by the Infectious Diseases Society of America. Clin Infect Dis 56: 1– 10. CrossrefPubMedWeb of Science®Google Scholar 8 Parkinson RW, Kay PR, Rawal A. 2011. A case for one-stage revision in infected total knee arthroplasty? Knee 18: 1– 4. CrossrefWeb of Science®Google Scholar 9 Senthi S, Munro JT, Pitto RP. 2011. Infection in total hip replacement: meta-analysis. Int Orthop 35: 253– 260. CrossrefPubMedWeb of Science®Google Scholar 10 Winkler H, Stoiber A, Kaudela K, et al. 2008. One stage uncemented revision of infected total hip replacement using cancellous allograft bone impregnated with antibiotics. J Bone Joint Surg Br 90: 1580– 1584. CrossrefCASPubMedWeb of Science®Google Scholar 11 Buechel FF, Femino FP, D'Alessio J. 2004. Primary exchange revision arthroplasty for infected total knee replacement: a long-term study. Am J Orthop (Belle Mead NJ) 33: 190– 198, discussion198. PubMedGoogle Scholar 12 Callaghan JJ, Katz RP, Johnston RC. 1999. One-stage revision surgery of the infected hip. A minimum 10-year followup study. Clin Orthop Relat Res 139– 143. CrossrefCASPubMedWeb of Science®Google Scholar 13 Cordero-Ampuero J, Esteban J, Garcia-Cimbrelo E, et al. 2007. Low relapse with oral antibiotics and two-stage exchange for late arthroplasty infections in 40 patients after 2-9 years. Acta Orthop 78: 511– 519. CrossrefPubMedWeb of Science®Google Scholar 14 Engesaeter LB, Dale H, Schrama JC, et al. 2011. Surgical procedures in the treatment of 784 infected THAs reported to the Norwegian Arthroplasty Register. Acta Orthop 82: 530– 537. CrossrefPubMedWeb of Science®Google Scholar 15 Goksan SB, Freeman MA. 1992. One-stage reimplantation for infected total knee arthroplasty. J Bone Joint Surg Br 74: 78– 82. CASPubMedWeb of Science®Google Scholar 16 Kurd MF, Ghanem E, Steinbrecher J, et al. 2010. Two-stage exchange knee arthroplasty: does resistance of the infecting organism influence the outcome? Clin Orthop Relat Res 468: 2060– 2066. CrossrefPubMedWeb of Science®Google Scholar 17 Parvizi J, Adeli B, Zmistowski B, et al. 2012. Management of periprosthetic joint infection: the current knowledge: AAOS exhibit selection. J Bone Joint Surg Am 94: e104. CrossrefPubMedGoogle Scholar 18 Zimmerli W, Trampuz A, Ochsner PE. 2004. Prosthetic-joint infections. N Engl J Med 351: 1645– 1654. CrossrefCASPubMedWeb of Science®Google Scholar 19 Buchholz HW, Elson RA, Engelbrecht E, et al. 1981. Management of deep infection of total hip replacement. J Bone Joint Surg Br 63-B: 342– 353. CASWeb of Science®Google Scholar 20 Cordero-Ampuero J, Esteban J, Garcia-Cimbrelo E. 2009. Oral antibiotics are effective for highly resistant hip arthroplasty infections. Clin Orthop Relat Res 467: 2335– 2342. CrossrefPubMedWeb of Science®Google Scholar 21 Deirmengian C, Greenbaum J, Stern J, et al. 2003. Open debridement of acute gram-positive infections after total knee arthroplasty. Clin Orthop Relat Res 129– 134. CrossrefPubMedWeb of Science®Google Scholar 22 Huang R, Hu CC, Adeli B, et al. 2012. Culture-negative periprosthetic joint infection does not preclude infection control. Clin Orthop Relat Res 470: 2717– 2723. CrossrefPubMedWeb of Science®Google Scholar 23 Leung F, Richards CJ, Garbuz DS, et al. 2011. Two-stage total hip arthroplasty: how often does it control methicillin-resistant infection? Clin Orthop Relat Res 469: 1009– 1015. CrossrefPubMedWeb of Science®Google Scholar 24 Mortazavi SM, Vegari D, Ho A, et al. 2011. Two-stage exchange arthroplasty for infected total knee arthroplasty: predictors of failure. Clin Orthop Relat Res 469: 3049– 3054. CrossrefPubMedWeb of Science®Google Scholar 25 Rasouli MR, Tripathi MS, Kenyon R, et al. 2012. Low rate of infection control in enterococcal periprosthetic joint infections. Clin Orthop Relat Res 470: 2708– 2716. CrossrefPubMedWeb of Science®Google Scholar 26 Raut VV, Siney PD, Wroblewski BM. 1994. One-stage revision of infected total hip replacements with discharging sinuses. J Bone Joint Surg Br 76: 721– 724. CASPubMedWeb of Science®Google Scholar 27 Rudelli S, Uip D, Honda E, et al. 2008. One-stage revision of infected total hip arthroplasty with bone graft. J Arthroplasty 23: 1165– 1177. CrossrefPubMedWeb of Science®Google Scholar 28 Singer J, Merz A, Frommelt L, et al. 2012. High rate of infection control with one-stage revision of septic knee prostheses excluding MRSA and MRSE. Clin Orthop Relat Res 470: 1461– 1471. CrossrefPubMedWeb of Science®Google Scholar 29 Ueng SW, Lee CY, Hu CC, et al. 2013. What is the success of treatment of hip and knee candidal periprosthetic joint infection? Clin Orthop Relat Res 471: 3002– 3009. CrossrefPubMedWeb of Science®Google Scholar 30 Ure KJ, Amstutz HC, Nasser S, et al. 1998. Direct-exchange arthroplasty for the treatment of infection after total hip replacement. An average ten-year follow-up. J Bone Joint Surg Am 80: 961– 968. CrossrefCASPubMedWeb of Science®Google Scholar 31 Walls RJ, Roche SJ, O'Rourke A, et al. 2008. Surgical site infection with methicillin-resistant Staphylococcus aureus after primary total hip replacement. J Bone Joint Surg Br 90: 292– 298. CrossrefCASPubMedWeb of Science®Google Scholar 32 Wongworawat MD. 2013. Clinical faceoff: One- versus two-stage exchange arthroplasty for prosthetic joint infections. Clin Orthop Relat Res 471: 1750– 1753. CrossrefWeb of Science®Google Scholar 33 Yoo JJ, Kwon YS, Koo KH, et al. 2009. One-stage cementless revision arthroplasty for infected hip replacements. Int Orthop 33: 1195– 1201. CrossrefPubMedWeb of Science®Google Scholar 34 Berend KR, Lombardi AV Jr, Morris MJ, et al. 2013. Two-stage treatment of hip periprosthetic joint infection is associated with a high rate of infection control but high mortality. Clin Orthop Relat Res 471: 510– 518. CrossrefPubMedWeb of Science®Google Scholar 35 Romano CL, Gala L, Logoluso N, et al. 2012. Two-stage revision of septic knee prosthesis with articulating knee spacers yields better infection eradication rate than one-stage or two-stage revision with static spacers. Knee Surg Sports Traumatol Arthrosc 20: 2445– 2453. CrossrefCASPubMedWeb of Science®Google Scholar 36 Romano D, Drago L, Romano CL, et al. 2013. Does two-stage revision of septic hip prosthesis provides better infection eradication rate than one-stage? Paper presented at: 14th EFFORT Congress; Istanbul. Google Scholar 37 Brandt CM, Duffy MC, Berbari EF, et al. 1999. Staphylococcus aureus prosthetic joint infection treated with prosthesis removal and delayed reimplantation arthroplasty. Mayo Clin Proc 74: 553– 558. CrossrefCASPubMedWeb of Science®Google Scholar 38 Hanssen AD, Rand JA, Osmon DR. 1994. Treatment of the infected total knee arthroplasty with insertion of another prosthesis. The effect of antibiotic-impregnated bone cement. Clin Orthop Relat Res 44– 55. CASPubMedWeb of Science®Google Scholar 39 Segawa H, Tsukayama DT, Kyle RF, et al. 1999. Infection after total knee arthroplasty. A retrospective study of the treatment of eighty-one infections. J Bone Joint Surg Am 81: 1434– 1445. CrossrefCASPubMedWeb of Science®Google Scholar 40 Westrich GH, Walcott-Sapp S, Bornstein LJ, et al. 2013. Modern treatment of infected total knee arthroplasty with a 2-stage reimplantation protocol. J Arthroplasty 25: 1015– 1021 1021.e1–1021.e2. CrossrefWeb of Science®Google Scholar 41 Joseph J, Raman R, Macdonald DA. 2003. Time interval between first and second stage revision hip arthroplasty for infection, the effect on outcome. J Bone Joint Surg Br 85-B: 58. Google Scholar 42 Ghanem E, Azzam K, Seeley M, et al. 2009. Staged revision for knee arthroplasty infection: what is the role of serologic tests before reimplantation? Clin Orthop Relat Res 467: 1699– 1705. CrossrefPubMedWeb of Science®Google Scholar 43 Kusuma SK, Ward J, Jacofsky M, et al. 2011. What is the role of serological testing between stages of two-stage reconstruction of the infected prosthetic knee? Clin Orthop Relat Res 469: 1002– 1008. CrossrefWeb of Science®Google Scholar 44 Shukla SK, Ward JP, Jacofsky MC, et al. 2010. Perioperative testing for persistent sepsis following resection arthroplasty of the hip for periprosthetic infection. J Arthroplasty 25(6 Suppl): 87– 91. CrossrefWeb of Science®Google Scholar 45 Springer BD, Lee GC, Osmon D, et al. 2004. Systemic safety of high-dose antibiotic-loaded cement spacers after resection of an infected total knee arthroplasty. Clin Orthop Relat Res 47– 51. CrossrefPubMedWeb of Science®Google Scholar 46 Bozic KJ, Ries MD. 2005. The impact of infection after total hip arthroplasty on hospital and surgeon resource utilization. J Bone Joint Surg Am 87: 1746– 1751. CrossrefPubMedWeb of Science®Google Scholar 47 Parvizi J, Pawasarat IM, Azzam KA, et al. 2010. Periprosthetic joint infection: the economic impact of methicillin-resistant infections. J Arthroplasty 25(6 Suppl): 103– 107. CrossrefPubMedWeb of Science®Google Scholar 48 Sculco TP. 1993. The economic impact of infected total joint arthroplasty. Instr Course Lect 42: 349– 351. CASPubMedGoogle Scholar 49 Gehrke T, Kendoff D. 2012. Peri-prosthetic hip infections: in favour of one-stage. Hip Int 22(Suppl 8): S40– S45. CrossrefWeb of Science®Google Scholar 50 Kurtz SM, Lau E, Watson H, et al. 2012. Economic burden of periprosthetic joint infection in the United States. J Arthroplasty 27(8 Suppl): 61– 65, e61. CrossrefPubMedWeb of Science®Google Scholar 51 Peel TN, Dowsey MM, Buising KL, et al. 2013. Cost analysis of debridement and retention for management of prosthetic joint infection. Clin Microbiol Infect 19: 181– 186. Wiley Online LibraryCASPubMedWeb of Science®Google Scholar 52 Klouche S, Sariali E, Mamoudy P. 2010. Total hip arthroplasty revision due to infection: a cost analysis approach. Orthop Traumatol Surg Res 96: 124– 132. CrossrefCASPubMedWeb of Science®Google Scholar 53 De Man FH, Sendi P, Zimmerli W, et al. 2011. Infectiological, functional, and radiographic outcome after revision for prosthetic hip infection according to a strict algorithm. Acta Orthop 82: 27– 34. CrossrefPubMedWeb of Science®Google Scholar 54 Wolf CF, Gu NY, Doctor JN, et al. 2011. Comparison of one and two-stage revision of total hip arthroplasty complicated by infection: a Markov expected-utility decision analysis. J Bone Joint Surg Am 93: 631– 639. CrossrefPubMedWeb of Science®Google Scholar 55 Filice GA, Nyman JA, Lexau C, et al. 2010. Excess costs and utilization associated with methicillin resistance for patients with Staphylococcus aureus infection. Infect Control Hosp Epidemiol 31: 365– 373. CrossrefPubMedWeb of Science®Google Scholar 56 Parvizi J, Azzam K, Ghanem E, et al. 2009. Periprosthetic infection due to resistant staphylococci: serious problems on the horizon. Clin Orthop Relat Res 467: 1732– 1739. CrossrefPubMedWeb of Science®Google Scholar 57 Kalra KP, Lin KK, Bozic KJ, et al. 2010. Repeat 2-stage revision for recurrent infection of total hip arthroplasty. J Arthroplasty 25: 880– 884. CrossrefWeb of Science®Google Scholar 58 Mortazavi SM, O'Neil JT, Zmistowski B, et al. 2012. Repeat 2-stage exchange for infected total hip arthroplasty: a viable option? J Arthroplasty 27: 923– 926, e921. CrossrefWeb of Science®Google Scholar 59 Azzam K, McHale K, Austin M, et al. 2009. Outcome of a second two-stage reimplantation for periprosthetic knee infection. Clin Orthop Relat Res 467: 1706– 1714. CrossrefPubMedWeb of Science®Google Scholar 60 Bejon P, Berendt A, Atkins BL, et al. 2010. Two-stage revision for prosthetic joint infection: predictors of outcome and the role of reimplantation microbiology. J Antimicrob Chemother 65: 569– 575. CrossrefCASPubMedWeb of Science®Google Scholar 61 Kubista B, Hartzler RU, Wood CM, et al. 2012. Reinfection after two-stage revision for periprosthetic infection of total knee arthroplasty. Int Orthop 36: 65– 71. CrossrefPubMedWeb of Science®Google Scholar 62 Maheshwari AV, Gioe TJ, Kalore NV, et al. 2010. Reinfection after prior staged reimplantation for septic total knee arthroplasty: is salvage still possible? J Arthroplasty 25(6 Suppl): 92– 97. CrossrefWeb of Science®Google Scholar 63 Pagnano MW, Trousdale RT, Hanssen AD. 1997. Outcome after reinfection following reimplantation hip arthroplasty. Clin Orthop Relat Res 192– 204. CrossrefCASPubMedWeb of Science®Google Scholar 64 Husted H, Toftgaard Jensen T. 2002. Clinical outcome after treatment of infected primary total knee arthroplasty. Acta Orthop Belg 68: 500– 507. CASPubMedGoogle Scholar 65 Rand JA, Bryan RS, Chao EY. 1987. Failed total knee arthroplasty treated by arthrodesis of the knee using the Ace-Fischer apparatus. J Bone Joint Surg Am 69: 39– 45. CASPubMedWeb of Science®Google Scholar 66 Knutson K, Lindstrand A, Lidgren L. 1985. Arthrodesis for failed knee arthroplasty. A report of 20 cases. J Bone Joint Surg Br 67: 47– 52. CrossrefCASPubMedWeb of Science®Google Scholar 67 Behr JT, Chmell SJ, Schwartz CM. 1985. Knee arthrodesis for failed total knee arthroplasty. Arch Surg 120: 350– 354. CrossrefCASPubMedWeb of Science®Google Scholar 68 Rothacker GW Jr, Cabanela ME. 1983. External fixation for arthrodesis of the knee and ankle. Clin Orthop Relat Res 101– 108. PubMedWeb of Science®Google Scholar 69 Wade PJ, Denham RA. 1984. Arthrodesis of the knee after failed knee replacement. J Bone Joint Surg Br 66: 362– 366. CASPubMedWeb of Science®Google Scholar 70 Wilde AH, Stearns KL. 1989. Intramedullary fixation for arthrodesis of the knee after infected total knee arthroplasty. Clin Orthop Relat Res 87– 92. CASPubMedWeb of Science®Google Scholar 71 Bengston S, Knutson K, Lidgren L. 1989. Treatment of infected knee arthroplasty. Clin Orthop Relat Res 173– 178. CASPubMedWeb of Science®Google Scholar 72 Damron TA, McBeath AA. 1995. Arthrodesis following failed total knee arthroplasty: comprehensive review and meta-analysis of recent literature. Orthopedics 18: 361– 368. CASPubMedWeb of Science®Google Scholar 73 Knutson K, Hovelius L, Lindstrand A, et al. 1984. Arthrodesis after failed knee arthroplasty. A nationwide multicenter investigation of 91 cases. Clin Orthop Relat Res 202– 211. CASPubMedWeb of Science®Google Scholar 74 Schoifet SD, Morrey BF. 1990. Persistent infection after successful arthrodesis for infected total knee arthroplasty. A report of two cases. J Arthroplasty 5: 277– 279. CrossrefCASPubMedGoogle Scholar 75 Ellingsen DE, Rand JA. 1994. Intramedullary arthrodesis of the knee after failed total knee arthroplasty. J Bone Joint Surg Am 76: 870– 877. CASPubMedWeb of Science®Google Scholar 76 Harris CM, Froehlich J. 1985. Knee fusion with intramedullary rods for failed total knee arthroplasty. Clin Orthop Relat Res 209– 216. CASGoogle Scholar 77 Jorgensen PS, Torholm C. 1995. Arthrodesis after infected knee arthroplasty using long arthrodesis nail. A report of five cases. Am J Knee Surg 8: 110– 113. CASGoogle Scholar 78 Lai KA, Shen WJ, Yang CY. 1998. Arthrodesis with a short Huckstep nail as a salvage procedure for failed total knee arthroplasty. J Bone Joint Surg Am 80: 380– 388. CrossrefCASPubMedWeb of Science®Google Scholar 79 Stiehl JB, Hanel DP. 1993. Knee arthrodesis using combined intramedullary rod and plate fixation. Clin Orthop Relat Res 238– 241. CASPubMedWeb of Science®Google Scholar 80 Waldman BJ, Mont MA, Payman KR, et al. 1999. Infected total knee arthroplasty treated with arthrodesis using a modular nail. Clin Orthop Relat Res 230– 237. CASPubMedWeb of Science®Google Scholar 81 Fern ED, Stewart HD, Newton G. 1989. Curved Kuntscher nail arthrodesis after failure of knee replacement. J Bone Joint Surg Br 71: 588– 590. CASPubMedWeb of Science®Google Scholar 82 Puranen J, Kortelainen P, Jalovaara P. 1990. Arthrodesis of the knee with intramedullary nail fixation. J Bone Joint Surg Am 72: 433– 442. CASPubMedWeb of Science®Google Scholar 83 Isiklar ZU, Landon GC, Tullos HS. 1994. Amputation after failed total knee arthroplasty. Clin Orthop Relat Res 173– 178. CASPubMedWeb of Science®Google Scholar 84 Sierra RJ, Trousdale RT, Pagnano MW. 2003. Above-the-knee amputation after a total knee replacement: prevalence, etiology, and functional outcome. J Bone Joint Surg Am 85-A: 1000– 1004. PubMedWeb of Science®Google Scholar 85 Fedorka CJ, Chen AF, McGarry WM, et al. 2011. Functional ability after above-the-knee amputation for infected total knee arthroplasty. Clin Orthop Relat Res 469: 1024– 1032. CrossrefWeb of Science®Google Scholar 86 Zalavras CG, Rigopoulos N, Ahlmann E, et al. 2009. Hip disarticulation for severe lower extremity infections. Clin Orthop Relat Res 467: 1721– 1726. CrossrefPubMedWeb of Science®Google Scholar Citing Literature Volume32, IssueS1January 2014Pages S141-S146 ReferencesRelatedInformation