Revision For Periprosthetic Joint Infection Research Articles

Differences in Success Rate of Two-Stage Revision for Periprosthetic Joint Infection of the Knee Depending on the Applied Definition

BackgroundSuccess rates of two-stage exchange arthroplasty are subject to substantial variance in the literature. An explanation is the lack of a universally accepted definition of what constitutes treatment success for periprosthetic joint infection (PJI). Therefore, the main objective of this study was to assess success rates, applying four definitions to identify the one definition that best captures “true” success from both a clinical and patient-centered perspective. MethodsThis was a retrospective study investigating the outcome of a consecutive series of 78 chronic knee PJIs that were treated with a two-stage revision at a single center between 2017 and 2020. Kaplan-Meier survival analyses were conducted to estimate success rates. ResultsAfter a mean follow-up of 36 months (range, 25 to 60), 64 patients (82%) were reimplanted after a mean interim period of 90 days (range, 22 to 201). There was one patient (1%) lost to follow-up, and the overall mortality was 15% (n = 12). Kaplan-Meier survival analyses were used to estimate treatment success at 2- and 3-years: implant survival was 93% (95% CI [confidence interval]: 82 to 97) and 87% (95% CI: 73 to 94), infection control was 90% (95% CI: 79 to 95) and 87% (95% CI: 73 to 93), success according to Delphi criteria was 88% (95% CI: 78 to 94), and success according to Musculoskeletal Infection Society (MSIS) criteria was 65% (95% CI: 53 to 74) at both timepoints. ConclusionSuccess rates were ranging between 65 and 93% depending on the applied definition, highlighting the need for universal success criteria. This variability mainly results from the differing approaches to patients who did not undergo reimplantation or passed away within a year of surgery. These patients exemplify cases of fatal treatment failures. Consequently, the MSIS criteria should be routinely employed to accurately report the “true” success rate.

Equivalent Survivorship of Total Hip Arthroplasty in Patients Who Have Inflammatory Bowel Disease

BackgroundInflammatory bowel disease (IBD) can have orthopaedic manifestations related to decreased bone mineral density and increased fracture risk. The impact of IBD-spectrum diseases, including Crohn’s disease (CD) and ulcerative colitis (UC), on the overall performance of total hip arthroplasty (THA), is not well understood. The present study sought to evaluate whether patients who have IBD were at an increased risk of THA failure compared to those who did not have IBD. MethodsThe Statewide Planning and Research Cooperative System was used to compare postoperative outcomes between patients who have IBD (CD and UC) and patients who do not have IBD from 2010 to 2020. A total of 119,094 patients were included in the study, of whom 1,165 had a diagnosis of IBD. Overall, 501 of those had CD, while 664 had UC. ResultsWhen controlling for comorbidities, patients who had CD had longer hospital length of stay (CD: 3.6 ± 2.5 versus UC: 3.4 ± 2.1 versus control: 3.2 ± 2.3 days, P < 0.001), higher rates of 90-day readmission (CD: 13.6 versus UC: 8.3 versus control: 7.7%, P < 0.001) and 1-year readmission (CD: 20.4 versus UC: 15.1 versus control: 12.8%, P < 0.001), and higher rates of 90-day emergency room visits (CD: 15.4 versus UC: 12 versus control: 11.1%, P = 0.007). There were no differences in all-cause revision or revision for periprosthetic joint infection between CD and UC compared with control patients. ConclusionsPatients who have UC had more emergency room visits and hospital readmissions following THA; however, survival analysis demonstrated that IBD patients are not at an increased risk of revision or periprosthetic joint infection after THA.

Do Organism Profile and Resistance Patterns Change between First and Subsequent Two-Stage Revision for Periprosthetic Joint Infection?

Increasing antibiotic resistance has been reported as an issue in the treatment of periprosthetic joint infection (PJI). A repeat two-stage revision for recurrent PJI is at high risk of reinfection. However, it is unclear if the microorganism profile plays a role with potentially more resistant or polymicrobial infections. This is a retrospective, single-center analysis of two-stage revisions performed between 2011 and 2017. We identified 46 patients who underwent a repeat resection arthroplasty for recurrent PJI of the same joint after a previous two-stage revision of the same joint at the same department. All microbiological findings were analyzed focusing on microbiological spectrum and resistance testing as well as the potential impact on reinfection-free survival. The most common organism found at the time of recurrent PJI were coagulase-negative Staphylococci (39%) followed by Gram-negative organisms (28%). The risk of polymicrobial infections, difficult-to-treat resistant organisms, and Gram-negative infections increased significantly. Among staphylococcal infections, there was a high percentage of methicillin-resistant species and resistance to oral antibiotics. Patients with Gram-negative organisms had a reduced infection-free survivorship, while resistant organisms were not associated with decreased survival. Patients who undergo a repeat two-stage revision for recurrent PJI have more polymicrobial and resistant organisms, although the impact on survivorship is unclear.

Can Periprosthetic Joint Infection of Tumor Prostheses Be Controlled With Debridement, Antibiotics, and Implant Retention?

Two-stage revision for periprosthetic joint infection (PJI) in patients who have undergone segmental replacement of the distal femur or proximal tibia after tumor resection can be associated with considerable morbidity, pain, and risk of complications because the procedure often results in removal of long, well-fixed stems from the diaphysis. A less-aggressive surgical approach, such as debridement, antibiotics, and implant retention (DAIR), may be attractive to patients and surgeons because of less morbidity, but the likelihood of eradicating infection in comparison to the traditional two-stage revision is not well established for oncology patients. Furthermore, the relative risk of subsequent amputation for DAIR versus two-stage revision has not been defined for this population. (1) How does DAIR compare with two-stage revision in terms of infection control for patients with distal femoral or proximal tibial segmental modular endoprostheses? (2) Is DAIR as an initial procedure associated with an increased risk of amputation compared with two-stage revision for infection? From the longitudinally maintained orthopaedic oncology surgical database at our institution, we identified 69 patients who had been treated for a clinical diagnosis of PJI at the knee between 1993 and 2015. We excluded 32% (22) of patients who did not meet at least one of the major criteria of the Musculoskeletal Infection Society (MSIS) for PJI, 3% (2) of patients who underwent immediate amputation, 3% (2) of patients who had a follow-up time of < 24 months, and 7% (5) of patients who did not have a primary tumor of the distal femur or proximal tibia. The study consisted of 38 patients, of whom eight underwent two-stage revision, 26 underwent DAIR, and four underwent extended DAIR (removal of all segmental components but with retention of stems and components fixed in bone) for their initial surgical procedure. To be considered free of infection, patients had to meet MSIS standards, including no positive cultures, drainage, or surgical debridement for a minimum of 2 years from the last operation. Factors associated with time-dependent risk of infection relapse, clearance, amputation, and patient survival were analyzed using Kaplan-Meier survivorship curves and the log-rank test to compare factors. Association of demographic and treatment factors was assessed using chi-square and Fisher exact tests. Continuous infection-free survival at 5 years was 16% (95% CI 2% to 29%) for patients undergoing DAIR compared with 75% (95% CI 45% to 100%) for patients undergoing two-stage revision (p = 0.006). The median (range) number of total surgical procedures was 3 per patient (1 to 10) for DAIR and 2 (2 to 5) for two-stage revision. Twenty-nine percent (11 of 38) of patients eventually underwent amputation. Survival without amputation was 69% (95% CI 51% to 86%) for DAIR compared with 88% (95% CI 65% to 100%) for two-stage revision at 5 years (p = 0.34). The cumulative proportion of patients achieving infection-free status (> 2 years continuously after last treatment) and limb preservation was 58% (95% CI 36% to 80%) for patients initially treated with DAIR versus 87% (95% CI 65% to 100%) for patients first treated with two-stage revision (p = 0.001). Infection control was better with two-stage revision than DAIR. The chance of eventual clearance of infection with limb preservation was better when two-stage revision was chosen as the initial treatment. However, the loss to follow-up in the two-stage revision group would likely make the true proportion of infection control lower than our estimate. Our experience would suggest that the process of infection eradication is a complex and difficult one. Most patients undergo multiple operations. Nearly one-third of patients eventually underwent amputation, and this was a serious risk for both groups. While we cannot strongly recommend one approach over the other based on our data, we would still consider the use of DAIR in patients who present with acute short duration of symptoms (< 3 weeks), no radiographic signs of erosion around fixed implants, and organisms other than Staphylococcus aureus. We would advocate the extended DAIR procedure with removal of all segmental or modular components, and we would caution patients that there is a high likelihood of needing further surgery. A prospective trial with strict adherence to indications may be needed to evaluate the relative merits of an extended DAIR procedure versus a two-stage revision. Level III, therapeutic study.

Systematic review and meta-analysis of single-stage versus two-stage revision for periprosthetic joint infection after knee arthroplasty: a call for a randomised trial.

Knee arthroplasty is an effective treatment for severe knee degeneration; however, periprosthetic joint infection (PJI) is one of its serious complications. Single- and two-stage revision are common treatments, but few studies have compared single- and two-stage revision for PJI after knee arthroplasty. This study aimed to compare the reinfection and reoperation rates of single- and two-stage revision through meta-analysis. The review process was conducted according to the PRISMA guidelines. We searched the PubMed, Medline, Embase and Cochrane Central Register of Controlled Trials databases for trials comparing single- and two-stage revision for PJI after knee arthroplasty from the respective inception dates to April 2023. Two researchers individually screened the studies, performed the literature quality evaluation and data extraction and used Stata 17 software for data analysis. The meta-analysis showed that the reinfection rate was significantly lower in the single-stage revision group than in the two-stage revision group. While the reoperation rates demonstrated no statistically significant difference between the two groups. We presented descriptive results because the discrepancies in the knee function scores and data reported in the studies meant that these data could not be combined in the meta-analysis. Based on the available research, single-stage revision is a reliable option for PJI after knee arthroplasty. However, when developing the best treatment strategy, it is still necessary to consider the individual circumstances and needs of the patient, as well as the risks of postoperative rehabilitation and complications.

Periprosthetic Joint Infection After Total Knee Arthroplasty With or Without Antibiotic Bone Cement

Despite increased use of antibiotic-loaded bone cement (ALBC) in joint arthroplasty over recent decades, current evidence for prophylactic use of ALBC to reduce risk of periprosthetic joint infection (PJI) is insufficient. To compare the rate of revision attributed to PJI following primary total knee arthroplasty (TKA) using ALBC vs plain bone cement. This international cohort study used data from 14 national or regional joint arthroplasty registries in Australia, Denmark, Finland, Germany, Italy, New Zealand, Norway, Romania, Sweden, Switzerland, the Netherlands, the UK, and the US. The study included primary TKAs for osteoarthritis registered from January 1, 2010, to December 31, 2020, and followed-up until December 31, 2021. Data analysis was performed from April to September 2023. Primary TKA with ALBC vs plain bone cement. The primary outcome was risk of 1-year revision for PJI. Using a distributed data network analysis method, data were harmonized, and a cumulative revision rate was calculated (1 - Kaplan-Meier), and Cox regression analyses were performed within the 10 registries using both cement types. A meta-analysis was then performed to combine all aggregated data and evaluate the risk of 1-year revision for PJI and all causes. Among 2 168 924 TKAs included, 93% were performed with ALBC. Most TKAs were performed in female patients (59.5%) and patients aged 65 to 74 years (39.9%), fully cemented (92.2%), and in the 2015 to 2020 period (62.5%). All participating registries reported a cumulative 1-year revision rate for PJI of less than 1% following primary TKA with ALBC (range, 0.21%-0.80%) and with plain bone cement (range, 0.23%-0.70%). The meta-analyses based on adjusted Cox regression for 1 917 190 TKAs showed no statistically significant difference at 1 year in risk of revision for PJI (hazard rate ratio, 1.16; 95% CI, 0.89-1.52) or for all causes (hazard rate ratio, 1.12; 95% CI, 0.89-1.40) among TKAs performed with ALBC vs plain bone cement. In this study, the risk of revision for PJI was similar between ALBC and plain bone cement following primary TKA. Any additional costs of ALBC and its relative value in reducing revision risk should be considered in the context of the overall health care delivery system.

Success Rate After 2-Stage Spacer-Free Total Hip Arthroplasty Exchange and Risk Factors for Reinfection: A Prospective Cohort Study of 187 Patients

BackgroundTwo-stage prosthesis exchange is the treatment of choice for chronic periprosthetic joint infection (PJI) of a total hip arthroplasty (THA), especially when the bone and surrounding soft tissues are compromised or difficult-to-treat pathogens are implicated. The aims of our study were as follows: (1) to determine the outcome of 2-stage prosthesis exchange for the treatment of PJI after THA and (2) to determine the risk factors for reinfection leading to subsequent revision surgeries after reimplantation. MethodsWe prospectively enrolled 187 consecutive patients who underwent a 2-stage THA exchange with resection arthroplasty for PJI from 2013 to 2019. The mean (± SD) duration of follow-up was 54.2 ± 24.9 months (range, 36 to 96), and the mean interval until reimplantation was 9.8 ± 8.9 weeks (range, 2 to 38). All patients remained in a spacer-free girdlestone situation between the 2 stages of treatment. Patients who remained infection-free after their 2-stage treatment were considered to have achieved treatment success. ResultsThe overall success rate was 85.6%. The cumulative probability of reinfection was 11.5% after one year and 14% after 2 years after reimplantation. High virulence or difficult-to-treat pathogens were significant and independent risk factors for reinfection (HR [hazard ratio] = 3.71, 95% CI [confidence interval]: 1.47 to 9.36, P = .006 and HR = 3.85, 95% CI: 1.73 to 8.57, respectively, P = .001), as was previous 2-stage hip prosthesis exchange (HR = 3.58, 95% CI: 1.33 to 9.62, P = .01). Overall reoperation and revision rates were 26.2 and 16.6%, respectively. Re-infected patients had an 80% higher probability of reoperation than noninfected ones (P < .001, log-rank = 102.6), and they were 55% more likely to undergo revision surgery during their follow-up (P < .001, log-rank = 55.4). ConclusionsReinfection rates after 2-stage spacer-free THA revision for PJI still remain high but are comparable to those including cement spacers. Patients who have had prior failed 2-stage implant exchanges or are infected by high-grade or difficult-to-treat pathogens are at high risk for treatment failure.

Diagnostic and Predictive Efficacy of Synovial Fluid Versus Serum C-Reactive Protein Levels for Periprosthetic Joint Infection and Reimplantation Success

BackgroundA 2-stage exchange revision for periprosthetic joint infection (PJI) is associated with major risks for reinfection. Although serum markers are frequently used for diagnosis, their effectiveness remains debatable. Synovial fluid markers may offer a more accurate diagnosis of PJI; however, the importance of these biomarkers, notably synovial fluid C-reactive protein (syCRP), remains controversial, particularly in the context of reimplantation. The present study aimed to clarify these diagnostic uncertainties by evaluating the diagnostic efficacy of syCRP versus serum CRP (seCRP) levels in the context of PJI and recurring or persisting infections before reimplantation. MethodsA total of 186 patients were enrolled and divided into 2 groups: aseptic revision (n = 112) and PJI revision (n = 74). Of the PJI group, 65 were categorized as success and 9 as failure, based on the presence of recurrent or persistent infection before reimplantation. The syCRP and seCRP levels and their changes were assessed preoperatively and in the first-stage and second-stage revisions. Additionally, receiver operating characteristic (ROC) curves and area under the ROC curves (AUCs) were analyzed. ResultsBoth seCRP and syCRP levels were significantly elevated in the PJI group compared with the aseptic group (P < .001). The ROC curve analysis highlighted the enhanced diagnostic accuracy of syCRP for PJI, with an AUC of 0.93 versus 0.80 for seCRP. Furthermore, syCRP proved to be more reliable in predicting reimplantation success, exhibiting an AUC of 0.86 versus 0.63 for seCRP. In evaluating trends in CRP levels to determine reimplantation timing, changes in syCRP levels demonstrated superior diagnostic utility, exhibiting an AUC of 0.79 versus 0.63 for changes in seCRP levels. ConclusionsIn assessing PJI and infections before reimplantation, syCRP may offer enhanced accuracy compared with seCRP. Nevertheless, variations in both syCRP and seCRP levels did not consistently predict the outcome of reimplantation.

Static spacers play a crucial role in the treatment of complex periprosthetic joint infections of the knee.

To determine the superior spacer design, a growing number of studies are comparing treatment results between patients having been treated with articulating and static knee spacers in the setting of two-stage revision for periprosthetic joint infection (PJI). In contrast, the primary objective of this study was to compare preoperative characteristics between patients from both spacer groups and examine whether significant differences were present prior to spacer implantation. This retrospective, single-centre, cohort study examined the preoperative situation of 80 consecutive knee PJIs between 2017 and 2020. All patients underwent two-stage revision, with 35 (44%) receiving an articulating and 45 (56%) a static spacer. No significant differences were observed in terms of patient gender (p = 0.083), age (p = 0.666), comorbidity (p = 0.1) and preoperative clinical function (p = 0.246). Static spacers were significantly more often used in the presence of a periarticular fistula (p = 0.033), infection of a revision implant (p < 0.001), higher degree of bone loss (p < 0.001) and infection caused by a difficult-to-treat pathogen (p = 0.038). Complication and revision rates were similar for both spacer types during the interim period, while patients with articulating spacers demonstrated a superior clinical function (p < 0.001) during the interim period and after reimplantation. Static spacers are being utilised in significantly more complex and unfavourable preoperative scenarios. Therefore, a preoperative selection bias may be at least partially accountable for any disparities observed in postoperative outcomes. To achieve the best possible results, surgeons should know and respect the distinct indications of static and articulating spacers and consequently understand and use them as complementary surgical options. Level III.

Similar Efficacy and Lower Cost Associated With Ceftazidime Compared to Tobramycin Coupled With Vancomycin in Antibiotic Spacers in the Treatment of Periprosthetic Joint Infection

BackgroundVancomycin and tobramycin have traditionally been used in antibiotic spacers. In 2020, our institution replaced tobramycin with ceftazidime. We hypothesized that the use of ceftazidime/vancomycin (CV) in antibiotic spacers would not lead to an increase in treatment failure compared to tobramycin/vancomycin (TV). MethodsFrom 2014 to 2022, we identified 243 patients who underwent a stage I revision for periprosthetic joint infection. The primary outcome was a recurrent infection requiring antibiotic spacer exchange. We were adequately powered to detect a 10% difference in recurrent infection. Patients who had a prior failed stage I or two-stage revision for infection, acute kidney injury prior to surgery, or end-stage renal disease were excluded. Given no other changes to our spacer constructs, we estimated cost differences attributable to the antibiotic change. Chi-square and t-tests were used to compare the two groups. Multivariable logistic regressions were utilized for the outcomes. ResultsThe combination of TV was used in 127 patients; CV was used in 116 patients. Within one year of stage I, 9.8% of the TV group had a recurrence of infection versus 7.8% of the CV group (P = .60). By final follow-up, results were similar (12.6 versus 8.6%, respectively, P = .32). Adjusting for potential risk factors did not alter the results. Cost savings for ceftazidime versus tobramycin are estimated to be $68,550 per one hundred patients treated. ConclusionsReplacing tobramycin with ceftazidime in antibiotic spacers yielded similar periprosthetic joint infection eradication success at a lower cost. While larger studies are warranted to confirm these efficacy and cost-saving results, our data justifies the continued investigation and use of ceftazidime as an alternative to tobramycin in antibiotic spacers.

Smoking is not closely related to revision for periprosthetic joint infection after primary total knee and hip arthroplasty

BackgroundThe influence of smoking on the risk of periprosthetic joint infection (PJI) remains unclear. The objective was to explore the impact of smoking on PJI after primary total knee (TKA) and hip (THA) arthroplasty. HypothesisCurrent smoking patients should have an increased risk of PIJ compared with nonsmoking patients. Patients and methodsA prospective registry-based observational cohort study was performed. A total of 4591 patients who underwent primary TKA (3076 patients) or THA (1515) were included. According to the smoking status at the time of arthroplasty, patients were classified as nonsmokers (3031 patients), ex-smokers (688), and smokers (872). Multivariate analysis included smoking status, age, gender, education level, body mass index, American Society of Anesthesiologists class, diagnosis (osteoarthritis, rheumatism), diabetes, chronic obstructive pulmonary disease, perioperative blood transfusion, site of arthroplasty (knee, hip), length of operation, and length of stay. ResultsThere were PJI after 59 (1.9%) TKA and 27 (1.8%) THA (p=0.840). There were PJI in 47 (1.6%) nonsmokers, 12 (1.7%) ex-smokers, and 17 (1.9%) smokers (p=0.413). There were wound complications (delayed wound healing and superficial wound infection) in 34 (0.7%) nonsmokers, 9 (1.3%) in ex-smokers, and 17 (1.9%) in smokers (p=0.045). In multivariate analysis, only the female gender was a significant predictor of PJI (OR 1.3, 95% CI 1.1–2.4 [p=0.039]). Specifically, the categories of ex-smokers (OR 0.8, 95% CI 0.2–1.7 [p=0.241]) and smokers (OR 1.1, 95% CI 0.6–1.5 [p=0.052]) were not significant predictors. The 4-year arthroplasty survival with PJI as the endpoint was 99.1% (95% CI: 99.0–99.7) for nonsmokers, 99.0% (95% CI: 98.8–99.2) for ex-smokers, and 98.7% (95% CI: 98.2–99.0) for smokers was not significantly different between smoking status groups (p=0.318). DiscussionSmoking was not identified as a significant predictor for PJI following primary TKA or THA. Level of evidenceIII, prospective cohort study.

Two-stage revision for periprosthetic joint infection after hip and knee arthroplasty.

Histology is widely used for diagnosis of persistent infection during reimplantation in two-stage revision hip and knee arthroplasty, although data on its utility remain scarce. Therefore, this study aims to assess the predictive value of permanent sections at reimplantation in relation to reinfection risk, and to compare results of permanent and frozen sections. We retrospectively collected data from 226 patients (90 hips, 136 knees) with periprosthetic joint infection who underwent two-stage revision between August 2011 and September 2021, with a minimum follow-up of one year. Histology was assessed via the SLIM classification. First, we analyzed whether patients with positive permanent sections at reimplantation had higher reinfection rates than patients with negative histology. Further, we compared permanent and frozen section results, and assessed the influence of anatomical regions (knee versus hip), low- versus high-grade infections, as well as first revision versus multiple prior revisions on the histological result at reimplantation. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), chi-squared tests, and Kaplan-Meier estimates were calculated. Overall, the reinfection rate was 18%. A total of 14 out of 82 patients (17%) with positive permanent sections at reimplantation experienced reinfection, compared to 26 of 144 patients (18%) with negative results (p = 0.996). Neither permanent sections nor fresh frozen sections were significantly associated with reinfection, with a sensitivity of 0.35, specificity of 0.63, PPV of 0.17, NPV of 0.81, and accuracy of 58%. Histology was not significantly associated with reinfection or survival time for any of the analyzed sub-groups. Permanent and frozen section results were in agreement for 91% of cases. Permanent and fresh frozen sections at reimplantation in two-stage revision do not serve as a reliable predictor for reinfection.

Patient-Related Predictors of Treatment Failure After Two-Stage Total Hip Arthroplasty Revision for Periprosthetic Joint Infection: A Systematic Review and Meta-Analysis

BackgroundPeriprosthetic joint infection (PJI) treatment has high failure rates even after 2-stage revision. Risk factors for treatment failure (TF) after staged revision for PJI are not well defined, nor is it well established how they correlate with the risks of developing an index PJI. Identifying modifiable risk factors may allow preoperative optimization, while identifying nonmodifiable risk factors can influence surgical options or advise against further surgery. We performed a systematic review and meta-analysis to better define predictors of TF in 2-stage revision for PJI. MethodsThe PubMed, Embase, and Scopus databases were searched from their inception in December 1976 to April 15, 2023. Studies comparing patient-related variables between patients successfully treated who had 2-staged revision total hip arthroplasty (THA) and patients with persistent infections were included. Studies were screened, and 2 independent reviewers extracted data, while a third resolved discrepancies. Meta-analysis was performed on these data. There were 10,052 unique studies screened, and 21 studies met the inclusion criteria for data extraction. ResultsThere was good-quality evidence that obesity, liver cirrhosis, and previous failed revisions for PJI are nonmodifiable risk factors, while intravenous drug use (IVDU) and smoking are modifiable risk factors for TF after 2-stage revision for hip PJI. Reoperation between revision stages was also significantly associated with an increased risk of TF. Interestingly, other risk factors for an index PJI including male gender, American Society of Anesthesiology score, diabetes mellitus, and inflammatory arthropathy did not predict TF. Evidence on Charlson Comorbidity Index was limited. ConclusionsPatients with a smoking history, obesity, IVDU, previous failed revision for PJI, reoperation between stages, and liver cirrhosis are more likely to experience TF after 2-stage revision THA for PJI. Modifiable risk factors include smoking and IVDU and these patients should be referred to services for cessation as early as possible before 2-stage revision THA.

Outcomes of rotating versus pure hinge knee arthroplasty in the setting of one-stage exchange for periprosthetic joint infection.

Rotating or pure hinge knee prostheses are often used in case of periprosthetic joint infection (PJI). Five-year survival data of rotating hinge implants ranging from 52 to 90%, whereas pure hinge data are sparse. This study describes the results of both hinge knee prostheses after one-stage septic exchange. One hundred sixty-seven one-stage septic exchanges of a primary unconstrained total knee arthroplasty (TKA) to a cemented hinge prosthesis (117 rotating and 50 pure hinge TKAs) performed between 2008 and 2017 were retrospectively reviewed. Exclusion criteria were stem extensions or augments used in primary TKA, history of extensor mechanism reconstruction, and a follow-up less than twoyears after surgery. Rates of reinfection, mechanical failures, and all-cause revision-free survival data were documented. At fiveyears, the all-cause revision-free survival was 77% (95% CI 69 to 82). Thirty-one patients (19%) had further revision for aseptic reasons. In the rotating hinge group, the mechanical failure rate was more than twice as high as in the pure hinge group (13% vs 6%), significantly influenced by higher body weight. At a mean follow-up of 6.7years, 21 (13%) patients had a reinfection and underwent a further surgery. Reinfection rates did not differ between the two groups. The use of hinge TKA in the revision of PJI shows favourable fiveyear infection-free and all-cause revision-free survival rates of 91% and 77%, respectively. Our study showed poorer results of the rotating hinge design. These results may help surgeons to choose proper implants in case of septic knee revision.

What Is the True Impact of Periprosthetic Joint Infection Diagnosis on Mortality?

BackgroundMortality is a quality indicator that may affect expenditures. Revisions for periprosthetic joint infection (PJI) are, on average, more expensive and exhibit higher morbidity than aseptic revisions, although reimbursement is similar. Therefore, we sought to determine (1) impact on mortality rates of revision total hip and/or knee arthroplasty performed for PJI diagnosis (septic) versus aseptic revisions, at any point in time, and (2) mortality predictors among PJI patients. MethodsRetrospective chart review of 978 consecutive patients who underwent revision at a single institution (January 2015 to November 2020). All revisions were evaluated, and it was determined whether patients had a revision for PJI at any point in time or not. Two groups were compared: (1) patients with septic revision(s) (n = 350) and (2) patients who only underwent aseptic revision(s) (n = 628). Demographics and mortality status at latest follow-up (mean 3 years, range: 0 to 18 years, from first revision ever) were assessed. Mortality status was also separately assessed among patients who exclusively had hip revision(s), or solely knee revision(s), or both. Multivariate regression analysis (Cox) was used to determine whether PJI diagnosis was an independent mortality predictor. Among PJI patients, potential mortality predictors were evaluated. ResultsOverall, 65 patients died (6.6%). The septic cohort had significantly more men and American Society of Anesthesiologists (ASA) class-IV patients. Mortality rates were 10.9% and 4.3% (P < .0001) for septic and aseptic revision groups, respectively. After controlling for sex, ASA, and number of revisions, PJI diagnosis was a significant mortality predictor (hazard ratio [HR]: 2.69, 95% confidence interval [CI]: 1.5 to 4.7, P = .001). Among PJI patients, age (HR: 1.05, 95% CI: 1.01 to 1.08, P = .009) and ASA (HR: 4.02, 95% CI: 1.67 to 9.67, P = .002) were independent predictors. ConclusionsHaving a revision due to PJI diagnosis was associated with 2.5 times increased mortality. Therefore, more accurate coding capturing the complexity and morbidity of revisions for PJI diagnosis is needed.

Ninety-day postoperative mortality and complications in continuous and unselected single-stage revisions for chronic periprosthetic joint infection.

Single-stage revision has gained significant attention as a major surgical approach for periprosthetic joint infection (PJI). However, the 90-day mortality and complication profile of single-stage revision is poorly characterized. The purposes of this study were to determine the incidence rates of and identify the risk factors for 90-day postoperative mortality and complications of single-stage revision for chronic PJI. A retrospective review was conducted on patients who underwent single-stage revision for PJI between August 2000 and May 2022. Patient demographics, 90-day mortality, and postoperative complications were recorded. Complications were categorized into systemic and local complications. Patients in this study were further categorized into knee and hip revision groups. Univariate and multivariate logistic regression analyses were performed to identify significant independent predictors of the outcome measures. 348 patients (144 knees and 204 hips) were included in this study. The 90-day mortality rate was 0.9%. The incidence rates of postoperative complications in knee and hip surgeries were 31.3% and 19.6%, respectively. The most common complication was deep-vein thrombosis (DVT). Rheumatoid arthritis (RA) was the independent predictor of mortality. In the knee revision group, fungal infection was identified as the independent predictor of recurrent PJI; regular alcohol use was predictive of wound dehiscence. Among hip PJI patients, age ≥ 80years was independently associated with DVT; RA was found to be a predictor of dislocation and wound dehiscence. For continuous and unselected patients with chronic PJI, single-stage revision demonstrated a satisfactory 90-day mortality. Nevertheless, the 90-day postoperative complication rates after single-stage revision in both knee and hip groups were relatively high.

Systematic review and meta-analysis of single-stage vs two-stage revision for periprosthetic joint infection: a call for a prospective randomized trial.

Periprosthetic joint infection (PJI) is a severe complication of joint arthroplasty that causes significant pain and economic loss. This study aimed to determine whether the current evidence supports single-stage revision for PJI based on reinfection and reoperation rates. We searched the PubMed, EBSCO, Medline, and Cochrane Library databases from inception to 30 May 2023 to identify studies that compared single-stage revision and two-stage revision for PJI. Data on reinfection and reoperation rates were pooled. This meta-analysis included a total of 40 studies with 8711 patients. Overall, there was no significant difference between single- and two-stage revision regarding the postoperative reinfection rate and reoperation rate. Subgroup analysis by surgery period and different surgical sites revealed no difference between the two groups in the reinfection and reoperation rates. Based on the available evidence, our study did not identify a significant difference in reinfection and reoperation rates between single- and two-stage revision for PJI. Given the limitations in inclusion/exclusion criteria and the observed heterogeneity, we acknowledge the complexity of drawing strong conclusions. Therefore, we suggest that the choice between single- and two-stage revision should be carefully considered on an individual basis, taking into account patient-specific factors and further research developments.

Temporal trends in revision rate due to knee periprosthetic joint infection: a study of 115,120 cases from the Danish Knee Arthroplasty Register.

We aimed to examine the temporal trends in periprosthetic joint infection (PJI) revision incidence after knee arthroplasty (KA) from 1997 through 2019. 115,120 primary KA cases from the Danish Knee Arthroplasty Register were followed until the first PJI revision. We computed cumulative incidences and adjusted hazard ratios (aHRs) of PJI revision by calendar periods and several patient- and surgical-related risk factors. Results were analyzed from 0-3 months and from 3-12 months after KA. The overall 1-year PJI revision incidence was 0.7%, increasing from 0.5% to 0.7% (1997 through 2019). The incidence of PJI revision within 3 months increased from 0.1% to 0.5% (1997 through 2019). The adjusted hazard ratio (aHR) within 1 year of primary KA was 5.1 comparing 2017-2019 with 2001-2004. The PJI revision incidence from 3-12 months of KA decreased from 0.4% to 0.2%, with an aHR of 0.5 for 2017-2019 vs. 2001-2004. Male sex, age 75-84 (vs. 65-74), and extreme obesity (vs. normal weight) were positively associated with the risk of PJI revision within 3 months, whereas only male sex was associated from 3-12 months. Partial knee arthroplasty (PKA) vs. total KA was associated with a lower risk of PJI revision both within 3 months and 3-12 months of KA. We observed an increase in PJI revision within 3 months of KA, and a decrease in PJI revision incidence from 3-12 months from 1997 through 2019. The reasons for this observed time-trend are thought to be multifactorial. PKA was associated with a lower risk of PJI revision.

Positive Intraoperative Cultures in Cup Revisions of THA: What Happens to the Stem?

Positive intraoperative cultures (PICs) are encountered in some patients undergoing revision of the acetabular cup after a previous THA. It is unknown whether PIC of the cup indicates whether the stem is infected as well and what happens to the stem during follow-up. (1) What proportion of patients undergoing THA who undergo cup revision have PICs? (2) What is the survival of the stem during follow-up in cup revisions with PICs versus that of those with negative cultures? (3) Does antibiotic treatment of PIC of the cup prevent revision THA during follow-up? In this retrospective, comparative multicenter study, five surgeons at four centers performed 338 acetabular cup revisions between January 2015 and December 2017. After evaluating the data, we excluded one patient because of an incomplete dataset and 77 patients because fewer than three intraoperative cultures were obtained during surgery, leaving 260 patients for analysis. Follow-up was 2 years. Patients were stratified into three cohorts: no PIC, one PIC, and two or more PICs. The proportion of patients with one or more PIC was 15% (39 of 260). A total of 8% (21 of 260) had one and 7% (18 of 260) had two or more PICs. Stem survival was lower in patients with two or more PICs, but stem revision for periprosthetic joint infection was similar between groups. Two-year survival, which was defined as freedom from revision for any cause or infection, was 97% (95% confidence interval 95% to 99%) in the group without PICs, 100% (95% CI 95% to 100%) in the group with one PIC, and 86% (95% CI 68% to 100%; p = 0.08) in the group with two or more PICs. None of the patients in the no PIC and one PIC groups were treated with antibiotics. In the two or more PICs cohort, 12 of 18 patients were treated. The stem survived in one of 12 patients treated with antibiotics versus two of six patients who were not treated with antibiotics. When treated with antibiotics, more than two PICs isolated during cup revision surgery do not have a major impact on survival of the stem during follow-up. A larger cohort of patients with PICs during cup revision might confirm these findings. Level III, therapeutic study.

Increased mortality after total hip prosthetic joint infection is mainly caused by the comorbidities rather than the infection itself.

Periprosthetic joint infection (PJI) is a feared complication of arthroplasty surgery. There is controversy as to whether PJI also correlates with increased mortality. Our aim was to investigate in a nationwide cohort if PJI is an independent risk factor for dying. We performed a retrospective cohort study based on data from the Swedish Hip Arthroplasty Register (SHAR). All patients with a revision THA performed between 1998 and 2017 were included. The outcome is mortality; exposure is PJI according to SHAR. The control group was study participants who underwent aseptic revision. Confounders were age, sex, diagnosis, and comorbidity according to the Elixhauser index. The outcome was analyzed with a Cox proportional hazards model. 4,943 PJI revisions and 12,529 non-infected revisions were included in the analysis. The median follow-up time was 4.1 years. In the PJI group, 1,972 patients died and in the control group, 4,512. The incidence rate ratio was 1.19 (95% confidence interval [CI] 1.13-1.25), the crude hazard ratio (HR) 1.19 (CI 1.13-1.25), and the adjusted HR 1.05 (CI 0.99-1.12) for the exposed versus the unexposed group. The strongest confounder was comorbidity. The increased mortality risk after revision due to PJI is mainly caused by the comorbidity of the patient, rather than by the infection itself.