2-stage Revision Arthroplasty Research Articles

Microvascular free flap coverage of complex soft tissue defects after revision total knee arthroplasty: a cross-sectional observation study.

Soft tissue defects after total knee arthroplasties (TKA) represent a major orthopedic challenge with amputation as a feared outcome. Microvascular free flap coverage (FFC) can increase limb salvage rates, but complications related to the procedure are yet to be explored further. We aimed to review a single-center experience with FFC for soft tissue defects related to revision total knee arthroplasty. Through a retrospective chart review from 2006 to 2021, we identified all patients who had FFC of a knee with an existing TKA. Typically, patients underwent 2-stage revision arthroplasty. To identify areas of intervention, we divided the entire regimen into 2 phases divided by the free flap surgery (pre- and post-free flap). We identified 18 patients with a median age at free flap surgery of 69 years (range 39-85), who were followed for a median of 5.1 years (range 2 months to 10.6 years). The median duration from primary TKA to their final operation was 17.5 months (range 19 days to 7 years). Patients underwent a mean of 7.6 surgical procedures on their knee with 3.6 orthopedic revisions prior to the FFC and 0.6 after. Soft tissue coverage was achieved in all patients and no patients underwent amputation. One-third of patients experienced early complications at recipient site after free flap surgery. There were no donor site complications. Microvascular FFC of complex soft tissue defects after revision total knee arthroplasty proved achievable in all patients with successful limb salvage in all patients.

High Incidence of Acute Kidney Injury Following Antibiotic-Loaded Spacer Insertion for Periprosthetic Joint Infection: An Updated Review of the Literature

BackgroundThe use of antibiotic-impregnated cement during 2-stage revision arthroplasty for periprosthetic joint infection poses a risk of renal complications following spacer insertion. This systematic review aimed to investigate the rate of acute kidney injury (AKI) following antibiotic-loaded spacer insertion and to identify risk factors associated with this complication. MethodsA systematic review was performed using PubMed, Cochrane Central, and Scopus databases. All clinical studies that documented renal complications following antibiotic-loaded spacer insertion for periprosthetic knee (total knee arthroplasty [TKA]) or hip (total hip arthroplasty [THA]) infection were included. Articles that combined THA and TKA outcomes were also included and labeled “THA + TKA.” Descriptive statistics were analyzed when data were available. ResultsThere were 24 studies (9 THA, 7 TKA, 8 THA + TKA) included. The mean incidences of spacer-related AKI across THA, TKA, and THA + TKA cohorts were 4.2 (range, 0 to 10%), 14 (range, 0 to 19%), and 27% (range, 0 to 35%), respectively. The most common patient-related risk factors for AKI were underlying chronic kidney disease or high baseline creatinine, low preoperative hemoglobin, and blood transfusion requirement. Spacer-related risk factors included high antibiotic dosage (>3.6 g/cement batch) and antibiotic type. While most recovered without complication, select patients required hemodialysis for acute management (2 THA, 18 THA + TKA) and/or developed chronic kidney disease (8 TKA, 8 THA). ConclusionThe rate of AKI following spacer insertion was high and likely under-reported in the literature. Surgeons should be cognizant of this devastating complication and should closely monitor at-risk patients for AKI following antibiotic-loaded spacer insertion.

Nontuberculous mycobacteria peri-prosthetic joint infection: An outcome analysis for two stage revision arthroplasty.

Nontuberculous mycobacteria periprosthetic joint infection (NTMPJI) is a rare complication of hip or knee joint arthroplasty. The experience for outcomes of NTMPJI treatment is still limited. The objective of this study was to investigate the outcome of hip or knee nontuberculous mycobacteria periprosthetic joint infection following treatment with two-stage exchange arthroplasty. From 1995 to 2020, 12 patients with NTMPJI were treated with two-stage exchange arthroplasty at our institution. We collected and analyzed variables including demographic data, comorbidity, microbiological data, treatment outcome and antibiotic formula in bone cement. Mycobacterium abcessus (n = 6) and Mycobacterium chelonae (n = 2) constitute the majority of the cases. Five patients had early-onset PJIs and the other seven patients were late onset. The success rate of two-stage exchange arthroplasty was 66.7% (8 of 12). Three patients experienced infection relapse, and one patient had soft tissue compromise complication. Post-operative antibiotic therapy may not improve the success rate (4 of 6 cases, 66.7%). Based on in vitro study, the most commonly used effective antibiotic in bone cement spacer for nontuberculous mycobacteria was amikacin. nontuberculous mycobacteria is a rare cause of PJIs and should be suspected especially in relatively immunocompromised patients. Resection arthroplasty with staged reimplantation is the preferred approach. Prolonged post-operative antibiotic therapy before reimplantation may not improve the success rate. Delayed revision surgery may not be needed and can be performed once C-reactive protein level is normal after a drug holiday.

Cost Drivers in Two-Stage Treatment of Hip Periprosthetic Joint Infection With an Antibiotic Coated Cement Hip Spacer

BackgroundThe current gold standard for treating chronic Periprosthetic Joint Infection (PJI) is a 2-stage revision arthroplasty. There has been little investigation into what specific patient and operative factors may be able to predict higher costs of this treatment. MethodsAn institutional electronic health record database was retrospectively queried for patients who developed a PJI after a total hip arthroplasty, and underwent removal of the prosthesis and implantation of an antibiotic-impregnated articulating hip cement spacer. Patient demographics, surgical variables, hospital readmissions, emergency department visits, and post-operative complications were collected. Total costs were captured through an internal accounting database through 2 years post-operatively. Negative binomial regressions were utilized for multivariable analyses. A total of 55 hips with PJI were available for cost analyses. ResultsA comorbidity index score was associated with a 70% increase (Odds Ratio (OR): 1.7 [1.18-2.5], P = .003) in total costs at 2-years. Illicit drug use was associated with a 70% increase in costs at 1-year post-operatively (OR 1.7 [1.18-2.5], P = .003). Metal-on-poly liners were associated with a 22% decrease in cost at 2-years post-operatively when compared to Cement-on-Bone articulating spacers, and Metal-on-poly -constrained liners accounted for 38% lower costs at 1-year (OR 0.62 [0.44-0.87], P = .004). Use of an intraoperative extended trochanteric osteotomy was associated with a 46 and 61% increase in cost at 1-year (OR 1.46 [1.14-1.89]) and 2-years (OR 1.61 [1.26-2.07], P < .001) post-operatively. ConclusionAge, comorbidity index score, drug use, and extended trochanteric osteotomy were associated with increased costs of PJI treatment. This may be used to improve reimbursement models and target areas of cost savings.

Effectiveness and safety of vancomycin powder injection locally applied in theprevention of prosthetic joint infection

Prosthetic joint infection is a rare but serious complication that is associated with considerable morbidity and financialburdens and other hardships for the individual. The available treatment options for PJI include both surgery andantimicrobial therapy. The surgical option includes debridement, antibiotics and implant retention (DAIR), that is usuallyrecommended at initial stages, one stage or two stage revision arthroplasty at advanced stages. These treatments are muchexpensive and time consuming and have around 11-30% failure rate. Therefore, there is an urgent need for a appropriate andaffordable treatment strategy. Vancomycin serves as an active agent against the pathogens that have ability to causepotential damage to the wounds after surgery. In its powder form, it ensures adequate surgical site concentrations whileminimizing the adverse effects caused by undetectable systemic distribution. Thus, we explored the effectiveness and safetyof vancomycin powder injection locally applied in the prevention of prosthetic joint infection (PJI). A total of 90 inpatientswho underwent total hip and knee arthroplasty from January 2018 to December 2019 were selected and randomly dividedinto control group (routine preventive antibiotic therapy) and treatment group (vancomycin applied based on the treatmentof control group). The incidence of PJI and adverse reactions within 3 months after operation was observed. The changes inbody temperature, neutrophil count, interleukin-6 (IL-6) and high-sensitivity C-reactive protein (hs-CRP) levels wererecorded before operation and 1, 3 and 7 days after treatment. Ninety days after treatment, the incidence rate of PJI intreatment group (0.00) was significantly lower than that of control group (8.89%) (P <0.05). Within a short period of time (1d and 3 d) after treatment, the body temperature, neutrophil count, IL-6 and hs-CRP levels were all lower in treatment groupthan those in control group (P <0.05). However, the above indices had no significant differences between the two groups at1 week (7 d) after treatment (P >0.05). There were 3 cases (6.67%) and 2 cases (4.44%) of adverse reactions in treatmentgroup and control group, respectively. The incidence rates of adverse reactions were similar (χ2=0.212, P=0.645).Vancomycin powder injection locally applied can control the body temperature, and reduce the neutrophil count, IL-6 andhs-CRP levels within a short period of time after operation, which is superior to routine preventive antibiotic therapy. It candecrease the incidence rate of PJI after arthroplasty.

Antibiotic Therapy in 2-Stage Revision for Periprosthetic Joint Infection: A Systematic Review.

Patients undergoing total joint arthroplasty (TJA) are at risk for developing periprosthetic joint infection (PJI). To treat PJI, orthopaedic surgeons can perform 1-stage or 2-stage revision arthroplasty. Although 2-stage revision yields superior long-term outcomes, the optimal antibiotic therapy duration and route of administration between stages remain uncertain. In this systematic review, we aimed to identify if variations in antibiotic therapy, duration, and administration during 2-stage hip or knee revision arthroplasty affect PJI eradication rates and surgical outcome measures. A literature search was performed using the PubMed and Google Scholar databases to identify all original reports from January 2000 to June 2021 involving 2-stage revision arthroplasty to treat PJI. Studies were included if they specified antibiotic duration, an intravenous (IV) route of antibiotic administration, type of antibiotic, and 2-stage revision PJI eradication rate and had a mean or median follow-up of at least 2 years after the second-stage operation. Included studies were classified into 3 groups based on the length of IV antibiotic therapy after prosthesis explantation: prolonged IV antibiotic therapy of 4 to 6 weeks, shortened IV antibiotic therapy of ≤2 weeks, and shortened course of IV antibiotic therapy followed by 6 to 12 weeks of oral antibiotics. Nine studies were included. Three studies utilizing a prolonged IV antibiotic therapy had PJI eradication rates of 79% to 96%. Four studies using a shortened IV antibiotic therapy showed PJI eradication rates of 88% to 100%. Finally, 2 studies utilizing a shortened course of IV antibiotic therapy with oral antibiotics had PJI eradication rates of 95% and 97%. There was no significant difference in eradication rates across IV antibiotic duration strategies, despite a diverse array of cultured microorganisms across the studies. Although the numbers are small, this systematic review suggests that prolonged IV antibiotic duration, shortened IV antibiotic duration, and shortened IV antibiotic duration supplemented with oral antibiotics confer similar PJI eradication rates after hip or knee arthroplasty. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Classification and management options for prosthetic joint infection.

Periprosthetic joint infection (PJI) is one of the major complications following arthroplasty implantation. Management of PJIs is a challenge for surgeons and various classification systems have been introduced, which consider variables such as onset of symptoms, pathogenesis and clinical manifestation. In an attempt to overcome the shortcomings which may limit their usefulness in borderline cases, a new classification system focusing on the topography of the infectious process has been proposed. This theory relies on the identification of the exact location of the bacterial colonization thus allowing to decide between a conservative or a more radical intervention irrespectively of the timing. The use of nuclear medicine device like radiolabelled white blood cells (WBC) scan could lead the path in identifying pathogenetic processes and their exact location thus guiding orthopaedic surgeons to the most appropriate diagnosis and treatment options. Currently management relies on debridement, antibiotics and implant retention (DAIR), which is traditionally performed at early stages, 1- or 2-stage revision arthroplasty which is commonly limited to chronic cases. Reports have demonstrated similar rates of infection recurrence following one and two-stage revisions, and the use of one-stage revision surgery is gaining popularity. More recently, satisfying results following partial implant retention during revision total arthroplasty for septic failures have been reported. In addition, in severe cases, definitive articulating antibiotic spacer, excision arthroplasty, arthrodesis or amputation can be performed.

Interim Spacer Exchange for Treatment of Periprosthetic Joint Infection: Almost Half the Patients Subsequently Fail.

Interim spacer exchange may be performed in patients undergoing 2-stage exchange for periprosthetic joint infection. Several studies have demonstrated that interim spacer exchange is associated with poor outcomes. This study investigated the survivorship and risk factors for failure in patients with an interim spacer exchange. Two institutional databases identified 182 patients who underwent spacer exchange from 2000 to 2017. Primary outcomes included progression to reimplantation, treatment success, and mortality. Bivariate analysis was performed to evaluate risk factors associated with failure. Kaplan-Meier curves using host and local grades were generated to evaluate for primary outcomes and differences in survivorship. The overall failure rate was 49% in patients with a spacer exchange. Most patients (60%) failed before 2 years. Higher comorbidity scores, elevated erythrocyte sedimentation rate, and non-White race were more prevalent in patients who failed. Negative cultures at the time of exchange were more prevalent in patients who did not fail. Failure rate was higher in immunocompromised conditions, and those who had revision prior to exchange. After considering clinically relevant variables, advanced host grade C was the single factor associated with treatment failure. Although survivorship curves were not significantly different between extremity local grades, higher host grades were associated with treatment failure. Almost 1 out of 2 patients with spacer exchange were found to fail the intended 2-stage revision arthroplasty. Benefits of delivering additional antibiotic load with a new spacer should be balanced against poor outcomes in patients with the aforementioned risk factors.

Efficacy of 2-stage revision using a prosthesis of antibiotic-loaded acrylic cement spacer with or without cortical strut allograft in infected total elbow arthroplasty.

We aimed to evaluate the efficacy of a self-manufactured prosthesis of antibiotic-loaded acrylic cement (PROSTALAC) spacer with or without cortical strut allograft in infected total elbow arthroplasty. Between March 2009 and February 2018, we enrolled 18 patients (mean age, 66.9 years) who underwent 2-stage revision arthroplasty for prosthetic infection following total elbow arthroplasty. After implant removal in the first stage, we performed débridement and PROSTALAC insertion. During the second stage, we performed reimplantation using a cortical strut allograft for patients with a considerably severe bone defect. The mean follow-up period was 34 months (range, 25-60 months), during which we evaluated the Mayo Elbow Performance Score (MEPS), range of motion (ROM), and blood markers. In all 18 patients, infection control was ensured using intravenous (IV) antibiotic therapy for 6 weeks or IV antibiotics for 4 weeks converting to oral antibiotics for 2 weeks following PROSTALAC insertion. The mean visual analog scale score improved from 8 points preoperatively to 2 points postoperatively, and the mean MEPS improved from 32 points preoperatively to 82 points postoperatively (P < .05). The average ROMs at the last follow-up were 9° to 132° from extension to flexion, respectively. Two patients experienced ulnar nerve neuropraxia after surgery, from which they were resolved. Moreover, 2 and 4 patients developed superficial wound infection and triceps insufficiency, respectively, and there was no infection recurrence. In the management of elbow prosthetic infection, 2-stage revision arthroplasty using PROSTALAC spacer insertion in the first stage and cortical strut allograft in the second stage for patients with severe bone defect revealed good clinical results and relatively low infection recurrence rates. However, the complication rate is substantial.

Experiences during Switching from Two-Stage to One-Stage Revision Arthroplasty for Chronic Total Knee Arthroplasty Infection.

The objective of this study was to evaluate our preliminary results after changing our surgical strategy from 2-stage revision arthroplasty to 1-stage revision arthroplasty for patients with chronic knee periprosthetic joint infection. We conducted a prospective study of knee arthroplasty patients that had been diagnosed with chronic infection and treated using a 1-stage revision regardless of the traditional criteria applied for indication thereof. We evaluated two main variables: infection control and economic costs. The definitive diagnosis of infection of the revision was determined by using the criteria proposed by the Musculoskeletal Infection Society. The costs were calculated as average costs in USD, as described by Srivastava (2019), for 1-stage or 2-stage revisions. Eighteen patients were included in the study, and infection was controlled in 17 patients. The total economic savings for our hospital from these 18 patients amounted to USD 291,152. This clinical success has led to major changes in how our hospital approaches the treatment of chronically infected knee replacements, in addition to substantial economic advantages for the hospital.

Comparaison à court terme des taux de complications entre 44 changements en deux temps versus 385 en un temps pour infection chronique de prothèse totale de hanche

BackgroundPeriprosthetic joint infection is a serious disease with severe consequences for the patient's life. It is not known whether one-stage or two-stage replacement arthroplasty is superior. So far, there have been no studies on short-term complications between both surgical procedures. Therefore, we performed a retrospective study aiming to determine: 1) Does two-stage septic exchange arthroplasty have a higher short-term complication rate than one-stage? 2) Is there a difference in length of hospital stay and the in-hospital mortality rate between two- and one-stage septic exchange arthroplasty? HypothesisTwo-stage septic exchange arthroplasty has a higher short-term complication rate than one-stage. Patients and methodsRetrospectively 429 patients who underwent a one- or two stage revision arthroplasty (288 hips and 141 knees) due to chronic PJI between January 2015 and December 2016 were recruited (one-stage: n=385, two-stage: n=44). Differences in postoperative complications, surgical therapy, ASA, Charlson Comorbidity Index (CCI), length of hospital, need for plastic surgery, pathogen, in-hospital morbidity and in-hospital mortality were compared using multiple logistic and Poisson regression. Regarding comorbidities, age, gender and BMI the groups were comparable. ResultsIt was 3.5 times more likely to suffer from a medical complication if a two stage septic exchange was performed (OR 3.465, (95 % CI: 2.573 – 4.358) (p<0.01)). In medical complications the two-stage group showed significantly more events (two-stage: 9 of 44=20.5 %; one-stage: 30 of 385=7.8 % (p=0.013)). The one-stage group showed more (not significant) nerve palsies after hip septic exchange. There was no difference in mortality between the groups (two-stage: 1/44=2.3 %; one-stage: 3/385=0.8 % (p=0.882)), the overall mortality was 0.93 %. The duration of hospital stay was 23.9±19 days for the one-stage and 42.2±17.7 days for the two-stage group (p<0.001). ConclusionWe found that it is more likely to develop a medical complication after two-stage septic revision arthroplasty. There was no difference in overall surgical complications between the two surgical approaches. There was no difference in short-term mortality between the two techniques. Level of evidenceIII, retrospective case control study.

Analysis of Culture Positive First and Second Stage Procedures in Periprosthetic Knee and Hip Joint Infections

BackgroundA positive microbiological result at reimplantation may lead to a failed 2-stage revision arthroplasty in the treatment of periprosthetic joint infections. Little is known about changes in microbiological spectrum and resistance pattern between culture positive first and second stage procedures in revision knee and hip arthroplasty. MethodsBetween January 2011 and December 2019, we performed 327 two-stage revision arthroplasties on 312 patients. There were 37 of 312 (11.9%) patients (20 hips/17 knees) who had a positive microbiological culture during the first and second stage procedure. We analyzed the microbiological spectrum, antimicrobial resistance pattern, and clinical outcome of culture positive first and second stage procedures as well as subsequent re-revisions. ResultsRe-revision was necessary in 40.5% (15/37) of patients with culture positive first and second stage procedure at a median follow-up of 3.5 years. We found microbiological changes in 83.8% (31/37) of patients between the first and second stage and in 88.9% (8/9) between the second stage and subsequent culture positive re-revision. Polymicrobial infections were found in 21.6% (8/37) of first and in 16.2% (6/37) of second stage procedures. In 27% (10/37) of patients, microorganisms persisted between the first and second stage procedure. The antimicrobial resistance pattern changed in 60% of persistent microorganisms between the first and second stage procedure. ConclusionChanges in microbiological spectrum and resistance pattern are common between culture positive first and second stage procedures as well as subsequent re-revisions. This has to be considered in the antimicrobial treatment of periprosthetic joint infections.

SINGLE STAGE KNEE ARTHROPLASTY REVISION SURGERY, OUR EXPERIENCE WITH ELEVEN CASES AND REVIEW OF THE LITERATURE

Knee replacement is a widely performed and very successful procedure for the management of knee arthritis. Nevertheless, it is postulated that a total of 2-5% of primary and revision total knee arthroplasties (TKAs) is infected every year [1,2]. Despite the low incidence, the absolute numbers of prosthetic joint infections (PJIs) are growing, owing to an increased number of replacement surgeries, and are associated with significant morbidity and socioeconomic burden [3,4]. Although several definitions of PJI exist, Musculoskeletal Infection’s Society (MSIS) definition is based on strict criteria and is one of the most used [5]. Patients with certain risk factors have an increased risk to develop PJI [6,7]. Risk factors include presence of systemic or local active infection in an arthritic knee; previous operative procedures in the same knee, diabetes mellitus, malnutrition, smoking, alcohol consumption, co-morbidities, and immunosuppression; end-stage renal disease on hemodialysis, liver disease, intravenous drug abuse, and low safety operative room environment. PJIs are classified according to the depth of infection, to superficial and deep infections. Superficial infections are limited to the incision and superficial tissues, while deep infections, that involve deep layers, may occur up to one year postoperatively, and influence surgical management strategy. Timing of infection is also an important factor in guiding treatment. PJIs are classified to acute postoperative, within a month of the index procedure, acute haematogenous, presenting with acute symptoms in a previously well – functioning joint, and late chronic, where infection develops later than one month postoperatively [8]. Management of PJI’s is mainly surgical, reserving conservative treatment for patients unable to undergo surgery [9]. Surgical options include debridement and retention of the prosthetic implants (DAIR), two – stage exchange revision, single – stage exchange revision, permanent resection arthroplasty, and finally amputation as the last measure [10]. DAIR is a viable option in early stages of acute infections, but established chronic infections necessitate more radical methods. Two – stage revision that was originally described by Install [11], secondly modified through the development of static spacers [12], and then articulating spacers [13], is considered the gold standard of TKA infection management [14]. A large volume of literature reports successful eradication of PJIs in more than 90% of patients using this approach [15,16,17]. Nevertheless, this procedure is costly, time-consuming, develops stiffness, arthrofibrosis, impairs mobility and increases inpatient stay. Single-stage revision arthroplasty for infection was first described in the 1980s [18, 19], has gained popularity for use in selected patients [20]. Infection control using this approach is achieved in 67% to 95% of patients [21, 22, 23, 24]. Furthermore, it is associated with less patient morbidity, improving functional outcome and reducing cost [25, 20]. This paper seeks to systematically review the results of using single – stage revision arthroplasty for chronic infection of TKAs. Furthermore, we report our experience with eleven cases of chronic knee arthroplasty infection, which were treated with the aforementioned technique.

Systematic review of single stage revision for prosthetic joint infection.

While advanced technology, increased medical knowledge and improved surgical technique has improved patient outcomes in total joint arthroplasty, prosthetic joint infection still remains one of the leading causes of increased healthcare costs, medical resources and societal burdens in orthopaedic care. Two stage arthroplasty revision remains the gold standard for treatment of prosthetic joint infection. Proponents of single stage revision arthroplasty for infection argue that it results in lower healthcare costs while improving patient reported functional outcomes and with equivalent success rates. Here we review the history of single stage revision arthroplasty, discuss the key principles, highlight the indications and contraindications, and review the reported outcomes with a focus on future developments of single stage revision arthroplasty for hip and knee periprosthetic joint infections.

Low-dose vancomycin-loaded cement spacer for two-stage revision of infected total hip arthroplasty.

Objectives This study aims to evaluate the success rate in terms of eradication of infection and long-term outcomes of two- stage revision arthroplasty with spacers loaded with low-dose vancomycin alone for the treatment of an infected hip arthroplasty.Patients and methods The records of 42 two-stage exchange arthroplasty patients (16 males, 26 females; mean age 61 years; range, 30 to 80 years) treated between January 1999 and January 2009 were included in this retrospective study. In the first stage, following removal of the prosthesis and debridement, a spacer consisting of 1 g of vancomycin per 40 g of cement was placed in the infected joint space. Patients received six weeks of intravenous antibiotics according to intraoperative cultures. After cessation of systemic antibiotic treatment, with normal C-reactive protein and erythrocyte sedimentation rate levels, second stage surgery with cementless components was performed.Results The mean follow-up duration was seven (range, 3 to 13) years. Two patients (4.7%) developed re-infection after two-stage reimplantation and one patient underwent a resection arthroplasty after repeated debridements. Five years of survival was 92.9% with Kaplan-Meier survival analysis.ConclusionFor chronic infected total hip revisions, two-stage revision arthroplasty with low-dose vancomycin impregnated cement spacers have comparable re-infection and success rates. Low-dose vancomycin promotes effective infection control and reduces antibiotic toxicity.

Outcomes and Risk Factors Associated With 2-Stage Reimplantation Requiring an Interim Spacer Exchange for Periprosthetic Joint Infection

BackgroundPatients undergoing a 2-stage revision for periprosthetic joint infection (PJI) often require a repeat spacer in the interim due to persistent infection. This study aims to report outcomes for patients with repeat spacer exchange and to identify risk factors associated with interim spacer exchange in 2-stage revision arthroplasty. MethodsA total of 256 consecutive 2-stage revisions for chronic infection of total hip arthroplasty and total knee arthroplasty with reimplantation and minimum 2-year follow-up were investigated. An interim spacer exchange was performed in 49 patients (exchange cohort), and these patients were propensity score matched to 196 patients (nonexchange cohort). Multivariate analysis was performed to analyze risk factors for failure of interim spacer exchange. ResultsPatients in the propensity score–matched exchange cohort demonstrated a significantly increased reinfection risk compared to patients without interim spacer exchange (24% vs 15%, P = .03). Patients in the propensity score–matched exchange cohort showed significantly lower postoperative scores for 3 patient-reported outcome measures (PROMs): hip disability and osteoarthritis outcome score physical function (46.0 vs 54.9, P = .01); knee disability and osteoarthritis outcome score physical function (43.1 vs 51.7, P < .01); and patient-reported outcomes measurement information system physical function short form (41.6 vs 47.0, P = .03). Multivariate analysis demonstrated Charles Comorbidity Index (odds ratio, 1.56; P = .01) and the presence of Enterococcus species (odds ratio, 1.43; P = .03) as independent risk factors associated with 2-stage reimplantation requiring an interim spacer exchange for periprosthetic joint infection. ConclusionThis study demonstrates that patients with spacer exchange had a significantly higher risk of reinfection at 2 years of follow-up. Additionally, patients with spacer exchange demonstrated lower postoperative PROM scores and diminished improvement in multiple PROM scores after reimplantation, indicating that an interim spacer exchange in 2-stage revision is associated with worse patient outcomes.

A comparison of short term complication rate between 44 two- and 385 one-stage septic exchange arthroplasties in chronic periprosthetic joint infections

BackgroundPeriprosthetic joint infection is a serious disease with severe consequences for the patient's life. It is not known whether one-stage or two-stage replacement arthroplasty is superior. So far, there have been no studies on short-term complications between both surgical procedures. Therefore, we performed a retrospective study aiming to determine: 1) Does two-stage septic exchange arthroplasty have a higher short-term complication rate than one-stage? 2) Is there a difference in length of hospital stay and the in-hospital mortality rate between two- and one-stage septic exchange arthroplasty? HypothesisTwo-stage septic exchange arthroplasty has a higher short-term complication rate than one-stage. Patients and methodsRetrospectively 429 patients who underwent a one- or two stage revision arthroplasty (288 hips and 141 knees) due to chronic PJI between January 2015 and December 2016 were recruited (one-stage: n=385, two-stage: n=44). Differences in postoperative complications, surgical therapy, ASA, Charlson Comorbidity Index (CCI), length of hospital, need for plastic surgery, pathogen, in-hospital morbidity and in-hospital mortality were compared using multiple logistic and Poisson regression. Regarding comorbidities, age, gender and BMI the groups were comparable. ResultsIt was 3.5 times more likely to suffer from a medical complication if a two stage septic exchange was performed (OR 3.465, (95% CI: 2.573–4.358) [p<0.01]). In medical complications the two-stage group showed significantly more events (two-stage: 9 of 44=20.5%; one-stage: 30 of 385=7.8% [p=0.013]). The one-stage group showed more (not significant) nerve palsies after hip septic exchange. There was no difference in mortality between the groups (two-stage: 1/44=2.3%; one-stage: 3/385=0.8% [p=0.882]), the overall mortality was 0.93%. The duration of hospital stay was 23.9±19 days for the one-stage and 42.2±17.7 days for the two-stage group (p<0.001). ConclusionWe found that it is more likely to develop a medical complication after two-stage septic revision arthroplasty. There was no difference in overall surgical complications between the two surgical approaches. We did not find a significant difference in short term mortality between the two techniques, although the mortality rate was slightly higher in the two-stage group. Level of evidenceIII, retrospective case control study.

Periprosthetic Joint Infection: A Review of Antibiotic Treatment.

A team approach among orthopaedic surgeons, infectious disease specialists, and patients is of paramount importance when treating periprosthetic joint infections (PJIs). Treatment usually includes various surgical approaches along with antibiotic treatment. Antibiotic selection requires a multifactorial decision that depends on the organism that is identified, its antibiotic-resistance profile, the extent of the infection, and factors associated with the host. Antibiotic duration is dependent on surgical intervention and the type of organism. Typically, patients are treated for 6 weeks after debridement, antibiotics, and implant retention (DAIR) and for 4 to 6 weeks after single-stage and 2-stage revision arthroplasty. Levofloxacin in combination with rifampin has shown favorable outcomes for Staphylococcus PJI treatment. Quinolones have excellent bioavailability and bone and joint concentrations. Ciprofloxacin can be used for sensitive gram-negative infections. Evidence is emerging that supports the use of oral antibiotics after 7 days of intravenous antibiotics for the treatment of PJI. Although this should be considered carefully, it can potentially alleviate the burden on patients and caregivers, with fewer intravenous lines and the potential for fewer complications.

Revision Patellar Tendon Reconstruction in Prosthetic Joint Infection following Total Knee Arthroplasty - A Case Report

Patellar tendon rupture is a rare but devastating complication following total knee arthroplasty. We report a case of a failed patellar tendon reconstruction and prosthetic joint infection following patellar tendon rupture. The objective of this case report is to highlight the favorable outcome following revision patellar tendon reconstruction with a synthetic graft and two stage revision arthroplasty.

Streptococcus bovis Hip and Knee Periprosthetic Joint Infections: A Series of 9 Cases.

Introduction: Prosthetic joint infection (PJI) due to Streptococcus bovis group (SBG), specifically S. bovis biotype I (S. gallolyticus), is rare and associated with colorectal carcinoma. Little has been published regarding SBG PJI. We analyzed nine cases of SBG PJI at our institution, the largest series to date.Methods: The medical records of patients diagnosed with SBG PJI between 2000-2017 were reviewed. Patients were followed until death, failure, or loss to follow-up. Mean follow-up was 37 months (range 0.5-74 months).Results: Nine PJI in 8 patients with mean prosthesis age at diagnosis of 8 years (range 4 weeks-17 years) were identified. The median duration between symptom onset and treatment was 38 weeks (range 0.3 weeks-175 weeks). 8/9 had their PJI eradicated with treatment based on acuity of symptoms. Acute PJI (2) was treated with DAIR, and chronic PJI (7) was treated with 2-stage revision arthroplasty. 1 PJI with chronic PJI developed recurrent infection after initial treatment. All patients received post-operative IV antibiotics. 7/8 patients received Ceftriaxone. Three patients received lifelong oral antibiotics. 7/8 patients underwent colonoscopy. 5/7 patients were found to have polyps following PJI diagnosis with one carcinoma and two dysplastic polyps. The two patients without polyps had identifiable gastrointestinal (GI) mucosal abnormality: tooth extraction prior to symptom onset and diverticulosis on chronic anticoagulation.Conclusion: SBG PJI is typically due to hematologic seeding. Colonoscopy should be pursued for patients with SBG PJI. Surgical treatment dictated by infection acuity and 6-week course of Ceftriaxone seems sufficient to control infection.