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Journal of Orthopaedics and Traumatology

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Open Access 01-12-2024 | Joint Infection | Original article

Risk factors for early septic failure after two-stage exchange total knee arthroplasty for treatment of periprosthetic joint infection

Authors: Woo-Suk Lee, Kwan Kyu Park, Byung-Woo Cho, Jun Young Park, Inuk Kim, Hyuck Min Kwon

Published in: Journal of Orthopaedics and Traumatology | Issue 1/2024

Abstract

Background

The cause of early septic failure after two-stage exchange revision total knee arthroplasty (TKA) for chronic periprosthetic joint infection (PJI) and the factors affecting it are not well known. The purpose of this study was to determine the surgical outcomes and the risk factors for early septic failure after two-stage revision TKA for chronic PJI.

Methods

We identified a total of 246 adult patients who met the Musculoskeletal Infection Society (MSIS) diagnostic criteria for chronic PJI at two academic tertiary hospitals from March 2012 to December 2018. Finally, 151 patients who consecutively received two-stage exchange revision TKA for chronic PJI and who had a minimum 3-year follow-up were enrolled and retrospectively reviewed. Successful surgical treatment was evaluated for two-stage revision TKA and risk factors for early septic failure were identified.

Results

Early septic failures occurred within 3 years after reimplantation in 48 patients (31.8%). After accounting for potentially confounding variables, we found that male patient [odds ratio (OR): 2.753, 95% confidence interval (CI) 1.099–6.893, p = 0.031], fungus or mycobacterial infection (OR: 5.224, 95% CI 1.481–18.433, p = 0.01), and positive culture at reimplantation (OR: 4.407, 95% CI 1.255–15.480, p = 0.021) were independently associated with early septic failure after two-stage exchange revision TKA.

Conclusion

Male patients, fungus or mycobacterial infection, and positive culture at reimplantation were independently associated with an increased risk of early septic failure after two-stage exchange revision TKA despite normal C-reactive protein values prior to reimplantation. Further prospective and high-quality studies are needed to determine the risk factors of two-stage exchange revision TKA for chronic PJI.

Level of evidence: level IV; retrospective comparison; treatment study.

Zmistowski B, Karam JA, Durinka JB, Casper DS, Parvizi J (2013) Periprosthetic joint infection increases the risk of one-year mortality. J Bone Joint Surg Am 95(24):2177–2184. https://doi.org/10.2106/JBJS.L.00789CrossRefPubMed

Barry JJ, Geary MB, Riesgo AM, Odum SM, Fehring TK, Springer BD (2021) Irrigation and debridement with chronic antibiotic suppression is as effective as 2-stage exchange in revision total knee arthroplasty with extensive instrumentation. J Bone Joint Surg Am 103(1):53–63. https://doi.org/10.2106/jbjs.20.00240CrossRefPubMed

Westberg M, Fagerberg ØT, Snorrason F (2023) Poor outcome after debridement and implant retention for acute hematogenous periprosthetic joint infection: a cohort study of 43 patients. Acta Orthop 94:115–120. https://doi.org/10.2340/17453674.2023.10312CrossRefPubMedPubMedCentral

Lum ZC, Natsuhara KM, Shelton TJ, Giordani M, Pereira GC, Meehan JP (2018) Mortality during total knee periprosthetic joint infection. J Arthroplasty 33(12):3783–3788. https://doi.org/10.1016/j.arth.2018.08.021CrossRefPubMed

Klemt C, Tirumala V, Oganesyan R, Xiong L, van den Kieboom J, Kwon YM (2021) Single-stage revision of the infected total knee arthroplasty is associated with improved functional outcomes: a propensity score-matched cohort study. J Arthroplasty 36(1):298–304. https://doi.org/10.1016/j.arth.2020.07.012CrossRefPubMed

Chen W, Klemt C, Smith EJ, Tirumala V, Xiong L, Kwon YM (2021) Outcomes and risk factors associated with failures of debridement, antibiotics, and implant retention in patients with acute hematogenous periprosthetic joint infection. J Am Acad Orthop Surg 29(23):1024–1030. https://doi.org/10.5435/jaaos-d-20-00939CrossRefPubMed

Johnson NR, Rowe TM, Valenzeula MM, Scarola GT, Fehring TK (2022) Do pre-reimplantation erythrocyte sedimentation rate/c-reactive protein cutoffs guide decision-making in prosthetic joint infection? Are we flying blind? J Arthroplasty 37(2):347–352. https://doi.org/10.1016/j.arth.2021.10.028CrossRefPubMed

Qiao J, Xu C, Chai W, Hao LB, Zhou Y, Fu J, Chen J (2021) Positive frozen section during reimplantation increases the risk of treatment failure in two-stage exchange arthroplasty even in patients with normal ESR and CRP. Bone Joint J. 103-B(5):916–922. https://doi.org/10.1302/0301-620X.103B5.BJJ-2020-0703.R3CrossRefPubMed

Wouthuyzen-Bakker M, Kheir MM, Moya I, Rondon AJ, Kheir M, Lozano L, Parvizi J, Soriano A (2019) Failure after 2-stage exchange arthroplasty for treatment of periprosthetic joint infection: the role of antibiotics in the cement spacer. Clin Infect Dis 68(12):2087–2093. https://doi.org/10.1093/cid/ciy851CrossRefPubMed

10.

Quinn J, Jones P, Randle R (2022) Clinical outcomes following revision total knee arthroplasty: minimum 2-year follow-up. Clin Orthop Surg 14(1):69–75. https://doi.org/10.4055/cios20206CrossRefPubMed

11.

Kuiper JWP, Verberne SJ, van Egmond PW, Slot K, Temmerman OPP, Vos CJ (2022) Are accuracy studies for periprosthetic joint infection diagnosis inherently flawed? And what to do with schrödinger’s hips? A prospective analysis of the alpha defensin lateral-flow test in chronic painful hip arthroplasties. Hip Pelvis 34(4):236–244. https://doi.org/10.5371/hp.2022.34.4.236CrossRefPubMedPubMedCentral

12.

Petis SM, Perry KI, Mabry TM, Hanssen AD, Berry DJ, Abdel MP (2019) Two-stage exchange protocol for periprosthetic joint infection following total knee arthroplasty in 245 knees without prior treatment for infection. J Bone Joint Surg Am 101(3):239–249. https://doi.org/10.2106/JBJS.18.00356CrossRefPubMed

13.

Cochran AR, Ong KL, Lau E, Mont MA, Malkani AL (2016) Risk of reinfection after treatment of infected total knee arthroplasty. J Arthroplasty 31(9 Suppl):156–161. https://doi.org/10.1016/j.arth.2016.03.028CrossRefPubMed

14.

Lewis PL, W-Dahl Annette, Robertsson O, Prentice HA, Graves SE (2022) Impact of patient and prosthesis characteristics on common reasons for total knee replacement revision: a registry study of 36,626 revision cases from Australia, Sweden, and USA. Acta Orthop 93:623–633. https://doi.org/10.2340/17453674.2022.3512CrossRefPubMedPubMedCentral

15.

Lichstein P, Su S, Hedlund H, Suh G, Maloney WJ, Goodman SB, Huddleston JI 3rd (2016) Treatment of periprosthetic knee infection with a two-stage protocol using static spacers. Clin Orthop Relat Res 474(1):120–125. https://doi.org/10.1007/s11999-015-4443-2CrossRefPubMed

16.

Mahmud T, Lyons MC, Naudie DD, Macdonald SJ, McCalden RW (2012) Assessing the gold standard: a review of 253 two-stage revisions for infected TKA. Clin Orthop Relat Res 470(10):2730–2736. https://doi.org/10.1007/s11999-012-2358-8CrossRefPubMedPubMedCentral

17.

Wang Q, Goswami K, Kuo FC, Xu C, Tan TL, Parvizi J (2019) Two-stage exchange arthroplasty for periprosthetic joint infection: the rate and reason for the attrition after the first stage. J Arthroplasty 34(11):2749–2756. https://doi.org/10.1016/j.arth.2019.06.021CrossRefPubMed

18.

Barton CB, Wang DL, An Q, Brown TS, Callaghan JJ, Otero JE (2020) Two-stage exchange arthroplasty for periprosthetic joint infection following total hip or knee arthroplasty is associated with high attrition rate and mortality. J Arthroplasty 35(5):1384–1389. https://doi.org/10.1016/j.arth.2019.12.005CrossRefPubMed

19.

Shao H, Bian T, Zhou Y, Huang Y, Song Y, Yang D (2022) Which serum markers predict the success of reimplantation after periprosthetic joint infection? J Orthop Traumatol 23(1):45. https://doi.org/10.1186/s10195-022-00664-5CrossRefPubMedPubMedCentral

20.

Triantafyllopoulos GK, Memtsoudis SG, Zhang W, Ma Y, Sculco TP, Poultsides LA (2017) Periprosthetic infection recurrence after 2-stage exchange arthroplasty: failure or fate? J Arthroplasty 32(2):526–531. https://doi.org/10.1016/j.arth.2016.08.002CrossRefPubMed

21.

Kandel CE, Jenkinson R, Daneman N et al (2019) Predictors of treatment failure for hip and knee prosthetic joint infections in the setting of 1- and 2-stage exchange arthroplasty: a multicenter retrospective cohort. Open Forum Infect Dis. 6(11):ofz452. https://doi.org/10.1093/ofid/ofz452CrossRefPubMedPubMedCentral

22.

Vahedi H, Aali-Rezaie A, Shahi A, Conway JD (2019) Irrigation, débridement, and implant retention for recurrence of periprosthetic joint infection following two-stage revision total knee arthroplasty: a matched cohort study. J Arthroplasty 34(8):1772–1775. https://doi.org/10.1016/j.arth.2019.04.009CrossRefPubMed

23.

Kurtz SM, Higgs GB, Lau E, Iorio RR, Courtney PM, Parvizi J (2022) Hospital costs for unsuccessful two-stage revisions for periprosthetic joint infection. J Arthroplasty 37(2):205–212. https://doi.org/10.1016/j.arth.2021.10.018CrossRefPubMed

24.

Zmistowski B, Della Valle C, Bauer TW et al (2014) Diagnosis of periprosthetic joint infection. J Arthroplasty 29(2 Suppl):77–83. https://doi.org/10.1016/j.arth.2013.09.040CrossRefPubMed

25.

Neufeld ME, Liechti EF, Soto F, Linke P, Busch SM, Gehrke T, Citak M (2022) High revision rates following repeat septic revision after failed one-stage exchange for periprosthetic joint infection in total knee arthroplasty. Bone Joint J 104-b(3):386–393. https://doi.org/10.1302/0301-620x.104b3.Bjj-2021-0481.R2CrossRefPubMed

26.

Ascione T, Balato G, Mariconda M, Smeraglia F, Baldini A, De Franco C, Pandolfo G, Siciliano R, Pagliano P (2021) Synovial cell count before reimplantation can predict the outcome of patients with periprosthetic knee infections undergoing two-stage exchange. Clin Orthop Relat Res 479(9):2061–2068. https://doi.org/10.1097/corr.0000000000001788CrossRefPubMedPubMedCentral

27.

Woon CYL, Nguyen J, Kapadia M, Russell CA, Henry M, Miller A, Westrich G (2021) Temporary new implant spacers increase post-reimplantation total knee prosthesis survival after periprosthetic joint infection. Knee Surg Sports Traumatol Arthrosc 29(11):3621–3632. https://doi.org/10.1007/s00167-020-06325-6CrossRefPubMed

28.

Tan TL, Gomez MM, Manrique J, Parvizi J, Chen AF (2016) Positive culture during reimplantation increases the risk of subsequent failure in two-stage exchange arthroplasty. J Bone Joint Surg Am 98(15):1313–1319. https://doi.org/10.2106/jbjs.15.01469CrossRefPubMed

29.

Akgün D, Müller M, Perka C, Winkler T (2017) A positive bacterial culture during re-implantation is associated with a poor outcome in two-stage exchange arthroplasty for deep infection. Bone Joint J 99-b(11):1490–1495. https://doi.org/10.1302/0301-620x.99b11.Bjj-2017-0243-r1CrossRefPubMed

30.

Theil C, Freudenberg SC, Gosheger G, Schmidt-Braekling T, Schwarze J, Moellenbeck B (2020) Do positive cultures at second stage re-implantation increase the risk for reinfection in two-stage exchange for periprosthetic joint infection? J Arthroplasty 35(10):2996–3001. https://doi.org/10.1016/j.arth.2020.05.029CrossRefPubMed

31.

Izakovicova P, Borens O, Trampuz A (2019) Periprosthetic joint infection: current concepts and outlook. EFORT Open Rev 4(7):482–494. https://doi.org/10.1302/2058-5241.4.180092CrossRefPubMedPubMedCentral

32.

Tai DBG, Wengenack NL, Patel R, Berbari EF, Abdel MP, Tande AJ (2022) Fungal and mycobacterial cultures should not be routinely obtained for diagnostic work-up of patients with suspected periprosthetic joint infections. Bone Joint J 104-b(1):53–58. https://doi.org/10.1302/0301-620x.104b1.Bjj-2021-0876.R1CrossRefPubMed

33.

Palan J, Nolan C, Sarantos K, Westerman R, King R, Foguet P (2019) Culture-negative periprosthetic joint infections. EFORT Open Rev 4(10):585–594. https://doi.org/10.1302/2058-5241.4.180067CrossRefPubMedPubMedCentral

34.

Basques BA, Bell JA, Fillingham YA, Khan JM, Della Valle CJ (2019) Gender differences for hip and knee arthroplasty: complications and healthcare utilization. J Arthroplasty 34(8):1593-1597.e1591. https://doi.org/10.1016/j.arth.2019.03.064CrossRefPubMed

35.

Hunt LP, Ben-Shlomo Y, Clark EM, Dieppe P, Judge A, MacGregor AJ, Tobias JH, Vernon K, Blom AW (2014) 45-day mortality after 467,779 knee replacements for osteoarthritis from the National Joint Registry for England and Wales: an observational study. Lancet 384(9952):1429–1436. https://doi.org/10.1016/s0140-6736(14)60540-7CrossRefPubMed

36.

Kong L, Cao J, Zhang Y, Ding W, Shen Y (2017) Risk factors for periprosthetic joint infection following primary total hip or knee arthroplasty: a meta-analysis. Int Wound J 14(3):529–536. https://doi.org/10.1111/iwj.12640CrossRefPubMed

37.

Hodges NA, Sussman EM, Stegemann JP (2021) Aseptic and septic prosthetic joint loosening: impact of biomaterial wear on immune cell function, inflammation, and infection. Biomaterials 278:121127. https://doi.org/10.1016/j.biomaterials.2021.121127CrossRefPubMed

38.

Li C, Renz N, Trampuz A, Ojeda-Thies C (2020) Twenty common errors in the diagnosis and treatment of periprosthetic joint infection. Int Orthop 44(1):3–14. https://doi.org/10.1007/s00264-019-04426-7CrossRefPubMed

Title: Risk factors for early septic failure after two-stage exchange total knee arthroplasty for treatment of periprosthetic joint infection
Authors: Woo-Suk Lee
Kwan Kyu Park
Byung-Woo Cho
Jun Young Park
Inuk Kim
Hyuck Min Kwon
Publication date: 01-12-2024
Publisher: Springer International Publishing
Keywords: Joint Infection
Antibiotic
Published in: Journal of Orthopaedics and Traumatology / Issue 1/2024
Print ISSN: 1590-9921
Electronic ISSN: 1590-9999
DOI: https://doi.org/10.1186/s10195-024-00750-w

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Risk factors for early septic failure after two-stage exchange total knee arthroplasty for treatment of periprosthetic joint infection

Abstract

Background

Methods

Results

Conclusion

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Abstract

Background

Methods

Results

Conclusion

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