Predictors of Treatment Failure After 2-Stage Reimplantation for Infected Total Knee Arthroplasty: A 2- to 10-Year Follow-Up

Abstract. Introduction: Two-stage revision is the most frequently performed revision procedure of a (suspected) periprosthetic joint infection (PJI) after total knee arthroplasty (TKA). The reported results of this treatment show large variability between studies, ranging between 0 - 40 percent failure. The purposes of this study were to determine long term (1) reinfection rate, (2) re-revision rates for any reason, and (3) the reinfection rate of patients with positive cultures at reimplantation.Methods: We prospectively followed and retrospectively reviewed 113 consecutive two-stage revision TKAs, performed between 2003 and 2013 in our clinic with a minimum follow-up of 2 years. Diagnosis of PJI was based on the major Musculoskeletal Infection Society criteria for PJI.Results: After a mean follow-up of 94 months (range 24-172 months), infection recurred in 23 cases (23%). Of these, nine cases (9%) were defined as relapse (same micro-organism as index revision) and in 14 cases another causative was found (14%). In 11 patients debridement, antibiotics and retention of the prosthesis successfully eradicated the reinfection. After overall follow-up 17 patients (17%) underwent re-revision surgery, 11 patients (11%) due to an infection and 6 patients (6%) for aseptic reasons.Conclusions: Treatment of a (suspected) infection of a TKA by a two-stage revision had acceptable results based on re-revision and re-infection rates in the long term (>5 years), resembling the short-term results (<2 years). Focussing on the cultures at the index two-stage revision, episodes of relapse and new infections during follow-up were almost equally divided. Reinfection rates were higher in cases with positive cultures at reimplantation. Patients should be counselled appropriately in this particular situation.

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“…Of our patients, 77% remained infection free, which is in line with most recent literature [9,14,15].…”

Section: Discussionsupporting

confidence: 92%

Reinfection and re-revision rates of 113 two-stage revisions in infected TKA

Bongers

Jacobs

Smulders

et al. 2020

J. Bone Joint Infect.

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“…A total of 23 risk factors for potential treatment failure following two-stage TJA were investigated. Among them, only older age, higher preoperative CRP level, and resistant organisms were associated with an increased risk of treatment failure, which were in line with previous studies that evaluated risk factors for treatment failure following two-stage exchange arthroplasty for chronic PJI [10, 28, 29]. Several studies have suggested resistant organisms are associated with treatment failure after two-stage exchange arthroplasty of PJI [30, 31].…”

Section: Discussionsupporting

confidence: 80%

“…Studies have attempted to evaluate factors influencing outcomes of the two-stage exchange arthroplasty for periprosthetic joint infection (PJI), including patients’ medical conditions, microbiologic results and laboratory tests [10–13]. However, the risk factors for failure following two-stage protocol for evolutive SA remains unknown, as the majority of studies mainly aimed at reporting on the treatment outcome [5–9].…”

Section: Introductionmentioning

confidence: 99%

Outcomes and predictors of treatment failure following two-stage total joint arthroplasty with articulating spacers for evolutive septic arthritis

Xu¹,

Kuo

Kheir

et al. 2019

BMC Musculoskelet Disord

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Background The treatment strategy for evolutive septic arthritis (SA) with coexistent degenerative joint disease is not well established. The purposes of this study were to 1) investigate treatment outcome and potential risk factors of treatment failure in patients with evolutive SA following two-stage procedure, including insertion of an antibiotic-loaded spacer at the first stage and subsequent implantation of a new prosthesis; and 2) determine the performance of serum erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), and Interleukin-6 (IL-6) in predicting persisting infection at second-stage procedure. Methods We retrospectively reviewed 74 patients with evolutive SA of hips and knees who underwent a two-stage TJA between 2008 and 2015. The treatment success was defined according to the modified Delphi criteria and Kaplan-Meier survivorship curves were constructed to determine treatment success. A Cox regression model was performed to identify risk factors for treatment failure. Receiver operating characteristic (ROC) curves were generated to determine the prognostic value of ESR, CRP, and IL-6 in predicting persistent infection before second-stage prostheses implantation. Results Overall, the treatment success rate was 93% for hips and 100% for knees after the first-stage surgery. The treatment success rate was 89% for hips and 84% for knees after second-stage prosthesis implantation with a mean follow-up of 4.7 (range, 2.2 to 10.8) years. Older age (Hazard ratio [HR] [per 10-year increase], 1.20; 95% confidential interval [CI], 1.11 to 1.62), higher preoperative CRP level (HR [per 1-mg/dL increase], 1.15; 95% CI, 1.04 to 1.28) and resistant organism (HR, 13.96; 95% CI, 3.29 to 19.20) were associated with an increased risk of treatment failure. All serologic tests presented limited values in predicting persisting infection, with the area under ROC curve of ESR, CRP, IL-6 and combination of the three markers was 57.8, 61.6, 60.3, and 62.1%, respectively. Conclusions Two-stage TJA is an adequate management of infection control in patients with evolutive SA. The three potential risk factors (old age, high preoperative CRP, and resistant organism profile) may predict treatment failure following a two-stage procedure for evolutive SA. Additionally, serum ESR, CRP, and IL-6 had no benefit in predicting persisting infection before second-stage prostheses implantation. These findings may be useful when treating patients with evolutive SA.

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“…Periprosthetic infection is a serious complication of TKA that incurs extensive costs and poor prognosis. [ 12 , 13 ] The running subcuticular closure results in better skin and soft-tissue perfusion close to the incision compared to intermittent closure, [ 14 ] which accelerates wound healing. Furthermore, the tighter suture used in intermittent closure not only worsens perfusion but also prevents drainage of the liquefied subcutaneous fat, which may lead to subcutaneous necrosis and infection [ 15 ] (Reviewer #1 point 4).…”

Section: Discussionmentioning

confidence: 99%

Clinical outcome of different skin closure in total-knee arthroplasty: running subcuticular closure vs intermittent closure

et al. 2020

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An intermittent closure with silk suture is routinely used for closing different surgical wounds. However, subcuticular closure with absorbable sutures has gained considerable attention due to convenience and better cosmetic appearance. To compare the clinical outcomes and risk of surgical-site infection of subcuticular and intermittent closure after total-knee arthroplasty (TKA), 106 patients that underwent TKA between January 2017 to June 2019 at the Department of Orthopedics in Xiangya Hospital of Centre South University were retrospectively assessed. Forty-three had received running subcuticular closure (group A) and 58 underwent intermittent closure (group B). The Knee Society score was measured before and 6 months after operation. Inflammation markers including the serum levels of procalcitonin, interleukin-6, and C-reactive protein, and the erythrocyte sedimentation rate were evaluated before operation, 1 day after and 1 month after operation. Patient satisfaction with the closure was evaluated using the Likert scale at the last follow-up. No significant difference was seen in the 6-month postoperative Knee Society score, or in the 1-day and 6-month postoperative inflammation marker levels between both groups ( P > .05). Likert scores were higher in group A compared to group B (4.0 ± 1.0 vs 3.6 ± 1.2, P < .05). Running subcuticular closure after TKA results in a better appearance compared to intermittent closure, although neither method has an advantage in terms of efficacy and risk of infection.

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Predictors of Treatment Failure After 2-Stage Reimplantation for Infected Total Knee Arthroplasty: A 2- to 10-Year Follow-Up

Cited by 42 publications

References 29 publications

Reinfection and re-revision rates of 113 two-stage revisions in infected TKA

Reinfection and re-revision rates of 113 two-stage revisions in infected TKA

Outcomes and predictors of treatment failure following two-stage total joint arthroplasty with articulating spacers for evolutive septic arthritis

Clinical outcome of different skin closure in total-knee arthroplasty: running subcuticular closure vs intermittent closure

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