Treatment options in PJI – is two-stage still gold standard?

Lazic, Igor; Scheele, Christian; Pohlig, Florian; Eisenhart-Rothe, Rüdiger von; Suren, Christian

doi:10.1016/j.jor.2020.12.021

Cited by 38 publications

(41 citation statements)

References 56 publications

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“…11 Two-stage revision, using intravenous antibiotics and an antibiotic-loaded cement spacer to deliver antibiotics, is currently the predominant treatment for chronic PJI. 22 Nevertheless, the results of this surgical approach for reinfection after multiple failed surgeries remain suboptimal. Kavolus et al 7 reported treatment failure in 42.9% (21/49) of patients treated with an antecedent DAIR before a two-stage exchange.…”

Section: Discussionmentioning

confidence: 99%

Effective single-stage revision using intra-articular antibiotic infusion after multiple failed surgery for periprosthetic joint infection

Zhang

et al. 2022

The Bone & Joint Journal

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Aims Periprosthetic joint infections (PJIs) with prior multiple failed surgery for reinfection represent a huge challenge for surgeons because of poor vascular supply and biofilm formation. This study aims to determine the results of single-stage revision using intra-articular antibiotic infusion in treating this condition. Methods A retrospective analysis included 78 PJI patients (29 hips; 49 knees) who had undergone multiple prior surgical interventions. Our cohort was treated with single-stage revision using a supplementary intra-articular antibiotic infusion. Of these 78 patients, 59 had undergone more than two prior failed debridement and implant retentions, 12 patients had a failed arthroplasty resection, three hips had previously undergone failed two-stage revision, and four had a failed one-stage revision before their single-stage revision. Previous failure was defined as infection recurrence requiring surgical intervention. Besides intravenous pathogen-sensitive agents, an intra-articular infusion of vancomycin, imipenem, or voriconazole was performed postoperatively. The antibiotic solution was soaked into the joint for 24 hours for a mean of 16 days (12 to 21), then extracted before next injection. Recurrence of infection and clinical outcomes were evaluated. Results A total of 68 patients (87.1%) were free of infection at a mean follow-up time of 85 months (24 to 133). The seven-year infection-free survival was 87.6% (95% confidence interval (CI) 79.4 to 95.8). No significant difference in infection-free survival was observed between hip and knee PJIs (91.5% (95% CI 79.9 to 100) vs 84.7% (95% CI 73.1 to 96.3); p = 0.648). The mean postoperative Harris Hip Score was 76.1 points (63.2 to 92.4) and Hospital for Special Surgery score was 78. 2 (63.2 to 92.4) at the most recent assessment. Polymicrobial and fungal infections accounted for 14.1% (11/78) and 9.0% (7/78) of all cases, respectively. Conclusion Single-stage revision with intra-articular antibiotic infusion can provide high antibiotic concentration in synovial fluid, thereby overcoming reduced vascular supply and biofilm formation. This supplementary route of administration may be a viable option in treating PJI after multiple failed prior surgeries for reinfection. Cite this article: Bone Joint J 2022;104-B(7):867–874.

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Section: Discussionmentioning

confidence: 99%

Effective single-stage revision using intra-articular antibiotic infusion after multiple failed surgery for periprosthetic joint infection

Zhang

et al. 2022

The Bone & Joint Journal

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“…Despite the comparable revision rates in both groups of this study, comparatively high infection-related revision rates were seen in this cohort study. A recent review of 29 studies by Lazic et al [21] showed a mean eradication rate of 87 ± 8.8% (single-stage revision) and 83 ± 11.7% (two-stage revision) in the treatment of PJI in TKA. Our cohort study showed significantly higher revision rates in this comparison, with implant survival in terms of reinfection of 71.4% (single-stage revision) and 82.4% (two-stage revision) at 2 years.…”

Section: Discussionmentioning

confidence: 99%

Detailed Revision Risk Analysis after Single- vs. Two-Stage Revision Total Knee Arthroplasty in Periprosthetic Joint Infection: A Retrospective Tertiary Center Analysis

et al. 2021

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Periprosthetic joint infection (PJI) remains one of the most common causes of revision knee arthroplasty. Controversy continues to surround the proper operative technique of PJI in knee arthroplasty with single- or two-stage replacement. Significant variations are seen in the eradication rates of PJI and in implant survival rates. This detailed retrospective analysis of a single tertiary center is intended to provide further data and insight comparing single- and two-stage revision surgery. A retrospective analysis of all revision total knee arthroplasty (TKA) surgeries from 2013 to 2019 was performed and screened with respect to single- or two-stage TKA revisions. Single- and two-stage revisions were analyzed with regard to implant survival, revision rate, microbiological spectrum, and other typical demographic characteristics. A total of 63 patients were included, with 15 patients undergoing single-stage revision and 48 patients undergoing two-stage revision. The mean follow-up time was 40.7 to 43.7 months. Statistically, no difference was found between both groups in overall survival (54.4% vs. 70.1%, p = 0.68) and implant survival with respect to reinfection (71.4% vs. 82.4%, p = 0.48). Further, high reinfection rates were found for patients with difficult-to-treat organisms and low- to semi-constrained implant types, in comparison to constrained implant types. A statistically comparable revision rate for recurrence of infection could be shown for both groups, although a tendency to higher reinfection rate for single-stage change was evident. The revision rate in this single-center study was comparably high, which could be caused by the high comorbidity and high proportion of difficult-to-treat bacteria in patients at a tertiary center. In this patient population, the expectation of implant survival should be critically discussed with patients.

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“…The number of PJIs is estimated to grow exponentially in the next decade due to the aging population and the dramatic increase of TJA [ 1 , 2 , 3 ]. The current standard management protocol for chronic PJI remains a two-stage exchange arthroplasty; however, it is exceptionally technically demanding, with a concerning failure rate [ 4 , 5 ]. Additionally, PJI treatment failure is not only associated with considerable medical costs but is also accompanied by higher mortality than some common cancers [ 6 , 7 ].…”

Section: Introductionmentioning

confidence: 99%

Moderate-to-Severe Malnutrition Identified by the Controlling Nutritional Status (CONUT) Score Is Significantly Associated with Treatment Failure of Periprosthetic Joint Infection

Maimaiti

et al. 2022

Nutrients

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The prevalence and role of malnutrition in periprosthetic joint infection (PJI) remain unclear. This study aimed to use measurable nutritional screening tools to assess the prevalence of malnutrition in PJI patients during two-stage exchange arthroplasty and to explore the association between malnutrition and treatment failure. Our study retrospectively included 183 PJI cases who underwent 1st stage exchange arthroplasty and had available nutritional parameters, of which 167 proceeded with 2nd stage reimplantation. The recently proposed Musculoskeletal Infection Society (MSIS) Outcome Reporting Tool was used to determine clinical outcomes. The Controlling Nutritional Status (CONUT), Nutritional Risk Index (NRI), and Naples Prognostic Score (NPS) were used to identify malnutrition at 1st and 2nd stage exchange, respectively. Multivariate logistic regression analyses were performed to determine the association between malnutrition and treatment failure. Restricted cubic spline models were further used to explore the dose–response association. Additionally, risk factors for moderate-to-severe malnutrition were evaluated. Malnourished patients identified by CONUT, NPS, and NRI accounted for 48.1% (88/183), 98.9% (181/183), and 55.7% (102/183) of patients at 1st stage, and 9.0% (15/167), 41.9% (70/167), and 43.1% (72/167) at 2nd stage, indicating a significant improvement in nutritional status. We found that poorer nutritional status was a predictor of treatment failure, with CONUT performing best as a predictive tool. Moderate-to-severe malnutrition at 1st stage identified by CONUT was significantly related to treatment failure directly caused by PJI (odds ratio [OR] = 5.86), while the OR was raised to 12.15 at 2nd stage (OR = 12.15). The linear dose–response associations between them were also confirmed (P for nonlinearity at both 1st and 2nd stage > 0.05). As for total treatment failure, moderate-to-severe malnutrition as determined by CONUT was associated with a 1.96-fold and 8.99-fold elevated risk at the 1st and 2nd stages, respectively. Age ≥ 68 years (OR = 5.35) and an increased number of previous surgeries (OR = 2.04) may be risk factors for moderate-to-severe malnutrition. Overall, the prevalence of malnutrition in PJI patients is very high. Given the strong association between moderate-to-severe malnutrition identified by CONUT and PJI treatment failure, COUNT could be a promising tool to evaluate the nutritional status of PJI patients to optimize treatment outcomes.

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Treatment options in PJI – is two-stage still gold standard?

Cited by 38 publications

References 56 publications

Effective single-stage revision using intra-articular antibiotic infusion after multiple failed surgery for periprosthetic joint infection

Effective single-stage revision using intra-articular antibiotic infusion after multiple failed surgery for periprosthetic joint infection

Detailed Revision Risk Analysis after Single- vs. Two-Stage Revision Total Knee Arthroplasty in Periprosthetic Joint Infection: A Retrospective Tertiary Center Analysis

Moderate-to-Severe Malnutrition Identified by the Controlling Nutritional Status (CONUT) Score Is Significantly Associated with Treatment Failure of Periprosthetic Joint Infection

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