Results of 2-stage reimplantation for infected total knee arthroplasty

doi:10.1016/S0883-5403(98)90071-7

The Journal of Arthroplasty

Volume 13, Issue 1, January 1998, Pages 22-28

https://doi.org/10.1016/S0883-5403(98)90071-7 Get rights and content

Abstract

Optimum treatment of the infected total knee arthroplasty has not been clearly established. To clarify the efficacy of two-stage reimplantation, experience with 66 infected total knee arthroplasties in 64 patients who had been treated with 2-stage reimplantation total knee arthroplasty between September 1980 and October 1993 was reviewed. Of these, 55 knees in 54 patients were available for follow-up examinations at an average of 61.9 months (range, 28–146 months). The initial diagnoses were rheumatoid arthritis (14 knees) and osteoarthritis (41 knees). Reimplantation was successful in 80.0% of knees with low-virulence organisms (coagulase-negative Staphylococcus, Streptococcus), 71.4% with polymicrobial organisms, and 66.7% with high-virulence organisms (methicillin-resistant Staphylococcus aureus). Reimplantation was successful in 82% of patients with osteoarthritis and in 54% of patients with rheumatoid arthritis (P = .024). The success rate was 92% if infection occurred after primary arthroplasty but only 41% if after multiple previous knee operations (arthroscopy, osteotomy, or revision total knee arthroplasty) (P < .001).

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Cited by (170)

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2023, Arthroplasty Today
Periprosthetic joint infection is a serious complication of total knee arthroplasty (TKA). Management usually involves irrigation and debridement, polyethylene liner exchange, one-stage revision, two-stage revision, knee arthrodesis, or ultimately above-knee amputation (AKA). We present our experience with 21 patients who underwent AKA as a sequela of unresolved infected TKA, highlighting their etiology and functional outcomes.
A retrospective chart review was performed for all cases of infected TKA treated with AKA at 1 institute from January 2007 to December 2020, with a minimum follow-up of 1 year. Patient demographics, Charlson comorbidity index, culture results, ambulation status, prosthesis fitting, and functional outcomes were collected. Short Form-36 and activities of daily living questionnaires were used for functional outcome assessment.
Twenty-one patients were identified, 7 of whom were male (33.3%). Mean ± standard deviation follow-up was 5.7 ± 3.1 years (range, 1-11 years). Mean ± standard deviation age was 57.9 ± 10.7 years (range, 38-87 years), and the mean body mass index was 33.5 ± 6.4 kg/m² (range, 25.4-46 kg/m²). Gram-positive organisms were identified in 15 cases (66.7%). Prosthesis fitting was successful in 17 patients (81%). Post-AKA ambulation was achieved in 12 patients (57.1%). The ambulating group showed higher Short Form-36 and activities of daily living scores when compared with patients who did not ambulate (60.2 vs 43.3, P = .041, and 67.2 vs 52.7, P = .029, respectively).
AKA should be considered solely as the final recourse for infected TKA. Despite the low-to-moderate patient-reported postoperative outcomes, prosthesis fitting and maintaining ambulation can improve postoperative functional outcomes.
Description of reinfection of joint prosthesis after 2-stage replacement (infection of the 2nd stage prosthesis): A multicenter study
2023, Enfermedades Infecciosas y Microbiologia Clinica
El recambio en 2 tiempos es un procedimiento habitual en el tratamiento de las infecciones de prótesis articular (IPA). Sin embargo, la prótesis que se coloca en el segundo tiempo (2T) puede reinfectarse de nuevo (ReIPA). Además, existe escasa evidencia sobre qué profilaxis antibiótica debe utilizarse en el 2T. Nuestro objetivo es describir las características de las ReIPA, su pronóstico y las profilaxis antibióticas que se emplean habitualmente en la cirugía del 2T.
Estudio observacional retrospectivo descriptivo multicéntrico en hospitales españoles de pacientes con ReIPA en el periodo 2009-2018.
Se registraron 92 casos de 12 hospitales. El microorganismo más frecuentemente implicado fue Staphylococcus epidermidis con 35 casos (38,5%). El 61,1% de Staphylococcus spp. eran resistentes a meticilina. En 12 casos (13%), la ReIPA fue provocada por el mismo microorganismo responsable de la IPA primaria. En comparación con la IPA primaria, hubo más casos producidos por gramnegativos (el más frecuente Pseudomonas spp.) y menos por grampositivos. En 69 casos (75%), la estrategia de tratamiento elegida fracasó. Se identificaron 43 pautas diferentes de profilaxis en la cirugía del 2T, la más frecuente cefazolina en dosis única preoperatoria, aunque lo más frecuente es que se administraran antibióticos antes y después del implante.
Los principales agentes causales de ReIPA son Staphylococcus spp. resistentes a meticilina, aunque los gramnegativos, particularmente Pseudomonas spp., también participan en una importante cuantía. Existe una notable heterogeneidad en la profilaxis antibiótica que se emplea en la cirugía del 2T. El tratamiento de la ReIPA tiene una alta tasa de fracasos.
Two-stage exchange is the gold standard in the surgical management of prosthetic joint infection (PJI). However, perioperative reinfections (RePJI) can occur to newly inserted prosthesis, which highlights the importance of an adequate antibiotic prophylaxis, although there is scarce evidence in this field. Our objective was to evaluate the characteristics of RePJI, its prognosis and the antibiotic prophylaxis that is commonly used in second-stage surgery.
Multicentric retrospective observational study in Spanish hospitals including patients with RePJI between 2009 and 2018.
We included 92 patients with RePJI from 12 hospitals. The most frequent isolated microorganism was Staphylococcus epidermidis in 35 cases (38.5%); 61.1% of staphylococci were methiciliin-resistant. In 12 cases (13%), the same microorganism causing the primary PJI was isolated in RePJI. When comparing with the microbiology of primary PJI, there were more cases caused by Gram-negative bacteria (the most frequent was Pseudomonas spp.) and less by Gram-positive bacteria. Failure occurred in 69 cases (75%). There were 43 different courses of antibiotic prophylaxis after the second-stage surgery; the most frequent was a unique preoperative cefazolin dose, but most patients received prophylaxis before and after the second-stage surgery (61 cases).
The most frequent microorganisms in RePJI are coagulase-negative staphylococci, although Gram-negative bacteria, especially Pseudomonas spp. are also common. There is a significant heterogeneity in antibiotic prophylaxis for a second-stage surgery. ReIPJI treatment has a high failure rate.
Treatment patterns and failure rates associated with prosthetic joint infection in unicompartmental knee arthroplasty: A systematic review
2022, Journal of Orthopaedics
Prosthetic joint infection (PJI) following unicompartmental knee arthroplasty (UKA) is a rare but challenging complication. A paucity of literature exists regarding the management of PJI in UKA. This systematic review aims to assess current treatment patterns in UKA PJI and analyze the failure rates associated with treatment.
PubMed, Scopus, and EMBASE were systematically searched for studies that presented cases of PJI following UKA. Data regarding study design, country of publication, index procedure type, diagnosis of PJI, number and incidence of PJI, timing of PJI (acute versus chronic), treatment, and outcomes were recorded. Failure rates in acute and chronic PJI as well as total failure rates were analyzed.
Sixteen articles were identified that met inclusion criteria. These included 97 PJI cases (37 acute, 58 chronic, 2 unknown timing); incidence across all studies of 0.80%. The most common treatment for all PJI cases was debridement, antibiotics, and implant retention (DAIR) (40.2%), followed by two-stage conversion to total knee arthroplasty (TKA) (33.0%), one-stage conversion to TKA (23.7%), and one-stage exchange UKA (3.1%). There were no significant differences in failure rates across procedures for acute, chronic or overall PJI management (p > 0.05 for all)
This systematic review found relatively few studies reporting on PJI after UKA compared to the available TKA evidence. Further research is warranted to better elucidate the most appropriate treatment of PJI after UKA in both the acute and chronic setting along with risk factors for failure.
Long Term Results of Two-Stage Revision for Chronic Periprosthetic Knee Infection: A Multicenter Study
2022, Journal of Arthroplasty
Long-term reinfection and mortality rates and clinical outcomes with sufficient subject numbers remain limited for patients undergoing two-stage exchange arthroplasty for chronic periprosthetic knee infections. The purpose of this study was to determine the long-term reinfection, complication, and mortality following reimplantation for two-stage exchange following knee arthroplasty.
Retrospective review of 178 patients who underwent two-stage exchange knee arthroplasty for chronic PJI at three large tertiary referral institutions with an average of 6.63-year follow-up from reimplantation from 1990 to 2015. Rates of reinfection, mortality, and all-cause revision were calculated along with the cumulative incidence of reinfection with death as a competing factor. Risk factors for reinfection were determined using Cox multivariate regression analysis.
Overall rate of infection eradication was 85.41%, with a mortality rate of 30.33%. Patients with minimum 5-year follow-up (n = 118, average 8.32 years) had an infection eradication rate of 88.98%, with a mortality rate of 33.05%.
This is a large series with long-term follow-up evaluating outcomes of two-stage exchange knee arthroplasty resulting in adequate infection eradication and high mortality. Results were maintained at longer follow-up. This technique should be considered in patients with chronic PJI; however, realistic expectations regarding long-term outcomes must be discussed with patients.
Static vs Articulating Spacers for Two-Stage Revision Total Knee Arthroplasty: Minimum Five-Year Review
2022, Arthroplasty Today
The gold standard treatment for infected total knee arthroplasty (TKA) is two-stage revision. The first stage involves a temporary antibiotic spacer, which can be static or articulating; it remains unclear which is best. We aimed to compare 5-year outcomes between static and dynamic spacers.
One hundred and seventy-six patients with infected TKA requiring two-stage revision were enrolled. Patients were organized based on the type of spacer used during the first-stage revision. One hundred and four patients received articulating spacers, and 72 received static spacers. At 5 years, postoperative range of motion (ROM), Short Form 12 (SF-12), Knee Society Score (KSS), and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores were recorded. Reinfection and revisions were also tracked.
Eradication of infection was similar in both groups, with 83.7% in the articulating group and 86.1% in the nonarticulating spacer group (P = .234). Articulating spacers resulted in significantly improved ROM (111 vs 82 degrees, P < .001), SF-12 physical component score (35.2 vs 31.0, P = .01), KSS (145.2 vs 113.7, P < .001), and WOMAC function scores (60.1 vs 51.1, P = .03) as compared to the static spacer group.
Treatment with an articulating spacer as opposed to a static spacer resulted in improved ROM, SF-12 physical component score, KSS, and WOMAC function scores at the final follow-up visit. There was no significant difference in reinfection rates. Patients requiring staged revision for infected TKA may benefit from an articulating spacer.
The Joint-Specific BACH classification: A predictor of outcome in prosthetic joint infection
2021, eClinicalMedicine
There is currently no commonly accepted method of stratifying complexity of prosthetic joint infection (PJI). This study assesses a new classification, the Joint-Specific, Bone involvement, Anti-microbial options, Coverage of the soft tissues, Host status (JS-BACH) classification, for predicting clinical and patient reported outcomes in PJI.
Patients who received surgery for PJI at two centres in the UK between 2010 and 2015 were classified using JS-BACH as ‘uncomplicated’, ‘complex’ or ‘limited treatment options’. Patient reported outcomes were recorded at 365-days following the index operation and included the EuroQol EQ-5D-3L index score and the EQ-visual analogue score (VAS). Clinical outcome data were obtained from the most recent follow-up appointment.
220 patients met the inclusion criteria. At 365-days following the index operation, patients with ‘uncomplicated’ PJI reported similar EQ-index scores (0.730, SD:0.326) and EQ-VAS (79.4, SD:20.9) compared to the age-matched population. Scores for ‘uncomplicated’ PJI were significantly higher than patients classified as having ‘complex’ (EQ-index:0.515 SD:0.323, p = 0.012; EQ-VAS:68.4 SD:19.4, p = 0.042) and ‘limited treatment options’ PJI (EQ-index:0.333 SD:0.383, p < 0.001; EQ-VAS:60.2, SD:23.1, p = 0.005). The median time to final follow-up was 4.7 years (inter-quartile range 2.7–6.7 years) where there were 74 cases (33.6%) of confirmed recurrence. Using death as a competing risk, the Cox proportional-hazards ratio of recurrence for ‘complex’ versus ‘uncomplicated’ PJI was 23.7 (95% CI:3.23–174.0, p = 0.002) and having ‘limited options’ verses ‘uncomplicated’ PJI was 57.7 (95% CI:7.66–433.9, p < 0.001).
The JS-BACH classification can help predict likelihood of recurrence and quality of life following surgery for PJI. This will aid clinicians in sharing prognostic information with patients and help guide referral for specialist management of PJI.
Data acquisition was funded by the National Institute for Health Research (NIHR), Trials No. ISRCTN91566927. AJH is funded by a Versus Arthritis clinical research fellowship. ERW is funded by a national institute of health research (NIHR) academic clinical fellowship. SMM and AA are funded by a NIHR University lectureship.

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Original articleResults of 2-stage reimplantation for infected total knee arthroplasty

Abstract

J Bone Joint Surg

J Arthroplasty

Orthop Clin North Am

Orthop Clin North Am

Clin Rheum Dis

Two-stage reimplantation for the salvage of infected total knee arthroplasty

J Bone Joint Surg

Reimplantation for the salvage of an infected total knee arthroplasty

J Bone Joint Surg

Two-stage reimplantation for the salvage of total knee arthroplasty complicated by infection

J Bone Joint Surg

Treatment of infected knee arthroplasty

Clin Orthop

Deep sepsis following total knee arthroplasty: ten year experience at the University of California Los Angeles Medical Center

J Bone Joint Surg

Management of infected total knee arthroplasty

Clin Orthop

Infection as a complication of total knee replacement arthroplasty

J Bone Joint Surg

Infected total knee replacements

J Am Acad Orthop Surg

Failed total knee arthroplasty: revision and arthrodesis for infection and noninfectious complications

Clin Orthop

Implant salvage in infected total knee arthroplasty

Clin Orthop

Periprosthetic knee sepsis: the role of irrigation and debridement

Clin Orthop

Treatment of infection after total knee arthroplasty by debridement with retention of the components

J Bone Joint Surg

Original article
Results of 2-stage reimplantation for infected total knee arthroplasty