Complications - Infection
Patients With Failed Prior Two-Stage Exchange Have Poor Outcomes After Further Surgical Intervention

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Abstract

Background

Failure of 2-stage exchange arthroplasty for the management of periprosthetic joint infection (PJI) poses a major clinical challenge. There is a paucity of information regarding the outcomes of further surgical intervention in these patients. Thus, we aim to report the clinical outcomes of subsequent surgery for a failed prior 2-stage exchange arthroplasty.

Methods

Our institutional database was used to identify 60 patients (42 knees and 18 hips), with a failed prior 2-stage exchange, who underwent further surgical intervention between 1998 and 2012, and had a minimum 2-year follow-up. A retrospective review was performed to extract relevant clinical information, including mortality, microbiology, and subsequent surgeries. Musculoskeletal Infection Society criteria were used to define PJI, and treatment success was defined using Delphi criteria.

Results

Irrigation and debridement (I&D) was performed after a failed 2-stage exchange in 61.7% of patients; 56.8% subsequently failed. Forty patients underwent an intended second 2-stage exchange; 6 cases required a spacer exchange. Reimplantation occurred only in 65% of cases, and 61.6% had infection controlled. The 14 cases that were not reimplanted resulted in 6 retained spacers, 5 amputations, 2 PJI-related mortalities, and 1 arthrodesis.

Conclusion

Further surgical intervention after a failed prior 2-stage exchange arthroplasty has poor outcomes. Although I&D has a high failure rate, many patients who are deemed candidates for a second 2-stage exchange either do not undergo reimplantation or fail after reimplantation. The management of PJI clearly remains imperfect, and there is a dire need for further innovations that may improve the care of these patients.

Section snippets

Study Design

After the institutional review board's approval, 482 patients (178 hips and 326 knees) who underwent 2-stage exchange arthroplasty between 1999 and 2013 at our institution were identified using our PJI database. Among the cohort, 59 patients (60 joints, 42 knees, and 18 hips) experienced failure of the 2-stage exchange and required further surgical intervention. Patients were included if they completed the reimplantation stage of a 2-stage exchange arthroplasty, met the International Consensus

Results

Of the 40 patients in our cohort who underwent an intended 2-stage exchange for repeat PJI, only 26 (65%) completed a second 2-stage exchange. Treatment success in this subset of patients was 62% (16/26). Of the ten cases that failed, 9 were reinfected and 1 patient died due to PJI. Of the 9 who were reinfected, one was reinfected with the same organism, one remained culture-negative, and the rest developed an infection with a different organism than their initial PJI. Staphylococcus was the

Discussion

In our study, further surgical intervention after a failed prior 2-stage exchange is associated with a high complication rate and dismal outcomes regardless of treatment choice. I&D has a high failure rate and many of the patients who are deemed candidates for a second 2-stage exchange either do not undergo reimplantation for various reasons or fail after reimplantation. In addition, high rates of spacer exchanges, complications, and salvage procedures were also demonstrated.

Prior studies

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One or more of the authors of this paper have disclosed potential or pertinent conflicts of interest, which may include receipt of payment, either direct or indirect, institutional support, or association with an entity in the biomedical field which may be perceived to have potential conflict of interest with this work. For full disclosure statements refer to http://dx.doi.org/10.1016/j.arth.2016.10.008.

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