Contemporary 2-Stage Treatment of Periprosthetic Hip Infection with Evidence-Based Standardized Protocols Yields Excellent Results: Caveats and Recommendations

1.5-Stage Versus 2-Stage Exchange Total Hip Arthroplasty for Chronic Periprosthetic Joint Infections: A Comparison of Survivorships, Reinfections, and Patient-Reported Outcomes

BACKGROUND

Management of periprosthetic joint infection after total hip arthroplasty (THA) has traditionally consisted of a 2-stage approach. However, 1.5-stage exchange has garnered recent interest. We compared 1.5-stage to 2-stage exchange recipients. Specifically, we assessed (1) infection-free survivorship and risk factors for reinfection; (2) 2-year surgical/medical outcomes (eg, reoperations, readmissions); (3) Hip Disability and Osteoarthritis Outcome Scores for Joint Replacement (HOOS-JR); and (4) radiographic outcomes (ie, progressive radiolucent lines, subsidences, and failures).

METHODS

We reviewed a consecutive series of 1.5-stage or planned 2-stage THAs. A total of 123 hips were included (1.5-stage: n = 54; 2-stage: n = 69) with mean clinical follow-up of 2.5 years (up to 8 years). Bivariate analyses assessed incidences of medical and surgical outcomes. Additionally, HOOS-JR scores and radiographs were evaluated.

RESULTS

The 1.5-stage exchange had 11% greater infection-free survivorship at final follow-up compared to 2 stages (94% versus 83%, P = .048). Morbid obesity was the only independent risk factor demonstrating increased reinfection among both cohorts. No differences in surgical/medical outcomes were observed between groups (P = .730). HOOS-JR scores improved markedly for both cohorts (1.5-stage difference = 44.3, 2-stage difference = 32.5; P < .001). A total of 82% of 1.5-stage patients did not demonstrate progressive femoral or acetabular radiolucencies, while 94% of 2-stage recipients did not have femoral radiolucencies and 90% did not have acetabular radiolucencies.

CONCLUSION

The 1.5-stage exchange appeared to be an acceptable treatment alternative for periprosthetic joint infections after THAs with noninferior infection eradication. Therefore, this procedure should be considered by joint surgeons for treatment of periprosthetic hip infections.

The Fate and Relevance of the Patella in Two-Stage Revision Total Knee Arthroplasty for Periprosthetic Joint Infection

BACKGROUND

It remains unclear whether reimplantation of a patellar component during a two-stage revision for periprosthetic total knee arthroplasty infection (PJI) affects patient reported outcome measures (PROMs) or implant survivorship. The purpose of this study was to evaluate whether patellar resurfacing during reimplantation confers a functional benefit or increases implant survivorship after two-stage treatment for PJI.

METHODS

Two-stage revisions for knee PJI performed by three surgeons at a single tertiary care center were reviewed retrospectively. All original patellar components and cement were removed during resection and the patella was resurfaced whenever feasible during reimplantation. PROMs, implant survivorship, and radiographic measurements (patellar tilt and displacement) were compared between knees reimplanted with a patellar component versus those without a patellar component.

RESULTS

A total of 103 patients met the inclusion criteria. Forty-three patients (41.7%) underwent reimplantation with, and 60 patients (58.3%) without a patellar component. At a mean follow-up of 33.5 months, there were no significant differences in patient demographics or PROMs between groups (P ≥ .156). No significant differences were found in the estimated Kaplan-Meier all-cause, aseptic, or septic survivorship between groups (P ≥ .342) at a maximum of 75 months follow-up. There was no significant difference in the change (pre-resection to post-reimplant) of patellar tilt (P = .504) or displacement (P = .097) between the groups.

CONCLUSION

Patellar resurfacing during knee reimplantation does not appear to meaningfully impact postoperative PROMs or survivorship. Given the risk of potential extensor mechanism complications with patellar resurfacing, surgeons may choose to leave the patella without an implant during total knee reimplantation and expect similar clinical outcomes.

LEVEL OF EVIDENCE

Level III.

Extended Oral Antibiotics Increase Bacterial Resistance in Patients Who Fail 2-Stage Exchange for Periprosthetic Joint Infection

BACKGROUND

Although studies have demonstrated reductions in recurrent periprosthetic joint infection (PJI) with the administration of prolonged oral antibiotics at second-stage reimplantation, the potential for increasing bacterial resistance has not been studied. The purpose of this study was to determine if oral antibiotics at second-stage reimplantation increased the rate of antibiotic resistance in subsequent infections.

METHODS

We retrospectively reviewed patients who underwent 2-stage exchange for chronic PJI from 2014 to 2019. We compared those who had received prolonged oral antibiotics at the time of stage 2 reimplantation with those who did not. The primary outcome was the presence of resistant organisms in any subsequent infection. The secondary outcome was the overall rate of recurrent PJI in the 2 groups. Multivariable analyses controlling for demographics and comorbid conditions were used.

RESULTS

Of the 211 patients who underwent 2-stage exchange for PJI, 158 patients received prolonged oral antibiotics. The mean follow-up was 2.2 years. Recurrent PJI was diagnosed in 24 of 158 (15%) patients who received oral antibiotics compared with 11 of 53 (21%) patients who did not receive antibiotics (P = .35). PJI with resistant organisms was identified in 16 of 24 (67%) patients who received antibiotics compared with 0 of 11 (0%) patients who did not receive antibiotics (P = .0001).

CONCLUSIONS

Prolonged oral antibiotics following 2-stage exchange increase drug resistance to that antibiotic in subsequent PJI. We recommend further research in the area to refine antimicrobial protocols as we consider the risks and benefits of prolonged antibiotic treatment.

Time Required for Planned and Unplanned Episodes of Care in Septic Two-Stage Revision Hip and Knee Arthroplasty

BACKGROUND

Septic revision total hip (rTHA) and knee (rTKA) arthroplasty requires more effort but is reimbursed less than primary procedures per minute of intraoperative time. This study quantified planned and unplanned work performed by the surgical team for septic 2-stage revision surgeries during the entire episode-of-care "reimbursement window" and compared that time to allowable reimbursement amounts.

METHODS

Between October 2010 and December 2020 all unilateral septic 2-stage rTHA and rTKA procedures performed by a single surgeon at a single institution were retrospectively reviewed. Time dedicated to planned work was calculated over each episode of care, from surgery scheduling to 90 days postoperatively. Impromptu patient inquiries and treatments after discharge, but within the episode of care, involving the surgeon/surgeon team constituted unplanned work. Planned and unplanned work minutes were summed and divided by the number of patients reviewed to obtain average minutes of work per patient.

RESULTS

Sixty-eight hips and 64 knees were included. For 2-stage rTHA and rTKA the average time per patient for planned care was 1728 and 1716 minutes and for unplanned care was 339 and 237 minutes. Compared to the Centers for Medicare and Medicaid Services' allowable reimbursement times, an additional 799 and 887 minutes of uncompensated time was required to care for 2-stage rTHA and rTKA patients.

CONCLUSION

Two-stage revision procedures are substantially more complex than primary procedures. Financially disincentivizing surgeons to care for these patients reduces access to care when high-quality care is most needed. These findings support increasing the allowable times for 2-stage septic revision cases.

High revision rates following repeat septic revision after failed one-stage exchange for periprosthetic joint infection in total knee arthroplasty

AIMS

The outcome of repeat septic revision after a failed one-stage exchange for periprosthetic joint infection (PJI) in total knee arthroplasty (TKA) remains unknown. The aim of this study was to report the infection-free and all-cause revision-free survival of repeat septic revision after a failed one-stage exchange, and to determine whether the Musculoskeletal Infection Society (MSIS) stage is associated with subsequent infection-related failure.

METHODS

We retrospectively reviewed all repeat septic revision TKAs which were undertaken after a failed one-stage exchange between 2004 and 2017. A total of 33 repeat septic revisions (29 one-stage and four two-stage) met the inclusion criteria. The mean follow-up from repeat septic revision was 68.2 months (8.0 months to 16.1 years). The proportion of patients who had a subsequent infection-related failure and all-cause revision was reported and Kaplan-Meier survival for these endpoints was determined. Patients were categorized according to the MSIS staging system, and the association with subsequent infection was analyzed.

RESULTS

At the most recent follow-up, 17 repeat septic revisions (52%) had a subsequent infection-related failure and the five-year infection-free survival was 59% (95% confidence interval (CI) 39 to 74). A total of 19 underwent a subsequent all-cause revision (58%) and the five-year all-cause revision-free survival was 47% (95% CI 28 to 64). The most common indication for the first subsequent aseptic revision was loosening. The MSIS stage of the host status (p = 0.663) and limb status (p = 1.000) were not significantly associated with subsequent infection-related failure.

CONCLUSION

Repeat septic revision after a failed one-stage exchange TKA for PJI is associated with a high rate of subsequent infection-related failure and all-cause revision. Patients should be counselled appropriately to manage expectations. The host and limb status according to the MSIS staging system were not associated with subsequent infection-related failure. Cite this article: Bone Joint J 2022;104-B(3):386-393.

Favourable outcomes of repeat one-stage exchange for periprosthetic joint infection of the hip

AIMS

One-stage exchange for periprosthetic joint infection (PJI) in total hip arthroplasty (THA) is gaining popularity. The outcome for a repeat one-stage revision THA after a failed one-stage exchange for infection remains unknown. The aim of this study was to report the infection-free and all-cause revision-free survival of repeat one-stage exchange, and to investigate the association between the Musculoskeletal Infection Society (MSIS) staging system and further infection-related failure.

METHODS

We retrospectively reviewed all repeat one-stage revision THAs performed after failed one-stage exchange THA for infection between January 2008 and December 2016. The final cohort included 32 patients. The mean follow-up after repeat one-stage exchange was 5.3 years (1.2 to 13.0). The patients with a further infection-related failure and/or all-cause revision were reported, and Kaplan-Meier survival for these endpoints determined. Patients were categorized according to the MSIS system, and its association with further infection was analyzed.

RESULTS

A total of eight repeat septic revisions (25%) developed a further infection-related failure, and the five-year infection-free survival was 81% (95% confidence interval (CI) 57 to 92). Nine (28%) underwent a further all-cause revision and the five-year all-cause revision-free survival was 74% (95% CI 52 to 88). Neither the MSIS classification of the host status (p = 0.423) nor the limb status (p = 0.366) was significantly associated with further infection-related failure.

CONCLUSION

Repeat one-stage exchange for PJI in THA is associated with a favourable five-year infection-free and all-cause revision-free survival. Notably, the rate of infection control is encouraging when compared with the reported rates after repeat two-stage exchange. The results can be used to counsel patients and help clinicians make informed decisions about treatment. With the available number of patients, further infection-related failure was not associated with the MSIS host or limb status. Cite this article: Bone Joint J 2022;104-B(1):27-33.

Complications in the treatment of periprosthetic joint infection of the hip: when do they occur?

Prosthetic joint infection (PJI) is a devastating complication after total hip arthroplasty (THA). The common treatment in the USA is a two-stage exchange which can be associated with significant morbidity and mortality. The purpose of this study was to analyze complications in the treatment course of patients undergoing two-stage exchange for PJI THA and determine when they occur. Methods: We analyzed all patients that underwent two-stage exchange arthroplasty for treatment of PJI after THA from January 2005 to January 2018 at a single institution. Complications were categorized as medical or surgical and divided into interstage and post-reimplantation. Minimum follow-up was 1 year. Success was based on the MusculoSkeletal Infection Society (MSIS) definition. Results: 205 hips (203 patients) underwent first stage of planned two-stage exchange. The median age was 68 (interquartile range (IQR) 18). There were 97 males and 106 females. Overall, 73/205 (38 %) patients had at least one complication during treatment: 13.5 % (25/185) of patients experienced a medical complication and 28.1 % (52/185) a surgical complication; 2.4 % died within 1 year of surgery, and 4.9 % (15/203) had mortality at a median of 2.5 years (IQR 4.9); 27 % of patients had complications during the interstage period, most commonly being recurrence of infection requiring additional surgery (63 %); and 14 % of patients experienced a complication following reimplantation, most commonly persistence or recurrence of infection (59 %). While 92 % of patients that initiated treatment were ultimately reimplanted, only 69 % were infection free at 1 year and required no additional treatment. Conclusions: While two-stage exchanges for PJI in THA have been reported as successful, there are few reports of the complications during the process. In our series, significant numbers of patients experienced complications, often during the interstage period, highlighting the morbidity of this method of treatment.