1
|
Pradhan TN, Viswanathan VK, Badge R, Pradhan N. Single-stage revision in the management of prosthetic joint infections after total knee arthroplasty - A review of current concepts. J Clin Orthop Trauma 2024; 52:102431. [PMID: 38854773 PMCID: PMC11153906 DOI: 10.1016/j.jcot.2024.102431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2024] [Revised: 05/08/2024] [Accepted: 05/24/2024] [Indexed: 06/11/2024] Open
Abstract
Introduction Prosthetic joint infection (PJI) is a devastating complication following total knee arthroplasty (TKA); and the gold standard surgical approach involves a two-staged, revision TKA (TSR). Owing to the newer, emerging evidence on this subject, there has been gradual shift towards a single-stage revision approach (SSR), with the purported benefits of mitigated patient morbidity, decreased complications and reduced costs. However, there is still substantial lacuna in the evidence regarding the safety and outcome of the two approaches in chronic PJI. This study aimed to comprehensively review of the literature on SSR; and evaluate its role within Revision TKA post PJI. Methods The narrative review involved a comprehensive search of the databases (Embase, Medline and Pubmed), conducted on 20th of January 2024 using specific key words. All the manuscripts discussing the use of SSR for the management of PJI after TKA were considered for the review. Among the screened manuscripts, opinion articles, letters to the editor and non-English manuscripts were excluded. Results The literature search yielded a total 232 studies. Following a detailed scrutiny of these manuscripts, 26 articles were finally selected. The overall success rate following SSR is reported to range from 73 % to 100 % (and is comparable to TSR). SSR is performed in PJI patients with bacteriologically-proven infection, adequate soft tissue cover, immuno-competent host and excellent tolerance to antibiotics. The main difference between SSR and TSR is that the interval between the 2 stages is only a few minutes instead of 6 weeks. Appropriate topical, intraoperative antibiotic therapy, followed by adequate postoperative systemic antibiotic cover are necessary to ascertain good outcome. Some of the major benefits of SSR over TSR include reduced morbidity, decreased complications (such as arthrofibrosis or anesthesia-associated adverse events), meliorated extremity function, earlier return to activities, mitigated mechanical (prosthesis-associated) complications and enhanced patient satisfaction. Conclusion SSR is a reliable approach for the management of chronic PJI. Based on our comprehensive review of the literature, it may be concluded that the right selection of patients, extensive debridement, sophisticated reconstruction strategy, identification of the pathogenic organism, initiation of appropriate antibiotic therapy and ensuring adequate follow-up are the key determinants of successful outcome. To achieve this will undoubtedly require an MDT approach to be taken on a case-by-case basis.
Collapse
Affiliation(s)
- Tej Nikhil Pradhan
- University College London, London, UK
- Imperial College London, London, UK
| | | | - Ravi Badge
- Warrington and Halton Hospitals NHS Foundation Trust, Warrington, UK
- Edge Hill University, Ormskirk, UK
- Liverpool University, Liverpool, UK
- Diploma in Sports Medicine (International Olympic Committee), UK
| | - Nikhil Pradhan
- Warrington and Halton Hospitals NHS Foundation Trust, Warrington, UK
- Edge Hill University, Ormskirk, UK
- University of Chester, Chester, UK
| |
Collapse
|
2
|
Bosco F, Cacciola G, Giustra F, Risitano S, Capella M, Vezza D, Barberis L, Cavaliere P, Massè A, Sabatini L. Characterizing recurrent infections after one-stage revision for periprosthetic joint infection of the knee: a systematic review of the literature. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2023; 33:2703-2715. [PMID: 36867259 PMCID: PMC10504163 DOI: 10.1007/s00590-023-03480-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/25/2022] [Accepted: 01/18/2023] [Indexed: 03/04/2023]
Abstract
BACKGROUND Periprosthetic joint infection (PJI) of the knee represents a severe complication after 1.5% to 2% of primary total knee replacement. Although two-stage revision was considered the gold-standard treatment for PJI of the knee, in the last decades, more studies reported the outcomes of one-stage revisions. This systematic review aims to assess reinfection rate, infection-free survival after reoperation for recurrent infection, and the microorganisms involved in both primary and recurrent infection. MATERIAL AND METHODS A systematic review of all studies reporting the outcome of one-stage revision for PJI of the knee up to September 2022, according to PRISMA criteria and AMSTAR2 guidelines, was performed. Patient demographics, clinical, surgical, and postoperative data were recorded. PROSPERO ID CRD42022362767. RESULTS Eighteen studies with a total of 881 one-stage revisions for PJI of the knee were analyzed. A reinfection rate of 12.2% after an average follow-up of 57.6 months was reported. The most frequent causative microorganism were gram-positive bacteria (71.1%), gram-negative bacteria (7.1%), and polymicrobial infections (8%). The average postoperative knee society score was 81.5, and the average postoperative knee function score was 74.2. The infection-free survival after treatment for recurrent infection was 92.1%. The causative microorganisms at reinfections differed significantly from the primary infection (gram-positive 44.4%, gram-negative 11.1%). CONCLUSION Patients who underwent a one-stage revision for PJI of the knee showed a reinfection rate lower or comparable to other surgical treatments as two-stage or DAIR (debridement, antibiotics, and implant retention). Reoperation for reinfection demonstrates a lower success compared to one-stage revision. Moreover, microbiology differs between primary infection and recurrent infection. Level of evidence Level IV.
Collapse
Affiliation(s)
- Francesco Bosco
- Centro Traumatologico Ortopedico (CTO), Department of Orthopaedic Surgery, University of Turin, Via Gianfranco Zuretti, 29, 10126, Turin, Italy
- Department of Orthopaedics and Traumatology, Ospedale San Giovanni Bosco - ASL Città di Torino, Piazza del Donatore di Sangue, 3, 10154, Turin, Italy
| | - Giorgio Cacciola
- Centro Traumatologico Ortopedico (CTO), Department of Orthopaedic Surgery, University of Turin, Via Gianfranco Zuretti, 29, 10126, Turin, Italy
| | - Fortunato Giustra
- Centro Traumatologico Ortopedico (CTO), Department of Orthopaedic Surgery, University of Turin, Via Gianfranco Zuretti, 29, 10126, Turin, Italy.
- Department of Orthopaedics and Traumatology, Ospedale San Giovanni Bosco - ASL Città di Torino, Piazza del Donatore di Sangue, 3, 10154, Turin, Italy.
| | - Salvatore Risitano
- Centro Traumatologico Ortopedico (CTO), Department of Orthopaedic Surgery, University of Turin, Via Gianfranco Zuretti, 29, 10126, Turin, Italy
| | - Marcello Capella
- Centro Traumatologico Ortopedico (CTO), Department of Orthopaedic Surgery, University of Turin, Via Gianfranco Zuretti, 29, 10126, Turin, Italy
| | - Daniele Vezza
- Centro Traumatologico Ortopedico (CTO), Department of Orthopaedic Surgery, University of Turin, Via Gianfranco Zuretti, 29, 10126, Turin, Italy
| | - Luca Barberis
- Centro Traumatologico Ortopedico (CTO), Department of Orthopaedic Surgery, University of Turin, Via Gianfranco Zuretti, 29, 10126, Turin, Italy
| | - Pietro Cavaliere
- Istituto Ortopedico del Mezzogiorno d'Italia "Franco Scalabrino", 98100, Messina, Via Consolare Pompea, Italy
| | - Alessandro Massè
- Centro Traumatologico Ortopedico (CTO), Department of Orthopaedic Surgery, University of Turin, Via Gianfranco Zuretti, 29, 10126, Turin, Italy
| | - Luigi Sabatini
- Centro Traumatologico Ortopedico (CTO), Department of Orthopaedic Surgery, University of Turin, Via Gianfranco Zuretti, 29, 10126, Turin, Italy
| |
Collapse
|
3
|
Otero JE, Brown TS, Courtney PM, Kamath AF, Nandi S, Fehring KA. What's New in Musculoskeletal Infection. J Bone Joint Surg Am 2022; 104:1228-1235. [PMID: 35700085 DOI: 10.2106/jbjs.22.00183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- Jesse E Otero
- OrthoCarolina Hip and Knee Center, Atrium Health Musculoskeletal Institute, Charlotte, North Carolina
| | - Timothy S Brown
- Department of Orthopedics and Sports, Houston Methodist Hospital, Houston, Texas
| | | | - Atul F Kamath
- Orthopaedic & Rheumatologic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Sumon Nandi
- University of Maryland School of Medicine, Baltimore, Maryland
| | - Keith A Fehring
- OrthoCarolina Hip and Knee Center, Atrium Health Musculoskeletal Institute, Charlotte, North Carolina
| |
Collapse
|
4
|
Barretto JM, Campos ALS, Ooka NHM. Periprosthetic Knee Infection - Part 2: Treatment. Rev Bras Ortop 2022; 57:193-199. [PMID: 35652024 PMCID: PMC9142269 DOI: 10.1055/s-0041-1729936] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Accepted: 12/17/2020] [Indexed: 11/29/2022] Open
Abstract
Several treatment modalities are proposed for periprosthetic infections, with variable success rates. However, efficacy is related to the appropriate selection of cases for each type of treatment. Debridement with implant retention is indicated in acute infections with fixed implant, and its success depends on the type of infection, comorbidities of the host, and virulence of the etiological agent. One- or two-stage revision is required in cases in which biofilm is forming, or of implant loosening. The choice between performing the review in one or two stages depends on factors such as etiological agent identification, pathogen virulence, local and systemic host factors. Rescue procedures such as arthrodesis, amputation, resection arthroplasty or even antibiotic suppression are reserved for cases in which the infection has not been eradicated.
Collapse
Affiliation(s)
| | - André Luiz Siqueira Campos
- Departamento de Ortopedia e Traumatologia, Hospital Federal dos Servidores do Estado, Rio de Janeiro, RJ, Brasil
| | | |
Collapse
|
5
|
Brunt ACC, Gillespie M, Holland G, Brenkel I, Walmsley P. Results of 'two-in-one' single-stage revision total knee arthroplasty for infection with associated bone loss : prospective five-year follow up. Bone Jt Open 2022; 3:107-113. [PMID: 35109666 PMCID: PMC8886320 DOI: 10.1302/2633-1462.32.bjo-2021-0148.r1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Aims Periprosthetic joint infection (PJI) occurs in approximately 1% to 2% of total knee arthroplasties (TKA) presenting multiple challenges, such as difficulty in diagnosis, technical complexity, and financial costs. Two-stage exchange is the gold standard for treating PJI but emerging evidence suggests 'two-in-one' single-stage revision as an alternative, delivering comparable outcomes, reduced morbidity, and cost-effectiveness. This study investigates five-year results of modified single-stage revision for treatment of PJI following TKA with bone loss. Methods Patients were identified from prospective data on all TKA patients with PJI following the primary procedure. Inclusion criteria were: revision for PJI with bone loss requiring reconstruction, and a minimum five years’ follow-up. Patients were followed up for recurrent infection and assessment of function. Tools used to assess function were Oxford Knee Score (OKS) and American Knee Society Score (AKSS). Results A total of 24 patients were included with a mean age of 72.7 years (SD 7.6), mean BMI of 33.3 kg/m2 (SD 5.7), and median ASA grade of 2 (interquartile range 2 to 4). Mean time from primary to revision was 3.0 years (10 months to 8.3 years). At revision, six patients had discharging sinus and three patients had negative cultures from tissue samples or aspirates. Two patients developed recurrence of infection: one was treated successfully with antibiotic suppression and one underwent debridement, antibiotics, and implant retention. Mean AKSS scores at two years showed significant improvement from baseline (27.1 (SD 10.2 ) vs 80.3 (SD 14.8); p < 0.001). There was no significant change in mean AKSS scores between two and five years (80.3 (SD 14.8 ) vs 74.1 (SD 19.8); p = 0.109). Five-year OKS scores were not significantly different compared to two-year scores (36.17 (SD 3.7) vs 33.0 (SD 8.5); p = 0.081). Conclusion ‘Two-in-one’ single-stage revision is effective for treating PJI following TKA with bone loss, providing patients with sustained improvements in outcomes and infection clearance up to five years post-procedure. Cite this article: Bone Jt Open 2022;3(2):107–113.
Collapse
Affiliation(s)
- Andrew C C Brunt
- Department of Orthpaedic Surgery, Victoria Hospital Kirkcaldy, Kirkcaldy, UK
| | - Matthew Gillespie
- Department of Orthpaedic Surgery, Victoria Hospital Kirkcaldy, Kirkcaldy, UK
| | - George Holland
- Department of Orthpaedic Surgery, Victoria Hospital Kirkcaldy, Kirkcaldy, UK
| | - Ivan Brenkel
- Department of Orthpaedic Surgery, Victoria Hospital Kirkcaldy, Kirkcaldy, UK
| | - Phil Walmsley
- Department of Orthpaedic Surgery, Victoria Hospital Kirkcaldy, Kirkcaldy, UK.,School of Medicine, University of St Andrews, St Andrews, UK
| |
Collapse
|
6
|
Razii N, Clutton JM, Kakar R, Morgan-Jones R. Single-stage revision for the infected total knee arthroplasty : the Cardiff experience. Bone Jt Open 2021; 2:305-313. [PMID: 34003026 PMCID: PMC8168544 DOI: 10.1302/2633-1462.25.bjo-2020-0185.r1] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Aims Periprosthetic joint infection (PJI) is a devastating complication following total knee arthroplasty (TKA). Two-stage revision has traditionally been considered the gold standard of treatment for established infection, but increasing evidence is emerging in support of one-stage exchange for selected patients. The objective of this study was to determine the outcomes of single-stage revision TKA for PJI, with mid-term follow-up. Methods A total of 84 patients, with a mean age of 68 years (36 to 92), underwent single-stage revision TKA for confirmed PJI at a single institution between 2006 and 2016. In all, 37 patients (44%) were treated for an infected primary TKA, while the majority presented with infected revisions: 31 had undergone one previous revision (36.9%) and 16 had multiple prior revisions (19.1%). Contraindications to single-stage exchange included systemic sepsis, extensive bone or soft-tissue loss, extensor mechanism failure, or if primary wound closure was unlikely to be achievable. Patients were not excluded for culture-negative PJI or the presence of a sinus. Results Overall, 76 patients (90.5%) were infection-free at a mean follow-up of seven years, with eight reinfections (9.5%). Culture-negative PJI was not associated with a higher reinfection rate (p = 0.343). However, there was a significantly higher rate of recurrence in patients with polymicrobial infections (p = 0.003). The mean Oxford Knee Score (OKS) improved from 18.7 (SD 8.7) preoperatively to 33.8 (SD 9.7) at six months postoperatively (p < 0.001). The Kaplan-Meier implant survival rate for all causes of reoperation, including reinfection and aseptic failure, was 95.2% at one year (95% confidence interval (CI) 87.7 to 98.2), 83.5% at five years (95% CI 73.2 to 90.3), and 78.9% at 12 years (95% CI 66.8 to 87.2). Conclusion One-stage exchange, using a strict debridement protocol and multidisciplinary input, is an effective treatment option for the infected TKA. This is the largest single-surgeon series of consecutive cases reported to date, with broad inclusion criteria. Cite this article: Bone Jt Open 2021;2(5):305–313.
Collapse
Affiliation(s)
- Nima Razii
- Cardiff and Vale Orthopaedic Centre, University Hospital Llandough, Cardiff, UK.,Department of Trauma and Orthopaedics, Glasgow Royal Infirmary, Glasgow, UK
| | - Juliet M Clutton
- Cardiff and Vale Orthopaedic Centre, University Hospital Llandough, Cardiff, UK
| | - Rahul Kakar
- Department of Trauma and Orthopaedics, Ninewells Hospital, Dundee, UK
| | | |
Collapse
|
7
|
Lum ZC, Holland CT, Meehan JP. Systematic review of single stage revision for prosthetic joint infection. World J Orthop 2020; 11:559-572. [PMID: 33362992 PMCID: PMC7745489 DOI: 10.5312/wjo.v11.i12.559] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2020] [Revised: 10/20/2020] [Accepted: 11/29/2020] [Indexed: 02/06/2023] Open
Abstract
While advanced technology, increased medical knowledge and improved surgical technique has improved patient outcomes in total joint arthroplasty, prosthetic joint infection still remains one of the leading causes of increased healthcare costs, medical resources and societal burdens in orthopaedic care. Two stage arthroplasty revision remains the gold standard for treatment of prosthetic joint infection. Proponents of single stage revision arthroplasty for infection argue that it results in lower healthcare costs while improving patient reported functional outcomes and with equivalent success rates. Here we review the history of single stage revision arthroplasty, discuss the key principles, highlight the indications and contraindications, and review the reported outcomes with a focus on future developments of single stage revision arthroplasty for hip and knee periprosthetic joint infections.
Collapse
Affiliation(s)
- Zachary C Lum
- Department of Orthopaedic Surgery, Davis Medical Center, University of California, Sacramento, CA 95817, United States
| | - Christopher Thomas Holland
- Department of Orthopaedics, University of California, Davis Medical Center, Sacramento, CA 95817, United States
| | - John P Meehan
- Department of Orthopaedics, University of California, Davis Medical Center, Sacramento, CA 95817, United States
| |
Collapse
|