Is two-stage revision surgery for infected hip arthroplasty worth the suffering, resources and results compared to one-stage?

Re-revision and mortality rate following revision total hip arthroplasty for infection

Aims

This study compares the re-revision rate and mortality following septic and aseptic revision hip arthroplasty (rTHA) in registry data, and compares the outcomes to previously reported data.

Methods

This is an observational cohort study using data from the German Arthroplasty Registry (EPRD). A total of 17,842 rTHAs were included, and the rates and cumulative incidence of hip re-revision and mortality following septic and aseptic rTHA were analyzed with seven-year follow-up. The Kaplan-Meier estimates were used to determine the re-revision rate and cumulative probability of mortality following rTHA.

Results

The re-revision rate within one year after septic rTHA was 30%, and after seven years was 34%. The cumulative mortality within the first year after septic rTHA was 14%, and within seven years was 40%. After multiple previous hip revisions, the re-revision rate rose to over 40% in septic rTHA. The first six months were identified as the most critical period for the re-revision for septic rTHA.

Conclusion

The risk re-revision and reinfection after septic rTHA was almost four times higher, as recorded in the ERPD, when compared to previous meta-analysis. We conclude that it is currently not possible to assume the data from single studies and meta-analysis reflects the outcomes in the 'real world'. Data presented in meta-analyses and from specialist single-centre studies do not reflect the generality of outcomes as recorded in the ERPD. The highest re-revision rates and mortality are seen in the first six months postoperatively. The optimization of perioperative care through the development of a network of high-volume specialist hospitals is likely to lead to improved outcomes for patients undergoing rTHA, especially if associated with infection.

Systematic review and meta-analysis of single-stage vs two-stage revision for periprosthetic joint infection: a call for a prospective randomized trial

BACKGROUND

Periprosthetic joint infection (PJI) is a severe complication of joint arthroplasty that causes significant pain and economic loss. This study aimed to determine whether the current evidence supports single-stage revision for PJI based on reinfection and reoperation rates.

METHODS

We searched the PubMed, EBSCO, Medline, and Cochrane Library databases from inception to 30 May 2023 to identify studies that compared single-stage revision and two-stage revision for PJI. Data on reinfection and reoperation rates were pooled.

RESULTS

This meta-analysis included a total of 40 studies with 8711 patients. Overall, there was no significant difference between single- and two-stage revision regarding the postoperative reinfection rate and reoperation rate. Subgroup analysis by surgery period and different surgical sites revealed no difference between the two groups in the reinfection and reoperation rates.

CONCLUSIONS

Based on the available evidence, our study did not identify a significant difference in reinfection and reoperation rates between single- and two-stage revision for PJI. Given the limitations in inclusion/exclusion criteria and the observed heterogeneity, we acknowledge the complexity of drawing strong conclusions. Therefore, we suggest that the choice between single- and two-stage revision should be carefully considered on an individual basis, taking into account patient-specific factors and further research developments.

Debridement, Antibiotics, and Implant Retention in Periprosthetic Joint Infection: What Predicts Success or Failure?

BACKGROUND

Debridement, antibiotics and implant retention (DAIR) is the treatment of choice for acute postoperative and acute hematogenous periprosthetic joint infection (PJI). There is limited literature on predictive prognostic factors for DAIR. We aim to report the outcomes of DAIR and investigate the predictive prognostic factors.

METHODS

We retrospectively reviewed 106 DAIRs. Failure was defined as requiring removal of TKA implants. Predictive factors that may influence success of DAIR treatment such as age, gender, body mass index, ethnicity, American Society of Anesthesiologists score, comorbidities, preoperative erythrocyte sedimentation rate (ESR) and C-reactive protein, symptom duration, time between total knee arthroplasty and DAIR, cultures, rifampicin use, polyethylene liner change, and antibiotic duration were analyzed.

RESULTS

The success rate of DAIR was 69.8% (74/106 patients). For successes, mean time from DAIR-to-mortality was longer than failures (61.6 ± 42.7 vs 9.75 ± 9.60 months, P = .0150). Methicillin-susceptible Staphylococcus aureus PJI (odds ratio [OR] 3.64, confidence interval [CI] 1.30-10.2, P = .0140) was a significant predictor for failure of DAIR. Higher preoperative ESR correlated to failure (OR 1.02, CI 1.01-1.04, P = .008). In successes, mean ESR was 75.4 (66.1-84.6), whereas mean ESR in failures was 116 (88.3-143) (P = .011). An ESR > 107.5 predicted failure with a sensitivity of 51.5 and specificity of 85.2. ESR > 107.5 correlated to failure (OR 6.60, CI 2.29-19.0, P < .001). Repeat DAIRs were strongly correlated to failure (OR 5.27, CI 1.99-13.9, P < .01).

CONCLUSION

DAIR failure is associated with earlier time to mortality. Repeat DAIRs, elevated ESR > 107.5, and S aureus PJI are associated with treatment failure and 2-stage revision is recommended.