Complications of Resection Arthroplasty in Two-Stage Revision for the Treatment of Periprosthetic Hip Joint Infection

Patient Factors Associated With Reimplantation After Girdlestone Resection Arthroplasty for Treatment of Periprosthetic Joint Infections of the Hip

INTRODUCTION

For patients unsuitable for prosthesis reimplantation or temporary spacer placement, Girdlestone resection arthroplasty (GRA) is a suitable option to eliminate infection. Using a large-scale database, this study aims to determine factors associated with reimplantation.

METHODS

This study included patients who underwent GRA and subsequent total hip arthroplasty (2012 to 2015 Medicare Limited Data Set with ≥5-year follow-up). A mixed-effects model measured associations between patient characteristics and reimplantation. Odds ratios (OR) with 95% confidence intervals (CI) were reported.

RESULTS

Among 2,772 GRA cases, 2,025 (73.1%) were reimplanted (median time to reimplantation 3.0 months). In multivariable analysis, patient factors associated with reduced odds of reimplantation were increased age (OR 0.96; CI, 0.94 to 0.97; P < 0.0001), Black race (OR, 0.58; CI, 0.37 to 0.90; P = 0.0149), obesity (OR, 0.74; CI, 0.58 to 0.94; P = 0.0150), and increased Deyo-Charlson comorbidities (1 comorbidity: OR, 0.78; CI, 0.61 to 0.99; P = 0.0453; two comorbidities: OR, 0.53; CI, 0.39 to 0.71; P < 0.0001; ≥3 comorbidities: OR, 0.69; CI, 0.49 to 0.95; P = 0.0244). Male (versus female) patients, however, had increased odds of reimplantation (OR, 1.64; CI, 1.32 to 2.02; P < 0.0001).

DISCUSSION

Age, race, and comorbidities influence the likelihood of reimplantation after GRA. Owing to variability in patients who undergo additional surgery, additional studies should be conducted to determine the rationale of patient selection.

Early-Outcome Differences between Acute and Chronic Periprosthetic Joint Infections-A Retrospective Single-Center Study

Periprosthetic joint infections (PJI) are serious complications after arthroplasty, associated with high morbidity, mortality, and complex treatment processes. The outcomes of different PJI entities are largely unknown. The aim of this study was to access the early outcomes of different PJI entities. A retrospective, single-center study was conducted. The characteristics and outcomes of patients with PJI treated between 2018 and 2019 were evaluated 12 months after the completion of treatment. Primary endpoints were mortality, relapse free survival (RFS) and postoperative complications (kidney failure, sepsis, admission to ICU). A total of 115 cases were included [19.1% early (EI), 33.0% acute late (ALI), and 47.8% chronic infections (CI)]. Patients with ALI were older (p = 0.023), had higher ASA scores (p = 0.031), preoperative CRP concentrations (p = 0.011), incidence of kidney failure (p = 0.002) and sepsis (p = 0.026). They also tended towards higher in-house mortality (ALI 21.1%, 13.6% EI, 5.5% CI) and admission to ICU (ALI 50.0%, 22.7% EI, 30.9% CI). At 12 months, 15.4% of patients with EI had a relapse, compared to 38.1% in ALI and 36.4% in CI. There are differences in patient characteristics and early outcomes between PJI entities. Patients with EI have better early clinical outcomes. Patients with ALI require special attention during follow-up because they have higher occurrences of relapses and postoperative complications than patients with EI and CI.

Articulating Hip Spacers with a Constrained Acetabular Liner: Effect of Acetabular Bone Loss and Cementation Quality

Articulating hip spacers for periprosthetic joint infection (PJI) offer numerous advantages over static spacers such as improved patient mobilization, hip functionality, and soft tissue tension. Our study aimed to determine complication rates of a functional articulating spacer using a constrained liner to determine the role of acetabular cementation mantle and bone loss on the need for second-stage surgery. A retrospective review of 103 patients was performed and demographic information, spacer components and longevity, spacer-related complications, reinfection rates, and grade of bone loss and acetabular cement mantle quality were determined. There was no significant difference in spacer-related complications or reinfection rate between PJI and native hip infections. 33 of 103 patients (32.0%) elected to retain their spacers. Between patients who retained their initial spacer and those who underwent reimplantation surgery, there was not a significant difference in cement mantle grade (p = 0.52) or degree of bone loss (p = 0.78). Functional articulating antibiotic spacers with cemented constrained acetabular liners demonstrate promising early results in the treatment of periprosthetic and native hip infections. The rate of dislocation events was low. Further efforts to improve cement fixation may help decrease the need for second-stage reimplantation surgery.

Acute kidney injury in the context of staged revision arthroplasty and the use of antibiotic-laden cement spacers: a systematic review

BACKGROUND

The most common cause of revision arthroplasty is prosthetic joint infection (PJI). Chronic PJI is commonly treated with two-stage exchange arthroplasty involving the placement of antibiotic-laden cement spacers (ACS) in the first stage, often containing nephrotoxic antibiotics. These patients often have significant comorbidity burdens and have higher rates of acute kidney injury (AKI). This systematic review aims to assess the current literature to identify (1) AKI incidence, (2) associated risk factors, and (3) antibiotic concentration thresholds in ACS that increase AKI risk following first-stage revision arthroplasty.

METHODS

An electronic search was performed of the PubMed database of all studies involving patients undergoing ACS placement for chronic PJI. Studies assessing AKI rates and risk factors were screened by two authors independently. Data synthesis was performed when possible. Significant heterogeneity prevented meta-analysis.

RESULTS

Eight observational studies consisting of 540 knee PJIs and 943 hip PJIs met inclusion criteria. There were 309 (21%) cases involving AKI. The most commonly reported risk factors included perfusion-related factors (lower preoperative hemoglobin, transfusion requirement, or hypovolemia), older age, increased comorbidity burden, and nonsteroidal anti-inflammatory drug consumption. Only two studies found increased risk with greater ACS antibiotic concentration (> 4 g vancomycin and > 4.8 g tobramycin per spacer in one study, > 3.6 g of vancomycin per batch or > 3.6 g of aminoglycosides per batch in the other); however, these were reported from univariate analyses not accounting for other potential risk factors.

DISCUSSION

Patients undergoing ACS placement for chronic PJI are at an increased risk for AKI. Understanding the risk factors may lead to better multidisciplinary care and safer outcomes for chronic PJI patients.

LEVEL OF EVIDENCE III

Commercially manufactured spacers for the treatment of periprosthetic joint infection of the hip

BACKGROUND

Periprosthetic joint infection remains a common and serious complication after hip arthroplasty. To improve function and patient comfort after joint removal in two-stage revision, commercially manufactured spacers for the hip joint allow retention of the anatomical joint geometry thereby limiting soft tissue contraction and allow mobilization.

INDICATIONS

Periprosthetic joint infection of the hip, septic arthritis with severe destruction of the hip cartilage and/or bone requiring arthroplasty.

CONTRAINDICATIONS

Allergies to polymethylmethacrylate (PMMA) or antibiotics, severe hip dysplasia with insufficient cranial support, incompliant patient, large osseous defect of the acetabulum, insufficient metaphyseal/diaphyseal support of the femoral bone, resistance of the microbiological pathogen to spacer-inert antibiotic medication, inability to perform primary wound closure requiring temporary open-wound therapy.

SURGICAL TECHNIQUE

Preoperative templating on radiograph; removal of joint prosthesis and thorough debridement with removal of all foreign material; trial spacer selection and insertion and trial reduction of the joint, fixing the spacer with PMMA to the proximal femur, final reduction, radiograph and stability test.

RESULTS

Data were analyzed from patients treated between 2016 and 2021. In all, 20 patients were treated with preformed spacers and 16 with custom-made spacers. Pathogens were detected in 23 of the 36 cases (64%). Polymicrobial infections were present in 8 of 36 cases (22%). In patients who received preformed spacers, there were 6 cases of spacer-related complications (30%). Of the 36 patients (83%), 30 were reimplanted with a new implant; 3 patients died due to septic or other complications before reimplantation (8%). Average follow-up was 20.2 months after reimplantation. There were no major differences between the two groups of spacers. Patient comfort was not measured.

Cure rate of infections is not an argument for spacer in two-stage revision arthroplasty of the hip

INTRODUCTION

 A devastating complication after total hip arthroplasty (THA) is chronic periprosthetic joint infection (PJI). Most frequently spacers (Sp) with or without antibiotics are implanted in a two-stage procedure even though not always indicated due to unknown pathogen, femoral and acetabular defects or muscular insufficiency.

MATERIALS AND METHODS

 A retrospective analysis of a prospectively collected database was conducted, analyzing the treatment of 44 consecutive cases with chronic PJI undergoing two-stage revision using a Girdlestone situation (GS) in the interim period between 01/2015 and 12/2018. Diagnostics included intraoperative microbiological cultures, histological analysis, sonication of the initial implant, analysis of hip aspiration, as well as laboratory diagnostics and blood cultures. We analyzed the general and age-group-specific success rate of treatment using GS. Furthermore, we compared our data with the current literature on spacer implantation regarding common complications.

RESULTS

In total, 21 female and 23 male patients at a mean age of 59.3 ± 9.6 years were included. Age groups were divided into young, mid-age, and elderly. In most patients, microbiology revealed Staphylococcus epidermidis in 39.1% of cases, following Staphylococcus lugdunensis and Staphylococcus aureus in 10.9% after THA explantation. For histology, Krenn and Morawietz type 2 (infectious type) was diagnosed in 40.9%, type 3 (infectious and abrade-induced type) in 25.0%. With GS, the total cure rate was 84.1% compared to 90.1% (range 61-100%) using Sp as described in the literature. Among age-groups, cure rate varied between 77.8 and 100%. Other complications, which only occurred in the mid-age and elderly group, included the necessity of transfusion in 31.1%, and in total, one periprosthetic fracture was identified (2.3%).

CONCLUSION

GS shows an acceptable cure rate at a minimum of 2 years when compared to the cure rate reported in the literature for Sp without major complications. For patients with increased risks for treatment failure using spacer, GS seems to be an alternative for chronic PJI when looking at the success rate of treatment.

LEVEL OF EVIDENCE

III, Retrospective trial.

Is long time to reimplantation a risk factor for reinfection in two-stage revision for periprosthetic infection? A systematic review of the literature

The two-stage revision arthroplasty is a common treatment option for chronic periprosthetic infection (PJI). The time to reimplantation (TTR) reported in the literature varies substantially from a few days to several hundred days. It is hypothesized that longer TTR could be associated with worse infection control after second stage. A systematic literature search was performed according to Preferred Reporting items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, in Pubmed, Cochrane Library and Web of Science Core Collection in clinical studies published until January 2023. Eleven studies investigating TTR as a potential risk factor for reinfection met the inclusion criteria (ten retrospective and one prospective study, published 2012-2022). Study design and outcome measures differed notably. The cutoff points above which TTR was regarded as "long" ranged from 4 to 18 weeks. No study observed a benefit for long TTR. In all studies, similar or even better infection control was observed for short TTR. The optimal TTR, however, is not yet defined. Larger clinical studies with homogeneous patient populations and adjustment for confounding factors are needed.

Revision arthroplasty with megaprosthesis after Girdlestone procedure for periprosthetic joint infection as an option in massive acetabular and femoral bone defects

Background and aim:

To evaluate the clinical outcomes of patients treated with Girdlestone procedure (GP) or excision arthroplasty (EA) for periprosthetic infection with massive bone defects and undergoing revision arthroplasty.

Methods:

All patients treated with EA or GP for hip periprosthetic infection between 2014 and 2017 and sustaining revision arthroplasty (RA) were included in the study. Patients with less than 24 months of follow-up or less than 12 months between GP or EA and RA were excluded. Any sign of implant mobilization or periprosthetic fracture was assessed through X-ray. Patients were evaluated with D’aubigne-Postel hip score before RA and at the last follow-up. Mann-Whitney U test was used to assess differences between pre-RA surgery and last follow-up. P value was set as <0.05.

Results:

Twelve patients meet the inclusion criteria (mean follow-up 58+/-9.72 months). No radiographic sign of implant mobilization or periprosthetic fracture was reported. A significant difference was found for each parameter of the D’Aubigne-Postel score (p < 0.0001); none of the patients reached more than fair results in the absolute hip score. The difference between pre and post-operative global status showed a fair improvement. A significant difference was found for leg length discrepancy between pre and post RA (p<0.0001).

Conclusions:

Conversion from EA or GP to RA in patients suffering from massive acetabular and femur defects is challenging; conversion procedure is able to reduce patients’ disability and to improve walking ability. (www.actabiomedica.it)

The Diagnosis and Treatment of Acetabular Bone Loss in Revision Hip Arthroplasty: An International Consensus Symposium

Despite growing evidence supporting the evaluation, classification, and treatment of acetabular bone loss in revision hip replacement, advancements have not been systematically incorporated into a single document, and therefore, a comprehensive review of the treatment of severe acetabular bone loss is needed. The Stavros Niarchos Foundation Complex Joint Reconstruction Center at Hospital for Special Surgery held an Acetabular Bone Loss Symposium on June 21, 2019, to answer the following questions: What are the trends, emerging technologies, and areas of future research related to the evaluation and management of acetabular bone loss in revision hip replacement? What constitutes the optimal workup and management strategies for acetabular bone loss? The 36 international experts convened were divided into groups, each assigned to discuss 1 of 4 topics: (1) preoperative planning and postoperative assessment; (2) implant selection, management of osteolysis, and management of massive bone loss; (3) the treatment challenges of pelvic discontinuity, periprosthetic joint infection, instability, and poor bone biology; and (4) the principles of reconstruction and classification of acetabular bone loss. Each group came to consensus, when possible, based on an extensive literature review. This document provides an overview of these 4 areas, the consensus each group arrived at, and directions for future research.

Microbiological pathogen analysis in native versus periprosthetic joint infections: a retrospective study

BACKGROUND

The presence or absence of an implant has a major impact on the type of joint infection therapy. Thus, the aim of this study was the examination of potential differences in the spectrum of pathogens in patients with periprosthetic joint infections (PJI) as compared to patients with native joint infections (NJI).

METHODS

In this retrospective study, we evaluated culture-positive synovial fluid samples of 192 consecutive patients obtained from January 2018 to January 2020 in a tertiary care university hospital. For metrically distributed parameters, Mann-Whitney U was used for comparison between groups. In case of nominal data, crosstabs and Chi-squared tests were implemented.

RESULTS

Overall, 132 patients suffered from periprosthetic joint infections and 60 patients had infections of native joints. The most commonly isolated bacteria were coagulase-negative Staphylococci (CNS, 28%), followed by Staphylococcus aureus (S. aureus, 26.7%), and other bacteria, such as Streptococci (26.3%). We observed a significant dependence between the types of bacteria and the presence of a joint replacement (p < 0.05). Accordingly, detections of CNS occurred 2.5-fold more frequently in prosthetic as compared to native joint infections (33.9% vs. 13.4% p < 0.05). In contrast, S. aureus was observed 3.2-fold more often in NJIs as compared to PJIs (52.2% vs. 16.4%, p < 0.05).

CONCLUSION

The pathogen spectra of periprosthetic and native joint infections differ considerably. However, CNS and S. aureus are the predominant microorganisms in both, PJIs and NJIs, which may guide antimicrobial therapy until microbiologic specification of the causative pathogen.

Analysis of Failed Two-Stage Procedures with Resection Arthroplasty as the First Stage in Periprosthetic Hip Joint Infections

Resection arthroplasty can be performed as the first stage of a two-stage procedure in some patients with severe periprosthetic hip joint infections with poor bone stock. This retrospective study aimed to evaluate factors associated with the subsequent failure or success of these patients. Between 2011 and 2020; in 61 (26.4%) of 231 patients who underwent a two-stage protocol of periprosthetic hip joint infections; no spacer was used in the first stage. The minimum follow-up period was 12 months. Patient's demographics and various infection risk factors were analyzed. In total, 37/61 (60.7%) patients underwent a successful reimplantation, and four patients died within the follow-up period. Patients within the failure group had a significantly higher Charlson comorbidity index (p = 0.002); number of operations prior to resection arthroplasty (p = 0.022) and were older (p = 0.018). Failure was also associated with the presence of a positive culture in the first- and second-stage procedures (p = 0.012). Additional risk factors were persistent high postoperative CRP values and the requirement of a negative-pressure wound therapy (p ≤ 0.05). In conclusion, multiple factors need to be evaluated when trying to predict the outcome of patients undergoing resection arthroplasty as the first stage of a two-stage procedure in patients with challenging periprosthetic hip joint infections.

Restoration of the hip geometry after two-stage exchange with intermediate resection arthroplasty for periprosthetic joint infection

Two-stage exchange with intermediate resection arthroplasty (RA) is a well-established surgical procedure in the treatment of chronic periprosthetic joint infection (PJI), whereby a higher failure rate of final hip geometry restoration due to tissue contraction is controversially discussed. The aim was to evaluate radiographic changes of hip geometry parameters during PJI treatment and to determine the impact of the intermediate RA on the final joint restoration after reimplantation of a total hip arthroplasty (reTHA). Radiographic parameters (leg length (LL), femoral offset (FO), horizontal/vertical acetabular center of rotation distance (h/vCORD)) of 47 patients (mean age: 64.1 years) were measured on standard radiographs of the pelvis and compared between four different stages during PJI treatment (pre-replacement status (preTHA), primary total hip arthroplasty (pTHA), RA and reTHA). The RA duration (mean: 10.9 months) and the number of reoperations during this period (mean: n = 2.0) as well as their impact on hip geometry restoration were evaluated. Between preTHA and pTHA/reTHA an equivalent restoration was measured regarding the FO (p < 0.001/p < 0.001) and hCORD (p = 0.016/p < 0.001), but not regarding the LL and vCORD. In contrast, analysis revealed no influence of RA and an equivalent reconstruction of LL (p = 0.003), FO (p < 0.001), v/hCORD (p = 0.039/p = 0.035) at reTHA compared to pTHA. Furthermore, RA duration (p = 0.053) and the number of reoperations after RA (p = 0.134) had no impact on radiographic hip geometry restoration. The two-stage exchange with intermediate RA does not alter the preexisting hip joint parameters, whereby a good restoration of the final hip geometry, independent of the duration or the number of reoperations, can be achieved.

Is There a Role for Spacer Exchange in Two-Stage Exchange Arthroplasty for Periprosthetic Joint Infection?

Periprosthetic joint infection (PJI) continues to be one of the most serious complications after hip and knee arthroplasty. The choice of surgical treatment depends on a multitude of factors like chronicity of infection, host factors, and institutional or surgeon experience. Two-stage exchange remains one of the most commonly used technique for chronic PJI in the United States of America. The intended two-stage revision may involve an additional interim procedure where the initial antibiotic cement spacer is removed and a new spacer is inserted. Mostly, the rationale behind spacer exchange is an additional load of local antibiotics before proceeding to reimplantation. There is no conclusive evidence whether a spacer exchange confers additional benefits, yet it delays reimplantation and exposes already fragile patients to the risks and morbidity of an additional surgery.

Two-stage revision arthroplasty in the treatment of periprosthetic hip infections with severe bone loss: Results from 182 cases

The optimum treatment for periprosthetic joint infection (PJI) of the hip with substantial bone defects remains controversial. A retrospective assessment was performed for 182 patients treated for PJI with a two-stage protocol from 2005 to 2015. Implant removal and debridement were followed by Girdlestone arthroplasty or spacer implantation. The results of the Girdlestone and spacer groups were compared. There were 71 cases that received spacers, and 111 Girdlestone procedures were performed. After the first stage, 26.37% of cultures were negative, and among patients with a detected pathogen, methicillin-sensitive Staphylococcus aureus was the most common organism (41.79%). Acetabular and femoral bone defects, according to the Paprosky classification, were more severe in the Girdlestone group (P<0.05). During the follow-up (mean, 5.95 years), the overall incidence of complications was 21.42%. The mean Harris hip score was significantly lower in the Girdlestone group (68.39 vs 77.79; P<0.0001). The infection recurrence rate reached 8.79%. Despite satisfactory infection control, the number of complications and poor functional outcomes associated with resection arthroplasty indicate the necessity for development of different approaches for patients with advanced bone loss.