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Purpose: Knee arthroplasty is an effective treatment for severe knee degeneration; however, periprosthetic joint infection (PJI) is one of its serious complications. Single- and two-stage revision are common treatments, but few studies have compared single- and two-stage revision for PJI after knee arthroplasty. This study aimed to compare the reinfection and reoperation rates of single- and two-stage revision through meta-analysis. Methods: The review process was conducted according to the PRISMA guidelines. We searched the PubMed, Medline, Embase and Cochrane Central Register of Controlled Trials databases for trials comparing single- and two-stage revision for PJI after knee arthroplasty from the respective inception dates to April 2023. Two researchers individually screened the studies, performed the literature quality evaluation and data extraction and used Stata 17 software for data analysis. Results: The meta-analysis showed that the reinfection rate was significantly lower in the single-stage revision group than in the two-stage revision group. While the reoperation rates demonstrated no statistically significant difference between the two groups. We presented descriptive results because the discrepancies in the knee function scores and data reported in the studies meant that these data could not be combined in the meta-analysis. Conclusion: Based on the available research, single-stage revision is a reliable option for PJI after knee arthroplasty. However, when developing the best treatment strategy, it is still necessary to consider the individual circumstances and needs of the patient, as well as the risks of postoperative rehabilitation and complications.
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We report a case of a 74-year-old female with a history of a prosthetic joint infection that was successfully treated with a single-stage exchange arthroplasty, off antibiotics, and without symptoms for 20 months. She presented 1 week after a cat scratch with acute knee pain, and aspiration grew Pasteurella multocida. She was successfully treated with surgical debridement and a prolonged course of antibiotics. Debate remains in the literature regarding whether recurrent infections represent a previously undetected organism or a new infection. Our report provides convincing evidence that, at least in some circumstances, the infection is new. Furthermore, this is the first case described of P. multocida resulting in a recurrent prosthetic joint infection after a previously successful exchange arthroplasty due to a different causative organism.
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INTRODUCTION: Similar to the management of periprosthetic joint infections of the lower limb, one-stage revision in total shoulder arthroplasty (TSA) infections is an option that has been highlighted in scientific publications since the early 2010s. However, there are only a few studies which validate this treatment and determine its scope of application in relation to two-stage treatment. HYPOTHESIS: Single-stage revision for infected TSA is a reliable treatment allowing good infection control and satisfactory functional results. METHODS: This single-center retrospective series of 34 consecutive patients operated on between 2014 and 2020 for a one-stage prosthetic revision was evaluated at a minimum of 2 years of follow-up. All of the patients included underwent revision shoulder arthroplasty during this period with the diagnosis of infection confirmed by microbiological analysis of surgical samples. Patients who did not benefit from a bipolar revision were excluded. All patients were followed at least 2 years after the intervention. Clinically suspected recurrence of infection was confirmed by a periprosthetic sample under radiographic guidance. Functional clinical outcomes as well as mechanical complications were also reported. RESULTS: The average follow-up was 40.4 months (24-102±21.6). A septic recurrence was observed in three patients (8.8%). A mechanical complication was present in four patients (14.7%), and three (11.8%) required at least one surgical revision. The mean Constant-Murley score at the last follow-up was 49 (42-57±21.83). DISCUSSION: Single-stage revision for shoulder periprosthetic joint infection results in a success rate of 91.2% with satisfactory functional results after more than 2 years of follow-up. LEVEL OF EVIDENCE: IV; retrospective study.
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Artroplastía de Reemplazo de Hombro , Infecciones Relacionadas con Prótesis , Reoperación , Humanos , Artroplastía de Reemplazo de Hombro/métodos , Estudios Retrospectivos , Masculino , Femenino , Infecciones Relacionadas con Prótesis/cirugía , Anciano , Estudios de Seguimiento , Persona de Mediana Edad , Prótesis de Hombro , Anciano de 80 o más AñosRESUMEN
PURPOSE: Single-stage revision has gained significant attention as a major surgical approach for periprosthetic joint infection (PJI). However, the 90-day mortality and complication profile of single-stage revision is poorly characterized. The purposes of this study were to determine the incidence rates of and identify the risk factors for 90-day postoperative mortality and complications of single-stage revision for chronic PJI. METHODS: A retrospective review was conducted on patients who underwent single-stage revision for PJI between August 2000 and May 2022. Patient demographics, 90-day mortality, and postoperative complications were recorded. Complications were categorized into systemic and local complications. Patients in this study were further categorized into knee and hip revision groups. Univariate and multivariate logistic regression analyses were performed to identify significant independent predictors of the outcome measures. RESULTS: 348 patients (144 knees and 204 hips) were included in this study. The 90-day mortality rate was 0.9%. The incidence rates of postoperative complications in knee and hip surgeries were 31.3% and 19.6%, respectively. The most common complication was deep-vein thrombosis (DVT). Rheumatoid arthritis (RA) was the independent predictor of mortality. In the knee revision group, fungal infection was identified as the independent predictor of recurrent PJI; regular alcohol use was predictive of wound dehiscence. Among hip PJI patients, age ≥ 80 years was independently associated with DVT; RA was found to be a predictor of dislocation and wound dehiscence. CONCLUSION: For continuous and unselected patients with chronic PJI, single-stage revision demonstrated a satisfactory 90-day mortality. Nevertheless, the 90-day postoperative complication rates after single-stage revision in both knee and hip groups were relatively high.
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Artroplastia de Reemplazo de Cadera , Complicaciones Posoperatorias , Infecciones Relacionadas con Prótesis , Reoperación , Humanos , Femenino , Masculino , Estudios Retrospectivos , Anciano , Reoperación/estadística & datos numéricos , Infecciones Relacionadas con Prótesis/epidemiología , Infecciones Relacionadas con Prótesis/etiología , Infecciones Relacionadas con Prótesis/cirugía , Infecciones Relacionadas con Prótesis/mortalidad , Persona de Mediana Edad , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/etiología , Artroplastia de Reemplazo de Cadera/efectos adversos , Artroplastia de Reemplazo de Cadera/métodos , Factores de Riesgo , Anciano de 80 o más Años , Artroplastia de Reemplazo de Rodilla/efectos adversos , Artroplastia de Reemplazo de Rodilla/métodos , Incidencia , Adulto , Enfermedad Crónica , Prótesis de la Rodilla/efectos adversos , Prótesis de Cadera/efectos adversosRESUMEN
BACKGROUND: The goal of treating periprosthetic infection, besides its eradication, is to avoid recurrence. The purpose of this study was to evaluate the impact of increasing Infection Severity (IS) score (based on the 2018 International Consensus Meeting on Orthopedic Infections statement), single-stage revision, and pathogenicity of the infective organism on the risk of infection recurrence. METHODS: A database of 790 revisions performed by a single surgeon from 2004-2020 was reviewed for patients with minimum 2-year follow-up and ≥1 positive culture finding and/or pathology result from the revision surgical procedure. In total, 157 cases performed in 144 patients met the inclusion criteria. These cases were then categorized by infection probability (IS score) according to the 2018 consensus statement. Of 157 cases, 46 (29%) were classified as definitely or probably infected; 25 (16%), possibly infected; and 86 (55%), unlikely to be infected. Additionally, patients were grouped by single-stage surgery and pathogenicity of the infective organism. RESULTS: A recurrence in this study was classified as the growth of the same organism in any patient requiring revision surgery. The 86 cases in the group with unlikely infection showed a recurrence rate of 2.3%. The 25 cases in the group with possible infection showed a recurrence rate of 12%. The 46 cases in the group with definite or probable infection showed a recurrence rate of 17.4%. Patients in the definite/probable infection group had a higher rate of recurrence than those in the groups with possible infection and unlikely infection (P = .009). The IS score was higher in the recurrence group than the non-recurrence group (7.5 ± 4.3 vs. 3.9 ± 3.4, P < .001). Overall, patients who underwent 1-stage revision had a 5.0% recurrence rate, but among the 34 patients with an infection classification of definite or probable who underwent 1-stage revision, the recurrence rate was 5.9%. Cases of highly virulent methicillin-resistant Staphylococcus aureus also showed a recurrence rate of 30.8% compared with 4.0% and 5.9% for Cutibacterium acnes and coagulase-negative staphylococci, respectively (P = .005). CONCLUSION: Recurrent infection after treatment of a periprosthetic infection is associated with increasing severity scores, as defined in the 2018 consensus statement, and more aggressive microorganisms. However, a single-stage surgical procedure, even in patients with higher IS scores, did not impart a significantly increased risk of recurrence.
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Artroplastía de Reemplazo de Hombro , Infecciones Relacionadas con Prótesis , Recurrencia , Reoperación , Humanos , Infecciones Relacionadas con Prótesis/microbiología , Infecciones Relacionadas con Prótesis/cirugía , Infecciones Relacionadas con Prótesis/etiología , Masculino , Femenino , Anciano , Artroplastía de Reemplazo de Hombro/efectos adversos , Persona de Mediana Edad , Factores de Riesgo , Estudios Retrospectivos , Prótesis de Hombro/efectos adversosRESUMEN
BACKGROUND: Patients who undergo total shoulder arthroplasty usually have excellent long-term outcomes. However, a subset of patients is diagnosed with a prosthetic joint infection (PJI) requiring revision procedures and prolonged recovery. The purpose of this study was to evaluate rates of recurrent shoulder PJI in patients undergoing débridement, antibiotics, and implant retention (DAIR), single-stage revision, and 2-stage revision. We also sought to compare outcomes and complications across procedures. METHODS: Retrospective chart review was conducted for patients diagnosed with PJI after primary shoulder arthroplasty between January 2010 and August 2021. Patients were included if they underwent treatment with DAIR, single-stage revision, or 2-stage revision. Demographic information, surgical details, complications, laboratory data, postoperative antibiotic regimen, and infectious pathogen were collected. Postoperative patient-reported outcomes were collected: American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form, Single Assessment Numeric Evaluation, Shoulder Activity Scale, and PROMIS Upper Extremity. Chi-square, t test, and 1-way analysis of variance were used as appropriate to evaluate each factor. RESULTS: Sixty-five patients were included in the study, 26% treated with DAIR, 9% treated with single-stage revision, and 65% treated with 2-stage revision. There were no significant differences in patient comorbidities. Patients undergoing DAIR were diagnosed significantly earlier than those undergoing single- and 2-stage revision procedures (12.6 ± 22.9 months vs. 49.6 ± 48.4 vs. 25.0 ± 26.6, P = .010). Recurrent PJI was noted in 23.1% of patients: 29.4% of DAIR patients, no single-stage patients, and 23.8% of 2-stage patients (P = .330). Patients undergoing 2-stage revision with treatment failure had a significantly higher Elixhauser Comorbidity Index (0.2 ± 3.7 vs. 3.7 ± 3.9, P = .027). There was no significant difference in patient-reported outcomes across groups. CONCLUSION: Patients undergoing treatment of shoulder PJI with DAIR did not have an increased rate of reinfection compared with single-stage and 2-stage revision procedures. Patients treated with DAIR were diagnosed with PJI significantly earlier than those undergoing single-stage and 2-stage revision procedures. There was no difference in complication rates between groups. This information adds to the body of work detailing outcomes after DAIR for shoulder PJI and provides encouraging data for use in this patient population. Future studies with a larger sample size may be conducted to further investigate specific pathogens, infection timelines, and antibiotic regimens that reduce the risk of treatment failure.
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Artroplastía de Reemplazo de Hombro , Infecciones Relacionadas con Prótesis , Humanos , Antibacterianos/uso terapéutico , Estudios Retrospectivos , Desbridamiento/métodos , Artroplastía de Reemplazo de Hombro/efectos adversos , Reoperación/métodos , Resultado del Tratamiento , Infecciones Relacionadas con Prótesis/diagnóstico , Infecciones Relacionadas con Prótesis/tratamiento farmacológico , Infecciones Relacionadas con Prótesis/etiologíaRESUMEN
PURPOSE: Malnutrition is a potentially modifiable risk factor of periprosthetic joint infection (PJI). The purpose of this study was to analyze the role of nutritional status as a risk factor for failure after one- stage revision hip or knee arthroplasty for PJI. METHODS: Retrospective, single-center, case-control study. Patients with PJI according to the 2018 International Consensus Meeting criteria were evaluated. Minimum follow-up was 4 years. Total lymphocyte count (TLC), albumin values, hemoglobin, C-reactive protein, white blood cell (WBC) count and glucose levels were analyzed. An analysis was also made of the index of malnutrition. Malnutrition was defined as serum albumin < 3.5 g/dL and TLC < 1500/mm3. Septic failure was defined as the presence of local or systemic symptoms of infection and the need of further surgery as a result of persistent PJI. RESULTS: No significant differences were found between increased failure rates after a one-stage revision hip or knee arthroplasty for PJI and TLC, hemoglobin level, WBC count, glucose levels, or malnutrition. Albumin and C-reactive protein values were found to have a positive and significant relationship with failure (p < 0.05). Multivariate logistic regression identified only hypoalbuminemia (serum albumin < 3.5 g/dL) (OR 5.64, 95% CI 1.26-25.18, p = 0.023) as a significant independent risk factor for failure. The receiver operating characteristic (ROC) curve for the model yielded an area under the curve of 0.67. CONCLUSION: TLC, hemoglobin; WBC count; glucose levels; and malnutrition, understood as the combination of albumin and TLC, were not found to be statically significant risk factors for failure after single-stage revision for PJI. However, albumin < 3.5 g/dL, alone was a statically significant risk factor for failure after single-stage revision for PJI. As hypoalbuminemia seems to influence the failure rate, it is advisable to measure albumin levels in preoperative workups.
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Artritis Infecciosa , Artroplastia de Reemplazo de Cadera , Hipoalbuminemia , Desnutrición , Infecciones Relacionadas con Prótesis , Humanos , Estudios Retrospectivos , Estudios de Casos y Controles , Proteína C-Reactiva/análisis , Infecciones Relacionadas con Prótesis/etiología , Infecciones Relacionadas con Prótesis/cirugía , Infecciones Relacionadas con Prótesis/diagnóstico , Hipoalbuminemia/complicaciones , Hipoalbuminemia/cirugía , Desnutrición/complicaciones , Desnutrición/cirugía , Artritis Infecciosa/cirugía , Albúmina Sérica/análisis , Glucosa , Artroplastia de Reemplazo de Cadera/efectos adversos , Reoperación/efectos adversosRESUMEN
A prosthetic joint infection (PJI) is possibly the most significant potential complication of total knee arthroplasty (TKA) and is associated with substantial morbidity and socioeconomic burden. It is a devastating complication for both the patient and the surgeon alike. A two-stage revision approach for infected TKA has been the standard for surgical management; however, there is growing interest in single-stage revision surgery due to fewer procedures, reduced inpatient hospital stay and reduced costs to healthcare systems. A one-stage exchange is indicated when there is no sign of systemic sepsis and in cases where a microorganism has been isolated. It involves removal of the old prosthesis, debridement of all infected tissue, a copious washout and re-draping, and finally, re-implantation of a new prosthesis. The two-stage approach involves the use of an antibiotic spacer before the second stage is carried out. The length of time between the stages is discussed. Patients with a PJI should be managed by a multidisciplinary team. We recommend these patients are managed in specialist arthroplasty centres by high volume revision arthroplasty specialists.
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Artritis Infecciosa , Artroplastia de Reemplazo de Rodilla , Prótesis de la Rodilla , Infecciones Relacionadas con Prótesis , Humanos , Artroplastia de Reemplazo de Rodilla/efectos adversos , Prótesis de la Rodilla/efectos adversos , Infecciones Relacionadas con Prótesis/cirugía , Infecciones Relacionadas con Prótesis/complicaciones , Antibacterianos/uso terapéutico , Reoperación/efectos adversos , Reimplantación , Artritis Infecciosa/cirugía , Estudios RetrospectivosRESUMEN
PURPOSE: The anterior cruciate ligament reconstruction (ACLR) failure rate continues to increase. Involvement of a young population with a desire to return to sport, explains the increased need for ACLR (revACLR) revision. The aim of this study was to evaluate clinical outcome, complications, failure rate and return to sport of a single-stage revACLR using bone patellar tendon-bone (BTBT) combined with lateral extra-articular tenodesis (LET). MATERIAL AND METHODS: A retrospective analysis was performed on 36 patients who underwent revACLR. Knee stability was assessed by Lachman and Pivot shift test. Objective anterior laxity was determined by KT-2000 arthrometer. The IKDC subjective, Lysholm, ACL-RSI Scores, level of sport activity and Forgotten Joint Score-12 were recorded. RESULTS: Of 36 patients, we collected data from 17 who underwent single-stage revACLR with autologous BTBT combined with LET, performed using an extra-articular MacIntosh procedure as modified by Arnold-Coker. The side-to-side difference in Lachman test and Pivot shift test significantly improved postoperatively. The subjective IKDC, Lysholm and ACL-RSI significantly improved from 71.4 ± 9.03 to 92 ± 6.9, from 58.3 ± 19.3 to 66.8 ± 27.7 and from 50.4 ± 12.2 to 68.6 ± 24.5, respectively during the post-operative follow-up. Ten patients (58.8%) returned to their desired level of sport. One patient was considered a failure because of the postoperative laxity. CONCLUSION: Single-stage revACLR with BPTB combined with LET is a safe procedure that shows good objective and subjective outcomes, and a high rate of return to the same level of sport. Reducing rotational instability and strain on intra-articular reconstructed structures results in a low rate of complications and failure.
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Lesiones del Ligamento Cruzado Anterior , Reconstrucción del Ligamento Cruzado Anterior , Inestabilidad de la Articulación , Ligamento Rotuliano , Tenodesis , Humanos , Tenodesis/métodos , Ligamento Rotuliano/cirugía , Lesiones del Ligamento Cruzado Anterior/complicaciones , Lesiones del Ligamento Cruzado Anterior/cirugía , Estudios Retrospectivos , Autoinjertos , Volver al Deporte , Articulación de la Rodilla/cirugía , Reconstrucción del Ligamento Cruzado Anterior/efectos adversos , Reconstrucción del Ligamento Cruzado Anterior/métodos , Inestabilidad de la Articulación/etiología , Inestabilidad de la Articulación/cirugíaRESUMEN
Revision shoulder arthroplasty is increasing with the number of primary shoulder replacements rising globally. Complex primary and revisions of shoulder arthroplasties pose specific challenges for the surgeon, which must be addressed preoperatively and intraoperatively. This article aimed to present strategies for the management of revision of shoulder arthroplasties through a single-stage approach. Preoperatively, patient factors, such as age, comorbidities, and bone quality, should be considered. The use of planning software can aid in accurately evaluating implants in situ and predict bony anatomy that will remain after explantation during the revision surgery. The planning from such software can then be executed with the help of mixed reality technology to allow accurate implant placement. Single-stage revision is performed in two steps (debridement as first step, implantation and reconstruction as the second step), guided by the following principles: adequate debridement while preserving key soft tissue attachments (i.e., rotator cuff, pectoralis major, latissimus dorsi, deltoid), restoration of glenoid joint line using bone grafting, restoration of humeral length, reconstruction and/or reattachment of soft tissues, and strict compliance with the postoperative antibiotic regimen. Preliminary results of single-stage revision shoulder arthroplasty show improvement in patient outcomes (mean 1 year), successful treatment of infection for those diagnosed with periprosthetic joint infection, and improved cost-benefit parameters for the healthcare system.
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AIMS: Periprosthetic joint infections (PJIs) with prior multiple failed surgery for reinfection represent a huge challenge for surgeons because of poor vascular supply and biofilm formation. This study aims to determine the results of single-stage revision using intra-articular antibiotic infusion in treating this condition. METHODS: A retrospective analysis included 78 PJI patients (29 hips; 49 knees) who had undergone multiple prior surgical interventions. Our cohort was treated with single-stage revision using a supplementary intra-articular antibiotic infusion. Of these 78 patients, 59 had undergone more than two prior failed debridement and implant retentions, 12 patients had a failed arthroplasty resection, three hips had previously undergone failed two-stage revision, and four had a failed one-stage revision before their single-stage revision. Previous failure was defined as infection recurrence requiring surgical intervention. Besides intravenous pathogen-sensitive agents, an intra-articular infusion of vancomycin, imipenem, or voriconazole was performed postoperatively. The antibiotic solution was soaked into the joint for 24 hours for a mean of 16 days (12 to 21), then extracted before next injection. Recurrence of infection and clinical outcomes were evaluated. RESULTS: A total of 68 patients (87.1%) were free of infection at a mean follow-up time of 85 months (24 to 133). The seven-year infection-free survival was 87.6% (95% confidence interval (CI) 79.4 to 95.8). No significant difference in infection-free survival was observed between hip and knee PJIs (91.5% (95% CI 79.9 to 100) vs 84.7% (95% CI 73.1 to 96.3); p = 0.648). The mean postoperative Harris Hip Score was 76.1 points (63.2 to 92.4) and Hospital for Special Surgery score was 78. 2 (63.2 to 92.4) at the most recent assessment. Polymicrobial and fungal infections accounted for 14.1% (11/78) and 9.0% (7/78) of all cases, respectively. CONCLUSION: Single-stage revision with intra-articular antibiotic infusion can provide high antibiotic concentration in synovial fluid, thereby overcoming reduced vascular supply and biofilm formation. This supplementary route of administration may be a viable option in treating PJI after multiple failed prior surgeries for reinfection. Cite this article: Bone Joint J 2022;104-B(7):867-874.
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Artritis Infecciosa , Artroplastia de Reemplazo de Cadera , Artroplastia de Reemplazo de Rodilla , Infecciones Relacionadas con Prótesis , Antibacterianos/uso terapéutico , Artritis Infecciosa/cirugía , Artroplastia de Reemplazo de Cadera/efectos adversos , Artroplastia de Reemplazo de Rodilla/efectos adversos , Estudios de Seguimiento , Humanos , Infecciones Relacionadas con Prótesis/tratamiento farmacológico , Infecciones Relacionadas con Prótesis/etiología , Infecciones Relacionadas con Prótesis/cirugía , Reinfección , Reoperación/métodos , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
BACKGROUND: The treatment of polymicrobial periprosthetic joint infection (PJI) confronted distinct challenges. No reports have assessed the efficacy of local antibiotic delivery combined with 1-stage exchange in polymicrobial PJI. METHODS: Between January 2013 and December 2018, we retrospectively analyzed the data of 126 patients, including 19 polymicrobial PJIs and 107 monomicrobial PJIs, who underwent single-stage revision using intra-articular antibiotic infusion. The risk factors, microbiology, infection control rate, and clinical outcomes were compared between the 2 groups. RESULTS: Higher body mass index, presence of a sinus tract, and prior revisions were the risk factors for polymicrobial PJI. Isolation of Staphylococcus epidermidis, Streptococcus, Enterococcus, and Gram-negative pathogens was highly associated with polymicrobial PJI. Of the 19 polymicrobial PJIs, only 2 patients occurred infection recurrence, which is similar with the result of 6 of 107 patients in the monomicrobial PJI (P = .225). The Harris Hip Score of the polymicrobial group showed no difference from that of the monomicrobial group (78 vs 80; P = .181). Nevertheless, the polymicrobial group exhibited inferior Hospital for Special Surgery knee score relative to the monomicrobial group (77 vs 79; P = .017). CONCLUSION: With rational and targeted use of antibiotics, single-stage revision can effectively control polymicrobial infections, and achieve favorable outcomes similar to that in monomicrobial patients. However, this regimen is still needed to be further confirmed, especially in the infections with different microbial species simultaneously. Additionally, obese patients with a sinus tract and those who had prior revisions had a greater risk of polymicrobial PJI.
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Artritis Infecciosa , Infecciones Relacionadas con Prótesis , Antibacterianos/uso terapéutico , Artritis Infecciosa/tratamiento farmacológico , Humanos , Infecciones Relacionadas con Prótesis/tratamiento farmacológico , Infecciones Relacionadas con Prótesis/cirugía , Reoperación , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
BACKGROUND: Despite the growing number of studies reporting on the best surgical treatment in the management of periprosthetic joint infection, there are no robust data regarding the type of infected prosthesis before any kind of exchange arthroplasty. To overcome these shortcomings, we asked the following questions: (1) What is the survivorship of nonhinged and hinged knee implants after one-stage exchange arthroplasty and (2) what is the functional outcome after one-stage exchange procedure focusing on knee prostheses and the type of prior infected knee implant. In a secondary radiographic analysis, we also investigated if (3) the type of femoral bone morphology measured by the inner femoral diameter influences the rate of aseptic failures also in patients with periprosthetic joint infection. METHODS: Between January 2011 and December 2017, we performed a retrospective designed study including 211 patients with infected knee prostheses. After all, seventy-six percent (161 of 211 patients) were available for final data analysis. These patients were divided into four groups as per the performed implant revision: (1) bicondylar total knee arthroplasty to rotating hinge implant, (2) rotating hinge to rotating hinge implant, (3) rotating hinge to full hinge implant, and (4) full hinge to full hinge implant. The mean follow-up (FU) was six years (range 3 to 9; standard deviation = 1.9), whereas a minimum FU of three years was required for inclusion. Survivorship and group analysis were performed, and the functional outcome was assessed using postoperative Oxford Knee Scores at the latest FU (60-point scale with lower scores representing less pain and greater function). Furthermore, in all cases, femoral bone morphology was determined as per the Citak classification system. RESULTS: At the final FU, the overall surgical revision rate was 23% (37/161 patients) with nine percent (15/161 patients) suffering a periprosthetic joint infection relapse. Group 1 consisted of 51, group 2 consisted of 67, group 3 consisted of 24, and group 4 consisted of 19 patients. The lowest overall revision rate was found in group 2 (16%, n = 11), compared with 28% (n = 14) in group 1, 29% (n = 7) in group 3, and 26% (n = 5) in group 4; however, no significant differences were found (P = .902). The functional outcome (Oxford Knee Score) was clinically constant in all groups, with 32 points in group 1, 37 points in group 2, 33 points in group 3, and 35 points in group 4 (P = .107). Concerning the number of patients with aseptic loosening as per bone morphology, 74% (14/19) of all aseptic loosening cases appeared in femoral bone type C morphologies according to Citak (75% in group 1, 56% in group 2, 100% in group 3, and 100% in group 4). CONCLUSIONS: The results obtained suggest a generally high overall revision rate (25%) with a good infection control rate (91%). Although we were unable to work out a specific group of patients with a statistically significant differing outcome, it is interesting to see that hinged implants can reach more or less the same functional outcome and revision rates as nonhinged implants, when it comes to revision surgeries. In this study, a relatively high number of aseptic failures contributed to a high overall revision rate. In this context, the bone morphology, measured as per the Citak classification system, could be confirmed as a risk factor for aseptic failures also in septic patients. Therefore, further research might focus on revision knee implant design.
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Artroplastia de Reemplazo de Rodilla , Prótesis de la Rodilla , Artroplastia de Reemplazo de Rodilla/efectos adversos , Humanos , Articulación de la Rodilla/diagnóstico por imagen , Articulación de la Rodilla/cirugía , Prótesis de la Rodilla/efectos adversos , Diseño de Prótesis , Falla de Prótesis , Reoperación , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
INTRODUCTION: This study was undertaken to analyse the outcome of 1-stage exchange in the management of streptococcal periprosthetic joint infection (PJI) of the hip at a single hospital. METHODS: We identified 30 patients with a streptococcal PJI of the hip who had been treated by 1-stage exchange at our hospital between 2002 and 2017. Postoperative complications and the need for any subsequent re-revision for infection or other reasons were analysed. The Harris Hip Score (HHS) was evaluated at final follow-up. RESULTS: The mean follow-up was 8.2 years (SD 4.1). The overall re-revision rate for any reason was 53% (16/30) at a mean 5.3 years (SD 0.68 years). Re-revision for infection was 20% (6/30) at a mean 1.8 years (SD 0.74 years). All re-revisions for PJI (6/6; 100%) were for relapse of the streptococcal infection. At final follow-up, the mean HHS was 68 points (SD 20). CONCLUSIONS: The rate of re-revision after 1-stage exchange for streptococcal PJI is high. Eradication of a streptococcal PJI of the hip remains challenging. Further extensive and comparative studies between 1-and 2-stage exchange are encouraged.
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Artritis Infecciosa , Artroplastia de Reemplazo de Cadera , Infecciones Relacionadas con Prótesis , Infecciones Estreptocócicas , Antibacterianos/uso terapéutico , Artritis Infecciosa/cirugía , Artroplastia de Reemplazo de Cadera/efectos adversos , Humanos , Infecciones Relacionadas con Prótesis/etiología , Infecciones Relacionadas con Prótesis/cirugía , Reoperación/efectos adversos , Estudios Retrospectivos , Infecciones Estreptocócicas/complicaciones , Infecciones Estreptocócicas/cirugía , Resultado del TratamientoRESUMEN
The objective of this study was to evaluate our preliminary results after changing our surgical strategy from 2-stage revision arthroplasty to 1-stage revision arthroplasty for patients with chronic knee periprosthetic joint infection. We conducted a prospective study of knee arthroplasty patients that had been diagnosed with chronic infection and treated using a 1-stage revision regardless of the traditional criteria applied for indication thereof. We evaluated two main variables: infection control and economic costs. The definitive diagnosis of infection of the revision was determined by using the criteria proposed by the Musculoskeletal Infection Society. The costs were calculated as average costs in USD, as described by Srivastava (2019), for 1-stage or 2-stage revisions. Eighteen patients were included in the study, and infection was controlled in 17 patients. The total economic savings for our hospital from these 18 patients amounted to USD 291,152. This clinical success has led to major changes in how our hospital approaches the treatment of chronically infected knee replacements, in addition to substantial economic advantages for the hospital.
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Periprosthetic joint infection (PJI) remains one of the most common causes of revision knee arthroplasty. Controversy continues to surround the proper operative technique of PJI in knee arthroplasty with single- or two-stage replacement. Significant variations are seen in the eradication rates of PJI and in implant survival rates. This detailed retrospective analysis of a single tertiary center is intended to provide further data and insight comparing single- and two-stage revision surgery. A retrospective analysis of all revision total knee arthroplasty (TKA) surgeries from 2013 to 2019 was performed and screened with respect to single- or two-stage TKA revisions. Single- and two-stage revisions were analyzed with regard to implant survival, revision rate, microbiological spectrum, and other typical demographic characteristics. A total of 63 patients were included, with 15 patients undergoing single-stage revision and 48 patients undergoing two-stage revision. The mean follow-up time was 40.7 to 43.7 months. Statistically, no difference was found between both groups in overall survival (54.4% vs. 70.1%, p = 0.68) and implant survival with respect to reinfection (71.4% vs. 82.4%, p = 0.48). Further, high reinfection rates were found for patients with difficult-to-treat organisms and low- to semi-constrained implant types, in comparison to constrained implant types. A statistically comparable revision rate for recurrence of infection could be shown for both groups, although a tendency to higher reinfection rate for single-stage change was evident. The revision rate in this single-center study was comparably high, which could be caused by the high comorbidity and high proportion of difficult-to-treat bacteria in patients at a tertiary center. In this patient population, the expectation of implant survival should be critically discussed with patients.
RESUMEN
AIMS: Single-stage revision total knee arthroplasty (rTKA) is gaining popularity in treating chronic periprosthetic joint infections (PJIs). We have introduced this approach to our clinical practice and sought to evaluate rates of reinfection and re-revision, along with predictors of failure of both single- and two-stage rTKA for chronic PJI. METHODS: A retrospective comparative cohort study of all rTKAs for chronic PJI between 1 April 2003 and 31 December 2018 was undertaken using prospective databases. Patients with acute infections were excluded; rTKAs were classified as single-stage, stage 1, or stage 2 of two-stage revision. The primary outcome measure was failure to eradicate or recurrent infection. Variables evaluated for failure by regression analysis included age, BMI, American Society of Anesthesiologists grade, infecting organisms, and the presence of a sinus. Patient survivorship was also compared between the groups. RESULTS: A total of 292 consecutive first-time rTKAs for chronic PJI were included: 82 single-stage (28.1%); and 210 two-stage (71.9%) revisions. The mean age was 71 years (27 to 90), with 165 females (57.4%), and a mean BMI of 30.9 kg/m2 (20 to 53). Significantly more patients with a known infecting organism were in the single-stage group (93.9% vs 80.47%; p = 0.004). The infecting organism was identified preoperatively in 246 cases (84.2%). At a mean follow-up of 6.3 years (2.0 to 17.6), the failure rate was 6.1% in the single-stage, and 12% in the two-stage groups. All failures occurred within four years of treatment. The presence of a sinus was an independent risk factor for failure (odds ratio (OR) 4.97; 95% confidence interval (CI) 1.593 to 15.505; p = 0.006), as well as age > 80 years (OR 5.962; 95% CI 1.156 to 30.73; p = 0.033). The ten-year patient survivorship rate was 72% in the single-stage group compared with 70.5% in the two-stage group. This difference was not significant (p = 0.517). CONCLUSION: Single-stage rTKA is an effective strategy with a high success rate comparable to two-stage approach in appropriately selected patients. Cite this article: Bone Joint J 2021;103-B(8):1373-1379.
Asunto(s)
Artroplastia de Reemplazo de Rodilla , Articulación de la Rodilla , Prótesis de la Rodilla/efectos adversos , Pautas de la Práctica en Medicina , Infecciones Relacionadas con Prótesis/etiología , Infecciones Relacionadas con Prótesis/cirugía , Reoperación/métodos , Adulto , Anciano , Anciano de 80 o más Años , Enfermedad Crónica , Estudios de Cohortes , Femenino , Hospitales Especializados , Humanos , Masculino , Persona de Mediana Edad , Recurrencia , Estudios Retrospectivos , Factores de Tiempo , Resultado del TratamientoRESUMEN
INTRODUCTION: Two-stage revision is the current gold standard treatment for infected total hip arthroplasties (THA) with good clinical outcomes. Single-stage revision THA offers the advantage of only a single surgical intervention, potentially leading to improved functional outcomes. This study aimed to compare the differences in patient-reported outcome measures (PROMs) and complications between single and two-stage revision THA for chronic periprosthetic joint infection (PJI). METHODS: A total of 159 consecutive revision THA patients for chronic PJI with complete pre-and post-operative patient-reported outcome measures (PROM) was investigated. A total of 46 patients with single-stage revision THA was matched to 92 patients following two-stage revision THA using propensity score matching, yielding a total of 136 propensity score-matched patients for analysis. RESULTS: Single and two-stage revision THA improved PROM scores post-operatively, with significantly higher PROMs for single-stage revision THA (HOOS-PS: 50.7 vs 46.4, p = 0.04; Physical SF 10A: 42.1 vs 36.6, p < 0.001; PROMIS SF Physical: 41.4 vs 37.4, p < 0.001; PROMIS SF Mental: 52.8 vs 47.6, p < 0.001). There was no significant difference between both cohorts for reinfection rates (p = 0.81) and 90-day mortality rates (p = 1.0). CONCLUSION: This study found a demonstrable functional benefit of single-stage revision compared to two-stage revision for THA with chronic periprosthetic joint infection, suggesting that single-stage revision THA may provide an effective alternative to two-stage revision in selected patients with chronic PJI. LEVEL OF EVIDENCE: Level III, case-control retrospective analysis.
Asunto(s)
Artroplastia de Reemplazo de Cadera , Infecciones Relacionadas con Prótesis , Artroplastia de Reemplazo de Cadera/efectos adversos , Estudios de Cohortes , Humanos , Medición de Resultados Informados por el Paciente , Puntaje de Propensión , Infecciones Relacionadas con Prótesis/cirugía , Reoperación , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
Fungal prosthetic joint infection is rare, and two-stage revision is usually advocated. We present our experience with 2 cases of fungal prosthetic knee joint infection presenting 25 months and 3 years after index surgery. Both patients were managed with single-stage revision arthroplasty and fluconazole monotherapy. They remain asymptomatic with good knee society score after 2 years of follow-up. Preoperative workup of all aseptic loosening cases should include extended culture for fungal elements. Single-stage revision with antifungal therapy for 3 months gives good results in nonimmunocompromised patients with good soft-tissue envelope.
RESUMEN
BACKGROUND: Preoperative tunnel widening is a frequently reported indication for performing a 2-stage revision anterior cruciate ligament reconstruction (ACLR) instead of a single-stage procedure. However, the strength of the available evidence to support a 2-stage strategy is low. PURPOSE/HYPOTHESIS: The purpose was to evaluate the clinical outcomes of a single stage-only approach to revision ACLR. It was hypothesized that this approach would be associated with significant improvements from baseline in patient-reported outcome measures (PROMs) and knee stability and that there would be no significant differences in any postoperative outcomes between patients with and without preoperative tunnel widening. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: A retrospective analysis was conducted of a large series of consecutive patients undergoing revision ACLR with a minimum follow-up of 2 years. Preoperative tunnel widening was assessed using digital radiographs. All patients underwent single-stage surgery with an outside-in technique, regardless of the degree of tunnel widening. Clinical outcomes were compared according to whether tunnel widening was present (either tunnel ≥12 mm) or not (both tunnels <12 mm). RESULTS: The study included 409 patients with a mean ± SD follow-up of 69.6 ± 29.0 months. After revision ACLR, there was a significant reduction in the side-to-side anteroposterior laxity difference, from 7.7 ± 2.2 mm preoperatively to 1.2 ± 1.1 mm at 2 years (P < .001). The mean International Knee Documentation Committee (IKDC) and all subscales of the Knee injury and Osteoarthritis Outcome Score (KOOS) exceeded the thresholds for the Patient Acceptable Symptom State defined for primary ACLR. An overall 358 patients had retrievable preoperative radiographs. According to the tunnel diameter measurements, 111 patients were allocated to group A (both tunnels <12 mm) and 247 patients to group B (either/both tunnels ≥12 mm). There were no significant differences between groups with respect to anteroposterior side-to-side laxity difference, graft rupture rates, non-graft rupture related reoperations, or contralateral anterior cruciate ligament injury rates. There was also no significant difference between groups that exceeded minimal detectable change thresholds for any of the PROMs recorded (ACL-RSI [Anterior Cruciate Ligament-Return to Sports After Injury], Lysholm, Tegner, IKDC, KOOS). CONCLUSION: A single-stage approach to revision ACLR is associated with excellent clinical results when an outside-in drilling technique is utilized. The presence of preoperative tunnel widening does not significantly influence PROMs, knee stability, graft rupture rates, or non-graft rupture related reoperation rates.