Elevated ESR/CRP Ratio Is Associated With Reinfection After Debridement, Antibiotics, and Implant Retention in Chronic Periprosthetic Joint Infections

Comparative Perioperative Inflammatory and Functional Outcomes in Single Versus Multiple Joint Replacements for Hemophilic Arthritis: A Pilot Study

OBJECTIVE

Hemophilic arthritis is a progressive joint disease often requiring surgical intervention in advanced stages. However, comparative evidence on perioperative inflammatory and coagulation responses between single joint replacement (SJR) and multiple joint replacement (MJR) remains scarce. This study aimed to assess the differences in perioperative outcomes, including inflammatory responses, blood transfusion requirements, and functional recovery, to guide surgical decision-making for hemophilic arthritis patients.

METHODS

This retrospective study included 29 male patients with moderate-to-severe hemophilic arthritis who underwent SJR (n = 12) or MJR (n = 17) at a single institution from October 2020 to October 2023. Data on inflammatory markers (CRP, ESR, IL-6, WBC), hemoglobin levels, blood transfusion requirements, and joint mobility were collected for the immediate postoperative period (days 1-14). Trends in inflammatory markers were analyzed using average percent changes (APC), and differences in outcomes were evaluated using the Mann-Whitney U test for continuous variables and Fisher's exact test for categorical variables. Longitudinal changes were analyzed using mixed-model repeated measures ANOVA with time points as fixed effects and subjects as random effects. Statistical significance was set at p < 0.05.

RESULTS

Postoperative CRP levels declined significantly in both groups, with APCs of -9.06% (95% CI: -15.63 to -1.98, p < 0.05) for the SJR group and -8.42% (95% CI: -16.18 to 0.06) for the MJR group. ESR showed a significant upward trend, with APCs of 10.82% (95% CI: 0.95-21.65, p < 0.05) in the SJR group and 17.54% (95% CI: 11.71-23.67, p < 0.05) in the MJR group. Blood transfusion requirements were comparable, with median transfusion volumes of 0.00 units (IQR: 3.50) for SJR and 0.00 units (IQR: 3.75) for MJR (p = 0.761). Notably, joint mobility scores were significantly better in the MJR group (mean: 31.88, SD: 19.31) compared to the SJR group (mean: 18.33, SD: 10.39; p = 0.030). Despite the larger surgical scope of MJR, no significant differences in infection or bleeding risks (SJR:median transfusion = 0.00 units, IQR: 3.50; MJR:median transfusion, 0.00 units, IQR: 3.75. p = 0.761) were observed between the groups.

CONCLUSION

This study demonstrates that MJR offers superior functional recovery compared to SJR, without increasing the risks of infection, bleeding, or transfusion. These findings support MJR as a safe and effective surgical option for hemophilic arthritis patients when appropriate perioperative management protocols are implemented. Future studies with larger sample sizes and long-term follow-up are needed to validate these results and explore extended outcomes.

Nomogram to predict periprosthetic joint infection after total hip arthroplasty using laboratory tests

BACKGROUND

Periprosthetic joint infection (PJI) is a catastrophic complication after joint arthroplasty. This study aimed to analyze the relationship between laboratory tests and PJI and establish a nomogram for predicting risks of PJI after total hip arthroplasty (THA).

MATERIALS AND METHODS

The clinical data of patients who underwent THA from January 2015 to December 2020 were retrospectively analyzed. Demographic and relevant clinical information of patients was collected; independent risk factors associated with PJI were determined by univariate and multivariate logistic regression analysis, and receiver operating characteristics (ROC) were drawn to analyze the specificity and sensitivity of each risk factor. Risk factors are included in the nomogram. Calibration curve and decision curve analysis were used to evaluate the predictive accuracy and discriminability of the model.

RESULTS

A total of 589 patients were enrolled in the study, of whom 87 were eventually diagnosed with PJI. Multivariate logistic regression analysis showed that serum C-reactive protein, erythrocyte sedimentation rate, polymorphonuclear neutrophils, D-dimer, and platelet count were independent risk factors for PJI after THA. The ROC curve analysis model of multivariate combined diagnosis had good diagnostic value, sensitivity was 77.01%, and specificity was 75.51%. The calibration curve shows good agreement between the prediction of the line graph and the actual observed results. The decision curve shows that the nomogram has a net clinical benefit.

CONCLUSIONS

The changes in serum C-reactive protein, erythrocyte sedimentation rate, polymorphonuclear neutrophils, D-dimer, and platelet count are related to the occurrence of PJI after hip arthroplasty. The nomogram prediction model established in this study is promising for the screening of PJI after hip arthroplasty.

LEVEL OF EVIDENCE

Level III evidence. Non-randomized controlled cohort/follow-up study.

Inflammatory Marker Changes Following Total Knee Arthroplasty for Rheumatoid Arthritis with Vancomycin-Loaded Calcium Sulfate Bone Filling

Rheumatoid arthritis (RA) patients undergoing total knee arthroplasty (TKA) face infection risk. The study evaluates vancomycin-loaded calcium sulfate bone as infection prevention. Patients with RA treated with TKA who had their femoral canal filled using either vancomycin-loaded calcium sulfate bone (experimental group [n = 35]) or the patient's own excised autologous bone (control group [n = 30]) at the Qingdao University Affiliated Hospital, Qingdao, China from January 1, 2017, to March 1, 2023, were retrospectively enrolled in this study. An experienced surgeon used midvastus approach. Surgeries included disinfection, antibiotics, and femoral filling. The age, gender, body mass index (BMI), comorbidities, and intraoperative details were extracted from the patient's medical records. Preoperation and postoperation markers (C-reactive protein [CRP], erythrocyte sedimentation rate [ESR]), pain scale (Visual Analog Scale [VAS]), infection rate, and Knee Society Score (KSS) were collected. Groups matched in age, gender, and BMI. No preoperative inflammatory marker differences were observed. However, compared to the control group, the postoperative inflammatory markers were significantly lower in the experimental group at 1-week postsurgery (CRP: 40.80 ± 23.17 vs. 60.80 ± 43.12 mg/L, p = 0.021; ESR: 72.06 ± 17.52 vs. 83.87 ± 21.52 mm/h, p = 0.012) and at 1-month postsurgery (CRP: 15.63 ± 6.56 vs. 21.17 ± 13.16 mg/L, p = 0.032; ESR: 25.25 ± 20.44 vs. 38.40 ± 25.26 mm/h, p = 0.024). There were no significant differences in the VAS (2.79 ± 0.90 vs. 2.70 ± 0.84 score, p = 0.689) and KSS (64.31 ± 17.88 vs. 66.57 ± 12.36) at 1-month postsurgery. Experimental group: zero infections; control group: only one infection. Administering vancomycin and calcium sulfate during TKA in RA patients reduces postoperative inflammation, but does not significantly affect infection risk; further research may be necessary for validation.

Monitoring of blood biochemical markers for periprosthetic joint infection using ensemble machine learning and UMAP embedding

INTRODUCTION

Periprosthetic joint infection (PJI) is a serious complication after total joint arthroplasty. It is important to accurately identify PJI and monitor postoperative blood biochemical marker changes for the appropriate treatment strategy. In this study, we aimed to monitor the postoperative blood biochemical characteristics of PJI by contrasting with non-PJI joint replacement cases to understand how the characteristics change postoperatively.

MATERIALS AND METHODS

A total of 144 cases (52 of PJI and 92 of non-PJI) were reviewed retrospectively and split into development and validation cohorts. After exclusion of 11 cases, a total of 133 (PJI: 50, non-PJI: 83) cases were enrolled finally. An RF classifier was developed to discriminate between PJI and non-PJI cases based on 18 preoperative blood biochemical tests. We evaluated the similarity/dissimilarity between cases based on the RF model and embedded the cases in a two-dimensional space by Uniform Manifold Approximation and Projection (UMAP). The RF model developed based on preoperative data was also applied to the same 18 blood biochemical tests at 3, 6, and 12 months after surgery to analyze postoperative pathological changes in PJI and non-PJI. A Markov chain model was applied to calculate the transition probabilities between the two clusters after surgery.

RESULTS

PJI and non-PJI were discriminated with the RF classifier with the area under the receiver operating characteristic curve of 0.778. C-reactive protein, total protein, and blood urea nitrogen were identified as the important factors that discriminates between PJI and non-PJI patients. Two clusters corresponding to the high- and low-risk populations of PJI were identified in the UMAP embedding. The high-risk cluster, which included a high proportion of PJI patients, was characterized by higher CRP and lower hemoglobin. The frequency of postoperative recurrence to the high-risk cluster was higher in PJI than in non-PJI.

CONCLUSIONS

Although there was overlap between PJI and non-PJI, we were able to identify subgroups of PJI in the UMAP embedding. The machine-learning-based analytical approach is promising in consecutive monitoring of diseases such as PJI with a low incidence and long-term course.

The role of antibiotic calcium sulfate beads in acute periprosthetic knee infection: a retrospective cohort study

Background

The study aimed to compare debridement, antibiotics, and implant retention (DAIR) vs. debridement antibiotic bead and retention of the implant (DABRI) in terms of infection-free success rate and treatment cost for acute periprosthetic joint infections after total knee arthroplasty (TKA).

Method

Between 2017 and 2020, 32 patients with acute periprosthetic joint infection who were treated by total knee arthroplasty were retrospectively reviewed. The patients were divided into a DAIR group (n=15) and a DABRI group (n=17). During the DABRI, additional calcium ulphate antibiotic beads were used. Patient age, the Musculoskeletal Infection Society score, microorganisms involved, and success rate were assessed.

Results

The mean age of DAIR group (n=15) was 69 years, with 7 being male, and 8 female. The mean follow-up period lasted 30 months. The success rate was 80% (12/15). The mean age of DABRI group (n=17) was 64 years, with 10 patients being male and 7 female. The mean follow-up period was 16 months. The success rate was 88% (15/17). There were no significant differences in patient age (P>0.05), the Musculoskeletal Infection Society score (P>0.05), and success rate (P>0.05). A significant difference was found in the follow-up period between the two groups (P<0.05).

Conclusion

Both DAIR and DABRI could be used to treat acute periprosthetic joint infections and the outcomes and treatment costs of the two procedures were comparable. Additional use of calcium sulfate beads was safe, but might not improve the treatment result. Randomized controlled studies are warranted for the routine use.

Outcomes of Tourniquet-Less Revision Total Knee Arthroplasty: A Matched Cohort Analysis

INTRODUCTION

A tourniquet is routinely used in total knee arthroplasty (TKA) to limit perioperative blood loss and increase the visibility of the surgeon's field of view. This study aims to evaluate the postoperative clinical outcomes and complications associated with tourniquet use in revision TKA.

METHODS

We conducted a retrospective review of 1,904 consecutive patients who underwent revision TKA. Propensity score-based matching was done to adjust for baseline differences in patient demographics and procedure details.

RESULTS

Propensity score matching resulted in a cohort of 548 revision total joint arthroplasty patients, 274 (50.0%) of whom were tourniquet patients matched to 274 (50.0%) tourniquet-less patients. Multivariate regression analyses demonstrated that, compared with the tourniquet-less cohort, the tourniquet cohort had significantly less intraoperative (413.7 to 353.2 mL, P < 0.01) and total perioperative (1,548.7 to 1,417.8 mL, P < 0.01) blood loss. However, no significant differences were present in total perioperative (8.4%, 6.6%, P = 0.43) transfusion rates. The tourniquet cohort had increased length of stay (3.2 to 3.7 days, P < 0.001) and 30-day readmissions (P = 0.04).

DISCUSSION

This study demonstrated that although omitting the tourniquet in revision TKA leads to markedly increased perioperative blood loss, notable differences in perioperative transfusion rates were not observed. Furthermore, revision TKA without tourniquet use was associated with reduced postoperative length of stay, 30-day readmissions, and increased range of flexion.

Trend of serum C-reactive protein is associated with treatment outcome of hip Periprosthetic joint infection undergoing two-stage exchange arthroplasty: a case control study

Background

Serum C-reactive protein (CRP) trends are critical for monitoring patients’ treatment response following a two-stage exchange arthroplasty for periprosthetic joint infection (PJI) of the hip. However, CRP trends are poorly described in the literature. The primary aim of this study was to identify the relationships between PJI treatment outcomes and our proposed CRP trend definitions, parameters, and microbiological data. The secondary aim was to investigate CRP trends after the occurrence of spacer-related complications.

Methods

We conducted a retrospective review of 74 patients treated with a two-stage exchange protocol for PJI in a tertiary referral joint center between 2014 and 2016. Patients with factors that may affect CRP levels (inflammatory arthritis, concomitant infections, liver and kidney diseases, and intensive care admissions) were excluded. CRP trends were categorized into five types and PJI treatment outcome was defined as “success” or “failure” according to the Delphi criteria.

Results

Treatment was successful in 67 patients and failed in 7 patients. Multivariate logistic regression analysis showed that type 5 CRP, defined as serum CRP fluctuation without normalization after first stage surgery (odds ratio [OR]: 17.4; 95% confidence interval [CI]: 2.3–129.7; p = 0.005), and methicillin-resistant Staphylococcus aureus (MRSA; OR: 14.5; 95% CI: 1.6–131.7; p = 0.018) were associated with treatment failure. Spacer-related complications occurred in 18 patients. Of these, 12 had elevated CRP levels at later follow-up, while six had no elevation in CRP levels.

Conclusions

We found that MRSA infection and type 5 CRP were associated with PJI treatment failure.

Outcomes and Risk Factors Associated With Failures of Debridement, Antibiotics, and Implant Retention in Patients With Acute Hematogenous Periprosthetic Joint Infection

BACKGROUND

Acute hematogenous periprosthetic joint infections (PJI) accounts for 20% to 35% of all PJI cases. Treatment options include débridement, antibiotics, and implant retention (DAIR) or implant revision (single-stage/two-stage revision). Because the reported success rates of DAIR for acute PJIs as reported in the literature varies widely, this study aimed to investigate (1) the outcome of DAIR as revision surgery procedure and (2) the potential risk factors for treatment failure of DAIR in patients with acute hematogenous PJI.

METHODS

We reviewed 106 consecutive cases of total joint arthroplasty patients who underwent DAIR for the diagnosis of acute hematogenous PJI. Outcomes of the cohort including infection free survival was investigated. Mean follow-up was 4.9 years. Demographics, case data, comorbidities, and extremity score were analyzed by univariate and multivariate regressions to identify risk factors for failure of DAIR.

RESULTS

The failure rate of patients who underwent DAIR was 23.6% (25 of 106 patients). Univariate regression demonstrated that diabetes mellitus (P = 0.01) and polymicrobial infections (P < 0.01) are associated with failure of DAIR. Multivariate regression confirmed diabetes mellitus and polymicrobial infections as independent risk factors for failure of DAIR.

DISCUSSION

Debridement, antibiotics, and implant retention may be a viable treatment option with moderate failure rates at the midterm follow-up in cases of acute hematogenous PJI. The study also identified diabetes mellitus and polymicrobial infections as independent risk factors for failure of DAIR. The findings of this study provide clinically useful information for surgeons in treatment of patients with acute hematogenous PJI.

Preoperative Serum C-Reactive Protein/Albumin Ratio Is a Predictor of Complications After Single-stage Revision for the Treatment of Periprosthetic Joint Infection

BACKGROUND

The C-reactive protein/albumin ratio (CAR) is a marker of inflammation that has been associated with negative outcomes in the general surgery. This study investigates the potential association of preoperative CAR with postoperative complications and readmission rates in the treatment of patients with single-stage revision total joint arthroplasty for periprosthetic joint infection.

METHODS

A total of 213 consecutive patients who had undergone single-stage revision for total joint arthroplasty with the preoperative diagnosis of periprosthetic joint infection and preoperative C-reactive protein and albumin values were included. The area under receiver operating characteristic curves was calculated to evaluate the CAR as a predictive value for the complications.

RESULTS

Significant differences between the mean CAR were found for patients with 30- and 60-day readmissions and reinfection (P < 0.01). CAR combined with serum and synovial fluid markers demonstrated significantly higher sensitivities and specificities for the prediction of 30-day (total knee arthroplasty [TKA]: 94%; 95%; total hip arthroplasty [THA]: 91%; 96%) and 60-day readmissions (THA: 94%; 95%; TKA: 92%; 96%) and reinfections (TKA: 94%; 95%; THA: 87%; 96%), when compared with only serum and synovial fluid markers combined (83%; 84%; 85%; 87%; 85%; 88%; P <0.01).

DISCUSSION

High preoperative CAR, when combined with serum and synovial fluid markers, was associated with increased risk of reinfection and 30- and 60-day readmissions, suggesting that preoperative CAR is a clinically useful predictor for postoperative complications in patients with periprosthetic hip and knee joint infections.

Comparison of patient reported outcome measures after single versus two-stage revision for chronic infection of total hip arthroplasty: a retrospective propensity score matched cohort study

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.

Impact of Smoking and Drinking on Complications After Revision Total Joint Arthroplasty: A Matched Cohort Analysis

INTRODUCTION

Smoking and drinking have been shown to impair postoperative outcomes in primary hip and knee total joint arthroplasty (TJA). This study aimed to evaluate the potential impact of smoking and drinking on complications after revision TJA.

METHODS

We retrospectively evaluated a total of 4,302 consecutive patients who underwent revision TJA. Patient demographics and complications were compared between four cohorts based on smoking and drinking status: (1) nonusers (nonsmokers and nondrinkers), (2) smokers, (3) drinkers, and (4) concurrent users.

RESULTS

A total of 1,924 patients were matched using propensity score analysis: 808 nonusers (42.0%), 421 smokers (21.9%), 483 drinkers (25.0%), and 212 concurrent users (11.1%). When compared with nonusers, smokers, drinkers, and concurrent users (simultaneous smokers and drinkers) exhibited higher odds for both inhospital complications (odds ratios, smokers: 2.40, drinkers: 1.55, and concurrent users: 5.13, P < 0.01). Among the user cohorts, although smokers and drinkers showed similar rates of 90-day postdischarge complications (smokers: 14.95% and drinkers: 14.80%, P = 0.95), concurrent users demonstrated the highest significant odds for these complications (odds ratio, 1.64, P = 0.02).

DISCUSSION

Our propensity-score-matched cohort study results demonstrate that although the smokers and drinkers groups shared similarly poor outcomes after discharge, concurrent users were found to have the worst outcomes compared with either single user group.

Outcome of Spinal Versus General Anesthesia in Revision Total Hip Arthroplasty: A Propensity Score-Matched Cohort Analysis

INTRODUCTION

Spinal anesthesia has been previously shown to offer improved patient outcomes compared with general anesthesia in revision total knee arthroplasty. This study aimed to evaluate the potential differences in perioperartive and postoperative outcomes in revision total hip arthroplasty (THA) between spinal or general anesthesia.

METHODS

A total of 2,656 consecutive patients who underwent revision THA were evaluated. Propensity-score-adjusted multivariate logistic regression analyses were applied to control for intergroup variability and evaluate the differences in outcomes and complications with anesthesia type.

RESULTS

Propensity score matching resulted in 1:1 matching with 265 patients in each anesthesia cohort. Multivariate analyses demonstrated that patients administered general anesthesia had a significantly longer procedure time (174.8 versus 161.3, P < 0.01), higher intraoperative (402.6 versus 305.5 mL, P < 0.01), and total perioperative blood loss (1802.2 versus 1,684.2 mL,P < 0.01). In addition, patients administered general anesthesia were found to have higher odds for two or more inhospital complications (odds ratio, 4.51, P < 0.01) and extended length of stay (odds ratio, 2.45, P = 0.02).

DISCUSSION

Our study shows that propensity-matched patients who received spinal anesthesia for revision THA exhibited notable reduction in surgical time, perioperative blood loss, and complications compared with patients who received general anesthesia, suggesting that spinal anesthesia is a viable alternative to general anesthesia in revision THA.

The role of fibrinogen in predicting reinfection after DAIR for periprosthetic joint infections

Background

Fibrinogen (FIB) has been found to be a promising marker in diagnosing periprosthetic joint infection (PJI), however, the value of FIB in predicting reinfection of PJI is unknown. The purpose of this study was to evaluate the value of FIB in predicting reinfection after debridement, antibiotics, and implant retention (DAIR) for PJI.

Methods

We retrospectively analyzed the clinical data of patients who were diagnosed with PJI and underwent DAIR from 2013 to 2019. The levels of the FIB, erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP) were measured before DAIR. After DAIR, patients were followed and reinfections were identified. For both acute and chronic PJI, the predictive value of FIB was evaluated by calculating the sensitivity, specificity, and area under the curve (AUC) of the receiver operating characteristic curve (ROC), and was compared with traditional inflammatory markers including ESR and CRP.

Results

The expression of FIB differed between patients reinfected and those not reinfected in both acute and chronic PJI (p < 0.05). In patients who underwent DAIR for acute PJI, the sensitivity and specificity of FIB were 81.82 and 83.33%, respectively, which were significantly higher than that of CRP (sensitivity, 72.73%; specificity, 50%; p < 0.05), while the specificity was higher than that of ESR (specificity, 41.67%; p < 0.05). In patients who underwent DAIR for chronic PJI, the sensitivity and specificity of FIB were 80.00 and 66.66%, respectively, which were significantly higher than that of CRP (sensitivity, 53.33%; specificity, 66.66%; p < 0.05) and ESR (sensitivity was 66.00%; specificity, 16.66%; p < 0.05). The ROC curves showed that FIB demonstrated the highest AUC among the biomarkers in both acute and chronic PJI.

Conclusion

FIB is a promising indicator in predicting reinfection after DAIR for both acute and chronic PJI, and it seems to perform better than ESR and CRP.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-021-04357-8.

The change in plasma D-dimer does not help to guide the timing of reimplantation in two stage exchange for periprosthetic joint infection

D-dimer has been included in the criteria by the Musculoskeletal Infection Society in 2018 as a novel parameter to diagnose prosthetic joint infection (PJI). However, it is unclear how D-dimer levels change in between stages of a two-stage exchange. We prospectively investigated 30 patients who underwent a two-stage exchange using a spacer for PJI. D-Dimer, CRP and IL-6 were collected before first and second stage surgery and the difference (Δ) in between stages was calculated. The levels of plasma D-Dimer did not change from first to second stage surgery (2770 ng/ml (IQR, 1600–3770 ng/ml) versus 2340 ng/ml (IQR, 1270–4100 ng/ml); p = 0.8) while CRP (4.0 mg/dl (IQR, 1.7–5.5 mg/dl) versus 0.6 mg/dl (IQR, 0.5–0.8 mg/dl); p < 0.001) and IL-6 (21 pg/ml (IQR, 10–29 pg/ml) versus 6 pg/ml (4–9 pg/ml); p < 0.001) decreased. The ΔD-dimer between both stages was 300 ng/ml (range: − 2820 to 4280 ng/ml), the median ΔCRP was − 3.4 mg/dl (IQR, − 1.2 to − 4.8 mg/dl) and ΔIL-6 was − 13 pg/ml (IQR, − 4 to − 20 pg/ml). In 15 of 30 cases (50%) the D-dimer level increased between both stages, whereas the level of CRP (93%; 28/30) and IL-6 (96%; 28/29) decreased in most patients. As the level of serum D-dimers varies greatly, lacks a uniform decrease and does not identify persisting infection, surgeons should be cautious when using it at the timing of reimplantation.

Outcomes and Risk Factors Associated With 2-Stage Reimplantation Requiring an Interim Spacer Exchange for Periprosthetic Joint Infection

BACKGROUND

Patients undergoing a 2-stage revision for periprosthetic joint infection (PJI) often require a repeat spacer in the interim due to persistent infection. This study aims to report outcomes for patients with repeat spacer exchange and to identify risk factors associated with interim spacer exchange in 2-stage revision arthroplasty.

METHODS

A total of 256 consecutive 2-stage revisions for chronic infection of total hip arthroplasty and total knee arthroplasty with reimplantation and minimum 2-year follow-up were investigated. An interim spacer exchange was performed in 49 patients (exchange cohort), and these patients were propensity score matched to 196 patients (nonexchange cohort). Multivariate analysis was performed to analyze risk factors for failure of interim spacer exchange.

RESULTS

Patients in the propensity score-matched exchange cohort demonstrated a significantly increased reinfection risk compared to patients without interim spacer exchange (24% vs 15%, P = .03). Patients in the propensity score-matched exchange cohort showed significantly lower postoperative scores for 3 patient-reported outcome measures (PROMs): hip disability and osteoarthritis outcome score physical function (46.0 vs 54.9, P = .01); knee disability and osteoarthritis outcome score physical function (43.1 vs 51.7, P < .01); and patient-reported outcomes measurement information system physical function short form (41.6 vs 47.0, P = .03). Multivariate analysis demonstrated Charles Comorbidity Index (odds ratio, 1.56; P = .01) and the presence of Enterococcus species (odds ratio, 1.43; P = .03) as independent risk factors associated with 2-stage reimplantation requiring an interim spacer exchange for periprosthetic joint infection.

CONCLUSION

This study demonstrates that patients with spacer exchange had a significantly higher risk of reinfection at 2 years of follow-up. Additionally, patients with spacer exchange demonstrated lower postoperative PROM scores and diminished improvement in multiple PROM scores after reimplantation, indicating that an interim spacer exchange in 2-stage revision is associated with worse patient outcomes.

Outcome of Revision Surgery for the Idiopathic Stiff Total Knee Arthroplasty

BACKGROUND

Idiopathic stiff total knee arthroplasty (TKA) represents one of the most challenging subsets of the stiff TKA, as the etiology is unknown and there is no consensus on the most appropriate surgical treatment modality. Therefore, the aim of this study is to report on postoperative outcomes of revision surgery for idiopathic stiff TKA.

METHODS

We retrospectively reviewed 189 consecutive patients (202 knees) who underwent revision TKA for stiffness: (1) 101 knees in the idiopathic stiffness cohort and (2) 88 in the non-idiopathic stiffness cohort. In the idiopathic stiffness cohort, 42 knees underwent isolated tibial insert exchange and 59 knees underwent component revision. Perioperative knee range of movement and complications were analyzed.

RESULTS

The overall revision surgery outcomes of the idiopathic stiffness cohort were worse than those of the non-idiopathic stiffness cohort with regard to maximum flexion (91.7° vs 100.1°, P = .02) and flexion range of motion (ROM) (87.6° vs 97.1°, P = .01). In the idiopathic stiffness cohort, isolated tibial insert exchange demonstrated greater maximum flexion (96.8° vs 88.4°, P = .06) and flexion ROM (93.2° vs 83.9°, P = .07). In terms of re-revision rates, the isolated tibial insert exchange idiopathic stiffness cohort demonstrated lower re-revision rates compared to the component revision idiopathic stiffness cohort (16.7% vs 31.0%, P = .01).

CONCLUSION

This study demonstrates that the overall revision surgery outcome of idiopathic stiff TKA is worse than non-idiopathic TKA stiffness. In idiopathic stiffness cohorts, isolated tibial insert exchange was associated with lower re-revision rates than component revision, with similar efficacy in improving ROM, suggesting that isolated tibial insert exchange may be a preferred surgical treatment option in TKA patients with idiopathic stiffness.

Development of a Preoperative Risk Calculator for Reinfection Following Revision Surgery for Periprosthetic Joint Infection

BACKGROUND

A recent systematic review demonstrated that reinfection rates following eradication of hip and knee periprosthetic joint infection (PJI) may be as high as 29%. This study aimed to develop a preoperative risk calculator for assessing patient's individual risk associated with reinfection following treatment of PJI in total joint arthroplasty (TJA).

METHODS

A total of 1081 consecutive patients who underwent revision TJA for PJI were evaluated. In total, 293 patients were diagnosed with TJA reinfection. A total of 56 risk factors, including patient characteristics and surgical variables, were evaluated with multivariate regression analysis. Analysis of the area under the receiver operating characteristics curve was performed to evaluate the strength of the predictive model.

RESULTS

Of the 56 risk factors studied, 19 were found to have a significant effect as risk factor for TJA reinfection. The strongest predictors for TJA reinfection included previous PJI treatment techniques such as irrigation and debridement, the number of previous surgical interventions, medical comorbidities such as obesity, drug abuse, depression and smoking, as well as microbiology including the presence of Enterococcus species. The combined area under the receiver operating characteristics curve of the risk calculator for periprosthetic hip and knee joint reinfection was 0.75.

CONCLUSIONS

The study findings demonstrate that surgical factors, including previous PJI surgical treatment techniques as well as the number of previous surgeries, alongside microbiology including the presence of Enterococcus species have the strongest effect on the risk for periprosthetic THA and TKA joint reinfection, suggesting the limited applicability of the existing risk calculators for the development of PJI following primary TJA in predicting the risk of periprosthetic joint reinfection.

One-stage revision is as effective as two-stage revision for chronic culture-negative periprosthetic joint infection after total hip and knee arthroplasty

AIMS

Removal of infected components and culture-directed antibiotics are important for the successful treatment of chronic periprosthetic joint infection (PJI). However, as many as 27% of chronic PJI patients yield negative culture results. Although culture negativity has been thought of as a contraindication to one-stage revision, data supporting this assertion are limited. The aim of our study was to report on the clinical outcomes for one-stage and two-stage exchange arthroplasty performed in patients with chronic culture-negative PJI.

METHODS

A total of 105 consecutive patients who underwent revision arthroplasty for chronic culture-negative PJI were retrospectively evaluated. One-stage revision arthroplasty was performed in 30 patients, while 75 patients underwent two-stage exchange, with a minimum of one year's follow-up. Reinfection, re-revision for septic and aseptic reasons, amputation, readmission, mortality, and length of stay were compared between the two treatment strategies.

RESULTS

The patient demographic characteristics did not differ significantly between the groups. At a mean follow-up of 4.2 years, the treatment failure for reinfection for one-stage and two-stage revision was five (16.7%) and 15 patients (20.0%) (p = 0.691), and for septic re-revision was four (13.3%) and 11 patients (14.7%) (p = 0.863), respectively. No significant differences were observed between one-stage and two-stage revision for 30- 60- and 90-day readmissions (10.0% vs 8.0%; p = 0.714; 16.7% vs 9.3%; p = 0.325; and 26.7% vs 10.7%; p = 0.074), one-year mortality (3.3% vs 4.0%; p > 0.999), and amputation (3.3% vs 1.3%; p = 0.496).

CONCLUSION

In this non-randomized study, one-stage revision arthroplasty demonstrated similar outcomes including reinfection, re-revision, and readmission rates for the treatment of chronic culture-negative PJI after TKA and THA compared to two-stage revision. This suggests culture negativity may not be a contraindication to one-stage revision arthroplasty for chronic culture-negative PJI in selected patients. Cite this article: Bone Joint J 2021;103-B(3):515-521.