1.5-Stage Versus 2-Stage Exchange Total Hip Arthroplasty for Chronic Periprosthetic Joint Infections: A Comparison of Survivorships, Reinfections, and Patient-Reported Outcomes

Results of 331 Two-Stage Exchanges for PJI Following THA: Low Reinfection and Mechanical Failure Rates at 10 Years

BACKGROUND

The relative advantages and disadvantages of 2-stage versus 1-stage management of infection following total hip arthroplasty (THA) are the current subject of intense debate. To understand the merits of each approach, detailed information on the short and, importantly, longer-term outcomes of each must be known. The purpose of the present study was to assess the long-term results of 2-stage exchange arthroplasty following THA in one of the largest series to date.

METHODS

We identified 331 periprosthetic joint infections (PJIs) that had been treated with a 2-stage exchange arthroplasty between 1993 and 2021 at a single institution. Patients were excluded if they had had prior treatment for infection. The mean age at the time of reimplantation was 66 years, 38% of the patients were female, and the mean body mass index (BMI) was 30 kg/m 2 . The diagnosis of PJI was based on the 2011 Musculoskeletal Infection Society criteria. A competing-risk model accounting for death was utilized. The mean duration of follow-up was 8 years.

RESULTS

The cumulative incidence of reinfection was 7% at 1 year and 11% at 5 and 10 years. Factors predictive of reinfection included BMI ≥30 kg/m 2 (hazard ratio [HR] = 2; p = 0.049) and the need for a spacer exchange (HR = 3.2; p = 0.006). The cumulative incidence of any revision was 13% at 5 and 10 years. The cumulative incidence of aseptic revision was 3% at 1 year, 7% at 5 years, and 8% at 10 years. Dislocation occurred in 33 hips (11% at 10 years); 15 (45%) required revision. Factors predictive of dislocation were female sex (HR = 2; p = 0.047) and BMI <30 kg/m 2 (HR = 3; p = 0.02). The mean Harris hip score (HHS) improved from 54 to 75 at 10 years.

CONCLUSIONS

In this series of 331 two-stage exchange arthroplasties that were performed for the treatment of infection, we found a low rate of aseptic revision (8%) and a low rate of reinfection (11%) at 10 years. These long-term mechanical and infection data must be kept in mind when considering a paradigm shift to 1-stage exchanges.

LEVEL OF EVIDENCE

Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence.

Can a 1.5-Stage Revision Be an Effective Alternative for Chronic Periprosthetic Hip and Knee Infections? A Systematic Review and Meta-Analysis

BACKGROUND

A 1.5-stage revision could be an alternative to a 2-stage revision for treating hip and knee chronic periprosthetic infections, guaranteeing the maintenance of joint function and infection control and preventing infection-free patients from undergoing further surgery. Our systematic review aimed to answer several questions about the indication, the infection eradication rate, and the long-term functional outcome of 1.5-stage revisions used to treat chronic periprosthetic infections of the hip and knee.

METHODS

A systematic review of the literature was performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, including studies dealing with the use of 1.5-stage and two-stage surgery for chronic periprosthetic joint infection following total knee arthroplasty or total hip arthroplasty The Coleman Methodology Score and the Methodological Index for Nonrandomized Studies score were used to assess the quality of the studies. A meta-analysis was performed to evaluate the infection eradication rate using either the 1.5-stage revision or the 2-stage technique. A total of 494 patients (111 hips and 385 knees) who underwent 1.5-stage with a mean age of 69 years (range, 61 to 82) were identified in the ten included studies.

RESULTS

The most common cause of reoperation was the conversion to the definitive prosthesis, followed by aseptic loosening. Infection control was reached in 84.6% of the 1.5-stage and 76.1% of the two-stage cohorts. The infection recurrence rate was higher in the two-stage cohort than the 1.5-stage group (21.8 versus 14.3%).

CONCLUSIONS

The 1.5-stage technique represents a valid treatment option in selected patients who have chronic periprosthetic joint infection who cannot undergo further surgeries, adding together the benefits of the 1- and 2-stage procedures. Furthermore, the 1.5-stage showed a better success rate in the infection resolution than the 2-stage technique.

1.5-Stage Revision for the Treatment of Periprosthetic Joint Infection: A Systematic Review

BACKGROUND

Although the two-stage exchange is the gold standard for the treatment of periprosthetic joint infection (PJI) in the United States, there is recent data to suggest that the utilization of a well-functioning destination spacer, also known as a "functional" or "1.5-stage revision," can be a viable treatment option in patients who have a PJI. The purpose of this systematic review was to evaluate the outcomes of patients undergoing a 1.5-stage revision for PJI and compare outcomes to a two-stage revision.

METHODS

A systematic review was performed through PubMed, Scopus, and Embase databases. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 guidelines were followed utilizing two reviewers. Following exclusions, 13 studies (n = 924 patients, 704 knees and 228 hips) were identified and included. A standardized template was utilized to capture demographic information (age, body mass index [BMI]), success/failure rate, mean follow-up time (years), and infection-free survivorship compared to two-stage revision. There were 556 patients (428 knees and 136 hips) who had 1.5-stage revisions included in the analyses. The mean age and body mass index were 65 years (range, 60 to 78) and 31 (range, 23.7 to 34.4), respectively.

RESULTS

At a mean follow-up time of 3.8 ± 1.1 years, the mean success rate was found to be 86.8%. The mean failure rate due to infection was 12.6%. In one study, infection-free survivorship was greater in the 1.5-stage revision cohort when compared to the two-stage revision cohort (94 versus 83%, P = 0.048). The remaining five studies that evaluated infection-free survivorship found no significant difference. However, there was a trend toward decreased the 90-day pain scores, postoperative complications, and cost in the 1.5-stage cohort.

CONCLUSIONS

Our systematic review demonstrated that a 1.5-stage revision is a viable and cost-effective treatment option for patients who have PJI. Infection-free survivorship was similar or greater when comparing a 1.5-stage revision to a two-stage revision. A 1.5-revision was associated with lower 90-day pain scores, postoperative complications, and decreased cost when compared to the two-stage revision in short-term follow-up, defined as less than five years. To better describe the procedure, we propose the name change to semipermanent eluting antibiotic revision procedure.

LEVEL OF EVIDENCE

IV.

Periprosthetic Joint Infection: Are Patients Still Better off Than if Primary Arthroplasty Had Not Been Performed?

BACKGROUND

This study sought to evaluate patient-reported outcome measures (PROMs) before primary total joint arthroplasty (TJA) and after successful treatment for periprosthetic joint infection (PJI), with the hypothesis that patients still demonstrate clinical improvement despite the occurrence of PJI.

METHODS

A single tertiary academic center's institutional database was retrospectively reviewed for patients who underwent primary TJA, developed PJI, and were managed for PJI from January 2019 to December 2023. Patients who did not have PROMs recorded were excluded from the study. Preoperative and postoperative generic and joint-specific PROMs were collected. Patient preprimary and postfinal revision surgery for PJI PROMs were subsequently compared. The minimum follow-up after PJI treatment was 6 months. A total of 55 patients (31 total knee arthroplasty and 24 total hip arthroplasty) were included with a mean follow-up of 1.8 years (range, 6 months to 4.5 years). All PJIs were managed via debridement, antibiotics, and implant retention, 1-stage, 1.5-stage, 2-stage revision, or resection arthroplasty.

RESULTS

After final revision surgery for PJI in total knee arthroplasty, patients had lower median patient-reported outcome measure information system (PROMIS) pain interference scores than before their primary surgery (62.0 [55.0, 67.0] versus 67.0 [65.0, 70.5]; P < 0.01). However, median PROMIS physical function postfinal revision for PJI and preprimary scores were similar (38.0 [33.0, 42.0] versus 34.0 [29.5, 40.0]; P = 0.08). After final revision surgery for PJI in total hip arthroplasty, patients had lower median PROMIS pain interference scores than before their primary surgery (57.5 [53.8, 64.0] versus 68.0 [66.5, 74.0]; P < 0.01). After final revision surgery for PJI, patients also had higher median PROMIS physical function scores than before their primary surgery (39.5 [33.5, 48.2] versus 29.5 [28.8, 34.2]; P < 0.01).

CONCLUSIONS

Patients who have been successfully managed for PJI show improvement in generic and joint-specific PROMs compared to their preprimary TJA PROMs.

Mid-term to long-term outcome and risk factors for failure of 158 hips with two-stage revision for periprosthetic hip joint infection

Introduction: This study aimed to evaluate infection-free survival and outcomes after two-stage revision surgery for hip periprosthetic joint infection (PJI) performed in a specialised arthroplasty unit over 20 years. Methods: We retrospectively identified 158 hips (154 patients) treated with two-stage revision surgery for hip PJI between 2001 and 2021. We analysed their data and presented their infection-free survival, re-operation rate, mortality, risk factors and complications. Results: The mean follow-up time was 9 (2 to 21.7) years. A total of 22 hips (13.9 %) were re-infected. The infection-free survival was 94.4 % at 2 years, 89.3 % at 5 years, 84.2 % at 10 years, and 82.6 % at 15 and 20 years. The re-operation rate for aseptic causes was 12 %, and the most common cause of re-operation was dislocation (7 %). The cumulative survival for re-operation for aseptic causes was 93.6 % at 2 years, 89.7 % at 5 years, 88.8 % at 10 years, and 82.8 % at 15 and 20 years. The cumulative survival for all-cause re-revision was 88.8 % at 2 years, 80.8 % at 5 years, 74.9 % at 10 years, and 68 % at 15 and 20 years. The mean Western Ontario and McMaster Universities Arthritis Index (WOMAC) hip score significantly improved from 68.3 at the pre-operative stage to 35.9 at 2.1 (2 to 3.3) years, 35.3 at 5.3 (5 to 8.4) years, 38.3 at 11.3 (10-15) years and 43.8 at 18.7 (16.5 to 21.7) years ( p < 0.01 ). Duration of antibiotics and gram-negative infection were the only predictive risk factors for re-infection. Conclusion: Our results of the two-stage revision protocol for hip PJI were satisfactory and comparable with the best reported outcomes.

A "1.5-Stage" Spacer Construct Using Revision Components for the Management of Periprosthetic Joint Infection of the Knee

BACKGROUND

The two-stage surgical protocols used for the treatment of periprosthetic joint infection following total knee arthroplasty are associated with marked patient morbidity. As such, alternatives, such as durable "1.5-stage" spacer constructs, have gained popularity. We sought to describe the outcomes of a novel "1.5-stage" spacer construct utilizing revision stemmed-tibia implants.

METHODS

Patients who underwent a "1.5-stage" for the management of a knee periprosthetic joint infectionat our institution were screened for inclusion. A "1.5-stage" was defined as a spacer placed with the intent of not performing a second stage, without the use of press-fit stems or cemented intramedullary fixation as is often done during a single-stage protocol. Procedures were categorized into two groups based on construct type: (1) hand-made constructs utilizing all-polyethylene tibial components; or (2) constructs utilizing stemmed-revision components precoated with cement before insertion. Patient demographics, comorbidities, and surgical details were collected and reported. The two-year Kaplan-Meier survival estimates for all-cause revision, revision for spacer loosening, and revision due to infection recurrence were reported. In total, 46 "1.5-stage" procedures were identified, including 12 handmade and 34 stemmed-revision constructs.

RESULTS

The stemmed-revision cohort was less likely to undergo reoperation for any reason (17.6 versus 50.0%, P = 0.028) or a revision for spacer loosening (0.0 versus 25.0%, P = 0.003) compared to the hand-made cohort. There were no differences with respect to infection recurrence or time to revision. The 2-year survival from revision for loosening was higher in the stemmed cohort compared to the handmade cohort though not statistically different (100%, 95% CI [confidence interval]: 2.5 to 100.0 versus 72.9%, 95% CI: 26.3 to 96.6%, P = 0.330).

CONCLUSIONS

A "1.5-stage" spacer construct using stemmed-revision components was associated with promising short-term results. Durable spacer constructs may be a viable option for select patients; however, longer-term follow-up is needed to identify patients who stand to benefit the most from this technique.

Comparison of Delphi Consensus Criteria and Musculoskeletal Infection Society Outcome Reporting Tool Definitions of Successful Surgical Treatment of Periprosthetic Knee Infection

BACKGROUND

Agreement on success following surgical treatment for periprosthetic joint infection (PJI) is important for comparing the efficacy of different surgical approaches with varying consequences and outcomes and setting patient expectations. We compared success rates following two-stage exchange arthroplasty for knee PJI using two expert-consensus definitions of success.

METHODS

Prospectively documented data for 57 knees treated by a single surgeon at an academic tertiary care center were retrospectively reviewed. Treatment outcomes were quantified using the Delphi Consensus Criteria and the Musculoskeletal Infection Society Outcome Reporting Tool (MSIS ORT).

RESULTS

Success rates were 81% using the Delphi Consensus Criteria and 56% using the MSIS ORT (P = .008). The MSIS ORT success rates increased to 76% when aseptic revisions and deaths unrelated to PJI were not penalized as failures of treatment. Predicted probabilities of successful treatment in a hypothetical case scenario were lowest based on the MSIS ORT and similarly higher using Delphi Consensus Criteria and MSIS ORT modified for both women (53.0, 90.8, and 88.7%) and men (29.1, 89.1, and 89.3%).

CONCLUSIONS

Study observations underscore the need for a uniformly accepted single definition of surgical treatment success.

Evaluating Modern Spacer Options and Outcomes in Revision Hip Arthroplasty

BACKGROUND

A 2-stage revision continues to be the standard treatment for periprosthetic joint infection (PJI) in hip arthroplasty. The use of "functional" spacers may allow patients to return to daily living while optimizing their health for revision surgery. We aimed to evaluate the clinical outcomes of different spacer types regarding infection eradication, mechanical complications, and functional outcomes.

METHODS

Patients who have complete Musculoskeletal Infection Society criteria for diagnosis of PJI that underwent one-stage or 2-stage revision were queried in an institutional surgical database between 2002 and 2022. Out of 286 patients, 210 met our inclusion criteria and were retrospectively reviewed for demographics, laboratory values, functional and patient-reported outcomes, and subsequent revisions. The study population had 54.3% women, a mean age of 61 years old, and a mean follow-up of 3.7 ± 3.2 years. There was no difference between age, body mass index, or Charlson Comorbidity Index scores between each cohort. Spacers were categorized as nonfunctional static, nonfunctional articulating, or functional articulating. Functional spacers were defined as those that allowed full weight bearing with no restrictions. Delphi criteria were used to define revision success, and failure was defined as a recurrent or persistent infection following definitive surgery.

RESULTS

There was a significantly lower reoperation rate after a definitive implant in the functional articulating cohort (P = .003), with a trending higher infection eradication rate and a lower rate of spacer failure compared to the nonfunctional spacer cohort. At 5 years, functional articulating spacers had a 94.1% survivorship rate, nonfunctional articulating spacers had an 81.2% survival rate, and nonfunctional static spacers had a 71.4% survival rate. In the functional articulating spacer cohort, 14.6% had yet to get reimplanted, with an average follow-up time of 1.4 years.

CONCLUSIONS

Within this large cohort of similar demographics, functional articulating spacers may result in better clinical outcomes and infection eradication during 2-stage revision arthroplasty for PJI.

High and Low Dosage of Vancomycin in Polymethylmethacrylate Cements: Efficacy and Mechanical Properties

INTRODUCTION

Prosthetic joint infections (PJIs) are difficult to treat and represent a significant burden to the healthcare system. Two-stage revision surgery with placement of an antibiotic-loaded cement spacer is currently the gold standard for treatment in the United States for late-onset infections. We evaluate the efficacy of varying doses of vancomycin added to antibiotic-containing acrylic cement spacers and discuss the biomechanical and antimicrobial properties of using high versus low doses of vancomycin in cement spacers in the hip and knee.

MATERIALS AND METHODS

Commercially available Copal cement containing either gentamicin and clindamycin (G + C) or gentamicin and vancomycin (G + V) was prepared with the manual addition of low (2 g) and high (6 g) doses of vancomycin. In vitro mechanical testing was then carried out according to ISO 5833 and DIN 53435, as well as inhibition zone assays against common PJI pathogens. Additionally, inhibition zone assays were conducted on two commercially available prefabricated spacers containing gentamicin: Copal Exchange G and Cemex Spacer-K.

RESULTS

In biomechanical testing, Copal G + V with the addition of 6 g of vancomycin failed to meet the ISO standard. Copal G + C and Copal G + V with low and high dosages of vancomycin were all effective against the tested pathogens and displayed constant efficacy for a duration of 42 days. High doses of vancomycin showed significantly lower mechanical stability. Moreover, Copal Exchange G showed significantly larger inhibition zones across 42 days.

DISCUSSION

While higher concentrations of vancomycin appear to improve the antimicrobial efficacy of cement, they also reduce its mechanical stability. Despite its smoother surface, the Copal Exchange G spacer exhibits large inhibition zones after 1 day and maintains consistently large inhibition zones over 6 weeks. Thus, it may be preferred for use in two-stage revision surgery.

CONCLUSION

Copal Exchange G is more effective than Cemex Spacer K against S. aureus and E. coli. The manual addition of vancomycin to cement containing double antibiotics is very effective. The influence on ISO compression is low, the ISO bending modulus is increased, and ISO bending, DIN bending, and DIN impact, are reduced.

Advancements in treatment strategies for periprosthetic joint infections: A comprehensive review

Periprosthetic joint infection (PJI) presents a critical challenge in orthopedic care, contributing to significant patient morbidity and healthcare costs. This burden is expected to increase secondary to growing demand for total joint arthroplasty (TJA). Despite the profound significance of PJI, there is currently no universally accepted "gold standard" diagnostic criteria using serum biomarker thresholds; latest criteria fail to differentiate acute infections from chronic or consider time since initial surgery. Furthermore, contemporary PJI treatment, which conventionally requires 2-stage revision surgery in conjunction with rigorous antibiotic treatment, can be particularly taxing on patients. Fortunately, recent years have seen marked evolution in both PJI diagnosis and treatment methods. Contemporary research supports time-dependent serum biomarker thresholds with greater sensitivity and specificity than previously reported, as well as alternative surgical options which may be more suitable for certain patients. The following narrative review aims to describe the significance and pathogenesis of PJI before characterizing current challenges, novel innovations, and the future landscape of PJI diagnosis and management. Here, we spotlight the emerging utility of novel biomarkers and metagenomic next-generation sequencing for diagnosis, advancements in patient-centered surgical outcome prediction tools for PJI risk assessment and prevention, and evolving surgical techniques including 1-stage and a "hybrid" 1.5-stage revision surgeries. Additionally, we explore cutting-edge therapeutic modalities including peptide and bacteriophage-based treatments, intraoperative anti-biofilm gel, the VT-X7 antibiotic pump, and promising immune-based interventions. Ultimately, these advancements hold the potential to revolutionize PJI management, offering hope for improved outcomes and reduced burdens on healthcare systems.