Mortality and re-revision following single-stage and two-stage revision surgery for the management of infected primary knee arthroplasty in England and Wales : evidence from the National Joint Registry

The Fate of the DAIR, Outcomes after 1 Year: A Large Database Study

Debridement with antibiotics and implant retention (DAIR) is commonly utilized for treatment of prosthetic joint infection (PJI) in total knee arthroplasty (TKA), particularly in cases of acute PJI. Reported success rates of DAIR have been highly variable, but the overall success rate of DAIR cohort studies is approximately 70 to 80%. However, no large database studies have investigated the success rate of DAIR. Therefore, we seek to provide a framework for large-database analysis of PJI interventions and their outcomes and to assess the success rate of DAIR. We queried the MarketScan Database for patients who underwent a DAIR (CPT 27310 and/or CPT 27486) procedure for indication of PJI (ICD-10 T84.53 OR T84.54) between January 1, 2017 and December 31, 2021. We identified reoperations (i.e., stage 1 revision, amputation, or arthrodesis) indicating failure of DAIR. Failure of DAIR treatment was defined by subsequent reoperation. We also identified prescriptions of suppression antibiotics more than 6 months after DAIR. We identified 1,018 patients who underwent a DAIR procedure for PJI. Of these patients, 195 (19.2%) underwent reoperation within 1 year and an additional 178 (17.5%) were prescribed suppressive antibiotics. For 780 patients with a minimum of 2 years of follow-up, 164 (21%) underwent reoperation and an additional 179 (22.9%) were prescribed suppressive antibiotics. Patients with obesity and patients younger than 60 years had significantly higher rates of having reoperation or suppressive antibiotics at 1 year following DAIR. DAIR is a viable option in the treatment of PJI, with an approximately 19% rate of reoperation at 2 years. Our findings are consistent with that of previously published literature.

Spacers in two-stage strategy for periprosthetic infection

In two-stage revision of infected implants, the first stage involves removing the implant and implanting a joint spacer, and the second stage involves implanting a new prosthesis at least 6 weeks later. Spacers have two main functions: local administration of high-dose antibiotics, and preservation of the joint space by reducing soft tissue retraction and improving patient comfort until reimplantation. The present review aims to detail the necessary characteristics of antibiotics added to cement to achieve good joint diffusion, to describe the steps of two-stage revision, and to present the types of spacer available according to the joint and complications. The antibiotic used in the spacer must be heat-resistant, water-soluble and chemically stable in the cement. Gentamicin and vancomycin are generally preferred. We recommend at least 3 months' systematic antibiotic therapy for periprosthetic joint infection. Reimplantation is performed either at 6 weeks without antibiotic washout or 3 months after 2 weeks' washout Spacers may be static (non-articulating) or dynamic (articulating). Static spacers are mainly used in the knee or hip in cases of severe bone defect or risk of soft-tissue lesions. An articulating spacer enables some joint functions to be preserved in the knee, hip or shoulder. The most frequent complications are the dislocation of dynamic spacers and the breakage of static or dynamic spacers. To optimize efficacy and minimize complications, the biomechanical and bacteriological characteristics of spacers must be considered. LEVEL OF EVIDENCE: Expert opinion.

Use of Hinged Implants for Multi-Stage Revision Knee Arthroplasty for Severe Periprosthetic Joint Infection: Remission Rate and Outcomes After a Minimum Follow-Up of Five Years

BACKGROUND

In severe periprosthetic joint infection after total knee arthroplasty (TKA), multistage procedures are indicated for ongoing signs of infection after implant removal during the spacer interval of an intended 2-stage exchange. In these cases, several additional debridement and spacer exchange surgeries may be necessary. Herein, we analyzed the complications, remission rates, and functional outcomes after multistage revision arthroplasty using hinged TKAs.

METHODS

Patients (n = 79) treated with multistage revision arthroplasty after chronic periprosthetic joint infection of the knee were included (2010 to 2018). During the prosthesis-free interval, a static spacer containing antibiotic-loaded bone cement was implanted. The mean number of surgeries, including implant removal and revision arthroplasty, was 3.8 (range, 3 to 8). The mean duration from implant removal to revision arthroplasty was 83 days (range, 49 to 318). Complications, remission, and mortality were analyzed after a minimum follow-up of 5 years. Outcomes were assessed based on the Knee Society Score (KSS) and the Western Ontario McMasters University Osteoarthritis Index.

RESULTS

During follow-up, 24 (30.4%) patients underwent revision surgery, with a mean time to surgical revision of 99 weeks (range, 1 to 261). After follow-up, the infection-free remission rate and overall mortality were 87.3 and 11.4%, respectively. The mean KSS was 74.3 (range, 24 to 99), the KSS Function Score was 60.8 (range, 5 to 100), and the Western Ontario McMasters University Osteoarthritis Index 30.2 (range, 5 to 83).

CONCLUSIONS

In difficult-to-treat cases, multistage revision arthroplasty showed high remission rates and low mortality after a follow-up of 5 years. The overall revision rate was comparably high, accounting for early and late reinfections most of the time. In cases of implant survival, functional outcomes comparable to those of revision hinge TKA reported in the literature can be achieved. Therefore, multistage procedures with additional debridement steps should be performed in cases of ongoing infections in intended 2-stage procedures.

Efficacy of a saline wash plus vancomycin/tobramycin-doped PVA composite (PVA-VAN/TOB-P) in a mouse pouch infection model implanted with 3D-printed porous titanium cylinders

Aims

The efficacy of saline irrigation for treatment of implant-associated infections is limited in the presence of porous metallic implants. This study evaluated the therapeutic efficacy of antibiotic doped bioceramic (vancomycin/tobramycin-doped polyvinyl alcohol composite (PVA-VAN/TOB-P)) after saline wash in a mouse infection model implanted with titanium cylinders.

Methods

Air pouches created in female BalBc mice by subcutaneous injection of air. In the first of two independent studies, pouches were implanted with titanium cylinders (400, 700, and 100 µm pore sizes) and inoculated with Staphylococcus aureus (1 × 103 or 1 × 106 colony-forming units (CFU)/pouch) to establish infection and biofilm formation. Mice were killed after one week for microbiological analysis. In the second study, pouches were implanted with 400 µm titanium cylinders and inoculated with S. aureus (1 × 103 or 1 × 106 CFU/pouch). Four groups were tested: 1) no bacteria; 2) bacteria without saline wash; 3) saline wash only; and 4) saline wash plus PVA-VAN/TOB-P. After seven days, the pouches were opened and washed with saline alone, or had an additional injection of PVA-VAN/TOB-P. Mice were killed 14 days after pouch wash.

Results

The first part of the study showed that low-grade infection was more significant in 400 µm cylinders than cylinders with larger pore sizes (p < 0.05). The second part of the study showed that saline wash alone was ineffective in eradicating both low- and high-grade infections. Saline plus PVA-VAN/TOB-P eradicated the titanium cylinder-associated infections, as manifested by negative cultures of the washouts and supported by scanning electron microscopy and histology.

Conclusion

Porous titanium cylinders were vulnerable to bacterial infection and biofilm formation that could not be treated by saline irrigation alone. Application of PVA-VAN/TOB-P directly into the surgical site alone or after saline wash represents a feasible approach for prevention and/or treatment of porous implant-related infections.

The Investigation and Management of Peri-Prosthetic Joint Infection After Total Knee Arthroplasty: An Update Based on the Latest British Orthopaedic Association Standard and Speciality Standard Guidelines

Peri-prosthetic joint infection (PJI) is a significant complication following total knee arthroplasty (TKA). Early identification and management are essential to prevent severe morbidity and mortality in these patients. Long-term complications of PJI include the need for multiple operations, disability, joint stiffness, reduced range of motion, and increased mortality. Clinical signs, inflammatory markers, imaging, tissue sampling, and synovial fluid analysis are required to diagnose PJI. Debridement antibiotics and implant retention (DAIR) is an effective management option, but single- or two-stage exchange arthroplasty may be ultimately required. All cases of PJI in TKA must be discussed in a multi-disciplinary (MDT) meeting. This review incorporates the updated British Orthopaedic Association (BOA) standard and speciality standard to provide an up-to-date guideline on the early identification and management of PJI. We highlight that adhering to the BOA guidelines and adopting an MDT approach are essential for optimal patient outcomes.

Synovial vancomycin and meropenem concentrations in periprosthetic joint infection treated by single-stage revision combined with intra-articular infusion

Aims

We aimed to determine the concentrations of synovial vancomycin and meropenem in patients treated by single-stage revision combined with intra-articular infusion following periprosthetic joint infection (PJI), thereby validating this drug delivery approach.

Methods

We included 14 patients with PJI as noted in their medical records between November 2021 and August 2022, comprising eight hip and seven knee joint infections, with one patient experiencing bilateral knee infections. The patients underwent single-stage revision surgery, followed by intra-articular infusion of vancomycin and meropenem (50,000 µg/ml). Synovial fluid samples were collected to assess antibiotic concentrations using high-performance liquid chromatography.

Results

The peak concentrations of vancomycin and meropenem in the joint cavity were observed at one hour post-injection, with mean values of 14,933.9 µg/ml (SD 10,176.3) and 5,819.1 µg/ml (SD 6,029.8), respectively. The trough concentrations at 24 hours were 5,495.0 µg/ml (SD 2,360.5) for vancomycin and 186.4 µg/ml (SD 254.3) for meropenem. The half-life of vancomycin was 6 hours, while that of meropenem ranged between 2 and 3.5 hours. No significant adverse events related to the antibiotic administration were observed.

Conclusion

This method can achieve sustained high antibiotic concentrations within the joint space, exceeding the reported minimum biofilm eradication concentration. Our study highlights the remarkable effectiveness of intra-articular antibiotic infusion in delivering high intra-articular concentrations of antibiotics. The method provided sustained high antibiotic concentrations within the joint cavity, and no severe side-effects were observed. These findings offer evidence to improve clinical treatment strategies. However, further validation is required through studies with larger sample sizes and higher levels of evidence.

Staged revision of the infected knee arthroplasty and endoprosthesis

Aims

Periprosthetic joint infection (PJI) is a challenging complication of any arthroplasty procedure. We reviewed our use of static antibiotic-loaded cement spacers (ABLCSs) for staged management of PJI where segmental bone loss, ligamentous instability, or soft-tissue defects necessitate a static construct. We reviewed factors contributing to their failure and techniques to avoid these complications when using ABLCSs in this context.

Methods

A retrospective analysis was conducted of 94 patients undergoing first-stage revision of an infected knee prosthesis between September 2007 and January 2020 at a single institution. Radiographs and clinical records were used to assess and classify the incidence and causes of static spacer failure. Of the 94 cases, there were 19 primary total knee arthroplasties (TKAs), ten revision TKAs (varus-valgus constraint), 20 hinged TKAs, one arthrodesis (nail), one failed spacer (performed elsewhere), 21 distal femoral endoprosthetic arthroplasties, and 22 proximal tibial arthroplasties.

Results

A total of 35/94 patients (37.2%) had spacer-related complications, of which 26/35 complications (74.3%) were because of mechanical failure of the spacer construct, while 9/35 (25.7%) were due to recurrence of infection. Risk factors for internal failure were a construct where the total intramedullary spacer length was less than twice the length of the central osseous defect (p = 0.009), where proximal or distal intraosseous spacer contact was < 10%, and after tibial tubercle osteotomy (p = 0.005). The incidence of spacer complications significantly increased the time to second stage: mean 157 days (42 to 458) in those without complications versus 227 days (11 to 528) with complications (p = 0.014).

Conclusion

The failure rate of static antibiotic-loaded cement spacers is much higher than anticipated. Complications of the spacer significantly increased the time to second-stage revision. The risk of mechanical failure is significantly increased if the spacer is less than double the size of the segmental defect, or if inadequate reinforcement is inserted into the residual bone. These findings serve as a guide for surgeons to avoid mechanical complications with static spacers.

Association Between Periprosthetic Joint Infection and Mortality Following Primary Total Hip Arthroplasty

BACKGROUND

Periprosthetic joint infection (PJI) remains a dreaded and unpredictable complication after total hip arthroplasty (THA). In addition to causing substantial morbidity, PJI may contribute to long-term mortality risk. Our objective was to determine the long-term mortality risk associated with PJI following THA.

METHODS

This population-based, retrospective cohort study included adult patients (≥18 years old) in Ontario, Canada, who underwent their first primary elective THA for arthritis between April 1, 2002, and March 31, 2021. The primary outcome was death within 10 years after the index THA. Mortality was compared between propensity-score-matched groups (PJI within 1 year after surgery versus no PJI within 1 year after surgery) with use of survival analyses. Patients who died within 1 year after surgery were excluded to avoid immortal time bias.

RESULTS

A total of 175,432 patients (95,883 [54.7%] women) with a mean age (and standard deviation) of 67 ± 11.4 years underwent primary THA during the study period. Of these, 868 patients (0.49%) underwent surgery for a PJI of the replaced joint within 1 year after the index procedure. After matching, patients with a PJI within the first year had a significantly higher 10-year mortality rate than their counterparts (11.4% [94 of 827 patients] versus 2.2% [18 of 827 patients]; absolute risk difference, 9.19% [95% confidence interval (CI), 6.81% to 11.6%]; hazard ratio, 5.49 [95% CI, 3.32 to 9.09]).

CONCLUSIONS

PJI within 1 year after surgery is associated with over a fivefold increased risk of mortality within 10 years. The findings of this study underscore the importance of prioritizing efforts related to the prevention, diagnosis, and treatment of PJIs.

LEVEL OF EVIDENCE

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

Debridement, antibiotics and implant retention (DAIR) following hip and knee arthroplasty: results and findings of a multidisciplinary approach from a non-specialist prosthetic infection centre

INTRODUCTION

Prosthetic joint infection (PJI) is a catastrophic complication following arthroplasty surgery. Recently a debridement, antibiotics and implant retention (DAIR) procedure has gained popularity for PJI where a thorough debridement, irrigation and modular component exchange is undertaken.

METHOD

We present the outcome for DAIR, data collected prospectively, in a busy orthopaedic unit but not one specialising in PJI. All patients with PJI were included without loss of data or patients from 2012 to 2018 with a minimum follow-up of 5 years.

RESULTS

Four total knee replacements, 17 total hip replacements, one revision total hip replacement and three hip hemiarthroplasties are included with an average duration from onset of symptoms to the DAIR procedure of 11 days (range 1-22 days). Staphylococcus aureus (24%) and Staphylococcus epidermidis (32%) were the most common causative organisms, and the most common antibiotic regimens included intravenous teicoplanin and flucloxacillin. Average follow-up was 67 months (range 9-104 months). Only four patients went on to require revision surgery. An analysis of midterm patient outcome measures for 6 of the total hip replacement (THR) DAIR patients were compared with a database of 792 THRs (with a minimum two-year follow-up) carried out by the same surgeon revealed no significant difference in Oxford hip scores at one-year post-surgery (OHS DAIR 36.2 vs 39 for control group).

CONCLUSION

This study includes 25 consecutive patients treated with DAIR with only one reinfection, with a mean follow-up period of 5 years. Using a strict protocol, DAIR appears to offer a successful treatment strategy for the management of early PJI.

Stochastic lattice-based porous implant design for improving the stress transfer in unicompartmental knee arthroplasty

BACKGROUND

Unicompartmental knee arthroplasty (UKA) has been proved to be a successful treatment for osteoarthritis patients. However, the stress shielding caused by mismatch in mechanical properties between human bones and artificial implants remains as a challenging issue. This study aimed to properly design a bionic porous tibial implant and evaluate its biomechanical effect in reconstructing stress transfer pathway after UKA surgery.

METHODS

Voronoi structures with different strut sizes and porosities were designed and manufactured with Ti6Al4V through additive manufacturing and subjected to quasi-static compression tests. The Gibson-Ashby model was used to relate mechanical properties with design parameters. Subsequently, finite element models were developed for porous UKA, conventional UKA, and native knee to evaluate the biomechanical effect of tibial implant with designed structures during the stance phase.

RESULTS

The internal stress distribution on the tibia plateau in the medial compartment of the porous UKA knee was found to closely resemble that of the native knee. Furthermore, the mean stress values in the medial regions of the tibial plateau of the porous UKA knee were at least 44.7% higher than that of the conventional UKA knee for all subjects during the most loading conditions. The strain shielding reduction effect of the porous UKA knee model was significant under the implant and near the load contact sites. For subject 1 to 3, the average percentages of nodes in bone preserving and building region (strain values range from 400 to 3000 μm/m) of the porous UKA knee model, ranging from 68.7 to 80.5%, were higher than that of the conventional UKA knee model, ranging from 61.6 to 68.6%.

CONCLUSIONS

The comparison results indicated that the tibial implant with designed Voronoi structure offered better biomechanical functionality on the tibial plateau after UKA. Additionally, the model and associated analysis provide a well-defined design process and dependable selection criteria for design parameters of UKA implants with Voronoi structures.

Ninety-day postoperative mortality and complications in continuous and unselected single-stage revisions for chronic periprosthetic joint infection

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.

Systematic review and meta-analysis of single-stage versus two-stage revision for periprosthetic joint infection after knee arthroplasty: a call for a randomised trial

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.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Outcomes of single- vs two-stage primary joint arthroplasty for septic arthritis: a systematic review and meta-analysis

Purpose

Septic arthritis (SA) is an intra-articular infection caused by purulent bacteria and the only effective method is surgical intervention. Two-stage arthroplasty is considered the gold standard treatment for SA, but recent studies have found that single-stage arthroplasty can achieve the same efficacy as two-stage arthroplasty. This study aimed to compare the efficacy of single- vs two-stage arthroplasty in the treatment of (acute or quiescent) SA.

Methods

The review process was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched the PubMed, EMBASE, Medline, and Cochrane Library databases to identify all literature on the treatment of SA using single- and two-stage arthroplasty from the date of database inception to November 10, 2022. Data on reinfection rates were expressed as odds ratios and 95% CIs.

Results

Seven retrospective studies with a total of 413 patients were included. Pooled analysis showed no difference in the reinfection rate between single- and two-stage arthroplasty. Subgroup analysis found no difference between the single- and two-stage arthroplasty groups in the incidence of purulent infection of the hip and knee. Cumulative meta-analysis showed gradual stabilization of outcomes.

Conclusions

Based on our meta-analysis of available retrospective studies, we found no significant difference in reinfection rates between single- and two-stage arthroplasty for SA. Further prospective cohort studies are needed to confirm our results, although our meta-analysis provides important insights into the current literature on this topic.

Artificial intelligence in orthopaedics

Cite this article: Bone Joint Res  2023;12(8):494–496.

Development of evidence-based guidelines for the treatment and management of periprosthetic hip infection

Periprosthetic hip-joint infection is a multifaceted and highly detrimental outcome for patients and clinicians. The incidence of prosthetic joint infection reported within two years of primary hip arthroplasty ranges from 0.8% to 2.1%. Costs of treatment are over five-times greater in people with periprosthetic hip joint infection than in those with no infection. Currently, there are no national evidence-based guidelines for treatment and management of this condition to guide clinical practice or to inform clinical study design. The aim of this study is to develop guidelines based on evidence from the six-year INFection and ORthopaedic Management (INFORM) research programme. We used a consensus process consisting of an evidence review to generate items for the guidelines and online consensus questionnaire and virtual face-to-face consensus meeting to draft the guidelines. The consensus panel comprised 21 clinical experts in orthopaedics, primary care, rehabilitation, and healthcare commissioning. The final output from the consensus process was a 14-item guideline. The guidelines make recommendations regarding increased vigilance and monitoring of those at increased risk of infection; diagnosis including strategies to ensure the early recognition of prosthetic infection and referral to orthopaedic teams; treatment, including early use of DAIR and revision strategies; and postoperative management including appropriate physical and psychological support and antibiotic strategies. We believe the implementation of the INFORM guidelines will inform treatment protocols and clinical pathways to improve the treatment and management of periprosthetic hip infection.