Single-Stage Revision Arthroplasty for Infection—An Underutilized Treatment Strategy

doi:10.1016/j.arth.2017.02.059

The Journal of Arthroplasty

Volume 32, Issue 7, July 2017, Pages 2051-2055

https://doi.org/10.1016/j.arth.2017.02.059 Get rights and content

Abstract

Background

The burden of revision arthroplasty surgery for infection is rising as the rate of primary arthroplasty surgery increases. Infected arthroplasty rates are now relatively low, but the sheer increase in volume is leading to considerable patient morbidity and significant increases in costs to the health care system. Single-stage revision for infection is one of the several accepted treatment options, but the indications and results are debated. This review aims to clarify the current evidence.

Methods

MEDLINE/PubMed databases were reviewed for studies that looked at single- or one-stage revision knee or hip arthroplasty for infection.

Results

There is increasing evidence that single-stage revision for infection can control infection and with decreased morbidity, mortality, and health care costs compared with a staged approach. However, the indications are still debated. Recently, there has been a determined effort to define an infected arthroplasty in a manner that will allow for standardization of reporting in the literature. The evidence supporting single stage for knee arthroplasty is catching up with the result with hip arthroplasty. High-quality data from randomized controlled trials are now pending.

Conclusion

After the gradual evolution of using the single-stage approach, with the widespread acceptance of this definition, we can now standardize comparisons across the world and move toward a refined definition of the ideal patient population for single-stage arthroplasty revision in both the hip and the knee population.

Section snippets

Definition

The application of the principles of management for PPI is hampered by inconsistencies in diagnosis and surveillance between institutions. This leads to a lack of certainty in patient selection, making the selection of the ideal patient for each treatment strategy unclear. As the true incidence is unknown, national joint registries specifically designed for PPI may well help and are already being designed. The current registries were not designed to capture these data, and any information

Results

Currently, there are no published randomized clinical trials (RCTs) that provide concrete indications or contraindications for single-stage exchange arthroplasty over 2-stage exchange arthroplasty, but there are RCTs on the clinical trials registry. These RCTs are currently recruiting, which should provide more data to guide us in the next few years [26], [27]. There are fewer reported series of single-stage revision cases than the more dominant 2-stage procedure, with fewer reports for knees

Inadvertent Single-Stage Revision

Some patients received an inadvertent single-stage revision. The data from the UCLH revision database from 1999 to 2015 showed 26 cases with infection diagnoses on the basis of >2 positive cultures of 5 tissue samples with the same organism and an antibiogram. There were 16 THA and 10 TKA cases. Significant infection was only diagnosed postoperatively, and therefore, the patient had an inadvertent single-stage revision. Antibiotics were continued in these patients until inflammatory, and

Mortality

The question of increased mortality is also complex as the average age and general health of the patients being treated lead to a significant baseline mortality rate before the effect of different procedures are examined. The risk of dying for an average 70-year-old American is between 2% and 3% per year.

Berend et al [39] looked at their database over a 15-year period, and of 202 patients treated with a 2-stage revision strategy, 14 patients (7%) died before the second-stage reimplantation

Cost

It is difficult to analyze the true difference in cost between a single-stage and a 2-stage strategy due to the variation in hospital facilities, patients, surgeons, and the infecting organism. Even the cost of the antibiotic eluting cement can vary widely depending on whether it is purchased commercially or mixed in the operating theater [42]. It is apparent that a single-stage strategy is likely to save costs associated with patient morbidity, operative time, operating room utilization,

Consensus

An international group of arthroplasty surgeons and researchers reached a consensus (78%) in 2014 that single-stage exchange arthroplasty is a reasonable option for the treatment of PJI in circumstances where effective antibiotics were available [47]. The group suggested exclusions to single-stage revision should be as follows:

•
The presence of generalized sepsis
•
Infections in which the bacteria is not identified
•
Infection causes by a drug-resistant bacteria
•
The presence of a sinus tract
•
The presence

Conclusion

The evidence for best practice in managing PPI of the joint is an evolving science. Single-stage revision has been shown to offer similar eradication rates to the commonly performed 2-stage procedure in selected cases. The indications for single-stage revision are increasing in both hip and knee surgery, so it is no longer a question of whether we should perform single-stage revision but more having clear criteria for when to do it. In the case of an acute THA infection, it is an easy procedure

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Cited by (50)

Differences in Diagnostic Sensitivity of Cultures Between Sample Types in Periprosthetic Joint Infections: A Systematic Review and Meta-Analysis
2024, Journal of Arthroplasty
Differences between the bacterial culture results of the preoperative fluid, intraoperative tissue, and sonication fluid of implants in the diagnosis of periprosthetic joint infection (PJI) are important issues in clinical practice. This study aimed to identify the differences in pooled diagnostic accuracy between culture sample types for diagnosing PJI by performing a systematic review and meta-analysis.
This study was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis statement. A comprehensive literature search of PubMed, Cumulative Index to Nursing and Allied Health Literature, and Cochrane Library databases was performed. Data extraction and study assessment using the quality assessment of diagnostic accuracy studies were performed independently by two reviewers. The pooled sensitivity, specificity, summary receiver operating characteristic curve, and area under the summary receiver operating characteristic curve were estimated for each sample type.
There were thirty-two studies that were included in the analysis after screening and eligibility assessment. The pooled sensitivities of preoperative fluid, intraoperative tissue, and sonication fluid for the diagnosis of PJI were 0.63 (95% confidence interval [CI] 0.56 to 0.70), 0.71 (95% CI 0.63 to 0.79), and 0.78 (95% CI 0.68 to 0.85), while the specificities were 0.96 (95% CI 0.93 to 0.98), 0.92 (95% CI 0.86 to 0.96), and 0.91 (95% CI 0.83 to 0.95), respectively. The area under the curves for preoperative fluid, intraoperative tissue, and sonication fluid were 0.86, 0.88, and 0.90, respectively.
Sonication fluid culture demonstrated better sensitivity compared with the conventional culture method, and preoperative fluid culture provided lower sensitivity in diagnosing PJI.
One- or two-stage reimplantation for infected total knee prosthesis?
2023, Orthopaedics and Traumatology: Surgery and Research
Citation Excerpt :
We, advocate the addition of antibiotics to the cement powder during the mixing phase. Calcium sulphate beads can also be utilized to fill voids created as a result of bone loss and can also be used to add local antibiotic delivery if using cementless implants [34,38,39]. Once the cement has set the surgical field should be washed again and a water-tight closure achieved.
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.
Risk Factors for Treatment Failure in Patients Who Have Knee Periprosthetic Joint Infection Treated With Two-Stage Exchange Arthroplasty as Well as Their Fate
2023, Journal of Arthroplasty
Two-stage exchange arthroplasty is considered the gold standard treatment for chronic periprosthetic joint infection (PJI). However, there is a scarcity of research investigating the major risk factors for infection recurrence and the prognosis after infection recurrence.
This study included 203 patients who underwent 2-stage exchange arthroplasty between June 22, 2010 and January 24, 2017. The need of reoperation for infection-related or PJI-related mortality was considered treatment failure. Participant age, gender, body mass index, comorbidities, culture results, length of hospital stay, cause of treatment failure, operative procedure, and fate were analyzed.
Fifty-three patients experienced treatment failure (26.1%). Mean follow-up was 63 months (range, 26-103). Based on the multivariate analyses, risk factors for treatment failure included men and positive intraoperative culture during reimplantation. Recurrent infection was most commonly caused by Staphylococcus aureus (32.1%, 17/53), and new microorganisms caused recurrent infection in 34 of 53 (64.2%) patients. In 44 patients who had treatment failure, debridement, antibiotic therapy, irrigation, and retention of prosthesis (DAIR) performed within 6 months of reimplantation and at <3 weeks from symptom onset resulted in a significantly higher success rate than the use of other DAIR protocols (P = .031).
Men and positive intraoperative culture are major risk factors for 2-stage exchange arthroplasty failure in patients who have knee PJI. Recurrent infection in these patients is usually caused by new microorganisms. DAIR within 6 months of reimplantation and at <3 weeks from symptom onset results in good outcomes in these patients.
One- or Two-Stage Reimplantation for Infected Total Knee Prosthesis?
2022, Revue de Chirurgie Orthopedique et Traumatologique
L’infection de prothèse articulaire (IPA) est peut-être la complication la plus sévère d’une arthroplastie totale du genou (PTG) et elle est corrélée à une morbidité significative et un coût socio-économique élevé. C’est une complication dévastatrice à la fois pour le patient et pour le chirurgien. La révision en 2 temps d’une PTG infectée a été le traitement chirurgical standard pendant longtemps. Cependant, il y a un intérêt croissant pour la chirurgie de révision en un temps en raison du plus petit nombre d’interventions nécessaires, de la moindre durée du séjour hospitalier et de son moindre coût pour le système de santé. La révision en un temps est indiquée en l’absence de signes d’infection systémique et dans les cas où un germe a été isolé. Elle comporte l’ablation de la prothèse en place, l’excision de tous les tissus infectés, un lavage abondant et une nouvelle installation et finalement la réimplantation d’une nouvelle prothèse. La stratégie en 2 temps comporte l’utilisation d’un espaceur en ciment aux antibiotiques avant que le 2e temps ne soit entrepris. La longueur de l’intervalle entre les 2 temps est discutée. Les patients qui présentent une infection prothétique doivent être pris en charge par une équipe multidisciplinaire. Nous recommandons également que ces patients soient traités dans des centres spécialisés en arthroplastie prothétique par des chirurgiens ayant une importante expérience de la révision prothétique.
Septic Failure After One-Stage Exchange for Prosthetic Joint Infection of the Hip: Microbiological Implications
2022, Journal of Arthroplasty
The microbiological implications of septic failure after 1-stage exchange for prosthetic joint infection (PJI) of the hip remain unclear.
Information was gathered on comorbidities, previous procedures, preoperative and postoperative microbiology results, methods of detection, and antibiotic resistance patterns, for all patients, who developed septic failure after 1-stage exchange for PJI of the hip performed at our institution during 2001-2017.
Seventy-seven patients were identified. Septic failure was diagnosed a mean of 1.7 (standard deviation 2.3, range 0-11.8) years later. Although the spectrum of microorganisms was similar to preoperative, in the majority of patients (55%), the initial microorganism(s) was (were) replaced by (a) totally different microorganism(s). Overall, there was a decrease in the number of polymicrobial PJIs. The number of patients with high virulent microorganisms decreased significantly from 52 to 36 (P = .034). The number of PJIs due to gram-negative pathogens remained similar (11 vs 14, P = .491). The number of rifampicin-resistant staphylococci, fluoroquinolone-resistant streptococci, enterococci, and fungi changed from 8 to 15, 0 to 2, 7 to 3, and 1 to 2, respectively, but these changes did not reach statistical significance.
The majority of reinfections is caused by different infecting bacteria, hence it is essential to perform a new diagnostic workup and not base treatment decisions (solely) on historical cultures. We were furthermore unable to irrefutably prove that, from a microbiological point of view, septic failure after 1-stage exchange comes with increased challenges. Given the time interval to failure, we propose that a longer follow-up of these patients is needed, than previously suggested.
The AAHKS Best Podium Presentation Research Award: Comparing the Efficacy of Irrigation Solutions on Staphylococcal Biofilm Formed on Arthroplasty Surfaces
2021, Journal of Arthroplasty
Citation Excerpt :
All solutions were prepared following written manufacturer specifications, or when such specifications were not compatible with experimental conditions, manufacturers were contacted to provide written input and guidance. Isotonic (0.9%) saline, isotonic saline mixed with vancomycin (1 mg/mL; MP Biomedicals, Solon OH), isotonic saline mixed with polymxin (500,000 U/L; Xellia Pharmaceuticals, Buffalo Grove IL) and bacitracin (50,000 U/L; PREMIERProRx, Charlotte NC), sterile 10% povidone-iodine (Aplicare Products, Meriden CT), sterile 10% povidone-iodine mixed 1:1 with 4% hydrogen peroxide (Hydox Laboratories, Elgin IL), sterile povidone-iodine diluted to 0.3% with saline, Irrisept (0.05% chlorhexidine gluconate; Irrimax Corporation, Lawrenceville, GA), a 0.04% polyhexanide and polyaminopropyl biguanide [PHMB] with betaine solution (derived from Prontosan; B. Braun Medical, Bethelem PA), and Bactisure (ethanol, acetic acid, sodium acetate, benzalkonium chloride and water, Zimmer-Biomet, Warsaw IN) were selected due to their prior documented use in PJI treatment within the orthopedic literature or recent claims of being able to eradicate biofilm [10,11,13–18]. Isotonic saline was made by dissolving sodium chloride (Thermo Fisher Scientific; Rockford IL) in deionized water and vacuum filtered through a 0.22 μm filter.
A diverse array of antibacterial solutions is utilized by orthopedic surgeons in an attempt to disperse bacterial biofilm. Few studies compare these agents against biofilm grown on clinically relevant orthopedic biomaterials, such as plastic, acrylic cement, and porous titanium.
MSSA biofilm was grown on plastic 48-well plates, polymethylmethacrylate cement beads and porous Ti-6Al-4V acetabular screw caps. Antibacterial solutions were tested according to manufacturer guidance and included: isotonic saline, vancomycin (1 mg/mL), polymyxin-bacitracin (500,000 U/L-50,000 U/L), povidone-iodine 0.3%, povidone-iodine 10%, a 1:1 combination of povidone-iodine 10% & 4% hydrogen peroxide, polyhexamethylene biguanide (PHMB) and betaine 0.04%, a commercial solution containing chlorhexidine gluconate (CHG) 0.05%, and a commercial solution containing benzalkonium chloride and ethanol. Twenty four and 72-hour biofilms were exposed to solutions for 3 minutes to reproduce intraoperative conditions. Solution efficacy was measured through sonication of treated surfaces followed by counting colony forming units and validated with a resazurin assay to assess cell viability. Experiments were performed in triplicate and repeated at least once. A three-fold log reduction in CFU counts versus controls was considered as a measure of solution efficacy.
Saline, vancomycin and polymyxin-bacitracin were ineffective compared to other solutions against planktonic MSSA. Povidone-iodine 10% and a 1:1 solution of povidone-iodine 10% and 4% hydrogen peroxide were the only effective solutions against biofilm across all three surfaces and time points.
Commercial antibacterial solutions vary significantly in their efficacy against MSSA biofilm. Efficacy globally decreased as biofilm maturity increased. Increased solution cost did not confer increased efficacy.

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: One or more of the authors of this paper have disclosed potential or pertinent conflicts of interest, which may include receipt of payment, either direct or indirect, institutional support, or association with an entity in the biomedical field which may be perceived to have potential conflict of interest with this work. For full disclosure statements refer to http://dx.doi.org/10.1016/j.arth.2017.02.059.

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AAHKS SymposiumSingle-Stage Revision Arthroplasty for Infection—An Underutilized Treatment Strategy

Abstract

Background

Methods

Results

Conclusion

Section snippets

Definition

Results

Inadvertent Single-Stage Revision

Mortality

Cost

Consensus

Conclusion

The impact of infection after total hip arthroplasty on hospital and surgeon resource utilization

J Bone Joint Surg Am

The epidemiology of revision total knee arthroplasty in the United States

Clin Orthop Relat Res

Prosthetic joint infection risk after TKA in the Medicare population

Clin Orthop Relat Res

Periprosthetic joint infection: the last frontier

Bone Joint J

Economic burden of periprosthetic joint infection in the United States

J Arthroplasty

12th Annual report

One-stage revision surgery of the infected hip. A minimum 10-year followup study

Clin Orthop Relat Res

Antibiotic prophylaxis in orthopaedic surgery

Bone Joint J

Minimising the risk of infection

Bone Joint J

The impact of patient and surgical factors on the rate of infection after primary total knee arthroplasty

Bone Joint J

The use of high-dose dual-impregnated antibiotic-laden cement with hemiarthroplasty for the treatment of a fracture of the hip

Bone Joint J

Intra-articular infusion

Bone Joint J

Prophylactic peri-operative local antibiotic irrigation

Bone Joint J

Reconstruction of the infected total hip and knee arthroplasty with gentamicin-impregnated Palacos bone cement

Instr Course Lect

Exchange arthroplasty for infection. Perspectives from the United Kingdom

Orthop Clin North Am

Infected total hip arthroplasty revision: one- or two-stage procedure?

Orthop Traumatol Surg Res

Hypercalcaemia following the use of antibiotic-eluting absorbable calcium sulphate beads in revision arthroplasty for infection

Bone Joint J

Interleukin-6 in two-stage revision arthroplasty: what is the threshold value to exclude persistent infection before re-implanatation?

Bone Joint J

One-stage exchange

Bone Joint J

Single stage revision: regaining momentum

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Deep infection after hip arthroplasty

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Can National Joint Registries play a role in improving our understanding of periprosthetic infections?

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Diagnosis of periprosthetic joint infection following hip and knee arthroplasty

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AAHKS Symposium
Single-Stage Revision Arthroplasty for Infection—An Underutilized Treatment Strategy